Every finding on record at Atlantic Specialty Care

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to notify the resident's representative in writing and the state ombudsman of a transfer to the hospital for 1 of 2 residents (#8). The facility also failed to provide a bed hold with reserve bed payment information for 2 of 2 residents (#6 & #8). The facility reported a census of 72 residents.Findings include:1.Resident #6's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated completely intact cognition. It included diagnoses of cancer, heart failure, and respiratory failure. It revealed the resident was independent with eating, required maximal assistance with toileting, personal and oral hygiene, lower body dressing, and footwear, and required moderate assistance with all other Activities of Daily Living (ADLs) and mobility.The Care Plan dated 1/02/26 included impaired cognitive function related to poor safety awareness and directed staff to keep her routine consistent.The Nurses Note dated 2/03/26 at 1:15 PM revealed the resident was transferred to the hospital due to breathing difficulty. A subsequent Nurses Note at 3:38 PM indicated the resident was admitted to the hospital with a pneumonia diagnosis. The Electronic Health Record (EHR) Standard Evaluations section did not include a documented bed hold authorization with reserve payment information nor did the EHR include family notification in writing of the reason for the resident's hospital transfer.On 4/06/26 at 1:26 PM, Resident #6 stated she did not remember whether or not staff mentioned a bed hold.On 4/07/26 at 2:46 PM, the resident stated she did not remember going to the hospital. The resident's representative stated the facility verbally notified them the resident was going to the hospital for pneumonia but stated the facility did not discuss a bed hold with reserve payment nor did she receive the transfer notification in writing.2. Resident #8's MDS dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of right hip fracture and non-Alzheimer's dementia. It revealed the resident required supervision with eating, maximal assistance with showering and mobility, and was dependent with all other ADLs and shower transfer.An Incident, Accident, Unusual Occurrence Note Progress Note dated 2/26/26 at 5:35 PM revealed the resident sustained a fall but lacked information in the Notifications: section. A Nurses Note Progress Note at 7:07 PM confirmed the resident was transferred to the hospital and the family was made aware.The February 2026 Notice Of Transfer Form To Long Term Care Ombudsman report did not include Resident #8's hospitalization transfer.The Care Plan revised 3/19/26 included a history of a fall with a fracture and a subsequent right thigh surgical incision.The EHR Standard Evaluations section did not include a documented bed hold authorization with reserve payment information nor did the EHR include family notification in writing of the reason for the resident's hospital transfer.On 4/07/26 at 12:18 PM, Staff B, Licensed Practical Nurse (LPN) stated bed hold information is documented under the EHR Evaluations tab and should be available on all residents.On 4/07/26 at 12:26 PM, the Social Services Coordinator (SSC) stated the official Ombudsman notification report did not include Resident #8's hospitalization.On 4/07/26 at 12:38 PM, the Business Office Manager (BOM) stated she was not able to locate documentation that the resident's representative was notified of a bed hold with reserve payment or the reason for the resident's hospital transfer in writing.On 4/07/26 at 12:58 PM, the Regional Nurse Consultant (RNC) stated the facility had not been notifying resident representatives in writing because the transfers were emergent.On 4/07/26 at 1:05 PM, the Director of Nursing (DON) stated she was not able to locate the resident's 2/26/26 hospitalization bed hold.A policy titled Bed-Holds and Returns revised [DATE] indicated:Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail:The rights and limitations of the resident regarding bed-holds;The reserve bed payment policy as indicated by the state plan (Medicaid residents);The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); andThe details of the transfer (per the Notice of Transfer).On 4/09/26 at 11:51 AM, the DON stated the nurse should've called the family to inquire about a bed-hold and sent to the family and to notify them why the resident was sent to the hospital. The transfer should have been reported to the Ombudsman.

Based on clinical record review, resident interview, staff interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, October 2025, the facility failed to complete and submit the admission Minimum Data Set (MDS) in the required time frame for 1of 19 residents reviewed (Resident #83). The facility reported a census of 72 residents. Findings include: The MDS assessment dated [DATE] for Resident #83 identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. On 4/8/26 the electronic clinical record MDS page revealed the MDS Admission, dated 3/30/26, was In Progress and the Assessment Reference Date (ARD) was 4/6/26, indicating the MDS admission was 2 days overdue. On 4/9/26 the electronic clinical record MDS page revealed the MDS Admission, dated 3/30/26, was Export Ready. The clinical record's clinical census revealed Resident #83 was admitted on [DATE]. On 4/6/36 at 1:34 PM the resident stated she had been in the facility for 2 weeks. On 4/8/26 at 11:17 AM the MDS Coordinator acknowledged the MDS admission had not been submitted and was late. The staff stated she had been working on the floor and required assistance from other facilities and Staff A, Registered Nurse (RN)/Travel MDS. The MDS Coordinator stated she had been working on the floor 2-3 times/week for the past couple of months. On 4/8/26 at 11:20 AM Staff A concurred she was assisting with the submission of the MDS's for the facility as when other facilities/staff assist they may not be a RN, which is a requirement for MDS submission. On 4/8/26 at 11:30 AM the Director of Nursing (DON) acknowledged the MDS Coordinator had been working on the floor as a Charge Nurse due to an increase in census and the need for additional staff. The DON expected the MDS's to be completed as required. On 4/8/26 at 11:35 AM the Regional Nurse Consultant stated the facility had been utilizing a Hybrid MDS to assist with the completion and submission of the MDS's. The staff concurred the MDS's needed to be submitted timely according to the RAI Manual. The Regional Nurse Consultant stated the facility did not have a MDS policy but followed the RAI Manual. The CMS RAI Manual Chapter 5: Submission and Correction of the MDS Assessments revealed the admission Assessment can be no more than 14 days from the date of admission.

Based on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 1 out of 19 residents (Residents #54) reviewed for comprehensive care plans. The facility reported a census of 72 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #54 dated 1/30/26 identified a Brief Interview for Mental Status (BIMS) score of 03, indicating moderately impaired cognition. The MDS identified Resident #54 required supervision/touching assistance with transfers and ambulation. The MDS included diagnoses of vascular dementia with agitation and restlessness. The MDS documented Resident #54 received antianxiety medication during the last 7 days. A Physician order dated 2/5/26 directed staff to administer Lorazepam (antianxiety) 0.5 mg (milligrams) by mouth twice a day for restlessness and agitation.Resident #54's Wandering Evaluations documented the following scores and wandering risk:11/21/25- 16= High Risk (A score of 12 or above indicated high risk for wandering)12/4/25- 17= High Risk1/20/26=-13= High RiskReview of Resident #54's care plan with target date 5/10/26 revealed the antianxiety medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. In addition, the care plan did not address Resident #54's risk for wandering and interventions to address the wandering. On 4/8/26 at 7:20 AM, the Director of Nursing (DON) acknowledged Resident #54's antianxiety medication was not addressed on the care plan. The DON reported the care plan was updated on 4/7/26 to include the antianxiety medication and interventions. On 4/8/26 at 7:40 AM, the DON acknowledged Resident #54's wandering was not addressed on the care plan. The DON reported she updated the care plan on 4/8/26 to include interventions for wandering. On 4/8/26 at 9:25 AM, the DON reported she would expect high risk medications to be addressed on the care plan.The facility policy titled Care Plan, Comprehensive Person- Centered revised December 2016 documented the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and incorporate risk factors associated with identified problems.

Based on observation, staff interview, clinical record review, and policy review, the facility failed to provide appropriate incontinence care for 1 of 1 resident (#49). The facility reported a census of 72 residents.Findings include:Resident #49's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, a stroke, multiple sclerosis, and hemiplegia (one-sided paralysis). It indicated he required supervision with eating and was dependent with all Activities of Daily Living (ADLs) and mobility. It also indicated he was always incontinent of bowel and bladder.The Care Plan revised 12/09/25 included bladder incontinence and directed staff to clean the peri-area with each incontinence episode. It revealed the resident was dependent with toileting and required 2-person staff assistance.During a continuous observation on 4/06/26 that began at 11:58 AM, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA provided Resident #49's incontinence peri-care. Both staff performed hand hygiene and put on gloves. Staff C verified the resident had an incontinent episode. After Staff D repositioned the resident on his side, Staff C grabbed a periwipe and wiped the resident's entire perineal area once and discarded the periwipe. Staff C removed her gloves, sanitized her hands, put on a new pair of gloves and turned the resident on his other side. Staff D removed the remainder of the resident's brief, grabbed a periwipe, and wiped the resident's anal area once and discarded the periwipe. Both staff repositioned the resident and fastened the resident's brief.At 12:07 PM, Staff D stated pericare includes removing the resident's brief and using separate periwipes to clean under the resident's belly, the right perineal area, then the left perineal area.At 12:12 PM, Staff C stated a separate periwipe should be used for each perineal sweep and should include retracting the foreskin (if applicable) and cleaning the penis tip. She stated she forgot to use separate wipes or to clean the resident's penis tip.Staff C's Orientation Checklist revealed her skills were reviewed on 3/24/26 and included incontinence care.A policy titled Perineal Care revised [DATE] directed staff to retract foreskin of the uncircumcised male and wash and rinse urethral area using a circular motion.On 4/09/26 at 11:53 AM, the Director of Nursing (DON) stated staff should've followed the facility policy.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair for 1 of 16 residents dependent on mechanical lift transfers (#49). The facility reported a census of 72 residents.Findings include:Resident #49's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, a stroke, multiple sclerosis, and hemiplegia (one-sided paralysis). It indicated he required supervision with eating and was dependent with all Activities of Daily Living (ADLs) and mobility. It also indicated he was always incontinent of bowel and bladder.The Care Plan revised 12/09/25 included bladder incontinence and directed staff to clean the peri-area with each incontinence episode. It revealed the resident was dependent with toileting and required 2-person staff assistance.A continuous observation on 4/06/26 that began at 11:58 AM revealed Staff C, Certified Nurse Aide (CNA) and Staff D, CNA transferred Resident #49 from his bed to a wheelchair. Both positioned the sling under the resident. Staff D positioned the mechanical lift over the resident and both staff connected the sling to the mechanical lift. Staff D raised the resident off the bed and positioned the resident in front of his wheelchair. Staff C stood behind the unlocked wheelchair, grabbed the sling, and used it to position the resident over the wheelchair cushion. Staff D lowered the resident onto the wheelchair cushion. Staff C locked the wheelchair wheels after the resident was seated in the wheelchair.At 12:07 PM, Staff D stated a wheelchair should be locked when lowering a resident onto it.At 12:12 PM, Staff C stated a wheelchair should be locked when lowering a resident onto it. She also stated she forgot to lock the resident's wheelchair during the transfer.A policy titled Lifting Machine, Using a Mechanical revised July 2017 revealed the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device and confirmed the mechanical lift may be used to transfer a resident from a bed to chair.On 4/09/26 at 11:54 AM, the Director of Nursing (DON) stated staff should've locked the wheelchair brakes.

Based on clinical record review, staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to provide the recommended influenza vaccine for 1 of 5 eligible residents (#2) and the recommended pneumococcal (pneumonia) vaccine for 1 of 5 eligible residents (#8). The facility reported a census of 72 residents.Findings include:1.Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of Parkinsonism (neurological movement disorder), high blood pressure, and respiratory failure. It revealed the resident was admitted [DATE] and had not received the seasonal influenza vaccine.A physician's order dated 11/06/25 indicated the resident may have the annual flu vaccine.The resident's admission Documents included a Vaccination Consent Form dated 11/06/25 that indicated the resident consented to receive the influenza vaccine.The Electronic Health Record (EHR) medication list revealed the influenza medication was never ordered. The EHR Vaccination tab lacked documented influenza vaccination administration.The Care Plan did not include a vaccination focus category.An Encounter Progress Note dated 3/25/26 at 2:00 AM revealed the resident's most recent influenza vaccine was on 10/06/23.A policy titled Influenza Vaccine revised [DATE] indicated Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized.2. Resident #8's MDS dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of right hip fracture and non-Alzheimer's dementia. It revealed the resident was admitted [DATE], received the influenza vaccine on 9/25/25, but had not received the pneumococcal vaccine.A physician's order dated 6/18/25 indicated the resident may have the pneumococcal vaccine if applicable.A Consent of Declination of the Pneumococcal Vaccine form dated 6/19/25 indicated the resident consented to receive the pneumococcal vaccination.The Electronic Health Record (EHR) medication list revealed the pneumococcal medication was never ordered. The EHR Vaccination tab lacked documented pneumococcal vaccination administration.The Care Plan did not include a vaccination focus category.A SPN-Admit/Re-Admit Progress Note dated 3/02/26 at 6:27 PM included an entry of Pneumococcal Vaccine: Declined (Refused or Historical - Complete Consent Form), Historical pneumococcal administration entered into residents immunization tab.A Center for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #1 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later.A policy titled Pneumococcal Vaccine revised [DATE] indicated Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. It also indicated Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.On 4/08/26 at 3:51 PM, the Director of Nursing (DON) stated the residents consented to the vaccinations but the facility had not administered them yet, but will.

Based on observations, documentation review, resident interviews, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to take and document temperatures of food in the kitchen prior to distribution. The facility reported a census of 61 residents. Findings include: Continuous observation on 3/25/25 at 11:15 AM found Staff C, cook, began placing items on the steam table with temperatures taken upon removal from the stove or steamer. At 12:17 Staff C began the meal service without taking temperatures at the steam table. Staff B, Dietary Services Manager Assistant, delivered plates to the dining room, and the room tray carts to the nurses station for the nursing staff to deliver to the rooms. At 1:30 PM the meal service concluded with the last of the room trays leaving the kitchen to be delivered with a sample tray included. The staff did not obtain food temperatures from the steam table at the completion of the meal service. Observed food items moving to the steam table 1 hour before service began, and the meal service took 1 hour and 15 minutes. Observed a room tray delivery cart with 6 meal trays sitting at the nurses station waiting for delivery that had left the kitchen prior to 1:30 PM. Staff B stated they had notified nursing of the need for delivery of the room trays. At 1:39 PM the sample tray returned to the kitchen for temperature checks with the CDM, Staff D, and RD. The CDM obtained a BBQ pork temperature of 142 degrees, carrots 109 degrees, and fried potatoes of 107 degrees. The CDM, Staff D, and RD concurred the temperatures were below the serving temperature requirements. Review of the Food Temperature Logs for January, February, and March provided opportunities for data entry for before and after each meal. The January log revealed 62/93 opportunities completely documented. The February log revealed 67/84 opportunities completely documented. The March log revealed 37/69 opportunities completed documented. The facility failed to completely document 80/246 (33%) food temperature entries for before, after, or complete meal. On 3/24/25 at 11:10 AM Resident #32 stated food was not served at appropriate temperatures. The resident indicated she ate both in the dining room and her bedroom. Resident #32 stated the temperatures were not correct in both locations, but the room trays were worse. On 3/24/25 at 1:55 PM Resident #25 stated she ate in the dining room and the food was often cold. On 3/26/25 at 1:32 PM the Registered Dietitian expected temperatures would be taken before and at the end of meal service from the steam table and the temperatures would be logged. The RD expected the facility to have food service completed within 45 minutes. On 3/26/25 at 1:56 PM the Administrator expected temperatures to be taken at the steam table prior to and after the meal service with logs kept for all cooking/serving temperatures. The facility's Food Preparation and Service Policy, revised 4/19, revealed specific temperatures/times required for specific foods, as well as the temperatures required for modified consistency diets, to be reached to inactivate pathogenic microorganisms. The document indicated temperatures of foods held in steam tables were to be monitored throughout the meal. The document further revealed dietary staff would adhere to proper practices to prevent the spread of foodborne illness. The Food and Drug Administration Food Code 2022 revealed the person in charge of the kitchen provides daily oversight of the employees ' routine monitoring of the cooking temperatures.

Based on observations, staff interviews, and policies reviewed the facility failed to store, prepare, serve, and distribute food in accordance with professional standards. The facility reported a census of 61 residents. Findings include: Observation on 3/24/25 at 9:28 AM revealed the walk in cooler did not have an interior thermometer. The walk-in cooler contained opened and undated food items of a cake, canned fruit in dessert cups, and a jug of Half and Half. The Half and Half liquid had an aluminum foil covering and a best if used by date of 3/8/25. The walk-in freezer contained an opened bag of ravioli, not sealed and undated. The milk cooler contained thick darkened frost inside along the right side of the cooler. The reach-in refrigerator contained an undated opened jug of milk and a container containing a yellow substance that was undated. The pantry contained opened and undated packages of Oreo Medium Cookie Pieces and pasta. The bottom shelf of the large food preparation counter in the main part of the kitchen revealed food remnants, crumbs, and was dirty in appearance. Continuous observation on 3/25/25 at 11:15 AM revealed Staff D, Travel Certified Dietary Manager, and the facility Certified Dietary Manager (CDM) wore gloves while preparing oranges and placing them in dessert cups. Staff C, cook, removed fried potatoes from the steamer and obtained temperatures of 165 degrees, 176 degrees, and 179 degrees. Staff C placed the potatoes in a metal container and placed them on the steam table at 11:20 AM. Staff C obtained a temperature of the baked beans of 179 degrees and moved them to the steam table. Staff C removed a tray of pork from the steamer with various temperatures observed ranging from 151 degrees to 161 degrees. Staff C added the pork to a container of pork with barbeque (BBQ) sauce, and placed it uncovered in the steamer. Staff C initiated making mashed potatoes, and placed the opened container of mashed potato mix under the prep table. Observed the mashed potato mix was not dated and put on the shelf under the prep table which had remnants of other food items. Staff C removed the BBQ pork and obtained temperatures from 155 degrees to 161 degrees. Staff D assisted Staff B by providing education on stirring food items before temperature check; with stirring the BBQ pork the temperature measured 165.8 degrees. Staff C moved the BBQ pork to the steam table. Staff A, cook, wearing gloves touched packaging and food items (lettuce, hard boiled eggs, cheese, meat) while making chef salads. Staff C indicated needed 8 mechanical soft servings of BBQ pork. The staff removed 8 servings of the BBQ pork and placed 4 servings twice in the lid of the Robot Coupe food processor to transfer to the bowl of the Robo Coupe. The staff placed the lid on the processor, turned the machine on, and walked away. The Registered Dietitian (RD) intervened as the mechanical soft BBQ pork had processed to a pureed consistency. Staff C obtained a temperature of 138 degrees, placed the uncovered pureed BBQ pork in the steamer. At 12:17 PM Staff C initiated the meal service without taking temperatures at the steam table. The CDM prepared the mechanical soft BBQ pork, covered, and placed in the steamer. The CDM checked the temperature of the puree BBQ pork, stated it needed to be covered and placed back in the steamer. Staff E, Cook, donned gloves without hand hygiene, and obtained supplies to prepare a grilled cheese sandwich. The staff touched the packaging and the bread. The CDM stopped the process, provided education to Staff E to not touch food items and packaging with gloves. The CDM indicated did not feel gloves were necessary for preparing a grilled cheese as the sandwich was not a ready to eat product as it was going to the stove. At 12:40 PM Staff stopped the meal service to prepare 3 servings of pureed baked beans. Upon completion of the puree process Staff C attempted to return them to the steam table when the CDM intervened and indicated a temperature was required due to the processing. Following the temperature check, Staff C placed the uncovered puree baked beans in the steamer. Observed the CDM make a special order peanut butter and jelly sandwich using butter/margarine, peanut butter, grape jelly, and bread that were all opened and undated sitting on the counter. The meal service concluded at 1:30 PM with the last tray leaving the kitchen. The staff did not take completion temperatures of the steam table. The continuous observation revealed inconsistent hand hygiene between kitchen tasks, and donning/removal of gloves. Review of the kitchen temperature logs for the milk cooler, walk-in cooler, walk-in freezer, reach-in refrigerator and reach-in freezer for the months of January, February, and March revealed January was the only month for data for all of the appliances with data for 25/31 days. Review of the March log for the reach-in freezer temperatures revealed 17/23 days with data. Record review of the March log for the reach-in refrigerator revealed 15/23 days with data. The facility failed to record temperatures for the milk cooler, walk-in cooler, and walk-in freezer for the months of February and March. The facility failed to record temperatures for the reach-in the freezer for the month of February and 6 days in March. The facility failed to record temperatures for the reach-in refrigerator for the month of February, and 8 days in March. The sanitizing solution logs for January, February, and March for the triple sink revealed opportunities for data entry at each mealtime for each date of the month. The documents revealed 217/246 data points obtained. The facility failed to record data for 29 opportunities The dish machine temperature logs for the months of January, February, and March revealed 3 opportunities per date for data entry. The logs revealed data entry for 219/246 possible entries. The facility failed to record data for 27 opportunities. On 3/24/25 at 9:50 AM the CDM stated she had been in the position approximately 2 weeks, and was not sure if logs were kept at all for the walk-in cooler and walk-in freezer. The CDM acknowledged there should be complete logs for all cooling appliances, the dish machine, and sanitizer for the triple sink. On 3/25/25 at 11:35 AM the RD completed a walk through of the walk-in cooler, walk-in freezer, and review of the milk cooler. The RD concurred items in the kitchen should have dates when received, opened, and sealed appropriately. The RD removed the previously observed Half and Half in the walk-in cooler, and ravioli in the walk-in freezer. The RD also noted the cookie dough uncovered and stated it would need to be discarded. The RD concurred the milk cooler should not have discolored frost in it, as well as wrappers from other food items. On 3/25/25 during the meal preparation the RD concurred the bread, peanut butter, butter/margarine, and grape jelly on the counter should be dated, and as it was not it should be discarded. The RD stated food items should be covered when placed in the steamer. On 3/26/25 at 1:32 PM the RD expected that food items should be dated with date received, date opened and to be stored in airtight containers. The staff stated if items were not in airtight containers, not dated or outdated they needed to be discarded. The RD stated at a minimum hand hygiene should be completed upon entry into the kitchen, between tasks, and prior to and removal of gloves. The staff stated gloves were for single use only, and staff could not touch containers and food items. The RD expected logs for cooler temperatures, dish machine, and triple sink sanitizer to be maintained. On 3/26/25 at 1:56 PM the Administrator expected there to be logs kept for all refrigerators, freezers, cooking/serving temperatures, dishwasher and sanitizer use. The Administrator expected all food items to be dated upon receiving and opening, and to be placed in sealed containers if not completely used. The Administrator expected hand hygiene to be completed in the kitchen at all times including before/after glove use, and staff not to touch food with their bare hands. The facility's Food Receiving and Storage Policy, revised 10/17, revealed dry foods be stored in bins and would be removed from the original packaging, labeled, and dated with use by date, and rotated with the first in - first out system. The document revealed wrappers of frozen foods must stay intake until thawing. The document indicated the refrigeration and food temperatures will be monitored and documented. The facility's Refrigerators and Freezers Policy, revised 12/14, revealed monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures. The document revealed the supervisor or designee would check and record the temperatures at the beginning and end of each day. The document indicated all food should be dated to ensure proper rotation by expiration dates with the received dates marked on the cases and if individual packages were removed from the case that they would have used by dates marked on the package. The facility's Sanitization Policy, revised 10/08, revealed the surfaces should be cleaned on a regular basis with oversight by the Food Services Manager. The facility's Food Preparation and Service Policy, revised 4/19, revealed bare hand contact with food was prohibited, gloves were for single-use items, worn when handling food directly, and discarded after each use.

Based on clinical record review, staff interview, hospital document review, staff interviews and facility assessment review the facility failed to implement care and treatment consistent with the resident care plan and physician orders placing the resident at risk for 1 of 16 residents reviewed. Resident #61 required special monitoring of weights and vital signs related to diagnosis of congestive heart failure. Staff failed to consistently monitor the weight and intervene with diuretic medication, and failed to conduct daily vital signs. The facility reported a census of 61 residents. Findings include: The Office/Progress Note from the hospital referral (page 6) to the facility showed that Resident #61 presented to the hospital on 1/27/25 with Shortness of Breath (SOB) and hypoxic respiratory failure. Was taken for cardiac catheterization and stent's were placed in the heart. She had pulmonary edema and required oxygen and diuretics (increases urine production and lowers blood pressure and fluid retention.) She presented with 2+ edema in the extremities. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status score of 15 indicating cognition intact. The MDS documented she was admitted from the hospital, had shortness of breath when lying flat and had surgery involving the heart. Her diagnoses included heart failure (CHF), coronary artery disease, renal insufficiency and pneumonia. The Care Plan for Resident #61, dated 2/10/25, documented she was on diuretic therapy related to CHF and chronic kidney disease and has weight fluctuations related to medication. The Care Plan directed staff told administer the diuretic medications as ordered by the physician and to monitor for side effects and effectiveness every shift. The Progress Notes documented the following: -On 2/5/25 at 5:49 PM, the admit note documented that Resident #61 weighed 149 pounds and had edema on the top of her feet/ankle +1 pitting (edema is graded on a scale of 0 to 3, where 0 means the absence of edema and 3 means severe pitting. The grading system is based on how deep the pits are and how long they last after you press the swollen area.) bilateral calves and upper arms. Generalized edema/swelling. -On 2/6/25 at 12:00 AM the provider encounter note, showed that Resident #61 was admitted with an order for a diuretic, furosemide 20 milligrams (mg) one tab every 24 hours as needed (PRN) for swelling, shortness of breath, or at provider discretion. And give 2 tablets every 24 hours PRN for shortness of breath, leg swelling or at providers discretion. The Progress Notes also documented the following for Resident #61: a. On 2/5/25 at 4:47 PM SOB with minimal exertion b. On 2/7/25 at 9:56 PM SOB while lying flat c. On 2/8/25 at 9:44 PM SOB while lying flat d. On 2/8/25 at 0000 bilateral lower extremities trace edema. e. On 2/9/25 at 7:39 PM SOB while lying flat f. On 2/11/25 at 10:19 PM nursing assessment SOB with minimal exertion edema to top of feet and ankle +1 pitting upper arms with generalized edema/swelling. g. On 2/13/25 at 10:16 PM SOB while lying flat h. On 2/15/25 at 4:11 PM the resident would continue to have daily vital signs as she was skilled. i. 2/17/25 at 3:22 PM generalized edema top of feet and ankle +1 pitting upper arms with generalized edema/swelling. j. On 2/18/25 at 3:50 PM generalized edema +1. The Medication Administration Record (MAR) for February showed that the PRN furosemide had not been used. The Progress Note dated 2/19/25 at 12:00 AM documented the Nurse Practitioner saw Resident #61 on the 19th and found that she had +3 bilateral lower leg edema. She started a scheduled order for furosemide 20 mg daily for edema, and continue PRN dose. Staff were to continue to monitor weight as directed. The Medication Administration Record (MAR) showed that Resident #61 received the first dose of Furosemide 20 mg on 2/20/25. The Progress Note dated 2/28/25 at 12:01 AM showed that the resident had a significant weight increase from 149.1 pounds (lbs.) on 2/6/2025 to 168.4 lbs. on 2/27/2025. She had bilateral +2 pitting edema in the lower extremities. The provider has been notified, and the plan of care includes continuing Lasix 40 mg daily to promote diuresis. Staff were directed to closely monitor the resident's fluid status, strict tracking of daily weights, fluid intake/output, and urine output. Staff had been instructed to carefully assess urine output for adequate response to diuretics and report any concerns regarding decreased output. A pulmonary assessment showed diminished lung sounds bilaterally without distress. The resident reported occasional exertion SOB. The chart lacked documentation of weights from 3/6/25 through 3/17/25. The chart lacked a daily skilled assessment on 2/21/25, 2/27/25, 3/14/25 and 3/16/25. On 3/24/25 at 10:52 AM, Resident #61 was in bed coughing, moaning and appeared uncomfortable as she shifted and tried to move in bed. The resident said the she was not feeling well after her heart surgery. She said that she had been coughing a lot and had phlegm coming up. On 3/26/25 at 3:00 PM, Staff G, Nurse Consultant said that she would have wanted the nurses to call the provider and get clarification with parameters on when to use the diuretic. On 3/27/25 at 10:52 AM, Staff L, Registered Nurse (RN.) acknowledged that Resident #61 had about +1 edema in her feet and ankles. She said that she was not aware of a PRN furosemide order and she would have used it or reached out to the doctor if/when there was a significant weight gain in a day or two. She agreed that parameters with the PRN order should have been clarified so they could've had the guidance on when to use it. On 3/27/25 10:56 AM, the Director of Nursing (DON) said that they did not have a policy on documentation for skilled assessments. They expect that the assessments would be complete daily, including vitals. The DON said that they did not have any policy on edema monitoring related to CHF, or a policy on weight monitoring. She said that they use nursing judgement and go by what was ordered by the doctor. The Facility assessment dated [DATE], included a section titled: Cardiac Services, Metabolic Disorders, Respiratory System, Assessments that showed that the facility would provide early identification of problems/deterioration, management of medical and psychiatric symptoms and condition such as heart failure, diabetes, chronic obstructive pulmonary disease, gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism.

Based on observations, staff interview and clinical record review the facility failed to implement interventions for the prevention of pressure ulcers for 1 of 3 residents reviewed. Resident #54 was at risk for chronic pressure injuries and was found to be without the treatment dressing or protective boots. The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. According to the MDS, dated [DATE], Resident #54 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive ability). She was totally dependent on the help from staff for eating, hygiene, toileting, dressing and turning in bed. Resident #54 had a Stage III pressure ulcer and her diagnoses included renal insufficiency, neurogenic bladder, Bipolar Disorder, schizophrenia, pressure ulcer of the right heel and intellectual disabilities. The Care Plan for Resident #54, updated on 2/3/25, showed that she occasionally rolled out of bed, and had a fall mat placed on the side of the bed. She required maximum assistance of 2 for bed mobility, had poor body positioning and trunk control, and leaned to the right. Resident #54 was at risk for skin impairment, staff were directed to float her heels when in bed, to put sheep skin boots on her feet at all times, and to complete weekly treatments. A Skin Observation dated 12/24/24 at 12:37 PM, showed that the resident did not have any new skin issues on that date. A Skin and Wound Evaluation dated 12/27/24 at 10:15 AM, showed that Resident #54 was found to have an unstageable pressure sore with slough and/or eschar on the right lateral forefoot. The total area measured 8.1 centimeters (cm) total area, 5.0 cm. length x 2.6 cm. width. The wound contained 100% Eschar (dead tissue that sheds or falls off from the skin, usually tan, brown or black.) The goal of care was to monitor/manage due to wound healing was not achievable because of untreatable underlying condition. An order dated 12/27/24 at 10:48 AM, directed nursing to apply skin prep, covered with high performance foam adhesive dressing to the lateral side of the right foot and the left heel on bath days, every Tuesday and Friday. The Skin and Wound Evaluation dated 3/19/25 documented a pressure ulcer to the left heel stage 3 in house acquired now measures 0.7 cm total area, 1.1 cm in length, 0.9 cm in width and no depth. 100 percent of wound bed covered with epithelial tissue and improving. Observations revealed the following: a. On 3/24/25 at 2:28 PM the door was cracked open and the resident was yelling get up. She was lying on the floor, on a mattress next to the bed. The nurse was preparing to get vitals and told Resident #54 that they would get her up as soon as she got her vitals. The resident was wearing socks on her feet and did not have on the heel protectors. b. On 3/25/25 at 5:56 AM, the resident was in bed, in low position. She was awake and restless. She did not have the protective boots on her feet. c. On 3/25/25 at 8:00 AM, Resident #54 was in her room in the wheel chair. The fall mat is next to the wheel chair. Her feet rested on the foot pedal with her right foot bent and resting on the lateral side of her foot. The heel protectors were on the floor. d. On 3/25/25 at 9:33 AM, the resident was in her wheel chair without the protective boots on. Staff K, Licensed Practical Nurse (LPN) gathered the treatment supplies for her treatment. She did not speak but squealed and said ouch several times throughout the procedure. Staff K encouraged her to stay calm as he removed her socks. Neither one of the feet had adhesive dressings on, and they were dry and scaly. Staff K applied lotion and completed the treatment to the right foot and dated the dressing. The heel of the right foot contained peeling white skin. No open or reddened areas were observed. The lateral area of right foot had a red spot that was not open or swollen. Staff K applied her socks and protective boots. e. On 3/25/25 at 9:43 AM, Staff K said that after completing the treatment on the right heel, he double checked the order, saw there was an order for a dressing to the right foot, then went back and completed that treatment. Staff K acknowledged that the resident did not have a dressing on either foot when he went in to complete that treatments earlier. Staff K thought that there would have been an As Needed (PRN) order to complete the treatment if/when the dressing fell off. f. On 3/26/25 at 11:58 AM, Resident #54 was in the wheel chair, wearing socks on her feet. The left protective boot was on, the right one was on the floor. On 3/26/25 at 8:50 AM, an addition had been made to the treatment order and read as follows: Apply skin prep covered with high performance foam adhesive dressing to lateral side of right foot and left heel. Change on bath days every day shift every Tuesday Friday for would and as needed if dressing falls off. On 3/27/25 at 9:06 AM, when asked about the size and description (8.1 cm. total area and 100% eschar) of the pressure discovered on 12/27/24 just 3 days after a Skin Observation showed that Resident #54 had no new skin issues, the Director of Nursing (DON) said she didn't know what the wound may have looked like three days prior. She said that she believed a wound could get to the point of eschar in just 3 days without prior warning signs. The DON said that she would expect the aides to come to nursing staff if/when they discovered that a wound dressings had fallen off. She would then expect the nurses to replace it as soon as it was discovered. A facility policy dated 4/2018, titled: Pressure Ulcers/Skin Breakdown - Clinical Protocol, showed that the staff would examine the skin of newly admitted residents for evince of existing pressure ulcers or other skin conditions. The physician would order pertinent wound treatments, including pressure reducing surfaces, wound cleansing and debridement approaches, dressings and application of topical agents.

Based on observation, interview and policy review the facility failed to ensure that medications were secured to prevent residents from access. In an observation the survey team found an unlocked, unattended medication cart in the hallway of resident rooms. The facility reported a census of 61 residents. Findings include: In an observation on 3/24/25 at 11:31 AM, it was discovered that an unlocked, unattended medication cart was at the end of a hallway of resident rooms. At 11:33 AM Staff I, Certified Medication Aide (CMA) came around the corner from the nurse's stations at the opposite end of the hallway. She said that she had been in a resident's room administering medications, then went down the hallway to talk to the nurse. She acknowledged that she failed to lock the drawers before she walked away from the cart. On 3/27/25 at 11:59 AM, the Director of Nursing (DON) said that the nurses and CMA's were expected to have the medication cart locked if/when they ever walk away from it and it's not within eye site. According to facility policy titled: Security of Medication Cart, dated April 2007, the medication carts must be securely locked at all times when out of the nurse's view.

Based on observation, document review, staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 1 of 61 residents reviewed. The facility reported a census of 61 residents. Findings include: Continuous observation on 3/25/25 at 12:05 AM of Staff C, Cook, prepared modified barbeque (BBQ) pork for the noon meal. Staff C indicated needed 8 ground servings of BBQ pork. The staff removed 8 servings of the BBQ pork and placed 4 servings twice in the lid of the Robot Coupe food processor to transfer to the bowl of the Robo Coupe. The staff placed the lid on the processor, turned the machine on, and walked away. Staff C removed the BBQ pork from the processor and poured it into a measuring cup. The Registered Dietitian (RD) intervened as the BBQ pork appeared as pureed consistency rather than mechanical soft. The RD instructed Staff C to place it back in the processor, add BBQ sauce to complete the puree process. Staff C referred to the [NAME] Brothers Pureed Diet Portion Sizes/Dishes for the serving size, the temperature taken at 138 degrees, and placed the uncovered pureed BBQ pork in the steamer. Staff C measured 3 servings for pureed baked beans, and placed them in the Robo Coupe for processing. The staff poured the processed food in a measuring cup and was moving to return to the steam table, when the Certified Dietary Manager (CDM) intervened, and instructed the staff to place the food in the steamer due to the temperature decreasing. Staff C placed the uncovered pureed baked beans in the steamer. Staff C began serving the final pureed meal, and noted there was an incomplete serving of the pureed baked beans. The staff stated there was a shortage of the pureed baked beans as they had dried up in the steamer. Staff C proceeded to place the plate with the incomplete serving on the room service tray for delivery. The staff failed to provide the resident with a full serving as required. On 3/27/25 at 10:55 AM the RD stated the facility followed the [NAME] Brothers Pureed Diet Portion Sizes/Dishes for determining serving size. The RD expected if there was a shortage on a serving size, the cook would stop and prepare additional food to provide a full serving. On 3/26/25 at 1:56 PM the Administrator stated she expected residents to receive full servings as required. The facility's Therapeutic Diets Policy did not specifically address the preparation and portion sizes of the mechanically altered diets.

Based on observation, resident interview, clinical record review, staff interview and policy review the facility failed to maintain accurate medical records for 1 of 16 residents reviewed. Staff documented that the vital signs for Resident #61 had been completed and the chart lacked documentation of those vitals. The facility reported a census of 61 residents. Findings include: The Care Plan for Resident #61, updated on 2/5/25, showed that she had diagnoses that included Congestive Heart Failure (CHF), acute respiratory failure, and weight fluctuation due to diuretic use and document signs and symptoms of Coronary Artery Disease (CAD) such as dependent edema. The Progress Note dated 2/5/25 at 4:47 PM, showed that Resident #61 was admitted for skilled nursing services from the hospital after Atrial fibrillation (AFib) with rapid ventricular response RVR (condition characterized by an irregular heartbeat with a rate exceeding 100 beats per minute.) The Progress Note dated 2/5/25 at 6:38 PM, showed that Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) On 3/24/25 at 10:52 AM, Resident #61 was in bed coughing, moaning and appeared uncomfortable as she shifted and tried to move in bed. The resident said the she was not feeling well after her heart surgery. She said that she had been coughing a lot and had phlegm coming up. A review of the clinical record revealed that on 2/15/25, 2/24/25 and 2/28/25 the chart lacked documentation of vital signs. Nursing notes included the following documentation: a. On 2/15/25 NN at 12:47 AM, obtain new vital signs: completed b. On 2/24/25 at 10:42 PM, obtain new vital signs: completed c. On 2/28/25 at 12:01 AM, obtain new vital signs: completed On 3/27/25 at 10:56 AM, the Director of Nursing (DON) said that she expected that skilled assessments would be completed daily, including a complete set of vital signs. A facility policy titled: Charting and Documentation dated July 2017, showed that documentation in the medical record would be objective, complete, and accurate. Documentation of procedures and treatments would include care-specific details, including; assessment data.

Based on observation, staff interview and facility policy review the facility failed to ensure that staff used appropriate infection control practices to prevent the spread of pathogens for 1 of 3 residents reviewed. Staff failed to change gloves after adjusting a soiled brief for Resident #27 she then touched other surfaces with the same gloved hand. The facility reported a census of 61 residents Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #27 had an indwelling catheter and a colostomy. He was totally dependent on staff for transfers, showers and personal hygiene. The resident had diagnoses that included: heart failure, renal insufficiency, multiple sclerosis and benign prostatic hyperplasia. The Care Plan last updated on 7/29/24 showed that Resident #27 had a Foley catheter and was at risk for a potential skin and soft tissue infections. Staff were instructed to use enhanced barrier precautions when performing high-contact care activities. On 3/25/25 at 7:04 AM, Resident #27 was sitting in the shower room and Staff H, Certified Nurse Aide (CNA) said that she was waiting for the nurse to come in and take a look at the catheter site. With gloved hands, she pulled back the brief to reveal a copious amount of blood around the penis and under the abdominal fold. The CNA then touched the arm of the mechanical lift and resident's shoulder with same gloved hand. On 3/27/25 at 10:40 AM, the Director of Nursing (DON) said that the staff were taught to change gloves after they become soiled. She would expect them to also use hand hygiene before applying clean gloves. According to facility policy titled: Handwashing/Hand Hygiene, dated August 2019, the use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections.

Based on interviews, clinical record review, and facility policy review the facility failed to provide dignity by staff swearing in the hallways outside the residents' rooms for 2 of 6 residents (Resident #2 and #5) reviewed. The facility reported a census of 57 residents. Findings Include: 1. Record review of the Minimum Data Set (MDS) for Resident #2, dated 8/8/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive functioning. The document revealed the resident had adequate hearing and did not utilize hearing appliances. On 10/22/24 at 12:43 PM Resident #2 stated he had heard staff using swearing when having conversations in the hall. The resident confirmed it was not another resident using swear words. Resident #2 stated the language that he heard did bother him. 2. Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The document revealed the resident had adequate hearing, and did not utilize a hearing appliance. On 10/22/24 at 11:53 AM Resident #5 stated she has heard swearing by staff while talking to each other across all shifts. The resident stated she could not identify any specific staff. Resident #5 stated she knew it was staff and not another resident. The resident stated the language was very upsetting to her. On 10/24/24 at 12:35 PM the Regional Nurse Consultant stated that residents should be treated with dignity and that swearing in the hallways would be upsetting to residents. The facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, revealed the facility should establish and maintain a culture of compassion and caring for all residents. The document further revealed the facility should provide support to prevent burnout, and stressful working situations. The facility policy, Resident Rights, revised 12/16, revealed all employees treat residents with kindness, respect, and dignity. The document provided that residents should have a dignified existence, be treated with respect, kindness and dignity.

Based on clinical record review, resident and family interviews, staff interviews and facility policy review the facility failed to provide the needed services in accordance with professional standards by not completing neuroogical assessments after falls for 2 of 2 residents (Resident #1 and #5) reviewed. Resident #1 self reported an unwitnessed fall from bed on 8/24/24 and sustained a hematoma on the right side of his forehead. Resident #5 had a witnessed fall involving a motorized scooter, and sustained a hematoma on the forehead and 3 skin tears on 9/12/24. The facility reported a census of 57 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment for Resident #1, dated 8/29/24 documented a Brief Interview for Mental Status (BIMS) score of 8 indicating a moderate cognitive impairment. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS documented diagnosis of hypertension, non-Alzheimer's Dementia, seizure disorder or epilepsy. The resident was independent with transfers. The resident used a wheelchair for mobility. The document revealed the resident had 2 falls without injury and 1 fall with injury during the reporting period. The MDS dated [DATE] for Resident #1 documented a BIMS score of 15 indicating intact cognition. The resident was frequently incontinent of bladder and bowel. The resident was independent with transfers. The resident used a wheelchair for mobility. The document revealed the resident had 2 falls without injury during the reporting period. Resident #1's electronic health record (EHR) document: Neurological Eval (multi section)-initiated 8/25/24 at 9:15 PM and locked on 8/29/24 at 3:09 AM, revealed incomplete nursing assessments throughout the document. The document provided for 18 assessments to be completed over the course of several days - initial, (4) 15 minute checks, (2) 30 minute checks, (2) 1 hour checks, and (9) 8 hour checks. The document required staff to enter the date/time vitals were assessed. The documents revealed this occurred 7/18 times. The vitals tab in the EHR provided the documentation for the vitals assessed, and revealed blood pressure (BP) entries for 16 entries, temperature for 7 entries, pulse for 15 entries, respirations for 6 entries, O2 saturations for 7 entries, and pain for 11 entries. The EHR contained the physician fax written on 8/25/24 at 11:32 PM indicated the resident sustained an unwitnessed fall with a hematoma present on the right side, forehead above the right eye. The physician acknowledged the fax on 8/27/24 at 7:28 AM. On 10/22/24 at 3:29 PM Resident #1's Power of Attorney (POA) stated she was notified of the resident's fall a day or so after the fall. The POA stated during the notification she was told the facility had done vitals, and was told the resident did not sustain an injury. The POA stated she visited the resident on 9/16/24 and observed a goose egg and very noticeable black eye. The POA stated the resident indicated he had fallen out of bed. On 10/22/24 at 3:40 PM Resident #1 stated he had been sleeping in bed and he fell out. The resident stated he was able to get off the floor and go to the nurses station to report his fall. Resident #1 was unable to recollect any further details of his fall. 2. Record review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The resident was occasionally incontinent of bladder and always continent of bowel. The MDS documented diagnosis of Crohn's disease, difficulty in walking and unsteadiness on feet. The resident was independent with transfers and ambulation up to 50'. Resident #5 utilized a wheelchair for mobility. The document revealed the resident had 0 falls during the reporting period. Resident #5's EHR document: Neurological Eval (multi section)-initiated on 9/12/24 at 7:35 PM and locked on 9/16/24 at 4:42 AM, revealed incomplete nursing assessments throughout the document. The document provided for 18 assessments to be completed over the course of several days - initial, (4) 15 minute checks, (2) 30 minute checks, (2) 1 hour checks, and (9) 8 hour checks. The document required staff to enter the date/time vitals were assessed. The documents revealed this occurred 14/18 times. The vitals tab in the EHR provided the documentation for the vitals assessed and revealed BP entries for 15 entries, temperature for 14 entries, pulse for 15 entries, respirations for 14 entries, O2 saturations for 14 entries, and pain for 9 entries. The EHR contained the physician note written on 9/12/24 and faxed at 5:35 PM that revealed the resident sustained a large goose egg above the left eye and skin tears to the left forearm when her scooter went off the sidewalk and fell . The document further revealed the resident did not want to go to the hospital. The physician acknowledged the fax on 9/12/24, ordered to continue to monitor, and if neuro change, notify the provider, and may need to send out. The fax was returned on 9/12/24 at 7:27 PM. On 10/22/24 at 11:53 AM Resident #6 stated she had been on her scooter on the date of the fall outside with her daughter, when her scooter went off the sidewalk and it tipped over and she fell . The resident stated she bumped her head and had quite the black eye. The resident stated she declined to go to the hospital. On 10/23/24 at 12:10 PM Staff C, Licensed Practical Nurse (LPN), stated neuro assessments were to be completed initially following a fall while the resident was still on the floor. The staff stated the assessment included eyes, range of motion (ROM), and vitals (BP, temperature, pulse, respirations, O2, pain), and if the resident remained in the facility the assessments would continue for 72 hours. Staff C stated each assessment that followed would be completed the same as the initial assessment. The staff stated if a resident had a bump on the head, the physician should be notified via phone for orders of whether to send the resident to the hospital. On 10/23/24 at 1:40 PM Staff D, Registered Nurse (RN), stated if a resident had an unwitnessed fall or witnessed fall while hitting their head, neuro assessments would be initiated. The staff stated neuro assessments included: pupils, strength/ROM for upper extremities (UEs) and lower extremities (LEs), orientation, vitals (pain, temp, BP, pulse, respirations, O2). The staff stated neuro assessments would continue for 15 minutes then graduate up on time. Staff D stated Point Click Care (PCC), EHR, will alert nurses that neuro assessment is due, some will use paper to track and document. The staff stated subsequent assessments for neuro assessments were supposed to be the same as the initial assessment as PCC prompts for filling out. The staff stated they would call a physician if it was urgent, after hours/weekends would call the on-call physician, if critical would send to the emergency room , and notify the physician. The staff stated if the resident had an obvious head injury, they would call the physician. Staff stated if there was not an injury they would send a fax. On 10/23/24 at 4:22 PM Staff E, RN, stated If the resident is observed to hit their head or the fall is unwitnessed neuro assessments should be completed. The staff stated a neuro assessment included: eyes (pupils, tracking), orientation, and vitals (pain, temperature, BP, pulse, O2 saturations, and respirations) The staff stated all assessments should include the same information. The staff stated a physician should be notified by phone with any sign of significant injury or need for sending to the hospital. The staff stated if the resident was developing a goose egg she would call the physician rather than fax the physician. On 10/23/24 at 3:17 PM the Director of Nursing (DON), stated when a resident has a fall witnessed with hitting their head or an unwitnessed fall she would expect staff to follow the steps in the neuro assessment. The staff stated it was expected that subsequent assessment(s) would be completed the same as the first assessment with data variation dependent upon the resident. The DON stated the time of the assessment would be indicated by the document or could be referenced on the vital entries. The staff stated the staff would complete all the standard vitals. The DON acknowledged that review of the neuro assessments for Resident #1 and Resident #5 did not have complete sets of standard vitals. The staff stated that an abrasion, skin tear, fall with pain, and hematoma would indicate an injury and would tell family of the injury. The DON stated the physician is notified by phone for a significant injury, change in status (neurological, ROM, pain, open injury). The staff stated if the resident had a lower neurological status, it would be up to the nurse whether to notify the physician by phone or fax. The facility policy, Neurological Assessment Level III, revised October 2010, revealed assessment of neurological status always includes frequent vital signs with attention paid to pulse pressure (difference between systolic and diastolic pressures). The document further provided that any change in vital signs should be reported to the physician immediately. The document included steps for assessment of temperature, pulse, respirations, and documentation of the date and time of the assessment.

Based on clinical record review, interviews, and facility policy reviews, the facility failed to provide adequate nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents (Resident #2, #3, #5, and #6). The facility reported a census of 57. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment of Resident #2 dated 8/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating normal cognitive functioning. The resident had diagnoses of displaced intertrochanteric fracture of left femur with routine healing, osteoarthritis, difficulty in walking, and low back pain. Resident #2 required partial/moderate assistance with transfers, lying to sitting on the edge of bed, and dressing. The resident was dependent on toileting. Resident #2 utilized a manual wheelchair (w/c) for mobility. The resident was always continent of bowels and bladder. On 10/22/24 at 12:43 PM Resident #2 stated he has waited longer than 30 minutes for a call light to be answered. The resident stated if he had to wait for longer than 30 minutes, he would have incontinence episodes. Resident #2 stated he had incontinence episodes. The resident stated longer call lights do not correlate to any specific shift. The resident stated he will yell for assistance if necessary, and has self transferred to prevent incontinence episodes. The resident stated he has fallen as a result of self transfer. 2. Record review of the MDS of Resident #3 dated 10/9/24 revealed a BIMS score of 15/15, indicating normal cognitive functioning. The resident had diagnoses of pressure ulcer to the left heel, right below the knee amputation, osteomyelitis of the left ankle and foot, and peripheral vascular disease. Resident #3 required total assistance/dependency on staff for transfers, bed mobility, dressing, and toileting. The resident utilized a wheelchair for mobility. The document revealed the resident was always continent of bowel and had a catheter. On 10/22/24 at 2:05 PM Resident #3 stated call lights have lasted up to 30 minutes before being answered. The resident stated it was felt to be due to low staffing. The resident did not relate the call lights to a specific shift. 3. Record review of the MDS of Resident #5 dated 9/5/24 revealed a BIMS score of 15/15 indicating intact cognition. The MDS documented diagnoses of Crohn's disease, difficulty in walking and unsteadiness on feet. The resident was independent with transfers and ambulation up to 50'. Resident #5 utilized a wheelchair for mobility. The resident was occasionally incontinent of bladder and always continent of bowel. On 10/22/24 at 11:53 AM Resident #3 stated sometimes it can take a long time for staff to answer call lights. The resident stated there had been times where both she and roommate had turned on the call light, and staff would only acknowledge her and not the roommate. Resident #3 stated she has had to wait for an hour or longer for a call light to be answered. The resident stated when necessary she will transfer to her w/c, and will go chase the staff down to get assistance for herself or roommate. 4. Record review of the MDS of Resident #6 dated 9/12/24 revealed a BIMS score of 14/15 indicating intact cognition. The MDS documented diagnoses of non-Alzheimer's dementia, depression, epilepsy, and essential tremor. Resident #6 was independent with transfers, required partial/moderate assistance for ambulation up to 10', and was independent with toileting and dressing. The resident utilized a wheelchair for mobility. The resident was occasionally incontinent of bladder and always continent of bowel. On 10/22/24 at 1:25 PM Resident #6 stated call lights can take longer than 20 minutes. The resident stated on 1 occasion she got tired of waiting for her call light to be answered, she left her room to go eat, and when she came back the staff finally came and answered her light. On 10/23/24 at 11:43 AM Staff A stated that call lights can be longer than want, longer than 15 minutes. The staff stated that it can occur when there are multiple lights going off. On 10/23/24 at 11:55 AM Staff B stated call lights can be longer than 15 minutes, especially between the hours of 6 and 10 as many residents want to go to bed as soon as they are finished with supper. On 10/23/24 at 3:17 PM the Director of Nursing (DON) stated call lights were supposed to be answered in less than 15 minutes. Review of facility grievances since 6/24 revealed 2 grievances for call lights not being answered in a timely manner. Review of Resident Council Minutes since 6/24 revealed 2 meetings where call lights were not being answered timely. The minutes on 6/5/24 further revealed the need to check on both residents when a call light is turned on. A further document, an unidentified date of minutes, revealed resident concerns of call lights going off and staff at the nurses station on their phones, laughing, and joking rather than assisting residents. Review of the facility policy, Answering the Call Light Level I, revised 3/21, revealed the purpose of that procedure was to ensure timely responses to the resident's requests and needs.

Based on observations, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during medication administration (Resident #8, #7, and #3). The facility reported a census of 63. 1. During continuous observation of medication administration on 8/12/24 at 11:40 AM Staff A, Certified Medication Aide (CMA) did not consistently complete hand hygiene between 4 residents. 2. During continuous observation of medication administration on 8/12/24 at 11:55 AM Staff B, CMA, did not complete consistent hand hygiene between 16 residents. 3. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive function, and the resident independent with toileting and transfers. Resident #8's Care Plan revealed the resident would transfer to the floor and independently use the toilet. At 12:55 PM on 8/12/24 Staff B placed Resident #7's eye drops in her pocket with gloves and a tissue. Staff B then obtained Resident #8's oral medication. Staff B entered Resident #8's room and provided the oral medication. Staff B then donned gloves and picked up a basin that was sitting on the floor. Resident #8 stated I squatted to use the toilet and left you a present. Staff B took the basin to the bathroom, emptied it, flushed the toilet, and rinsed the basin before returning it to the room. Staff removed gloves, washed hands, tied the trash and removed it from the room. Staff B discarded the trash and used hand sanitizer. 4. Review of the MDS assessment dated [DATE] revealed Resident #7 had an indwelling catheter, received more than 51% of total calories through parenteral feeding, and had a BIMS score of 00 indicating severe cognitive impairment. The Clinical Physician Orders dated 8/13/24 revealed Resident #7 required enhanced barrier precautions (EBP) related to a PEG tube/Foley catheter. Resident #7's Care Plan revised on 8/8/24 revealed the resident had EBP related to a urinary catheter and a Peg Tube. At 1:03 PM on 8/12/24 Staff B used hand sanitizer, donned gloves, and entered Resident #7's room. Staff provided eye drops to each eye per order and removed gloves from her pocket for wiping around the resident's eyes. Gloves were removed as the staff left the room. Staff B did not use additional personal protective equipment (PPE). On 8/13/24 at 9:20 AM Resident #7's catheter bag was observed to be hanging from a low bed touching the floor without a cover. 5. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating normal cognitive function. The resident used a manual wheelchair and could propel up to 150 feet independently. Resident #3 had an ostomy. Resident #3's Clinical Physician Orders dated 8/13/24 revealed the resident had EBP related to a colostomy. Resident #3's Care Plan revealed the resident had EBP related to a history of colectomy with ileostomy. On 8/12/24 at 1:06 PM Staff B pushed Resident #3's wheelchair into her room, donned gloves and provided eye drops per physician orders. Staff removed gloves upon exiting the room. Resident #3 had a sign posted on her door indicating EBP. Staff B only used gloves. On 8/13/24 at 12:58 PM the Director of Nursing (DON) stated hand hygiene should be completed between each resident during medication administration. Hand hygiene should also be completed before and after glove use. The DON stated best practice would be to keep eye drops in the box prior to administration. The DON stated staff would find out who has EBP by referring to the Kardex as it is the best place for information. The staff stated individuals who may have EBP include those with Foley catheters, ostomies, wounds. The DON provided a document, Enhanced Barrier Precautions Everyone Must, that provided instructions on what should be worn during resident care activities. On 8/13/24 at 1:25 PM the Administrator stated staff need to follow recommendations for PPE for those with EBP. The facility document Enhanced Barrier Precautions Everyone Must indicated staff and providers must clean their hands when entering and exiting the room, wear gloves and gowns during high contact resident care activities. The facility policy, Handwashing/Hand Hygiene, revised August 2019 instructed staff to perform hand hygiene prior to applying and upon removing non-sterile gloves. The document also revealed hand hygiene should be completed before and after direct contact with residents. The facility policy, Administering Oral Medications, revised October 2010, revealed staff are to complete hand washing prior to administration of medications and hand antisepsis upon completion. The facility policy, Catheter Care Urinary, revised September 2014 revealed the catheter tubing and drainage were to be kept off the floor.

Based on observations, clinical record review, and staff interviews, the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (#3, #9). The facility reported a census of 63 residents. Findings include: 1. Review of Resident #3's Minimum Data Set ( MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive function. The resident used a manual wheelchair (w/c) and could propel up to 150 feet independently. Resident #3's care plan revealed the resident used a w/c for mobility. On 8/12/24 at 1:06 PM Staff B, Certified Medication Aide, pushed Resident #3 from the dining room to her room without the use of foot pedals. On 8/12/24 at 2:36 PM the resident stated she normally self propels her w/c. On 8/13/24 at 11:15 AM Resident #3 self propelled her w/c in the hallway. 2. Review of Resident #9's MDS assessment dated [DATE] revealed a BIMS score of 11/15 indicating moderate cognitive impairment. The resident utilized a w/c and self propelled the w/c up to 150 ' independently. Resident #9's Care Plan revealed the use of a w/c for mobility and the resident self propelled. On 8/13/24 at 10:50 AM observed the Assistant Director of Nursing (ADON) pushing Resident #9's w/c to the medical clinical office. The resident did not have a leg rest on the right side. On 8/13/24 at 11:15 AM the resident self propelled her w/c around the dining room using her right upper extremity and right lower extremity. The left foot plate was in place. On 8/13/24 at 11:00 AM Staff G, Certified Nursing Assistant (CNA), stated a resident must have foot pedals on their w/c to be pushed. On 8/13/24 at 11:14 AM Staff D, Certified Medication Aide (CMA), stated foot plates have to be on the w/c for pushing. On 8/13/24 at 11:25 AM Staff H, CNA, stated staff cannot push residents without foot pedals. If a resident needed a push and there were no pedals on the w/c they would look in the resident's room. If there were no pedals there staff would look in the spare parts room. On 8/13/24 at 11:28 AM Staff C, Registered Nurse/Charge Nurse, stated resident's must have foot plates on the w/c to push to prevent injury. On 8/13/24 at 12:58 PM the Director of Nursing (DON) stated residents are required to have foot pedals on their w/c's to be pushed. On 8/13/24 at 1:25 PM the Administrator stated residents must have foot pedals on their w/c's to be pushed. Review of the facility provided document, Wheelchair (Use of) dated 1/15 taken from the Nursing Guidelines and Procedure Manual, foot rests should be folded up out of the resident's way for safety and not removed. When pushing residents lower footrests and place resident's feet on the footrests.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 65 residents. Findings include: The PBJ Staffing Data Report run date 5/31/24 triggered for Excessively Low Weekend Staffing - submitted weekend staffing data is excessively low. Review of Facility Daily Assignment Sheets for each day of the months of October, November and December 2023 staffing revealed staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. The month of December reflected 3 CNA's frequently on the overnight shift during the week and on weekends. On 6/5/24 at 12:06 PM the Administrator confirmed the submission of the data for the PBJ was not submitted correctly. The Administrator stated she spoke with Corporate. The Administrator stated Corporate told him that the report triggers this response because there is no management on the weekends and this has been an issue at their other facilities.

Based on observation, record review, and staff, physician, and family interviews, the facility failed to provide comprehensive assessments and implement timely interventions for 4 of 4 residents reviewed (Resident #1, 2, 3, and 4). On [DATE], the bath aide identified a change in Resident #1's abdominal hernia. She reported her observation to Staff G, Licensed Practical Nurse (LPN) who looked at the area and told Staff E the area did not look very good. When Staff F, RN, the nurse assigned to care for Resident #1 that day returned from lunch break, Staff G reported her findings related to the resident's hernia to her. However, Staff F failed to address the area at all. On [DATE], the bath aide alerted the nurse that the hernia appeared black in color and oozed fluid. The facility notified the physician and sent Resident #1 to the hospital where she underwent surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . It becomes incarcerated when part if the intestine or abdominal tissue becomes trapped in the hernia sac and it cuts off the blood flow to the trapped area). Resident #1 subsequently passed away on [DATE] as a result of the incarcerated hernia. In an additional occurrence regarding a different resident, on [DATE], Resident #3 admitted to the facility after gallbladder surgery. On [DATE], she reported significant upper abdominal pain and the nurse identified Resident #3 had hypoactive bowel sounds with no bowel movement (BM) since admission on [DATE]. The nurse faxed the physician on [DATE] regarding no BM, but failed to convey the resident's complaint of abdominal pain or her finding of hypoactive bowel sounds. The physician's day off was [DATE] and therefore she did not respond to the fax until the latter part of the day on [DATE], when she ordered magnesium [MEDICATION(S)]. On [DATE], Resident #3 continued to deteriorate and staff sent Resident #3 to the emergency room (ER). Resident #3 died in the emergency room due to [CONDITION(S)] and [CONDITION(S)] (gallbladder inflammation) with a complicating factor of a bowel obstruction. These circumstances constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 68 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated [DATE] Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident demonstrated severely impaired cognitive skills and was rarely understood due to [CONDITION(S)] with no speech. The MDS documented Resident #1 required staff supervision for bed mobility, transfers, walking, dressing, eating, personal hygiene, and toilet use. The Care Plan revised [DATE] identified Resident #1 had an advanced directive and directed staff to honor her wishes. The care plan documented Resident #1 as dependent on staff for meeting her emotional, intellectual, physical, and social needs related to cognitive deficits. The Cardiopulmonary Resuscitation (CPR) Order Form dated [DATE] documented Resident #1 requested CPR to prolong her life. The Nursing Admission Screening dated [DATE] documented the resident had no wounds and contained no additional information regarding skin and/or wounds. Resident #1's Progress Notes included the following information: - On [DATE] at 4:42 PM, the resident's roommate alerted the nurse resident actively vomiting and staff found Resident #1 spitting in a trash can. She denied an upset stomach or not feeling well. (The chart lacked vitals or a comprehensive assessment). - On [DATE] at 1:02 PM, a skin and wound note identified a venous wound found on the resident's left abdomen. The total area measured 16.6 cm: length 5.2 cm and width 4.2 cm with increased pain, redness, inflammation, warmth, and streaking noted. Staff documented they suspected infection as the periwound area felt hot and the resident rated her pain at a ,d+[DATE], with 0 depicting no pain and 10 as the worst pain ever experienced. - On [DATE] at 1:05 PM, the bath aide described the resident's hernia as bigger with a black, oozing center that emitted a foul odor. The nurse notified the resident's medical provider and received an order to send resident to the emergency room ; report called to the nurse in the emergency room (ER). Vital Signs (VS) were Temperature (T) 97.5 Fahrenheit (F), Pulse (P) 92, Respirations (R) 20, Blood Pressure (BP) ,d+[DATE], and Oxygen Saturation (O2 Sat) 90% on room air (RA). - On [DATE] at 5:40 PM, hospital nurse called the facility and reported Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse also reported Resident #1's open abdominal hernia area had a wound vacuum device in place and she was actively dying. The bath schedule revealed Staff E gave Resident #1 a bath on Monday, [DATE] and Thursday, [DATE]. During an interview on [DATE] at 2:02 PM, Staff E reported she used to work at a different facility; Resident #1 used to live at that same facility and Staff E had cared for Resident #1 there, also. She described the hernia and the area around as normally barely protruding and skin colored. She stated she gave the resident her scheduled bath every Monday and Thursday. She reported on Monday [DATE], the resident's hernia was red, distended, and just didn't look normal. She went to find the resident's nurse (Staff F, RN) but could not find her and told Staff G, LPN instead. Staff E said that Staff G looked at the hernia area with her and commented that it did not look very good, so she would let Staff F, RN know. On Thursday [DATE], Staff E said when she went to give Resident #1 a bath, she noticed she was not acting right: she stated the resident was shaking and started gagging so she went to get a nurse. When they removed the resident's pants, they discovered the hernia appeared black and necrotic and was oozing. Staff E added the resident's underwear was stained from the drainage. She stated the area had never looked horrible like that before. During an interview with Staff F, RN on [DATE] at 2:17 PM, she stated she did not recall Staff G telling her about any abnormalities with regard to Resident #1's hernia on [DATE]. She added she did not recall hearing anything about Resident #1's hernia or any abnormalities with regard to it at all last week. During an interview on [DATE] at 2:27 PM with Staff G, LPN she stated Staff E asked her to look at Resident #1's hernia on [DATE] because Staff F, RN was at lunch. Staff E reported the resident's hernia area looked bigger than normal, darker pink in color, and warm to touch. She added when Staff F returned from lunch around 1:30 PM, she told her about it and she did not know why Staff F said she did not know about it. Staff G explained if she had been Resident #1's nurse that day, she would have faxed the physician and made sure they were aware of the area; if the provider did not fax her back, then she would call them. Staff G became upset during the call and stated she should have just done it herself so she would have known it was taken care of. During an interview on [DATE] at 3:10 PM, the Director of Nursing (DON) said she knew Staff G, LPN told Staff F, RN about the area on [DATE]. She explained she was the nurse that sent Resident #1 to the emergency room (ER) on Thursday [DATE], because Staff G came and got her to show her the area. She stated Staff G was upset because she told Staff F about the area on Monday and she did not do anything about it. She stated they have had trouble with Staff F dropping the ball on other things, so that is why she believes Staff G over Staff F. She added that she could not believe that Staff F did not admit to it during her interview. During an interview with the ER nurse on [DATE] at 3:24 PM she stated the resident came in with an incarcerated hernia and was in serious condition. They transferred her to another hospital because she would require multiple surgeries. During an interview with the court appointed guardian on [DATE] at 9:05 AM, she identified herself as the resident's niece. She stated the resident is at the hospital and stable, but the hospital had her a sign a do not resuscitate (DNR). She explained Resident #1 had one surgery, but in order for her to recover, she would need many more surgeries and a [CONDITION(S)] and she does not want to put her through all that. The resident is on comfort care and the hospital is contacting hospice today. During an interview on [DATE] at 9:46 AM, the resident's physician stated the resident arrived at theER on [DATE] with an incarcerated hernia. She reported her abdominal hernia had ,d+[DATE] cm of redness with the center bulging 10 cm with ,d+[DATE] cm of black necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply). The physician stated in the [AGE] years she has been a doctor she has never seen anything like it: it was horrific. She added it was negligence on the facility's part and if they had intervened the day they found it on [DATE], they could have done surgery and she was hopeful the resident could have lived. She stated the hospital took the resident off her ventilator and she is now actively dying. She stated the resident will be hospice level of care and return to the facility to die. During an interview with the DON on [DATE] at 1:13 PM she stated she was informed that Resident #1 just passed away before they could bring her back to the facility. The Change of Condition/Hot Chart Protocol facility policy dated [DATE] documented the following: Condition change is an alteration from normal status which could include, but is not limited to: accidents, incidents with or without injury, noted reaction to medications, skin changes, vital sign changes, decreased urinary output, signs and symptoms of dehydration, physical decline in resident's condition, and cognitive and emotional changes in the resident. The policy included these guidelines: 1. Observe/assess resident to determine resident's status. 2. Notify the attending physician as appropriate. 3. Notify resident's family/responsible party. 4. Carry out new orders received. 5. Monitor resident for response. 6. Establish advanced directive status as needed. 2. According to the MDS assessment tool dated [DATE], Resident #3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 14 of 15 possible points on the Brief Interview of Mental Status (BIMS) test which meant she demonstrated intact cognitive abilities. The MDS documented she required extensive assist of 2 staff for bed mobility, transfers, and toilet use; extensive assist of 1 staff for dressing, personal hygiene, and bathing; and supervision with eating. The MDS also documented she denied pain. The Care Plan dated [DATE] indicated Resident #3 had an advanced directive and directed staff to honor her wishes. Resident #3's Progress Notes included documentation as follows: - On [DATE] at 8:47 AM, the resident admitted to the facility and denied pain. - On [DATE] at 2:18 AM, the resident denied pain when asked. - On [DATE] at 3:24 PM, the resident requested Tums and [MEDICATION(S)] for gas relief. - On [DATE] at 6:44 PM, the physician ordered Tums and [MEDICATION(S)]. - On [DATE] at 9:00 AM, the resident complained of significant upper abdominal pain. The resident had an ostomy (a surgical opening that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of the abdomen) in place due to a fistula and had not had a bowel movement (BM) since admission on [DATE]. The assessment revealed bowel sounds present and hypoactive in the left upper and left lower quadrant. The nurse faxed the physician and requested magnesium [MEDICATION(S)]. - On [DATE] at 10:48 AM, bowel sounds hypoactive, abdomen firm and tender, as needed (PRN) laxatives given and ostomy bag changed. The area drained thin, mauve-colored drainage with a foul odor. - On [DATE] at 6:09 PM, the provider ordered okay to give 5 oz. mag [MEDICATION(S)] today - if no BM, give another 5 oz. tomorrow. - On [DATE] at 8:51 AM, bowel sounds hypoactive and the resident reported she felt like she needed to have a BM. Staff gave mag [MEDICATION(S)] and the resident had 2 large emesis that smelled like BM. Provider notified and gave staff an order to send Resident #3 to the ER, and staff then notified the resident's brother. The resident requested to use the toilet before the ambulance arrived and while using the toilet, the resident became unresponsive. Staff performed a sternal rub and the resident came to with slurred speech. The emergency medical squad arrived and transferred Resident #3 to the ER. The [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Office Progress Notes from the hospital dated [DATE], documented Resident #3 at 16 days post-op for cholelithiasis with acute [CONDITION(S)] without biliary obstruction (inflammation of the gallbladder with the presence of one or more gallstones located in gallbladder that do not obstruct a bile duct). The surgical record documented the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The scar tissue typically forms after surgery as part of the healing process, but can also develop after an infection or a condition that causes inflammation). The notes also documented the ostomy as a wound drain with 450 cc of [MEDICATION(S)] (pertaining to the small intestine) content due to an enterocutaneous fistula (an abnormal connection that develops between the intestinal tract or stomach and the skin. As a result, contents of the stomach or intestines leak through to the skin) status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's Bowel Elimination Record documented the following: - On [DATE] medium, watery loose BM - On [DATE] medium, watery loose BM - On [DATE] medium, watery loose BM - On [DATE] no BM - On [DATE] two medium, watery loose BMs On [DATE] small, soft watery BM On [DATE] small, watery loose BM On [DATE] medium, watery loose BM On [DATE] no BM On [DATE] small, watery loose BM On [DATE] no BM During an interview on [DATE] at 8:31 AM with the DON, she stated the resident had a BM every day except on [DATE], [DATE], and [DATE]. During an interview on [DATE] at 2:25 PM, Resident #3's brother reported his sister passed away at the hospital on [DATE]. He stated the facility told him she had not had a bowel movement in quite a while, so they were sending her to the hospital to do something about it but she died before they could. During an interview on [DATE] at 9:37 AM, Resident #3's physician the cause of death as [CONDITION(S)] and [CONDITION(S)] (inflammation of the gallbladder) with a complicating factor of a bowel obstruction, according to her Death Certificate. She explained she took Wednesday's off, so she was not in work status when the facility faxed her on [DATE]. The physician said since the resident reported new, significant abdominal pain and a change in bowel sounds, she would have expected facility staff to call the clinic and speak to one of the other providers. She added she requested a hospital discharge summary from the facility when the resident admitted and it took quite a while to get it. It caused an issue because she did not know when Resident #3 had surgery and what kind, or why she had an ostomy. During an interview on [DATE] at 10:43 AM with nurse Staff H, she reported she documented the resident did not have a bowel movement since admission as that's what the resident told her. She stated the aides thought the resident had a [CONDITION(S)] bag and documented the output as bowel movements, which caused the resident's name to not appear on the bowel list. However, the resident did not have a [CONDITION(S)] bag, she had a bag for fistula drainage rather than for bowel output. She explained when the aides do not document on the bowel elimination record for 2 or 3 days, the system generated a list that alerted the nurse and that's why the system did not alert the nurses regarding Resident #3's lack of BMs since admission. She added she clarified all of this after reviewing the resident's admission records from the hospital. During an interview on [DATE] at 10:48 AM, the DON reported Staff H informed her on [DATE] of the resident not having a bowel movement since admission. She stated the nurse had gone through the paperwork from the hospital and found that the ostomy was from a fistula and not a [CONDITION(S)]. She stated they did not call the provider on [DATE] because when they had previously, the providers had gotten upset because the facility had not tried medications first. Because of this, they had decided to administer Resident #3 milk of magnesia, a suppository, and prune juice and then fax the physician. She stated if the resident rated their pain at 6 or 7, they would call the physician. If the resident rated it any number below 6 or 7, they would fax the physician. 3. According to the MDS dated [DATE] Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented he scored 15 of 15 possible points on the BIMS test which meant she demonstrated intact cognitive abilities. The MDS also documented he required extensive assist of 2 staff for bed mobility and dressing, extensive assist of 1 staff for transfers, personal hygiene, and toilet use. The MDS revealed he had no pressure or venous stasis ulcers, but was at risk for developing pressure ulcers. The Care Plan dated [DATE] for Resident #2 indicated he has impairment to his skin. The care plan directed staff to do weekly documentation to include measurement of each area of skin breakdown, type of issue and exudate and any other notable changes or observations. The Non-Pressure Skin Condition Assessments facility policy dated [DATE] documented its purpose: to provide a weekly skin assessment of all skin conditions not identified as pressure sores, to help prevent infections or other complications for all non-pressure skin [CONDITION(S)], and to provide comprehensive documentation of skin conditions. The Skin and Wound Evaluation documented the following for the resident's right foot: - On [DATE] at 2:10 PM, right foot abrasion in house acquired on [DATE]. 0.6 cm area with length by width (L x W) 1.1 cm x 0.7 cm and no depth. Wound bed bleeding with periwound edges attached. PCP and daughter updated. - On [DATE] at 2:19 PM, the right foot abrasion area is less than 0.1 cm. (L x W) 0.4 cm x 0.3 cm edges attached and area improving. - On [DATE] at 11:55 AM, abrasion on left foot is resolved. The Skin and Wound Evaluation documented the following for the resident's coccyx: - On [DATE] at 2:37 PM abrasion on coccyx in house acquired [DATE]. Area 1.9 cm (L x W) 1.7 cm x 1.6 cm with no depth. One hundred percent granulation of the wound bed with no evidence of infection, no exudate and edges attached. Provider and daughter informed. - On [DATE] abrasion on coccyx area 22.4 cm. (L x W) 5.6 cm x 6 cm with no depth. One hundred percent epithelial of wound bed. No drainage and no signs of infection. - On [DATE] abrasion on coccyx 0.3 cm. (L x W) 0.8 cm x 0.5 cm with 70 percent epithelial and 30 percent granulation of wound bed. No evidence of infection. - On [DATE] abrasion on coccyx area 9.6 cm. (L x W) 3.2 cm x 4 cm with no depth. One hundred percent epithelial tissue of wound bed. No exudate and no signs of infection. The Skin and Wound Evaluation documented on [DATE] staff identified a skin tear on the resident's left outer forearm present on admission [DATE]. Area 2.8 cm with (L x W) 2.6 cm x 1.7 cm and 100 percent granulation. Edges attached with no exudate and no signs of infection. Review of the clinical record revealed no other skin assessments for the right foot, coccyx and skin tear. During an interview with the Administrator on [DATE] at 2:29 PM, he stated there were no other skin assessments for Resident #2. 4. According to the MDS dated [DATE] Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) test, which indicated he demonstrated severe cognitive impairment. The MDS documented the resident required extensive assist of two staff for bed mobility, transfers, ambulation, dressing and toileting. The MDS documented the resident required extensive assist of one staff for hygiene and bathing and was independent with eating with set up help. The MDS documented he admitted with pressure ulcers and had a diabetic foot ulcer. The Care Plan dated [DATE] documented the resident as dependent on staff for meeting his emotional, intellectual, physical and social needs related to cognitive deficits and physical limitations. The care plan documented he has impaired cognitive function and directed staff to communicate with the family regarding his capability and needs. The care plan documented he has an impairment to his skin and directed staff to do weekly treatment documentation to include measurements of each area of skin breakdown, type of tissue and exudate, and any other notable change or observations. The facility Wound Evaluations for the resident dated [DATE] documented the following: - Right lateral calf present on admit. Area 5.8 cm, length 2.95 cm, width 3.15 cm - Right shin present on admit. Area 1.93 cm, length 1.94 cm, width 1.31 cm - Left foot 1st digit Stage 3 present on admit. Area 1.51 cm, length 1.29 cm, width 1.53 cm and wound bed contained 100 percent epithelial tissue. The photo revealed a pink wound bed with no black tissue present. - Left foot 2nd digit present on admit. Area 0.3 cm, length 0.68 cm, width 0.72 cm - Right foot 2nd digit present on admit. Area 0.22 cm, length 0.48 cm, width 0.57 cm - Right foot 1st digit present on admit. Area 0.46 cm, length 0.93 cm, width 0.69 cm - Right foot 1st digit hallux present on admit. Area 0.91 cm, length 0.94 cm, width 1.26 cm The clinical record lacked any documentation of open areas on the resident's coccyx and lacked any documentation of wound assessments except for those completed on [DATE]. The Emergency Department (ED) Provider Note dated [DATE] documented skin breakdown present on resident's feet and skin with [CONDITION(S)] and wounds present. The ED Note included pictures. Left foot 1st digit presented with black wound bed. The ED Note included a picture of an open area on the resident's bottom. During an interview on [DATE] at 1:00 PM with the DON she stated the facility only completed skin assessment on [DATE] for the resident. She stated the nurses are to assess any open wounds once a week. The facility was notified of the Immediate Jeopardy on [DATE]. The IJ was removed on [DATE] when the facility completed the following actions: 1. The facility re-educated all nurses regarding the need to assess residents and notify the provider of any and all changes in status immediately. The education included the change of condition policy. 2. The facility educated all nursing assistants about using the alerts available through the facility's electronic health record system. The education included the need to verbally notify the nurse when they had concerns about a resident or if they noted any changes as soon as they became aware of them.

Based on observations, clinical record review, facility record review, staff and family interviews, the facility failed to provide adequate to ensure the resident environment remained as free of hazards as possible for 1 of 3 residents reviewed (Resident #5). On 12/11/21, between 9:00 PM and 11:30 PM, Resident #5 eloped (exited the building without staff knowledge or permission). The outside temperature at the time measured 28 degrees with a wind chill of 20 degrees. Staff reported they did not know how he left as he wore a wanderguard bracelet, but it did not cause an alarm to sound. A person from the community heard the resident yelling for help, found the resident approximately 100 yards west of the facility in a field, and contacted the police. The police responded at 11:42 PM, identified the resident showed signs of cold exposure, and sent him to the hospital. The resident demonstrated severe cognitive impairment, had a history of wandering, and had attempted to leave the building before but had not succeeded in doing so in the past. These circumstances constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 68 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment tool dated 11/11/21 documented Resident #5 had diagnoses that included [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], metabolic [CONDITION(S)], and [CONDITION(S)]. The MDS revealed the resident scored 5 out of 15 possible points on his Brief Interview of Mental Status (BIMS) test, which indicated the resident demonstrated severe cognitive impairment. The MDS documented he required minimal assist of one staff for transfers, ambulation (walking), dressing and toilet use, extensive assist of one staff for bathing; and supervision with bed mobility and eating. The MDS also documented his balance as not steady and he used a walker and wheelchair for ambulation. The Care Plan dated 11/5/21 identified Resident #5 had impaired cognitive function related to dementia and showed a risk for elopement risk related to wandering and attempts to leave the facility unattended. The Care Plan noted the resident wore a monitoring device that triggered alarms when he left the building and directed staff to remain aware of which exits he favored for elopement and to alert staff that worked in those areas. The Wandering Evaluation dated 11/4/21 documented the resident as at high risk of wandering and elopement. Resident #5's Progress Notes documented the following: - On 11/24/21 at 4:36 AM, resident exit-seeking looking for his vehicle this shift. The note documented the resident as not steady with ambulation and non-compliant with assistance. The note identified the resident as a wanderer and revealed he wore a wanderguard. -On 11/28/21 at 12:51 AM, Resident #5 experienced had impaired mobility, but ambulated independently even when educated and encouraged to call for assistance due to poor awareness resulting from dementia. The resident made multiple attempts to transfer alone and continued to exit-seek. The nurse instructed staff to check on the resident frequently. -On 12/1/21 at 8:34 PM, the resident behaved aggressively toward staff while trying to get out of the door and attempted to punch the nurse when she tried to stop him. - On 12/6/21 at 1:17 AM, resident had multiple attempts to transfer independently and leave the facility while becoming increasingly agitated with staff attempts to keep him from approaching the front door. Behaviors subsided with casual conversation with staff. - On 12/6/21 at 2:11 PM, resident confused per usual self and adamant about leaving the facility. Nurse redirected him several times and suggested he call his daughter. Resident #5's mood improved after speaking to her. - On 12/6/21 at 2:38 PM, resident agitated when not able to go next door because he thought for sure he parked his truck in that location. Resident redirected by staff several times with suggestion to talk to his daughter. - On 12/8/21 at 10:46 AM, resident adamant about leaving the facility. Reassured his daughter had his tractor-trailer at her house. - On 12/9/21 at 12:21 AM, resident currently independent to extensive assist with his activities of daily living and uses a wheelchair for mobility purposes. Resident confused and continues with delusions at times: believes people are saying things they are not or things are happening that are not. Redirection by staff not always effective and at times makes the resident more upset. - On 12/10/21 at 11:22 PM, wanderguard checked and expires on 12/11/22. - On 12/12/21 at 3:57 AM, the police department called and notified the facility they have the resident in their custody. Resident has a history of door-seeking behaviors, although staff on shift reported they did not hear door or wanderguard alarms sound - wanderguard was faulty on 12/10/21. Assistant Director of Nursing notified and resident currently in the hospital. The Police Department Report dated 12/11/21 documented at 11:39 PM on 12/11/21 they received a call that a private residence heard a male subject screaming for help in a field. At 11:42 PM, the officer responded and found the male subject in the private residence garage. The male subject was trying to walk to a bench to sit down. The male subject was having trouble speaking due to how cold he was. The officer had to remove the wallet from the male subjects back pocket because he was unable to. Another officer was able to identify the male subject as a resident at the nearby nursing facility. The report documented the officer went to the facility and spoke to the nurse [NAME]. He informed the officer the facility is having issues with the alarming system not notifying the staff when a resident leaves the building and this was the reason they did not detect the resident leaving. The officer asked the nurse if the facility had a policy in place for staff that once the alarming system is down, they were to check on the residents more often. The nurse did not answer the question. The officer explained that if the resident had not screamed for help or been heard it could have been a lot worse. The nurse acknowledged he understood. The Emergency Department Note dated 12/12/21 at 12:21 AM documented resident brought in after being found outside yelling for help. The note identified he wore a wanderguard bracelet and complained of being cold but denied pain. The note documented he has audible wheezing but the other systems were negative upon review. Vitals Temperature 97.8, Pulse 72, Respiration 15, Blood Pressure 168/74 and O2 saturation level 98 percent. Resident admitted for observation. The note documented the resident stated he used to be a truck driver and was out looking for his truck. The notes documented he had moderate bacteria, blood and nitrates in his urine and [MEDICATION(S)] initiated for a urinary tract infection. The Elopement Prevention facility policy dated January 2015 documented the purpose of the policy: to maintain resident safety and prevention of injury. Guidelines included the following: Evaluate all residents for potential of elopement from the facility. Provide wanderguard bracelets to all residents who have been determined to have a potential for elopement. Document all attempts for elopement and evaluate precipitating factors. Document effective measures taken to return the resident to the facility. Assess resident's ability to remain in the facility safely. The resident care plan will contain interventions and actions to monitor and prevent elopement. All staff will respond promptly to all door alarm activation. If immediate reason for door alarm is not determined, staff will account for all residents at this time. During an interview on 12/13/21 at 10:25 AM with the Administrator, he stated Resident #5 eloped Saturday 12/11/21 sometime between 9:00 and 11:30 PM. He stated the staff reported the door alarms did not sound so they were not aware he had left. Police notified because the resident attempted to enter a private residence nearby the facility. The police called the facility around 11:30 PM. The resident admitted to the hospital for cold exposure, but no other harm or injury found. The Administrator stated they interviewed all the staff and none of them heard the doors alarm. The resident wore a wander guard and it was working. The staff reported they saw him for medication pass at 8:30 PM and again in the hall around 9:00 PM. The facility has the wander guard system but not the mag lock system. He stated the facility had purchased the mag lock system but not installed it yet. They contacted the company they bought the wander guard from to come out and check the system, but they informed them the system is too old to check or service. The nurses are checking each resident's wanderguard bracelet daily and maintenance is checking the door alarms daily. During an interview on 12/13/21 at 11:03 AM, the Director of Nursing (DON) reported the police notified the facility at 11:48 PM resident was found in the field just west of the building. She stated located is a parking lot no one uses, a hill he would have gone down, and the field. During an interview on 12/13/21 at 1:10 PM, Staff A stated he was the charge nurse responsible for the resident on 12/11/21. He reported he administered the resident his medications and checked the wanderguard around 7:30 PM and at that time he was in his room as usual. He proceeded to pass his bedtime medications to other residents. He said the other charge nurse last saw the resident around 9:00 or 9:30 PM at the nurses station seated next to another resident. He received a call from the police department around 11:30 PM and they asked if he knew the resident and he informed them he did. He reported he did not hear any door alarms and none of the other staff working heard the door alarms or wanderguard either. He stated the resident was not wandering that night and if he had been they would have redirected him. He reported the resident's walker was in his room and when he checked the resident's wanderguard that night, it worked. He added the previous day the wanderguard was faulty. They called the Assistant Director of Nursing (ADON), she came to the facility, called Maintenance and told them the system needed to be unplugged to reset it. He reported Staff B found the wanderguard system unplugged when they received a call from the police department on 12/11/21, and when they checked the resident's room he had all his belongings packed. They also found another wanderguard bracelet in his room. Observation on 12/13/21 at 1:20 PM revealed the wanderguard system plugged in at the nurse's station. The facility had placed a screw in the outlet so staff could not unplug it. The Nurse Consultant stated she checked the system and it still sounds when unplugged, it is just not as loud. Unable to unplug the unit with the screw in place. During an interview on 12/13/21 at 1:29 PM with Staff C, charge nurse, she stated she was passing meds around 9:00 to 9:30 PM on 12/11/21 and she saw the resident sitting at the nurse station next to another resident. She stated she was not his nurse so that was the only time she saw him. She stated she did not hear any door or wanderguard alarms sound that night and the other staff stated they did not hear any alarms either. She stated if they did hear alarms they would have responded immediately to check and see if anyone left. The previous night there was a resident with a wanderguard positioned close to a door and it triggered the alarm. They could not silence the alarm, so they did a full head count to ensure nobody had exited. Staff C stated once they accounted for everyone, the alarm still sounded so they contacted the ADON. She came into the facility and told them to unplug the wanderguard for an hour and plug it back in to reset it. She stated staff plugged the system back in around midnight. During an interview on 12/13/21 at 1:42 PM, the DON stated the ADON told her she unplugged the wanderguard system on 12/10/21 to reset it and she had Staff B set an alarm on her phone as a reminder to plug it back in. The DON stated when she worked the morning of 12/11/21, the system was plugged in. During an interview on 12/13/21 at 3:43 PM, Staff B, Certified Nursing Assistant (CNA) stated she got to work at 6:00 PM on 12/11/21 and last saw Resident #5 in his room at 6:30 PM eating supper. She added the resident is independent with cares and they were busy getting other residents ready for bed. She stated she was working with 2 other girls that were new to the facility and she was busy helping them; it was very busy that night with call lights and transferring residents that required lifts into bed. She explained she did not have time to check on the independent residents. She reported at 11:30 PM, she entered his room while handing out new toothbrushes and basins, but he was not in his room so she informed the nurse. The nurse told her he normally wanders in his wheelchair and stays up late. She verified they never heard any door alarms at all that night and if they had they would have responded to them to see if anyone had gone out the door. She stated the night before, the wanderguard system would not stop beeping after a resident wandered close to a door. The ADON came into the facility and told the staff to unplug it to reset it. She stated she set an alarm on her phone and plugged it back in at midnight. She reported there were at least two to three other residents that had family visiting that night, so she thinks he could have followed someone out the front door. During an interview on 12/13/21 at 5:56 PM, the Police Officer on duty that evening stated the police were called at 11:39 PM and arrived on scene at 11:42 PM. He stated they were called by a family that found the resident in a field behind a private residence because he yelled for help; when he responded, the resident was confused, cold and having difficulty walking due to being stiff and shaking. The Police Officer reported they called the ambulance because of these symptoms and the ambulance crew decided to take him to the emergency room due to wheezing heard in his lungs. He added they called the facility because they saw he wore a wanderguard bracelet and when they called the facility, staff were not aware he was missing from the building. During an interview on 12/14/21 at 1:34 PM with Staff D, she stated she was working the evening of 12/11/21 when the resident got out of the facility, although it was only her second night at the facility so she cannot recall what he looked like. She reported it was a very busy night with many call lights and they were busy getting residents ready for bed. She added she did not hear any door alarms sound that night, and as far as she knew the system was working and she could rely on the door alarms. During an interview on 12/14/21 at 2:22 PM, the ADON recalled she went into the facility on [DATE] and heard the wanderguard system sounding at the end of Hall 2 and at the nurse's station. She stated she tried several codes and could not get it silenced, so she called maintenance who directed her to unplug it for an hour to reset it. She said they had trouble with it a couple other times that day and the maintenance director rewired it but that did not fix it. She stated she unplugged it and told Staff B to set an alarm on her phone as a reminder to plug it back in after an hour. She stated when the system at the nurses station is unplugged, it still sounds it is just not as loudly and reported there are two spouses of residents that stay that late. The facility called them and both stated none of the residents followed them out of the facility. She added one of them is very hard of hearing and has some mental decline, so it is possible the resident followed him out, but the spouse denied it. She said she does not think the staff that worked that night are being honest about no alarms sounding that night. She stated they had just changed the front door code and that door alarm had been sounding all day with visitors leaving because they did not know the code. She reported Resident #5 remained in the hospital and the facility is trying to find placement for him in a secure dementia unit. She added that if they had to take him back he would require one-to-one supervision at all times. During another interview on 12/14/21 at 4:44 PM, the Administrator reported on 12/10/21, they were having trouble with the wanderguard system malfunctioning. He stated the Maintenance Director rewired it and reset it, then the system went off again on Friday night that is when the ADON went into the facility and after talking to the Maintenance Director, reset the system. Staff found the system unplugged after the police notified them of the elopement and that is when the DON started hourly checks to make sure staff do not unplug it again. He stated the Maintenance Director spoke to the company that installed the wanderguard system on Monday 12/13/21, and they would not come and service it because it was too old. They did direct him to replace all the batteries in the system and then reset all the doors, which maintenance completed on Monday 12/13/21. On 12/15/21 at 9:56 AM, the Administrator clarified the facility re-educated staff on 12/12/21 after the elopement, but not on 12/10/21 when they were having problems with the enunciator. The facility was notified of the Immediate Jeopardy (IJ) on 12/15/21. It was determined the IJ was removed on 12/12/21 when the facility implemented the following measures: 1. Identified residents at high risk of elopement 2. Educated all staff related to alarm system functioning and residents at high risk of elopement 3. Posted a sign at the door to inform visitors to alert staff immediately if they see a resident near the door or attempting to exit. 4. Completed a missing resident drill with staff

Based on observations, record review, interviews and facility investigation notes, the facility failed to provide adequate supervision for 1 of 3 sampled on quarantine (Resident #1). The facility found Resident #1 unsupervised in the kitchen. Resident #1 sustained a burn to her right 3rd, 4th and 5th fingers. The facility reported a census of 49. Findings include: Review of the Minimum Data Set (MDS) assessment tool dated 11/10/2020 revealed the following [DIAGNOSES REDACTED]. The MDS listed a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment. Resident #1 required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use and used a wheelchair. Resident #1 wandered 1 to 3 days during the 7-day review period. Review of Resident #1's Care Plan 11/30/2020 showed impairment to skin integrity of the 3rd, 4th, and 5th fingertip related to a burn. On 11/30/2020, the facility applied a stop sign to her doorframe to remind her to stay in her room until the COVID-19 outbreak precautions are lifted. Review of Care Plan dated 12/21/2017 showed impaired cognitive function/dementia or impaired thought processes and wandering behaviors. Review of Resident #1's Care plan dated 12/21/2017 noted impaired cognitive function/dementia or impaired thought processes. Care plan dated 12/26/2019 noted a behavior problem related to wandering in the facility. Observation on 12/2/2020 at 10:20 a.m. of kitchen entry revealed locking doors with keypad entries. Both doors had stop signs posted and witnessed staff members entering code to gain access to kitchen and verbal queues from Dietary Staff to Kitchen Staff to ensure doors were closed after entering. Review of incident report dated 11/28/2020 documented that at 10:25 a.m. CNAs saw Resident #1 go through the kitchen doors. CNAs removed Resident #1 from the kitchen and were advised by Resident that she had burned her right hand by touching the steam table. Resident's 3rd, 4th, and 5th fingertips were red, blanchable, and tender to the touch. Resident #1 stated she was just seeing what was going on. The nurse applied a cool washcloth for comfort. Review of Resident #1's skin evaluation form dated 11/28/2020 noted another type of skin injury on her upper limb(s) that needed evaluated today. Facility response on form indicated a new injury of right 3rd, 4th, and 5th fingertips burned, red, blanchable, and tender to the touch and a 0.2 centimeter (cm) x 0.2cm intact blister on right 4th fingertip. Record review of nursing notes for Resident #1: -11/28/2020 at 10:36 a.m.: CNAs brought Resident #1 out of the kitchen and told this nurse that she had burnt her hands on the stove in there. The nurse took Resident #1 to her room and assessed her fingers. Her 3rd, 4th, and 5th fingers are reddened, blanchable, and tender to the touch, no blisters noted at that time. Cool washcloth applied to fingertips for comfort. The CNAs stated that they did not see her touch the stove but they witnessed her going through doorway and went to remove her from area. The CNAs stated they had not arrived prior to her touching it. The entry way doors to kitchen were open. The kitchen staff stated that they did not see or hear her in there. The kitchen staff told her that one staff member was in the dishwashing room and the other had her back turned to the doorway. This nurse educated staff that doors were to be kept shut at all times to prevent residents and other people besides staff to enter the kitchen. Resident #1 stated that she was just seeing what was going on and was roaming around. She was educated that she needed to remain in her room or down her hall due to COVID-19 and isolation policies. She stated that she understood and wouldn't go past the double doors. Resident #1's family was contacted with update on incident, her primary care provider and Director of Nursing (DON) were notified too. This was documented by Staff E Registered Nurse (RN). -11/28/2020 at 11:01 a.m., clarification, Resident #1's right 3rd, 4th, and 5th fingers were burned on the steam table in kitchen and not the actual stove. This was documented by Staff E. -11/28/2020 at 12:37 p.m., Resident #1 had 1 small blister on her 4th finger on the right hand: 0.2 cm x 0.2cm. This nurse called Resident #1's family to notify her of area, updated her primary care provider and will continue to monitor area. This was documented by Staff E. -12/1/2020 at 12:04 p.m., weekly skin evaluation completed. Resident #1 had no blisters noted on her fingertips and all skin was blanchable. She stated the skin was tender to touch but nothing more than that. They will discontinue the weekly monitoring of skin as there was nothing to monitor at that time. Review of facility's investigative file noted education provided to staff after the incident on 11/28/2020. Education included: doors to the kitchen and entryway doors are to be kept shut at all times. If residents are roaming around the facility then they need to be reminded to return to their rooms and hallways since they are not allowed in the main parts of the facility yet due to COVID-19 and isolation policies. If a resident is a known wanderer they need to be checked on frequently. At no point should a resident ever be inside the kitchen or the entry ways doors. All stop signs should be put into place at all times. Resident #1 now has one in her doorway and the kitchen doors will have one also. Please sign at the bottom to show that you have read and acknowledged this. Staff signatures are on education form showing acknowledging new policy. During interview of Resident #1 on 12/2/2020 at 10:39 a.m., observed stop sign affixed to door fame of room. Resident sitting in recliner with feet elevated, call light within reach, and her wheelchair in the bathroom. Resident #1 was asked what happened to her fingers on Saturday, she stated she touched a skillet. Resident #1 was asked why she went into the kitchen, she stated she did not remember why she went in there and people just do dumb things some times. When asked if the kitchen doors were open off of the main dining room leading to the kitchen, she indicated she thought they were open. When asked if they are usually open, she stated not usually. Resident #1 was asked how long she had her hands on the skillet she stated not very long and once she felt it was hot, she took her hand off of it. She stated they took care of her right away and her fingers are healing up good, fingers are a bit stiff. Observed a red oblong circle on her right middle finger, no open areas noted. During interview of Staff C Certified Nursing Assistant (CNA) on 12/2/2020 at 11:06 p.m., advised doors used to remain open when passing trays or serving and that key pads have always been on the doors. Stated she used to work in the kitchen and a long time ago they could keep the doors open but not anymore. During interview of Administrator on 12/2/2020 at 11:10 a.m., she stated meal times are: breakfast 7:30 a.m. - 9:00 a.m., lunch 12:00 p.m. - 1:00 p.m., dinner 5:30 p.m. - 6:30 p.m. and that the times are skewed based on delivering all meals to residents in their rooms. During interview of Staff A Cook on 12/2/2020 at 11:15 a.m., stated his back was turned to the door when he heard Staff B Dietary Aide talking. Staff A turned around and saw Resident #1, at which time Staff B advised Resident #1 she could not be in kitchen. Resident #1 touched the steam table and said ow, that is hot, don't touch that it is hot. CNA arrived and took Resident #1 out of kitchen. Staff A stated he did not know why kitchen doors were open and that he keeps doors shut when he is working. He advised before the incident the doors were allowed to be open during meal service, but it is not allowed anymore. He confirmed that doors are now locked at all times and required a key code to enter. He advised he was not certain if kitchen staff were allowed to remove residents from kitchen and would not feel comfortable doing so since he is not a CNA or a Nurse. Staff A stated on the day the incident took place, the Dietary Manager sent out a text message to everyone that the kitchen doors needed to be shut at all times even during service. During interview of Staff B on 12/2/2020 at 3:05 p.m., verified at time of incident she was in the kitchen rolling silverware with her back turned towards the door. She heard someone talking, turned around and a CNA was talking to Resident #1. She stated Resident #1 had already put her hand on the steam table. She did not see her hand because the CNA was already there helping the resident out of the kitchen. When asked if the doors were open, she stated they were open and she wasn't aware they needed to be closed all the time. She added she was not sure who opened them. She stated since the incident she was told the doors have to be closed now all the time, even during meal service. When asked what time the incident happened she said maybe 1:30 p.m. An attempt was made to speak with Staff E RN on 12/03/2020 at 11:26 a.m. with no response. During an interview on 12/3/2020 at 11:50 a.m., Staff D CNA confirmed she worked on 11/28/2020. She was asked to describe what happened with Resident #1. She stated she worked on hall 3 that day. She stated she was walking down the hall, looked towards kitchen and saw Resident #1 had propelled in to the kitchen. Staff D stated when she got to the kitchen, Resident #1 had just gone through the 2nd door. When she arrived Resident #1 had turned towards the steam table in her wheelchair. She stated she did not see her touch the steam table. Staff D was asked if the kitchen doors were open she stated she assumed so since Resident #1 went in to the kitchen. When asked if Resident #1 told her why she went in the kitchen, Staff D stated the resident didn't make sense when she told her she was trying to find something. She stated after she removed her from the kitchen, she took Resident #1 to her room and the other CNA got the nurse. Staff D stated Resident #1 liked to wander around the facility. During a follow-up interview on 12/3/2020 at 11:28 a.m., Staff C was asked what Resident #1's level of care was, she stated she required assistance of 1 staff for dressing. She stated Resident #1 could get herself around the facility in her wheelchair. She stated Resident #1 does have camera in her room that is monitored at the nurse's station, but she likes to move it around alot in her room. When asked what the purpose of this camera was, she stated Resident #1 liked to transfer herself, so staff would watch to see movement. Staff C was asked if Resident #1 liked to wander around the facility and she stated she did. When asked if the kitchen doors can be open she stated from her understanding they needed to be closed at all times. She stated they are not always closed, especially when residents were eating in the dining room they would leave the doors open during service. During an interview on 12/3/2020 at 1:35 p.m., DON was asked what her role was after the incident took place. She stated Staff E called her to let her know what had happened and asked the DON what else she needed to do. The DON stated they had already applied cold wash cloths to Resident #1's fingers, put a Velcro stop sign on the resident's door way, closed the kitchen doors and put stop signs on them. They held a 5 minutes meeting that informed staff to keep an eye on residents that wander and keep the kitchen doors closed at all times. They monitored her wound and put her on hot charting. The DON was asked what Resident #1's level of care was she stated she transferred with stand-by assistance, she needed help with dressing herself, and was able to propel herself around the facility in her wheelchair. DON stated she does get confused and requires frequent redirection. Stated Resident #1 did wander, but never tried to leave, she just liked to go up and down halls to check on every one. The DON was asked if Resident #1 had a camera in her room, she confirmed she does and there is another one at the nurse's station. She stated staff can watch at the nurse's station and she indicated someone was not up at the nurse's station before the incident and that is why they did not see her going to the kitchen. The DON was asked if they require staff to be at the nurse's station at time, she stated they are not required to be up there all the time to check. She stated she expected staff to check it regularly. When asked what the purpose of the camera was, she stated to help prevent falls at night because she got up a lot. The DON was asked if the kitchen doors could be left open before incident occurred, she stated they were ok to be open, from her understanding the doors are allowed to be open when serving and when they are done they should be shut. When asked what time Staff E called her she stated approximately at 10:30 AM. The DON was asked what injuries Resident #1 sustained, she stated just the one blister on her 4th finger. During interview on 12/3/2020 at 1:47 p.m., Dietary Manager (DM) was asked if the kitchen doors were allowed to be open before the incident that took place on 11/28/2020. She stated they could leave them open frequently because it would get hot in the kitchen and so staff could come in a get items for the residents when they wanted. She stated since the incident, it has changed and the doors are kept shut. The DM was asked to describe what education was provided after the incident took place. She stated that once informed of incident she sent out a blast text message to all the kitchen staff and held a meeting after arriving to the facility. She advised staff there had been an incident and now stop signs were to remain on kitchen doors and the doors needed to be closed at all times. She stated when she sent out the text to all staff, she asked them to respond yes to text so she knew everyone had read it. Review of facility provided past non-compliance effective on 11/28/2020 at 10:25 a.m., Resident #1 entered the kitchen unattended and received a burn to her right hand 3rd, 4th, and 5th digits. The digits were red, blanchable, and tender to the touch immediately following the incident. The resident rated her pain 2 out 10, 10 being the worst pain. A cold washcloth was immediately applied to the resident's fingertips. An intact blister developed on Resident #1's 4th digit approximately 2 hours after the incident, the blister had reabsorbed by 11/30/2020. The resident is known to wander through out the facility due to her underlying cognition and [DIAGNOSES REDACTED]. Resident #1 wheeled herself through the kitchen door and was able to access the steam table. Plan of correction: Resident #1 was immediately assessed and treatment to digits was provided. Stop signs were placed on Resident #1's door as a visual reminder to stay in her room, stop signs were also placed on the dining and kitchen doors as a visual reminder. Staff members were educated on ensuring staff was in the kitchen at all times when residents are present. If not staff members are in the kitchen the door is to be locked, and the key pad is to be utilized. The kitchen door should remain closed at all times. The Dietary Supervisor or designee will be auditing at different times a minimum of 3 times weekly to ensure the stop signs are in place and the kitchen doors are closed. In-depth analysis- the kitchen door was left open as kitchen staff were present in other parts of the kitchen, but not able to visually see the steam table. A resident with known Alzheimer's entered through this door not knowing the steam table was hot and burned her right hand. Due to the residents being in isolation, kitchen staff felt it was ok to have the door open to the dining room at that time. The root cause was because of lack of education of staff members; the kitchen door should remain closed at all times, even with residents in isolation. Corrective action taken for resident(s) affected: a stop sign was placed on Resident #1's door and stop signs were placed on the dining room and kitchens doors to provide a visual cue. Kitchen doors should remain closed at all times, the doors are to be locked, and the key pad will be utilized if no kitchen staff are present in the kitchen. Staff will provide verbal reminder and support residents to redirect them to their room during the isolation period. Planned monitoring of corrective actions to ensure practice is corrected and will not occur: Dietary Supervisor or designee will completed an audit minimum of 3 times weekly at random times to ensure the kitchen door is closed, locked when staff not present in the kitchen. Stop signs are in place on the doors and visible. The results of these audits will be taken to the morning quality assurance (QA) meetings and reviewed. Any areas of concern will be addressed and documented follow up will be completed. The audits will continue until reviewed at the quarterly QA meeting and substantial compliance is met. The checklist had an anticipated date of completing for this plan of correction of 11/28/2020. The checklist was signed and dated by the Director of Nursing (DON) on 12/2/2020.

Based on observation, interview, and record review, the facility failed to provide a safe environment for two of eight residents reviewed (Residents #1 and #6). The alarm system was turned off on three of nine exits, which allowed Resident #1 to exit facility without staff knowledge, resulting in an immediate jeopardy to health and safety. Resident # 6 was transferred without mechanical lift device, according to the care plan resulting in injury. FINDINGS INCLUDE: 1. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/2/20 for Resident #1 showed resident to have a Brief Interview Status Score (BIMS) of 04, indicating a severe cognitive impact. MDS showed Resident #1 to have a [DIAGNOSES REDACTED]. The MDS showed the Resident required supervision with set up help for ambulation and transfers. The MDS also indicated wandering behavior occurred daily. A review of the incident report dated 10/19/20 at 9:00 pm prepared by Staff B showed the Resident #1 was found outside the front door and was believed to have removed her wander guard. Factors noted on report indicated Resident #1 was an active exit seeker and a wanderer. The incident report indicated the physician was notified on 10/20/20 at 7:06 am. Records showed that on 9/1/20, 6/3/20, 3/4/20, 12/4/19, 9/4/19, 6/5/19, and 3/13/19 Resident #1 scored a 10 on the Wandering Evaluation. Scoring a 10 or higher on the wandering evaluation indicated a high risk for wandering and a WanderGuard bracelet needed to be applied to the resident. A review of the care- plan with a completion date of 9/16/20 showed Resident #6 to wander the facility and the need to wear a WanderGuard device for safety. A review of the physician's orders [REDACTED]. A review of the Treatment Authorization Request (TAR) showed that no WanderGuard check tasks were indicated for the resident until 10/20/20. Further review of the TARs showed that the last WanderGuard check task was dated 2/4/19 when the WanderGuard was discontinued. During an interview on 10/21/20 at 2:50 pm with Staff C CNA stated that Staff A used the walkie asking for help as she found the resident outside sitting next to the main door of the facility. Staff A and C helped bring the resident indoors to the nurse's station and Staff B completed a head to toe assessment. Staff C stated the resident was covered with blankets, as she was very cold. Staff C stated the resident was wearing a long sleeved shirt, pants, and gripper socks. Staff C stated she did not remember the last time she saw the resident and she did not hear any alarms going off before the resident was found. Staff C stated she could not remember if the resident was wearing a WanderGuard. During an interview on 10/21/20 at 3:05 pm with Staff D, CNA advised, she could not recall when the last time she had saw the resident the evening of the incident. Staff D stated that no alarms went off before the incident, that the alarms were tested after the resident was found. During the testing of the alarms, it was found that alarms #1 and #6 were shut off at the mainboard. Observation on 10/21/20 of the main alarm board located in the central area of the facility next to the nurse's station had a sign taped up that stated Do Not Shut Alarms Off and leave them off, Always turn them back on. During an interview on 10/21/20 at 3:25 pm Staff E CNA stated the evening of 10/19/20 was crazy that there were four CNA's on the floor. Stated she did not hear any alarms before the incident. Staff E stated she believes she last saw the resident around 8 to 8:30 pm on 10/19/20 as she was sitting in a chair by the nurse ' s station. Staff E stated it was normal for the Resident to wander the facility. Staff E stated the alarms were tested after the resident was found and door #1 and #6 were not working, that they had been shut off. Staff E stated that it is common for the alarms to be shut off if the ambulance crew is coming into them. Staff E stated that three residents had been transferred out that evening. A review of records showed that Resident #2 was sent to Cass County Emergency for a less than 24-hour stay and returned on 10/20/20 at 8:53 pm, Resident # 3 was sent to Cass County Emergency for a stay less than 24 hours and returned to the facility via Emergency Medical Services (EMS) on 10/20/20 at 3:46 am. Interview on 10/21/20 at 3:40 pm with Staff B LPN stated she was the nurse on duty at the time of the elopement, Staff B recalled the night had been crazy and residents had been transferred in and out. Staff B recalled that Staff A notified her of the resident being found outside. She assessed the resident for injury, stated the resident was cold and confused, and checked vital signs. The Resident was brought into the building, warmed up, and started neurological assessments. Staff B stated she applied a WanderGuard on the Resident as there was not one on her at that time. Interview on 10/22/20 at 9:45 am the Director of Nursing (DON) stated that Staff B called her and informed her of the incident at 9:09 pm on 10/19/20. Stated that Staff A went to the main door for a pharmacy delivery. DON stated she last saw the Resident at 6 pm wandering around the nurse's station. DON had Staff B test all the alarms. Staff B informed DON that some of the alarms were shut off on the main control board. DON advised that Resident WanderGuard had been discontinued in February but was unsure why this happened. DON advised that staff were educated through a 5-minute meeting about the alarm system. DON was notified of the resident ' s room location and stated that the Resident had tested positive for COVID and would be moving today. Review of facilities investigation dated 10/20/20 showed that the facility found halls 1, 4, and 6 had their exit door alarms turned off. A review of the current list of residents wearing a WanderGuard bracelet showed that the facility has 10 other residents wearing a WanderGuard bracelet due to elopement risk. Interview on 10/22/20 at 1:14 pm with Iowa Climatologist who stated the weather conditions on 10/19/20 between the hours of 8:00 pm and 9:00 pm were; Temperature 32 degrees, humidity at 100%, and wind at 5 MPH. The combined weather conditions made a wind chill of 27 degrees. Interview on 10/26/20 at 12:10 with Resident's Power of Attorney stated that she was not notified of the elopement until the DON called on 10/21/20 to inform her that the resident had tested positive for COVID and had asked if staff contacted her regarding the resident's elopement. Interview on 10/26/20 at 1:35 Angela Weppler, Medical Doctor (MD) stated she was unaware of the resident's elopement, stated she never received a phone call or fax from the facility mentioning the elopement. Review of Elopement Prevention Policy dated January 2015 stated to provide WanderGuard bracelet to all residents who have been determined to have a potential for an elopement, residents care plan will contain interventions and actions to monitor and prevent elopement, all staff will respond promptly to all door alarms activation, If the immediate reason for door alarm is not determined, all residents will be accounted for at this time. All door alarms will be checked daily by Quality Assurance (QA) team members to make sure they are working properly. QA members will document conditions of alarms. Interview with the DON on 11/3/20 at 9:30 am, showed that staff are expected to make sure the door alarm system is reset and working properly and that all residents who requires a WanderGuard bracelet have one in place and that it is working properly and that the care plan is updated with WanderGuard placement and followed. 2. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/20 for Resident #6 showed the resident to have a Brief Interview Status Score (BIMS) of 15 which indicates intact cognitive. The MDS showed the Resident to have a [DIAGNOSES REDACTED]. The MDS identified the resident as totally dependent on staff for transfers and requires the assistance of two people and a Hoyer lift. The resident required locomotion with a wheelchair and the assistance of two people. Review of care plan showed resident was a risk for falls as of 3/8/2019 and needed monitoring for unsteady gait, is unable to transfer independently, and requires staff assistance as. Review of Progress note dated 8/6/20 at 3:32 am stated Resident #6 was being transferred to the bathroom when Residents left foot gave out and the resident was lowered to the floor. Resident #6 was unable to bear weight on the left leg and was sent to the emergency room . Review of Progress note dated 8/6/20 at 4:24 a.m, showed staff signed a contract that would use a gait belt with all ambulation transfers. Review of the incident report dated 8/6/20 at 3:58 a.m. indicated that Staff F mentioned while transferring the resident to the bathroom her left foot gave out. Resident #6 started to fall forward and that Staff F tried to catch her with her arm in the Resident ' s right armpit and her other arm around the Residents abdomen. Stated she could not hold her well enough to get her standing again, using her right knee to reduce her fall impact. A review of the facility's self-report dated 8/6/20 stated the resident was being transferred by Staff F and had a fall, which resulted in a [MEDICAL CONDITION]. Staff F was terminated based upon investigation findings that the resident did not have a gait belt on. A review of the admission record for Methodist Health System in Council Bluffs showed an admission date of [DATE] at 12:10 pm with a left [MEDICAL CONDITION] requiring surgical repair. Review of Major Injury Determination form dated 8/6/20 at 8:18 a.m. showed Resident had a fall while ambulating with staff to the bathroom with no gait belt applied and received a fractured left hip. Resident #6 previous functional ability was extensive assist with ambulation and transfers. A review of the MDS with ARD of 6/10/20 showed the resident was an extensive assist with the use of one person for transfers. MDS with ARD of 8/6/20 showed resident was an extensive assist with the use of one person for transfers. Review of progress notes dated 8/7/20 showed the resident had surgical repair of the left [MEDICAL CONDITION], review of progress note dated 8/10/20 at 5:37 p.m. showed resident returned to the facility. A review of the care plan showed Resident #6 requires a mechanical lift for all transfers with an initiation date of 8/10/20. The care plan showed staff educated to use a gait belt with the initiation date of 8/6/20. Review of Termination of Service Form dated 8/6/20 showed staff F terminated from employment due to not using a gaitbelt and resident falling fracturing a hip. Interview with DON on 10/27/20 at 2:10 pm showed expectations are for staff to use a gait belt with any resident who requires staff assistance with transfers and ambulation. Interview with Staff D CNA on 10/27/20 at 2:20 p.m. showed staff should use a gaitbelt on any transfer or ambulation unless they are a lift or independent. Stated gaitbelts are located in Resident ' s rooms hung over the sharp containers located on the wall. Interview with Staff G RN on 10/27/20 at 2:27 pm, confirmed gaitbelts are required for all non-mechanical transfers unless they are standby assist or independent. Interview with Staff H on 10/27/20 at 2:35 pm confirmed staff should use a gait belt with all transfers unless they are independent or lift. Stated the facility has a lot of gaitbelts available. Observed Staff transfer Resident #7 on 11/2/20 at 1:25 pm by Hoyer, transfer performed appropriately. Review of gaitbelt policy dated 1/ 2025 states gaitbelts should be used by all staff, to allow for easier handling of residents which should help avoid injuries, both to residents and staff. Firmly grasping the belt in the middle of the resident's back, if the resident begins to lose their balance, draw the resident close to you and ease him/her down with your hold of the gaitbelt. This protects you and the resident from head or body injury.

Based on clinical record review, resident interview, staff interview, pharmacy record review and facility policy review, the facility failed to obtain narcotic pain medication within the first 48 hours of a resident's admission to the facility who entered with a new abdominal surgical wound and failed to intervene with an effective pain intervention to minimize the pain experienced by the resident who described the pain as excruciating, suffering for the first 2 days of admit (Resident #167). The facility failed to provide non-pharmalogical pain interventions for a separate resident (Resident #62); out of 3 residents reviewed for pain management. The facility reported a census of 66 residents. Findings include: 1. The Discharge Return Anticipated (DRA) Minimum Data Set (MDS) assessment dated [DATE] for Resident #167 identified the resident admitted to the facility on [DATE] then transferred to the hospital 9/2/19. The MDS revealed the resident required extensive physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS recorded the presence of a ostomy (a surgically created opening in the abdomen that allows waste or urine to leave the body). The MDS documented [DIAGNOSES REDACTED]. The MDS identified the resident received scheduled pain medication regimen and PRN (as needed) pain medications or offered PRN pain medication declined during the 5 day look back period. The medication section of the MDS recorded the resident received opioid medications on 4 out of 5 days. The admission MDS assessment dated [DATE] identified the resident returned from the hospital on [DATE]. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 13 without signs/symptoms of [MEDICAL CONDITION]. A score of 13 indicated intact cognition. The MDS documented additional [DIAGNOSES REDACTED]. The MDS identified the resident did not receive scheduled pain medication regimen in the 5 day look back period but did receive PRN pain medications or PRN pain medication offered and declined. The MDS pain assessment recorded the resident reported the presence of frequent, severe pain. The MDS documented the presence of a surgical wound. The Care Area Assessment (CAA) Summary identified pain care area triggered. On 8/29/19, the Care Plan identified the use of a [MEDICAL CONDITION] (artificial opening in the abdominal wall so as to bypass a damaged part of the colon) and documented the presence of an ostomy due to perforation of intestine (a hole developed all the way through the intestines). The Care Plan documented the resident experienced acute pain related to surgical wound located midline abdomen and identified the resident used opioid (narcotic pain medication) [MEDICATION NAME] related to pain. The Care Plan informed staff the resident preferred to have pain controlled by medication and instructed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The hospital Discharge Orders printed, 8/29/19 at 12:38 p.m., documented the resident hospitalized [DATE] thru 8/29/19 with primary [DIAGNOSES REDACTED]. The report documented an incision present on the mid-abdomen. The instructions included directives to call the provider for severe uncontrolled pain. The Medication List included the following medicines to be started or continued: a. [MEDICATION NAME] (muscle relaxer) 5 mg (milligrams) by mouth 3 times a day at 12:00 p.m., 5:00 p.m., and 8:00 p.m. (last hospital dose at 12:34 p.m. on 8/29/19). b. [MEDICATION NAME] (migraine medication also known as [MEDICATION NAME]) 6 mg/0.5 ml (milliliter) injection; inject 0.5 ml subcutaneously as needed for migraine. c. [MEDICATION NAME]/[MEDICATION NAME] (narcotic pain medication combined with Tylenol) 7.5/325 mg tablet; 1 tablet by mouth 3 times a day as needed for pain (last hospital dose at 12:25 p.m. on 8/29/19). d. pregabalin (nerve pain medication) 75 mg by mouth 3 times a day at 8:00 a.m., 12:00 p.m., and 8:00 p.m. (last hospital dose at 10:09 a.m. on 8/29/19). The hospital orders contained a section on opioid pain medicine information. The report educated opioids helped to reduce or eliminate pain and when used for short periods of time, they helped a person to: sleep better; do better in physical or occupational therapy; feel better in the first few days after an injury; and recover from surgery. The Progress Notes dated 8/29/19 at 3:41 p.m. recorded the resident admit nursing assessment. The entry documented responses to assessing the residents pain. The resident experienced pain which was worse in the afternoons, felt sharp, and located in the surgical wound on the abdomen. The pain documented as relieved by medication, deep relaxation, and frequent position changes. The assessment noted the resident received scheduled pain medication of [MEDICATION NAME]/[MEDICATION NAME] 7.5 mg/325 mg tablet, 1 tablet by mouth every 8 hours as needed with pain medication effective within 45 minutes. The Progress Notes dated 8/29/19 at 8:08 p.m. documented [MEDICATION NAME] 650 mg PRN given for complaints of mid abdominal pain rated a 5 out of 10 on the pain scale of 0 to 10 (0 = no pain and 10 = worst pain imaginable). On 8/30/19 at 4:56 a.m. the Progress Notes recorded the PRN [MEDICATION NAME] effective with a follow-up pain rating of 3. At 5:31 a.m., the notes recorded [MEDICATION NAME] 650 mg PRN again given to the resident. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 8/30/19 at 5:31 a.m. a pain level of 9 out of 10. On 8/30/19 at 5:54 a.m. the Progress Notes recorded the resident alert and oriented with incision to mid abdomen, staples intact to the upper portion, and lower portion packed. The entry documented the dressing changed, incision cleaned, and new dressing applied. The entry recorded the resident's medications did not arrive from pharmacy and the nurse passed on to the day nurse to contact pharmacy first thing in the morning; [MEDICATION NAME] PRN given twice that shift for pain and a temp of 99.9 degrees. At 9:24 a.m. thru 9:33 a.m., the notes contained multiple entries that recorded several medications not given to the resident as no supply available which included pregabalin. At 9:34 a.m., the notes documented PRN [MEDICATION NAME] effective with some help and continued pain rating of 5 out of 10. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 8/30/19 at 10:39 a.m. a pain level of 8 out of 10. On 8/30/19 at 10:42 p.m. the Progress Notes recorded a daily skilled comprehensive nursing assessment. The entry documented a surgical incision on the abdomen above and below the naval with redness, purulent drainage, foul odor present, and packing lower portion of incision covering with ABD pad (type of dressing). The resident reported experiencing pain with the additional symptoms of anxiety associated with the pain, worse in the morning. The resident reported: the pain located at the sacrum and abdomen; described as splitting, throbbing, and hurt a whole lot; pain relieved by medication, frequent position changes, and distraction; PRN pain medication received; and the pain medication NOT effective. On 8/30/19 at 11:23 a.m. thru 11:24 a.m., the Progress Notes again contained multiple entries that recorded several mediations not given to the resident as no supply available which included [MEDICATION NAME] and pregabalin. At 3:47 p.m. thru 3:49 p.m. the notes again contained multiple entries that recorded several mediations not given to the resident as no supply available which included [MEDICATION NAME]. The Consolidated Delivery Sheets dated 8/30/19 at 5:46 p.m. recorded the pharmacy delivery of medications to the facility. The delivery included [MEDICATION NAME] 10 mg tablet; 33 tablets for Resident #167. The delivery did not contain the ordered medications of [MEDICATION NAME]/[MEDICATION NAME] (combination narcotic pain medication) or pregabalin (the nerve pain medication). The Progress Notes dated 8/31/19 at 3:49 a.m. recorded a daily skilled short note. The note documented an Observation, Evaluation, and Development of Plan of Care, Pain, that recorded the resident rated pain at an 8 and declined PRN Tylenol. On 8/31/19 at 9:27 a.m. the Progress Notes documented pregabalin pain medication to be given 3 times a day not available to give, then at 11:41 a.m. again the notes documented the medication not available to give, and at 8:12 p.m. not available to give. At 8:14 p.m. the notes documented [MEDICATION NAME] 650 mg PRN given for pain. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 8/31/19 at 8:14 p.m. a pain level of 9 out of 10. On 8/31/19 at 9:19 p.m. the Progress Notes recorded the PRN [MEDICATION NAME] ineffective with a follow-up pain scale of 7 and [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg tablet given PRN for severe pain. At 11:06 p.m. the notes recorded the PRN [MEDICATION NAME]/[MEDICATION NAME] effective with a follow-up pain rating of 0. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 9/1/19 at 7:22 a.m. a pain level of 5 out of 10 and on 9/1/19 at 8:31 a.m. a 9 out of 10. On 9/1/19 at 7:57 a.m. the Progress Notes recorded the pregabalin medication not available to give the resident. At 8:31 a.m. the notes documented [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg tablet PRN given for severe pain. The entry recorded medication brought in by the family due to pharmacy not filling prescription because no written script from the provider on file. The entry documented the resident had been suffering from severe pain since admission. The nurse wrote the clinic, on-call (physician), discharging hospital, facility pharmacy, and Rex Pharmacy all contacted the day before to try to resolve the issue but no resolution discovered. The entry documented the facility would use the personal supply of medications from the family until Tuesday (9/3/19) when the primary provider could be contacted. At 12:02 p.m. the notes recorded the pregabalin pain medication not available to give. At 2:07 p.m. the notes recorded a daily skilled comprehensive nursing assessment. The assessment documented the resident experienced abdominal pain increased by movement, worse in the morning, localized due to abdominal incision, felt sharp, and hurt a whole lot. The note recorded the pain relieved by medication, PRN pain med utilized, and PRN effective. At 2:59 p.m. the notes recorded the PRN [MEDICATION NAME]/[MEDICATION NAME] effective with a follow-up pain rating of 4. At 7:07 p.m. the notes recorded [MEDICATION NAME] 650 mg PRN given for a temperature of 100.3 degrees. At 8:21 p.m. the notes recorded the pregabalin not available to give. At 8:21 p.m. the notes recorded [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg tablet given PRN for severe pain. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 9/1/19 at 8:21 p.m. a pain level of 8 out of 10. On 9/1/19 at 8:22 p.m. the Progress Notes recorded the PRN [MEDICATION NAME] effective with a temperature of 99.6 degrees and follow-up pain rating of 6. At 10:52 p.m. the notes recorded the PRN [MEDICATION NAME]/[MEDICATION NAME] effective with follow-up pain rating of 0. On 9/2/19 at 2:01 a.m. the Progress Notes documented the resident's bandage came off and the wound to abdomen with thick purulent drainage with staple that had come loose opening up several dime size areas to the wound. A large red area surrounded the wound, warm to touch, and the resident more lethargic complaining of increased pain. The notes recorded the physician was contacted. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 9/2/19 at 7:20 a.m. a pain level of 6 out of 10. On 9/2/19 at 8:16 a.m. the Progress Notes recorded the pregabalin not available to give. At 10:44 a.m. the notes recorded [MEDICATION NAME] 650 mg PRN given for general discomfort. The Weight and Vitals Summary printed 12/23/19 recorded the resident reported on 9/2/19 at 10:44 a.m. a pain level of 7 out of 10 and on 9/2/19 at 10:55 a.m. a 7 out of 10. On 9/2/19 at 10:55 a.m. the Progress Notes recorded [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg tablet given for severe pain. The entry documented the pills brought in by family due to pharmacy not receiving a written script from the provider. At 11:51 a.m., the notes recorded the resident discharged to the hospital with family present at 11:40 a.m. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED] The (MONTH) 2019 MAR indicated [REDACTED]. On 12/23/19 at 11:36 a.m. Resident # 167 confirmed she had to wait 2 days to get her medicines when she first arrived at the facility even though the hospital called early before she left the hospital. Resident #167 stated the facility did not have any of her medications that were ordered. Resident # 167 commented she had to suffer for 2 days without her medications that should have been available on the first day. Resident #167 expressed she suffered with a lot of pain from her wound and felt Tylenol alone did not cut it. On 12/23/19 at 2:08 p.m. the Administrator responded she would need to check with the DON (Director of Nursing) as she thought Resident # 167 had a history of [REDACTED]. On 12/23/19 at 2:27 p.m. the DON responded she put new admit orders into the computer then Staff B, Registered Nurse (RN)/Unit Manager checked the orders the day of admit then the orders sent to pharmacy for them to go thru and look for allergies [REDACTED]. The DON commented the facility usually received pharmacy deliveries at night and she believed the cut off order time 4:00 p.m. for the facility pharmacy in order to receive medications the same day as ordered except on holidays. The DON reported the facility pharmacy delivered on Saturdays but not Sundays. The DON voiced Resident #167 skilled so she used the facility pharmacy as the facility responsible to provide medications when a resident skilled. The DON responded her expectation if a nurse got an order without a script would be usually make sure she got the orders before a resident arrived then if needed, call the on-call physician to get an order to send to pharmacy for the medication. At 3:37 p.m., the DON responded to question of why she thought the medications did not come with she thought most meds came but things that needed scripts the pharmacy would not send. The DON said she read from the clinical record other pharmacies not able to get the medications and staff not able to pull from the E-kit (Emergency Medication supply) as they couldn't get the narcotic medication out of the kit without prior authorization. On 12/23/19 at 4:20 p.m., Staff C, Licensed Practical Nurse (LPN), reported she worked for 3 years at the facility and since (MONTH) 2019 as an LPN. Staff C recalled Resident #167 and the resident had a lot of pain with the stomach area where the wound vac was. Did not recall caring for the resident when originally admitted [DATE] prior to the wound vac. On 12/24/19 at 7:30 a.m. the DON acknowledged the medications not received timely for Resident # 167 upon her admission. The DON confirmed Resident # 167's medications not received until the next evening following admission, 8/30/19. The DON acknowledged the narcotic pain medication given to the resident on 8/31/19 should not have been given from the supply family brought in. The DON responded she agreed the resident may have needed something stronger than Tylenol medication for the abdominal surgical wound. The DON clarified the surgeon the original prescriber for the narcotic pain medication [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) and thought that was part of the difficulties getting the written script for the pharmacy on that weekend. The DON commented part of the problem with getting the medication related to the county hospital unwilling to provide services for the resident, other pharmacies contacted who said no, and therefore she thought the facility had to wait on the surgeon. The DON responded she thought the family brought the narcotic pain medication from home from Resident # 167's previous home order. The DON commented she had instructed the nurses to destroy some of the narcotic medication due to improper labeling or identification. On 12/24/19 at 8:24 a.m. Staff D, Certified Medication Aide (CMA), recalled working as a med aide at the time Resident #167 resided in the facility. Staff D confirmed there was a medication the facility had difficulty acquiring and stated she just documented the medication not available. Staff D stated she did recall the resident having pain in the stomach area but she did not deal with the medication [MEDICATION NAME]. On 12/24/19 at 9:26 a.m., Staff E, LPN, recalled working with Resident #167 during the resident's original admit. Staff [NAME] recalled the resident did not have her narcotic pain medication as they could not get a hand signed script from the prescribing doctor who was the surgeon. Staff [NAME] stated she called the resident's primary physician, the hospital where the surgery performed, that hospital attempted to track down the surgeon and was not able to get a signed script. Staff [NAME] responded she did not talk to the facility medical director as once she discovered it was the surgeon who ordered the medication, she knew she needed his signature to get the medication from pharmacy. Staff [NAME] stated yes the resident having pain and Resident #167's family member brought the pain med from home. Staff [NAME] explained Resident #167 took the medication previously at home on a routine basis as she had chronic pain and thought that medication was [MEDICATION NAME]. Staff [NAME] stated the usual facility process for obtaining narcotic medication for a newly admitted resident was a script received from the hospital discharge packet. Staff [NAME] said it was a blue script paper and it required a signature from a physician, then sent to pharmacy. Staff [NAME] commented it was nearly impossible to get the signed script for Resident #167's pain medication. Staff [NAME] said she did not know if the difficulties getting the narcotic pain medication related to Resident #167 having a previous home script. Staff [NAME] said it actually happened the first time the resident ever at the facility where the family member had to bring in pain medication for Resident #167. Staff [NAME] stated the family member reluctant to bring medication so only brought a few at a time. Staff [NAME] stated the nurses wrote down the number of pills brought in from the family on a count paper. Staff [NAME] responded the nurses verified the medication in the bottle with the resident's name listed on the bottle and thought pharmacy also verified the medication. Staff [NAME] stated Resident #167 definitely experienced pain and it was sad as she could see the resident in pain and just knew it by looking at her. Staff [NAME] said Resident #167 described her pain as excruciating. Staff [NAME] recalled Resident #167 gripped the rails of the bed during dressing changes as they were so painful. Staff [NAME] responded she did not feel Tylenol enough of a pain med to control the resident's pain. Staff [NAME] commented the resident's abdominal wound large and a person could see right down into the resident's stomach as the wound had dehisced (separation of the incision line prior to complete healing resulting in an open wound). Staff [NAME] said the wound dehiscing was the reason the resident originally admitted to the facility on [DATE] and then the resident rapidly became septic (infected) which lead to the resident going back to the hospital. Staff [NAME] said when Resident #167 returned from the hospital she re-entered the facility with a wound vac to the abdominal surgical wound site. Staff [NAME] commented Resident #167 never talked about not getting her pain medication but if Staff [NAME] were the resident, she would have been upset about not getting the pain medication as Staff [NAME] knew Resident #167 in a lot of pain. On 12/24/19 at 10:01 a.m. Staff F, CMA, recalled working with Resident #167. Staff F said she didn't deal with actual pain medications but knew pharmacy didn't send meds right away and they did take some medications out of the E-kit. Staff [NAME] couldn't recall if it were just the pain medications the facility didn't received. On 12/24/19 at 10:18 a.m. Staff G, LPN, responded she vaguely recalled Resident #167 as she only worked with her 1 time. Staff G refreshed her memory by looking at the resident's progress note completed on 8/30/19 at 10:42 a.m. Staff G confirmed she did assess the resident had pain and believed she recalled the pain located in the abdomen. Staff G did not recall what she did for a pain intervention but stated if she had given a pain medication it would have been reflected in the progress notes. Staff G confirmed she could not find any other notes by her to reflect an intervention performed by her. Staff G stated she did find an entry by Staff F on 8/30/19 at 9:24 a.m. that showed Resident #167 received Tylenol at that time. Staff G could not recall if the Tylenol effective for the resident's pain. Staff G stated she believed the resident hurt the most when getting up. Staff G responded she would expect the CMA to report to her if a resident asked for pain medication but Staff G responsible for conducting pain assessments and interventions. Staff G did not recall if Staff F said anything about Resident #167's pain. The pharmacy Request for Removal of a Controlled Substance From the E-Kit instructed the following process to obtain a narcotic: - Attention: if faxing AFTER HOURS, please contact the pharmacy using emergency procedures (phone # given). - Section to complete for demographics of resident and medication needed. - Section to complete by facility: if a new Schedule 2-5 medication order, before faxing the request, contact the practitioner and request a prescription be faxed to the pharmacy OR a verbal order called to the pharmacy (fax and phone numbers provided); if existing Schedule 2-5 medication order fax the request directly to the pharmacy. - Section for pharmacy to complete authorizing release of the E-Kit supply or not authorizing as pharmacy did not have a valid prescription and the practitioner had not contacted the pharmacy with a faxed or verbal authorization. 2. Resident #62's admission MDS assessment dated [DATE] documented he had intact memory and cognition as evidenced by a BIMS score of 15. The assessment documented [DIAGNOSES REDACTED]. The assessment documented he experienced frequent pain at an 8 of a zero to ten pain scale which did not impair his sleep or limit his daily activities. The MDS documented Resident #62 received as needed pain medications and non-medication interventions for pain. The Care Area Summary of the MDS documented pain as a triggered care area and included in care planning. The resident's Care Plan focus area dated 11/25/19, documented he experienced pain related to a flare-up of gouty arthritis. The interventions instructed to anticipate his need for pain relief and respond immediately to any complaint of pain, to evaluate the effectiveness of pain interventions within one hour of administration and review for compliance, alleviating of symptoms, dosing schedules and his satisfaction with results and impacts on functional ability and cognition, to monitor and document for side effects of pain medication, to monitor, document, and report to nurse as needed any signs or symptoms of nonverbal pain and to notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain. The Care Plan contained no instructions and examples of non-medication interventions to alleviate Resident #62's pain. During interview on 12/16/19 at 3:36 PM, Resident #62 stated he could not remember staff offering non-medication interventions for his pain (like hot packs, ice packs or having his feet up); just medications. The resident stated he tried to keep his feet up and that hospital staff told him to do that. During interview on 12/19/19 at 10:48 AM, Staff A, RN stated the resident receives [MEDICATION NAME] (opiate medication) for pain. Staff A stated the [MEDICATION NAME] seemed to work, but she did not recall any non-medication interventions for his pain. On 12/19/19 at 11:50 AM, the DON stated she thought nurses try non-medication interventions for the resident's pain but they were not added to the care plan. The DON stated a general expectation would be to try position changes, to get a resident up, or use ice or heat before trying medications.

Based on clinical record review and staff and physician interviews, the facility to ensure a resident remained free of significant medication errors for 1 of 4 residents reviewed (Resident #1). On 7/4/19, Resident #1 received medication that was not ordered for her. Due to this error, the resident experienced a life-threatening drop in blood sugar and blood pressure which required treatment in the emergency room (ER) and a subsequent 5 day stay in the Intensive Care Unit (ICU). This caused an Immediate Jeopardy (IJ) to resident health and safety. The facility identified a census of 73 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 4/3/19, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented she had no memory or cognitive impairment, as evidenced by a brief interview for mental status score of 15/15. The assessment documented the resident did not require insulin injections. Resident #1's care plan, updated on 4/8/19, contained no interventions related to diabetes management. The care plan documented she received a regular diet with ground meat. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 7/4/19 at 9:41 am documented an RN (or registered nurse, Staff A, pool nurse) entered the resident's room around 7 a.m. to check her pain level and apply a patch to the resident's back. Resident #1 was alert and oriented x 3 (to person, place and time) and rolled over on request for placement of the patch. Resident #1 had no complaints at the time. A CNA (certified nursing assistant) approached Staff A 10 minutes later stating the resident was concerned about multiple shots she got in her right upper arm. Staff A re-entered the room and told the resident she put applied a patch; no shots were given. Resident #1 told Staff A it wasn't you; okay. The resident got up in her wheelchair per her usual routine and a CNA assisted her to the bathroom. The CNA then approached Staff A to check the resident 5 minutes later. Resident #1 had slumped over in her wheelchair and had unresponsive, dilated pupils. The resident's respiratory rate measured 20 with shallow respirations. Staff A checked the resident's blood sugar and it measured 20 (a very low reading). The resident's blood pressure measured 68/43 (also low), her pulse 95 and regular, and her oxygen saturation measured 95%. Staff gave sugar to the resident on her tongue. Resident #1 spit out small amounts of yellow clear emesis. Staff rechecked her blood sugar and it measured 26. Staff called the physician on-call and received an order to administer [MEDICATION NAME] 1 mg (milligram, to raise blood sugar), obtained the medication from the facility's Emergency kit, and gave it to the resident at 7:48 am. Upon re-check, the resident's blood sugar measured 28. A call was placed to the on-call doctor with receipt of an order to transfer Resident #1 to the ER (emergency room ). Staff notified the resident's son and the Director of Nursing (DON). Resident #1 left the facility at 8:15 am via ambulance. At that she time communicated one word answers and her pupils were responsive. emergency room records dated 7/4/19 documented Resident #1 had a history of [REDACTED]. Resident #1 arrived by ambulance due to a blood glucose of 20 and BP of 50/30 with concerns she may have gotten an insulin shot last night or this morning but was not on insulin. It is possible she was given her roommate's insulin by accident; long acting last night or short acting this morning. The resident did not act normally, did not respond to questions and her blood glucose measured 20. The resident received [MEDICATION NAME] at the nursing home and then medics gave her [MEDICATION NAME] paste and started a [MEDICATION NAME] IV (intravenous solution). Upon arrival, Resident #1's blood glucose measured 130 and her BP 70's/30's. She answered easy questions but acted sleepy. Later, the nursing home called the ER and related the patient accidentally received [MEDICATION NAME] (insulin) last night but did not know if the resident received any other medications that were not her own. The History and Physical section of the hospital records recorded it appeared Resident #1 wrongly got her roommate's insulin yesterday evening, 7/3/19. Resident #1 is a diet-controlled diabetic and does not require any insulin or oral medications. This morning, she was not responsive, had a blood sugar of 20 and a systolic blood pressure of 50. When given [MEDICATION NAME] per the nursing home protocol, she reportedly told staff it was the second injection she got since last night, when is when the error became realized. Resident #1 transported to ER and remained hypotensive (with a low blood pressure) despite fluids. Hospital staff started [MEDICATION NAME] to assist in raising her blood pressure and the resident admitted to the Intensive Care Unit. The Discharge Summary dated 7/9/19 documented Resident #1 slowly improved each day, being slightly more alert and more interactive. She had been off supplemental blood glucose for two days, had improved over five days and was at her mental baseline. Resident #1 returned to the nursing facility on 7/9/19. During interview on 7/10/19 at 2:30 pm, Staff A stated she saw the resident first on 7/4/19 at roughly 6:45. She went in Resident #1's room, asked if she had pain and the resident denied pain. Staff A asked Resident #1 to roll for a pain patch, she obliged, and Staff A changed the patch and did nothing else for her. Staff B, CNA went to get the resident up and called Staff A from the door; the resident said she got a shot in her arm. Staff A went in the room and asked the resident if she remembered application of the pain patch. Resident #1 told her 'you're not the one' and wheeled by; Staff A recalled Staff B being in the room at the time. Staff A reported since this would have been the first or second time she worked the hall, she was unsure if Resident #1 woke up confused or not. Staff A stated she was absolutely sure she did not give the resident a shot. Five or ten minutes later, another CNA asked her to check on Resident #1. The resident was unresponsive, with fixed and dilated pupils, slumped in her chair and with saliva running out of her mouth. Staff A thought the resident was having a stroke. When she checked the resident's blood sugar and the result was 20, she asked another nurse (Staff D) to call the doctor for a [MEDICATION NAME] order. She put sugar in the resident's mouth and obtained [MEDICATION NAME] from the Emergency kit. The resident did not pink up and her blood pressure measured about 60/40, so she asked Staff D to call for ambulance transport. Resident #1 then started to dry heave and she had a respiratory rate of 20 with a pulse oximetry reading of 95% on room air. On 7/10/19 at 3 pm, Staff B, CNA stated she cared for Resident #1 on 7/4/19. Sometime between 6:15 and 6:30 am, Staff A turned the resident's call light on after applying a patch because the resident had been incontinent. Staff B finished assisting another resident and saw Resident #1's light on. Resident #1 informed Staff B a nurse gave her a shot and she wanted to talk to her. Staff B got Staff A, who went back in Resident #1's room. Staff B stated she showed Staff A a spot on the resident's arm. She did not recall Resident #1's denial of Staff A giving her a shot. Staff B then got Resident #1 out of bed, took her to the bathroom, dressed her, and left the room. Resident #1 put her light on and Staff B moved the resident to the sink for morning cares. Staff B stated when she left the room, Resident #1 appeared fine. About 20 minutes later, Staff B returned to the resident's room and found her slumped in her wheelchair, wheeling back and forth into her bed. The resident wouldn't talk to her. She called another CNA, Staff C on the walkie-talkie, got help and asked her to get the nurse. Staff B recalled the resident sweating profusely and it took approximately 15 minutes for Staff A to get there. While Staff C held Resident #1's head up, Staff A checked her blood sugar and then told Staff B to get a food tray. When Staff B returned, Staff A was giving the resident 1 1/2 spoonfuls of sugar. The ambulance came and the resident transported to the hospital. Staff B thought the resident got a shot, but she did not know who may have given it. An undated written statement by Staff D, LPN (licensed practical nurse) as part of the facility's investigation documented he worked on 7/4/19. When Staff A assessed Resident # 1, she asked Staff D's opinion on why Resident #1 had slumped in the wheelchair. He thought it looked like a blood sugar problem. Staff D asked Staff A what first vital sign she took, and Staff A responded blood sugar. Staff D told Staff A to get an order for [REDACTED].#1 got insulin when assisting them and wrote he called the ER later to let staff know he thought insulin was given. During interview on 7/15/19 at 2:15 pm, Staff C recalled receiving a page from Staff B to help in Resident #1's room. She told Staff A then went into the resident's room. Staff B sat on the bed with Resident #1 in her wheelchair. Resident #1 asked where's that nurse? She gave me a shot. The resident's right shoulder had a red bump. Resident #1 said it had been her nurse. They waited a few minutes, got the nurse, and returned to the room. Resident #1 now drooled and had slumped down in the wheelchair and appeared unconscious. Staff C held the resident's head up, Staff B talked her and Staff A asked them to bring the resident to the nurse's station. The resident's blood sugar measured 20. Staff A told her to get sugar from the kitchen gave the resident a spoonful, and her blood sugar next tested 21. Staff A got [MEDICATION NAME], injected the resident and a re-test showed her blood sugar measured 'LO' (too low to register). Staff called paramedics. Staff C took Resident #1 towards her room, but the time they got there the EMTs had arrived. During interview on 7/15/19 at 2:30 pm, Staff F, CNA stated she cared for Resident #1 during the night shift on 7/3/19. She recalled the resident's activity was low that night. Staff F put the resident to bed, assisting her to use the toilet, brushing her teeth, washing her face and helping her to bed. Every night, Resident #1 went to bed at 8:30 pm. She checked on the resident at 9:30 pm and noted she had been incontinent of urine. The resident told Staff F she did not feel well. Staff F checked the resident again at 12:30 pm, when she said she did not need to use the toilet and then at 12:45 am when the resident had incontinence. At 2:30 am, Resident #1 denied needing to use the toilet and had no incontinence. Staff F concluded her shift on 7/4/19 at 3 am. During interview on 7/15/19 at 8:20 am, Staff E, RN remembered caring for Resident #1 the evening and night shifts of 7/3/19. She gave Resident #1 her night time medications about 8:20 pm. The resident lay in bed at the time, awake, alert and swallowing well. Staff [NAME] asked how the resident was doing, and Resident #1 replied she felt okay. Staff [NAME] stated it was the second time she'd given Resident #1 her medications, but she looked the same as when they had first met. The resident had no indications of low blood sugar. Staff [NAME] was sure she did not give the resident any injections. An undated written statement composed by Staff [NAME] as part of the facility's investigation documented 7/3/19 had been a very hard night. She gave Resident #1's roommate her bedtime insulin. She had not worked that side of the building before and asked for resident verification from other staff if she did not know who the residents were. She said pictures in the electronic health record help, but she had to ask for verification for insulin. Staff [NAME] wrote she got into it with a disrespectful aide and that did not help. By the end of her shift, Staff [NAME] felt upset due the shift being non-stop (the EMAR verified Staff F checked the roommate's blood sugar at 8:33 pm and administered long-acting insulin at 8:36 pm). Staff [NAME] was sure she did not give Resident #1 any insulin shots. On 7/15/19 at 3:40 pm, interview with the physician who supervised Resident #1's care in the hospital stated that in his opinion, Resident #1 had no other condition while hospitalized that would have dropped her blood sugars so severely. He thought it probable Resident #1 received insulin not ordered for her. Review of Resident #1's roommate's (Resident #2) clinical record showed she had orders for Detemir insulin 20 units subcutaneously (SQ) every morning and also daily at bedtime. The resident's MDS assessment of 4/24/19 recorded she had a BIMS of 12, indicating moderate memory impairment. On 7/16/19 at 7:35 am, Resident #2 remembered the morning of 7/4/19. She was out of their room having a bath and did not hear Resident #1 report a nurse gave her a shot. When she returned to the room, her roommate lay in bed, out of it and couldn't say anything. Staff got her up in the wheelchair and the girls were concerned. She recalled receiving her insulin shot a bit late the morning of 7/4/19, due to her shower, and the nurse got a new flex pen to administer the injection. Review of her Progress Notes revealed an entry dated 7/5/19 at 3:12 pm that she remembered receiving her medications and injections the evening of 7/3/19 and both she and Resident #1 were in the room at the time. On 7/17/19 at 7:40 am, when asked how agency or pool nurses received training, the DON stated that before the medication error, an experienced staff member would tour the facility with the agency or pool nurses. Training was easier if the agency nurse showed familiarity with the electronic health record (EHR). Only one agency nurse had no experience with the EHR and he had worked with her on it. Most agency and pool staff worked during the day shift, so he asked how they were doing or if anything needed for their work. Contract pool staff agreed to come to the facility for a set time period, like 13 weeks, so their orientation was easier. The facility abated the Immediate Jeopardy on 7/16/19 by implementing the following: 1) Agency staff will go through general orientation process. An orientation checklist will be performed and completed. This checklist will be kept in a binder/folder for reference as needed to show staff was educated on job requirements/duties. Agency staff will be educated on the 5 rights of medication pass (right resident, right med, right dose, right time, right route) as part of their orientation process. 2) Facility nursing staff will be educated on the proper protocols for insulin administration with resident identification stressed. PCC has pictures but NEED TO ASK RESIDENT IDENTIFICATION if unsure. Ask the resident and or other staff if unsure who resident is. This will also be stressed when passing any medication. This will include the 5 rights of passing medication as well. (right resident, right med, right dose, right time, right route) Educations began 7/11/19 with facility nurses and med aides. 3) Staff will be audited on insulin administration as well as general medication administration ensuring proper resident identification takes place as well as proper technique is maintained. This will be done for general medication administration as well. 4) New staff (including Agency staff) will be educated during orientation process prior to caring for residents and passing medications. Education will be provided regarding proper resident identification for all medication administration types followed by medication administration audits as part of their orientation process. This will also include the 5 rights of passing medication (right resident, right med, right dose, right time, and right route) Education began 7/11/19 with facility nurses and med aides and was completed on 7/16/19.

Based on observation, record review, interviews with staff, family and a wound care nurse and review of the facility policy and procedures, the facility failed to promote healing of a pressure sore for 1 of 4 residents reviewed and failed to provide measures to reduce the potential for the development of additional or worsening pressure ulcers for 1 of 4 residents reviewed with pressure sores (Resident #5). The facility identified a census of 75 residents. Findings include: Resident #5 had a Minimum Data Set (MDS) assessment with a reference date of 4/5/17. The MDS indicated Resident #5 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 identified no problems with cognition. The MDS indicated the resident required extensive assistance of staff with bed mobility, transfers and personal hygiene and did not ambulate. The assessment indicated the resident had a bladder indwelling catheter, occasionally incontinent of bowels and at risk for pressure ulcers. The resident had no current ulcer areas and the resident did not have a turning/repositioning program. A Care Plan dated 4/19/17 indicated the resident had problems that included a chronic excoriation to his/her buttock area and at risk for other skin breakdown because of limited mobility and required assistance with his/her activities of daily living (ADL's) because of limited mobility from a [DIAGNOSES REDACTED]. a. I liked to sleep in my recliner, but I had a bed in my room that may have been used for repositioning. b. I had a pressure reduction cushion on my bed and in my wheel chair (w/c). c. I liked to sit in my recliner after lunch. d. ROHO cushion to the recliner. e. I required 2 staff assistance to reposition frequently. f. I used adaptive devices per physical therapy (PT) and occupational therapy (OT) recommendations. Review of Non-Pressure Skin Condition Report forms revealed the following documentation as dated: Right buttock: On 4/26/17 - area closed On 5/3/17 - closed On 5/10/17 - closed On 5/17/17 - closed On. 5/24/17 - 2.0 centimeters (cm) by (x) 2.0 cm, superficial depth, no exudate, tunneling or odor, wound bed with [MEDICATION NAME] and granulation tissue and pink surrounding skin and normal surrounding wound edges. On 5/31/17 - 0.3 cm x 0.3 cm, superficial depth, no exudate, tunneling or odor, wound bed with granulation tissue and pink surrounding skin and normal surrounding wound edges. On 6/7 - 2.6 cm x 2.4 cm, superficial depth, no exudate, tunneling or odor, wound bed with [MEDICATION NAME] and granulation tissue and pink surrounding skin and normal surrounding wound edges. On 6/14/17-13.0 cm x 7.4 cm, superficial depth, a small amount of serosanguinous (blood and serum) exudate, no tunneling or odor, wound bed with [MEDICATION NAME] and granulation tissue and pink surrounding skin and normal surrounding wound edges. Left buttock: On 5/24/17- 2.2 cm x 2.0 cm, superficial depth, no exudate, tunneling or odor, wound bed with [MEDICATION NAME] and granulation tissue and pink surrounding skin and normal surrounding wound edges. On 5/31 - 1.7 cm x 0.4 cm, superficial depth, no exudate, tunneling or odor, wound bed with granulation tissue and pink surrounding skin and normal surrounding wound edges. On 6/7 - 2.8 cm x 1.0 cm, superficial depth, no exudate, tunneling or odor, wound bed with granulation tissue and pink surrounding skin and normal surrounding wound edges. On 6/14 - 8.0 cm x 3.5 cm, superficial depth, a small amount of serosanguinous exudate, no tunneling or odor, wound bed with granulation tissue with pink surrounding skin and normal surrounding wound edges. Review of a Wound Care Consult note dated 6/19/17 at 11 a.m. included the following documentation: The resident had a 13 cm x 13 cm unstageable pressure ulcer on his/her sacrum with the right side having had the most involvement of necrotic tissue. There had been more superficial open areas on the periphery but the 13 cm measured the entire area involved. Staff reported the ulcer area came on very quickly. The patient reported he/she sat in his/her chair much of the time and slept in his/her recliner. The resident had a ROHO cushion in both of the chairs; however, the ROHO cushion in the recliner had been flat in the back right corner of the cushion. Staff reported the cushion flat for a while. Review of a Wound Care Consult note dated 6/19/17 from 11:15 a.m. until 12:00 p.m. included the following documentation: The wound care nurse consulted with 2 physicians upon her/his return to the hospital. One physician felt the resident needed a gastrointestinal and plastic surgery consult but it had been more than he wanted to take on due to the possible involvement of the rectal mucosa. The wound care nurse then spoke with another physician who felt the resident needed a specialist to take care of the issue and felt the patient should have been brought to the emergency room at the local hospital in preparation for a transfer to a larger facility. An Emergency Physician Documentation form dated 6/19/17 at 1:52 p.m. included the following documentation: A [AGE] year old male/female presented to the emergency department (ED) day with a large decubitus ulcer on the buttocks and the peril rectal area. He/she stated that area had gone from a small area of breakdown to the large area of breakdown in about a week. Apparently the area healed up and doing well prior. Not only had there been breakdown of the skin surrounding the rectal area, there appeared to have been involvement of the rectal mucosa as it almost looked like the anus and rectum had been dissected away from the surrounding tissue. Due to his/her MS he/she had been confined to a wheelchair. He/she slept in a recliner at night. The resident also had a ROHO cushion present in both of the chairs but 1 had been partially deflated. A wound assessment in the ED dated 6/19/17 at 1:12 p.m. included the following documentation: A necrotic pressure ulcer that measured 13 cm x 13 cm, depth at full thickness and a scant amount of yellow/tan drainage. The MDS described pressure sores as the following: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. During an interview on 6/23/17 at 12 p.m., the wound care nurse confirmed the following: The wound care nurse received a call on 6/19/17 and reported the resident had a black area on his/her bottom so she asked the staff to lay the resident down. She arrived at the facility, observed the large, black eschar covered wound and felt the area significant and she knew she could not treat the area. The nurse took a picture to show the physicians at the hospital. She then returned to the hospital and consulted with physicians who both agreed the resident needed to have been treated. It was determined the pressure areas could have started 10 days to 2 weeks prior. The wound nurse stated the area had been avoidable as she thought the deflated ROHO cushion caused the injury. She indicated where the right posterior portion of the ROHO cushion had been deflated caused a ridge which resulted in the tissue damage to the anal area and the increase in size of the pressure area. Because of the resident's [MEDICAL CONDITION] related to the MS, the resident had a decline in pain receptors at the site so the facility should have intervened. During an interview 6/27/17 at 2:30 p.m., the Administrator, Director of Nursing (DON) , Corporate Nurse Consultant and Staff A, Registered Nurse (RN) conducted a re-enactment of positioning on a ROHO cushion with a deflated right posterior quadrant at which time the Corporate Nurse Consultant felt the pressure would have been on the resident's left buttock not the right. During an interview 6/27/17 at 2:34 p.m., the wound care nurse confirmed she did not agree with the facilities theory because the resident would have been leaning towards the right side and sitting funny with his/her left side up and right side down which would have caused pressure on the sacral area. The wound care nurse re-iterated the cause of the deterioration in the pressure ulcer area had been caused from the deflated ROHO cushion. During an interview 6/28/17 at 11:16 a.m., a Physician confirmed if the wound care nurse stated the cause of the pressure ulcer had been from the deflated ROHO cushion she believed what she said as the wound care nurse had been right on it and she trusted her judgement. During an interview on 6/23/17 at 11:05 a.m., the DON stated the resident frequently requested the Physical Therapist Assistant (PTA) to check and inflate his/her ROHO cushion in the wheelchair but not the recliner. During an interview 6/27/17 at 1:29 p.m., the Occupational Therapist (OT) confirmed she had not checked the inflation rates on the ROHO cushions utilized in the facility and that it had been the nursing departments responsibility. During an interview 6/27/17 at 12:35 p.m., the PTA confirmed the resident had gone into the therapy room when he/she felt the ROHO cushion in his/her wheelchair had been getting low and he inflated the device, however, he never checked the ROHO in the resident's recliner and had not known he/she had one. The ROHO group shape fitting technology form (not dated) identified Caution areas as follows: a. Deflation: Failure by you to protect cushion or misuse of the cushion could have caused loss of air and resulted in bottoming out and/or pressure sores if not immediately fixed. b. Bottoming out: Failure by you to determine if any part of the individual had been touching the cushion base (too much air released) would decrease therapeutic value of the cushion and could have caused pressure sores. The product must have been adjusted to 1/2 inch (1 cm) of air laid between the support surface and lowest bony prominence. According to a Pressure Ulcer Skin Assessments form dated January 2015, the purpose included the following: a. To promote the healing of pressure ulcers.

Based on observation, record review, resident and staff interviews and review of the policy and procedures, the facility failed to transfer Resident #1 in a safe and secure manner and failed to protect against hazards in the environment which resulted in multiple skin tears and bruising. The sample consisted of 4 residents and the facility reported a census of 75 residents. The Care Card (located in the resident's room) directed the staff to use a Hoyer (mechanical) lift and 2 staff members to transfer the resident. The facility staff member manually lifted the resident from the wheelchair, the resident became uncooperative and obtained skin tears and bruising on the bed side rails of the bed. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 4/19/17. The assessment identified the resident had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated the resident had a severe cognitive impairment. The MDS indicated the resident required extensive assistance of 2 staff members with transfers and did not ambulate. A Care Plan dated 2/15/17 identified the resident at risk for falls. The approaches included the following: The resident required 2 staff to assist with transfers. The resident uses a Hoyer lift (mechanical left) device as needed (PRN). On 6/22/17 (time unknown), observation identified a Care Card hanging in the resident's closet in his/her room. The documentation on the card identified the resident required a Hoyer lift for transfers and the assistance of 2 staff members. An Incident/Accident/Unusual Occurrences Form dated 6/8/17 at 9 p.m. documented the resident was raised with a Hoyer lift device but when the device stopped, he/she started to kick and fight (per the Certified Nursing Assistant (CNA). This resulted in 2 skin tears to the right knee and U shaped. One measured 1 centimeters (cm) X (by) 3.5 cm and the other 1 cm x 6 cm. On 6/9/17 (time unknown) the Assistant Director of Nursing (ADON) spoke with Staff B, CNA who stated the resident was fine until he/she began lifted up in the Hoyer lift. The resident then started freaking out, yelling and flailing his/her arms and kicking his/her legs. The staff member was positioned behind the resident and then went to the side to try and provide safety to the resident. The resident was laid in bed and staff noticed the skin tear to the right knee. The staff indicated the skin tear was from failing. During an interview 6/22/17 at 12:36 p.m., Staff B, CNA confirmed he self transferred the resident independently from the wheel chair (w/c) to the bed without the use of a Hoyer lift device. The staff member stated as he started to transfer the resident, he/she became uncooperative and tried to kick him but ultimately ended up kicking the side rail on the bed which caused the skin tears to the right knee. The resident began to yell help so Staff C entered the room and assisted to position the resident in bed. Staff B stated he was informed the resident utilized a Hoyer lift device PRN and otherwise the resident required 2 person staff assistance with transfers. During an interview on 6/22/17 at 3:25 p.m., Staff C, CNA confirmed she heard the resident yelling for help so she opened the resident's door and observed Staff B as he self transferred the resident to bed without the use of a Hoyer lift device. When the resident observed Staff C he/she kept saying help me, help me. Staff C placed her hands under the resident's thighs and calves as Staff B supported the resident's upper body and positioned the resident in bed at which time she noticed 3 skin tears on the resident's right knee. The staff member confirmed the resident had been strictly a Hoyer lift with all transfers. During an interview on 6/22/17 at 3:25 p.m., Staff C, CNA confirmed the resident as strictly a Hoyer lift for all transfers. During an interview on 6/28/17 at 1:18 p.m., Staff D, CNA confirmed the resident required a Hoyer lift for all transfers. During an interview on 6/28/17 at 4:23 p.m., Staff E, CNA confirmed the resident required a Hoyer lift for all transfers. Review of Non-Pressure Skin Condition Report forms identified the following documentation as dated: On 6/8/17- A skin tear on the resident's right knee measured 6 cm, with no depth, a scant amount of serosanguinous drainage, no odor, normal skin in the wound bed and normal surrounding skin and wound edges. On 6/8/17- A skin tear on the resident's right knee that measured 3.5 cm, with no depth, a scant amount of serosanguinous drainage, no odor, normal skin in the wound bed and normal surrounding skin and wound edges. On 6/9/17- A skin tear on the resident's right middle knee that measured 2.5 cm x 0.1 cm, with no depth, no drainage, no odor, bruised surrounding skin and peripheral tissue edema on the wound edges. On 6/9/17-A bruise on the resident's left inner forearm measured 7.8 cm x 8.6 cm, with no depth, drainage or odor and normal surrounding skin and wound edges. On 6/9/17- a bruise on the resident's left upper arm measured 5.4 cm x 4.1 cm, with no depth, drainage or odor and normal surrounding skin and wound edges. On 6/9/17- A bruise on the resident's left inner wrist measured 1.6 cm x 4.0 cm, with no depth, drainage or odor and normal surrounding skin and wound edges. On 6/12/17- A bruise on the resident's left shin measured 20.6 cm x 25.2 cm, with no depth, drainage or odor and normal surrounding skin and wound edges. On 6/12/17 - A bruise on the resident's right upper arm that measured 1.9 cm x 3.9 cm, with no depth, drainage or odor and normal wound bed, surrounding skin and wound edges. On 6/12/17- A bruise on the resident's posterior upper right leg that measured 5.9 cm x 0.8 cm, with no depth, drainage or odor and normal wound bed, surrounding skin and wound edges. On 6/12/17- A bruise on the resident's right shin that measured 10.5 cm x 4.3 cm, with no depth, drainage or odor and normal wound bed, surrounding skin and wound edges. On 6/12/17- A bruise on the resident's right lower wrist measured 3.9 x 3.9 cm, with no depth, drainage or odor and normal wound bed, surrounding skin and wound edges. During an interview on 6/28/17 at 12:45 p.m., the Director of Nursing (DON) confirmed she felt all bruising from 6/9/17 and 6/12/17 had been a result of the staff member self transferring the resident on 6/8/17. The facility policy and procedures titled Lift - Mechanical, dated January 2015, the purpose of the mechanical lift is to provide a safe transfer for non-ambulatory residents.