Every finding on record at Avoca Specialty Care

Based on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for 4 of 6 Residents (Resident #4, #25, #23, and #33) reviewed. The facility reported a census of 33. Findings include:1. Review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed an admission to the facility from a short-term general hospital stay on 1/9/26. The MDS further revealed diagnoses of anxiety disorder, and depression. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order with a start date of 2/10/26 for Buspirone HCL oral tablet (antianxiety). Give 1 tablet by mouth in the morning. Review of Resident #4's Care Plan with a revision date of 1/20/26 revealed no documentation of antianxiety medication. 2. Review of Resident #25's MDS dated [DATE] revealed an admission to the facility from a skilled nursing facility on 10/26/23. The MDS further revealed Resident #25 utilized antianxiety, and diuretic medication during the look back period. Review of Resident #25's EHR page titled, Clinical Physician Orders revealed orders for: a. Lorazepam oral tablet 0.5mg (antianxiety). Give 1 tablet by mouth one time a day. b. Lasix oral tablet 20mg (Diuretic). Give 1.5 tablets by mouth in the morning every Tuesday, Thursday, Saturday, and Sunday. Review of Resident #25's Care Plan with a revision date of 3/2/26 revealed no documentation of antianxiety, or diuretic medications. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #23 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS documented Resident #34 had diagnoses of chronic kidney disease, urinary tract infection, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified dementia, moderate with behavioral disturbance and depression. Review of Resident #23's Electronic Health Record (EHR) titled, Care Plan indicated no focus, goal or interventions related to opioid use, pain or antipsychotic medication. Review of Resident #23 Electronic Health Records (EHR) titled, Orders documented a physician's order with a start date of 1/14/26 for Rexulti oral tablet 0.25 mg give 0.5 mg by mouth one time a day for dementia with behaviors and a physician's order with a start date of 12/11/25 for oxycodone-acetaminophen 7.5-325 mg give one tablet by mouth 3 times a day for pain. Review of Resident #23 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented a physician's order with a start date of 1/14/26 for Rexulti oral tablet 0.25 mg give 0.5 mg by mouth one time a day for dementia with behaviors and a physician's order with a start date of 12/11/25 for oxycodone-acetaminophen 7.5-325 mg give one tablet by mouth 3 times a day for pain. 4. The MDS dated [DATE] for Resident #33 documented a BIMS of 12 indicating moderate cognitive impairment. The MDS documented Resident #33 had diagnoses of malignant neoplasm of breast, malaise, weakness and failure to thrive. On 3/2/26 at 12:02 PM Resident #33 stated she had back pain that the medication was not helping Review of Resident #33's EHR titled, Care Plan indicated no focus, goal or interventions related to opioid use or pain. Review of Resident #33 Electronic Health Records (EHR) titled, Orders documented a physician's order with a start date of 12/27/25 for oxycodone oral capsule 5 mg to give 5mg by mouth 3 times a day for pain. Review of Resident #33 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented a physician's order with a start date of 12/27/25 for oxycodone oral capsule 5 mg to give 5mg by mouth 3 times a day for pain. On 3/3/26 3:47 PM Staff A, MDS coordinator stated pain and or opioid use should be identified on Resident #33's care plan because Resident #33 was on an opioid. Staff A acknowledged there was no care plan identified for use of an opioid, pain and for Resident #33 and there should have been. Staff A, MDS coordinator stated antipsychotic, pain and or opioid should be identified on Resident #23's care plan because Resident #23 was on an antipsychotic and an opioid. Staff A acknowledged there was no care plan identified for use of an antipsychotic, opioid or pain for Resident #23 and there should have been. Staff A acknowledged Resident #4 did not have a care plan that included a focus, goal or interventions for use of an antianxiety medication and Resident #4 had a physician's order for an anti-anxiety medication. Staff A explained Resident #25 did not have a care plan that included a focus, goal or interventions use of a diuretic or anxiety medication on her care plan and utilized both. On 3/3/26 at 4:21 PM the DON acknowledged an opioid and / or pain should be on Resident #33's care plan because she had a physician's order for an opioid and was not. The DON acknowledged Resident #23 utilized antipsychotic and opioid as a medication. The DON stated antipsychotic, opioid and / or pain should be documented on Resident #23's care plan and was not. The DON acknowledged Resident #4 did not have a care plan that included a focus, goal or interventions for use of an antianxiety medication and Resident #4 utilized an anti-anxiety medication. The DON stated Resident #25 did not have a care plan that included a focus, goal or interventions use of a diuretic or anxiety medication on her care plan and utilized both. Review of a policy revised 12/16 titled, Care Plans, Comprehensive Person-Centered documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems and reflect currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on facility document review, clinical record review, resident interview, family interview and staff interviews, the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner and not responding to a request for toileting in a timely manner for 3 of 16 resident reviewed (Resident #10, #33, and #34). The facility reported a census of 33 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 3/4/26 at 2:02 PM Resident #10 stated during the resident council meeting that call lights took longer than 15 minutes to be answered. Resident #10 explained there was only 1 Certified Nurse Assistant (CNA) last night on the pm shift. Resident #10 stated it took longer than 30 minutes last night for his call light to be answered. 2. The MDS dated [DATE] for Resident #33 documented a BIMS of 12 indicating moderate cognitive impairment. The MDS documented Resident #33 had diagnoses of malignant neoplasm of breast, malaise, weakness and failure to thrive.On 3/2/26 at 11:46 AM Resident #33 stated at the lunch hour it can be longer than 15 minutes to answer her call light. Resident #33 explained this had occurred in the last week or two. Resident #33 explained it could at times take up to 30 minutes. Resident #33 explained in the last 2 weeks there was only one CNA on the floor and once there was no staff and the nurses had to get her ready. 3. The MDS dated [DATE] for Resident #34 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented Resident #34 had a diagnosis of obesity. On 3/2/26 at 1:02 PM Resident #34 explained he had sat in his chair for longer than 2 or 3 hours waiting for staff to assist him to bed after turning the call light on. Resident #34 said sometimes he will have to turn the call light on multiple times, sometimes it helps, sometimes it doesn't. 4. On 3/5/26 at 1:59 PM Resident #15's husband stated he was at the facility over the last weekend and a resident that was sitting with them in the day room requested to use the toilet and it had taken an hour once for the staff to take the resident to the restroom. On 3/4/26 at 4:27 PM Staff E, Certified Medication Assistant (CMA) / CNA explained last night she had only one nurse working as a CNA on the floor with her last night. Staff E stated it can be a struggle sometimes with staffing at the facility and providing care to the residents in a timely manner. Staff E stated at times the call lights last longer than 15 minutes to be answered. Staff E acknowledged there were probably call lights that lasted longer than 15 minutes the night before. On 3/3/26 at 11:56 AM Staff F, Certified Nurse Assistant (CNA) stated she had worked a 6:00 AM - 2:00 PM shift with only one other CNA and 2 nurse or 1 nurse / 1 Certified Medication Assistant (CMA). Review of documents titled, Grievance/Concern investigation Form revealed on 1/7/26 Resident #15 sat in bed for 25 minutes with the call light on to use the commode. Resident #15 indicated that it had happened between 1:00 PM - 10:00 PM several times. On 2/6/26 Resident #14 explained she had been timing call lights and waited 30 minutes.Review of Quarter 4 nurse staffing schedule documented:7/4/25 10:00 PM - 6:00 AM 1 CNA and 2 nurses7/5/25 6:00 AM - 2:00 PM 2 CNA's and 2 nurses7/6/25 6:00 AM - 2:00 PM 2 CNA's and 2 nurses7/10/25 10:00 PM - 6:00 AM 1 CNA and 2 nurses7/12/25 6:00 AM - 2:00 PM 2 CNA's and 2 nurses7/13/25 6:00 AM - 2:00 PM 2 CNA's and 2 nurses7/27/25 6:00AM - 2:00 PM 1 nurse 0 CMA and 3 CNA's7/27/25 10:00 PM - 6:00 AM 1 CNA and 2 nurses7/29/25 10:00 PM - 6:00 AM 1 CNA and 2 nurses8/2/25 6:00AM - 2:00 PM 1 nurse 0 CMA and 3 CNAs8/2/25 2:00PM - 10:00 PM 1 nurse 0 CMA and 2 CNA's8/3/25 2:00PM - 10:00 PM 1 nurse 0 CMA and 2 CNA's8/8/25 2:00PM - 10:00 PM 1 nurse 0 CMA and 2 CNA's8/16/25 2:00PM - 10:00 PM 1 nurse 0 CMA and 2 CNA's8/17/25 6:00AM - 2:00 PM 1 nurse 0 CMA and 2 CNA's9/9/25 6:00 AM - 2:00 PM 2 CNA and 2 nurses9/18/25 6:00 AM - 2:00 PM 2 CNA and 2 nurses9/26/25 2:00 PM - 10:00 PM 1 CNA and 2 nurses9/27/25 2:00 PM - 10:00 PM 1 nurse and 2 CNA's1/30/26 6:00 - 2:00 PM 2 CNA's and 2 nurses2/4/26 10:00 PM - 6:00 AM 1 CNA and 2 nurses2/8/26 6:00 - 2:00 PM 1 nurse and 3 CNA'sOn 3/3/26 at 12:21 PM the Director of Nursing (DON) said when the facility was under 30 residents for a census she tried to have 3 CNA's on day shift, 2 CNA's on PM shift and 2 CNA's on the Overnight shift 2. The DON stated if there are more than 30 residents for a census she would like 4 CNA but ran with 3 CNA in the morning. The DON explained on the pm shift 2:00 PM - 10:00 PM 1 nurse and 2 CNA's would work but the nurse would be busy and the CNA's could do it but it was not ideal. The DON stated it probably has happened since she had worked at the faculty. The DON stated the facility assessment had a Per Patient Day (PPD) was 3.54. The DON acknowledged the facility was under the PPD minimum at times. On 3/5/26 at 2:52 PM the DON stated that one or two days that were presented might not have been ideal but the residents' needs were being met. The DON explained in a facility like this, the facility census does not fluctuate that much. The DON acknowledged the national average PPD was 3.1 and the facility has more than that average. The DON explained 3.1 for the PPD would also be the minimum staffing for the facility. The DON stated she felt that 3 staff total were enough for the PM shift on 3/3/26.

Based on clinical record review, staff interviews, and policy review the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications for 5 of 5 sampled residents reviewed (Resident #4, #8, #25, #23, and #33). The facility reported a census of 33 residents.Findings include: 1. Review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. The MDS further revealed Resident #4 utilized antipsychotic, and antidepressant medication during the seven day look back period. Review of Resident #4's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for antianxiety medication with no antipsychotic medication listed. Further review of the Clinical Physician Orders revealed an order for Buspirone HCL oral tablet 10 MG (Antianxiety medication). Give 1 tablet by mouth in the morning. The Clinical Physician Orders further revealed an order for Venlafaxine HCl Oral Tablet 100 MG (antidepressant) Give 1 tablet by mouth twice a day. There were no antipsychotic medications listed. Review of Resident #4's Care Plan with a revision date of 1/20/26 lacked non-pharmacological interventions for antianxiety, and antidepressant medications. 2. Review of Resident #8's MDS dated [DATE] revealed Resident #8 had a BIMS score of 9 indicating moderate cognitive impairment. The MDS further revealed Resident #8 utilized antipsychotic, antianxiety, and antidepressant medications during the seven day look back period. Review of Resident #8's EHR page titled, Clinical Physician Orders revealed the following orders: a. Risperidone Oral Tablet 2 MG (antipsychotic). Give 2 MG by mouth one time a day. b. Clonazepam Tablet 0.5 MG (antianxiety). Give 1 tablet by mouth two times a day. c. Escitalopram Oxalate Tablet 10 MG. Give 1.5 tablets by mouth one time a day. Review of Resident #8's Care Plan with a revision date of 3/2/26 lacked non-pharmacological interventions for antipsychotic, antianxiety, and antidepressant medications. 3. Review of Resident #25's MDS dated [DATE] revealed Resident #25 had a BIMS score of 15 indicating intact cognitive functioning. The MDS further revealed Resident #25 utilized antianxiety, antidepressant, and hypnotic medications during the seven day look back period. Review of Resident #25's EHR page titled, Clinical Physician Orders revealed the following orders: a. Lorazepam Oral Tablet 0.5 MG (antianxiety). Given 1 tablet by mouth daily. b. Paroxetine HCl Tablet 20 MG (antidepressant). Give 1 tablet by mouth daily. c. Zolpidem Tartrate Oral Tablet 5 MG (Hypnotic). Give 5 mg by mouth daily. Review of Resident #25's Care Plan with a revision date of 1/2/26 lacked non-pharmacological intervention for antianxiety, antidepressant, and hypnotic medications. 4. The Minimum Data Set (MDS) dated [DATE] for Resident #23 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS documented Resident #34 had diagnoses of chronic kidney disease, urinary tract infection, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified dementia, moderate with behavioral disturbance and depression. Review of Resident #23's Electronic Health Record (EHR) titled, Care Plan indicated no individualized behaviors or non-pharmacological interventions in place for the use of antidepressants or antipsychotics. Review of Resident #23 Electronic Health Records (EHR) titled, Orders documented a physician's order with a start date of 1/14/26 for rexulti oral tablet 0.25 mg give 0.5 mg by mouth one time a day for dementia with behaviors, a physician's order with a start date of 1/22/26 for venlafaxine ER oral tablet to give 37.5 mg by mouth one time a day and a physician's order with a start date of 10/17/25 for sertraline oral capsule 150 mg to give one capsule by mouth at bed time. Review of Resident #23 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented a physician's order with a start date of 1/14/26 for rexulti oral tablet 0.25 mg give 0.5 mg by mouth one time a day for dementia with behaviors, a physician's order with a start date of 1/22/26 for venlafaxine ER oral tablet to give 37.5 mg by mouth one time a day and a physician's order with a start date of 10/17/25 for sertraline oral capsule 150 mg to give one capsule by mouth at bed time. 5. The MDS dated [DATE] for Resident #33 documented a BIMS of 12 indicating moderate cognitive impairment. The MDS documented Resident #33 had diagnoses of major depressive disorder without psychotic features, malaise, weakness and failure to thrive. Review of Resident #33's EHR titled, Care Plan indicated no individualized behaviors or non-pharmacological interventions in place for the use of antidepressants. Review of Resident #33 Electronic Health Records (EHR) titled, Orders documented a physician's order with a start date of 2/6/26 for lamotrigine oral tablet 25 mg to give 1 tablet by mouth one time a day for depression, a physician's order with at start date of 2/3/26 for sertraline oral capsule 200 mg to give 1 capsule by mouth at bed time related to major depressive disorder and a physician's order with a start date of 4/25/25 for clonazepam oral tablet 1 mg to give 1 tablet by mouth 3 times a day related to major depressive disorder. Review of Resident #33 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented a physician's order with a start date of 2/6/26 for lamotrigine oral tablet 25 mg to give 1 tablet by mouth one time a day for depression, a physician's order with at start date of 2/3/26 for sertraline oral capsule 200 mg to give 1 capsule by mouth at bed time related to major depressive disorder and a physician's order with a start date of 4/25/25 for clonazepam oral tablet 1 mg to give 1 tablet by mouth 3 times a day related to major depressive disorder. On 3/3/26 at 3:47 PM Staff A, MDS coordinator acknowledged Resident #4, #8, #23, #25 and #33 should have individualized behaviors and non-pharmacological interventions included in their care plans when the resident utilized medications such as anti-anxiety, antidepressants, antipsychotic, and opioids and did not. On 3/3/26 at 4:21 PM the DON explained Resident #4, #8, #23, #25 and #33 should have individualized behaviors and non-pharmacological interventions included in their care plans when the resident utilized medications such as anti-anxiety, antidepressants, antipsychotic, and opioids. The DON acknowledged Resident #4, #8, #23, #25, and #33 did not have individualized behaviors or non-pharmacological interventions in place when indicated on their care plans. Review of a policy revised 12/16 titled, Care Plans, Comprehensive Person-Centered documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems and reflect currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on clinical record review, staff interviews, and facility policy review the facility failed to verify the resident's advanced directive choice documented accurately for 1(Resident #7) of 16 residents reviewed. The facility reported a census of 33 residents. Findings include:Resident #7's Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) Order Declaration Form, signed by the resident [DATE] and signed by the physician [DATE], documented DNR. The Clinical Resident Profile, in the electronic health record (EHR), for Resident #7, dated [DATE], revealed a code status of CPR. The Clinical Physician Orders form for Resident #7, dated [DATE], documented a physician's order, revision date of [DATE], for CPR. Interview on [DATE] at 2:12 PM, Staff C, Registered Nurse stated in the event of an emergency with a resident she would check for the resident's advanced directive choice in the resident's electronic health record. Staff C stated she was not aware if the facility had an Advanced Directives book to check the residents' code status. Interview on [DATE] at 2:50 PM, the Director of Nursing confirmed the records did not match and stated the expectation for the CPR and DNR Order Declaration Form and EHR to be accurate and match. Facility Advanced Directives policy, revised [DATE], documented upon admission the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an advanced directive and information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on clinical record review, staff interviews, and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) for 3 of 5 residents (Resident #25, #5, #33) reviewed. The facility reported a census of 33 residents. Findings include: 1. Review of Resident #25's Minimum Data Set (MDS) dated [DATE] revealed Resident #25 utilized antipsychotic medication during the look back period. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician's Orders revealed no orders for antipsychotic medications. 2. The MDS dated [DATE] for Resident #5 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS further documented placement of an indwelling catheter. On 3/3/26 at 8:31 AM Resident #5 stated he had never had a catheter. On 3/3/26 at 1:34 PM Resident #5's son stated his dad was at the hospital for a severe bladder infection. Resident #5 stated his dad never had a catheter that he remembered. Review of Resident #5's Electronic Health Record (EHR) titled, Care Plan documented no focus, goal, or interventions since admission related to placement of a catheter. Review of Resident #5's EHR titled, Progress Note dated 1/6/26 at 12:27 PM entered by the DON documented no catheter at time of admission. Review of Resident #5 Electronic Health Records (EHR) titled, Orders documented no physician's order for catheter placement. Review of Resident #5 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented no physician's order for catheter placement. On 3/4/26 at 8:41 AM Staff A, MDS Coordinator acknowledged she had incorrectly documented Resident #5 had an indwelling catheter on the MDS dated [DATE]. On 3/4/26 at 8:35 AM the DON explained Resident #5 had never had a catheter since admission to the facility on 1/5/26. The DON acknowledged Resident #5's MDS dated [DATE] incorrectly documented that Resident #5 had an indwelling catheter. 3. The MDS dated [DATE] for Resident #33 documented a BIMS of 12 indicating moderate cognitive impairment. The MDS documented Resident #33 utilized an antipsychotic medication. Review of Resident #33's EHR titled, Care Plan documented no focus, goal, or interventions since admission related to use of an antipsychotic medication. Review of Resident #33 Electronic Health Records (EHR) titled, Orders documented no physician's order for an antipsychotic medication. Review of Resident #33 Medication Administration Records - Treatment Administration Records (MAR-TAR) documented no physician's order for an antipsychotic medication. On 3/3/26 at 3:47 PM Staff A, MDS Coordinator stated Resident #33 was not on any antipsychotic. Staff A explained she must have mistakenly coded the MDS incorrectly when looking at the Lamotrigine for Resident #33. On 3/3/26 at 4:21 PM the DON acknowledged Resident #33 was not on an antipsychotic. The DON acknowledged possible coding issues on the MDS. Review of a policy revised 11/19 titled, Certifying Accuracy of the Resident Assessment documented any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action.

Based on clinical record review, staff interview, and policy review the facility failed to Incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination and the PASRR evaluation report into a resident's care plan for 1 (Resident #13) of 3 resident reviewed. The facility reported a census of 33 residents. Findings include: The Minimum Data Set assessment for Resident #13, dated 2/6/26, included diagnoses of schizophrenia, anxiety disorder, and depression. Resident #13's Notice of PASRR Level II Outcome, dated 1/21/26, revealed the resident required specialized services for ongoing psychiatric medication management by a psychiatrist and rehabilitative services of supportive counseling. Resident #13's Care Plan, with a target date of 5/7/26, lacked documentation of PASRR specialized services. Interview on 3/4/26 at 4:00 PM, the Director of Nursing stated the expectation for specialized services to be included in the resident's care plan. Facility Comprehensive Person-Centered Care Plans Policy, revised December 2016, revealed the comprehensive person-centered care plan will describe any specialized services to be provided as a result of PASRR recommendations.

Based on observation, prescription package insert review, clinical record review, staff interviews, and policy review the facility failed to meet professional standards of care when administering insulin to one (Resident #24) of one residents reviewed. The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #24, dated 12/12/25 included a diagnosis of Diabetes Mellitus and documented the resident received insulin. Observation on 3/4/26 at 11:25 AM, Staff A, MDS Coordinator drew up 4 units of Novolog Aspart insulin, from a multi-use vial (bottle) of insulin, into a syringe and administered the insulin by injection to Resident #24. The vial was labeled with an open date of 1/19/26. Interview on 3/4/26, the MDS Coordinator stated she thought the insulin was good for 30 days, maybe 90 days. Package Insert/Prescribing Information for Insulin Aspart Injection, updated 3/10/25, revealed multi-dose vial storage date of 28 days after opened. Facility Insulin Administration Policy, revised September 2014, revealed in steps in the procedure for insulin injections via syringe to check expiration date, if drawing from a multi-dose vial, and if opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). Interview on 3/4/26 at 4:00 PM, the Director of Nursing stated the vial of insulin was only good for 28 days after opened and the expectation that the insulin needs to be disposed of 28 days after the open date.

Based on clinical record review, resident and staff interviews, and policy review the facility failed to ensure residents received showers to maintain good personal hygiene for 2 (Residents #7 and #34) of 3 residents reviewed. The facility reported a census of 33 residents. Findings include:1. The Minimum Data Set (MDS) assessment for Resident #7, dated 12/26/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. Interview on 3/2/26 at 12:57 PM, Resident #7 revealed that she does not get baths twice a week. Resident #7 further stated she would like to have her baths twice a week, but there is only one bath aide at the facility and she can't get to every bath during her shift. Review of Resident #7's clinical record task form for showers, dated 3/3/26, for a 30 day period from 2/4/26 - 3/3/25, showers were documented as completed for 5 days: 2/5, 2/7, 2/11, 2/18, and 2/25. The task form documented the resident was to receive a shower on Wednesdays and Saturdays. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #34 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented it was very important to choose between a tub bath, shower, bed bath, or spine bath Resident #34. The MDS also documented the ability for Resident #34 to shower or bathe self was not attempted due to medical condition or safety concerns. On 3/2/26 at 12:55 PM Resident #34 stated he had only received a bed bath since he had been admitted to the facility. Resident #34 explained that he did not always get 2 baths a week as he was supposed to either. Review of Resident #34's Care Plan dated 1/21/26 documented an intervention for bathing that Resident #34 was dependent on 2 staff for assistance. Review of Resident #34's EHR titled, ADL Self Care - Shower/Bathe self Tuesday and Friday documented Resident #34 was dependent and the helper did all the effort and the bath was completed on 2/3, 2/20, and 2/24 between the dates of 2/3/26 - 3/3/26. Review of document dated 3/5/26 titled, Follow Up Question Report ADL Self Care Shower/Bathe Self Tuesday and Friday provided by the DON documented bathing was completed 2/20, 2/24 and 3/3 between the dates of 2/5/26 - 3/5/26. On 3/3/26 at 11:56 AM Staff F, Certified Nurse Assistant (CNA) stated residents are supposed to get baths at least twice a week. Staff F stated there was not a bath aide at the facility but she wanted to be the bath aide and completed most of the baths on the am shift. Staff F acknowledged residents at the facility missed baths sometimes and they were not made up. Staff F explained some residents only want one bath a week. Staff F stated she would document the resident refusal and there is a form that they put the refusal on. Staff F explained the nurse was given the form and then would ask the resident over the next couple days. Staff F explained if there was only one CNA and her then the baths would not get completed and the pm shift would have to complete them. Staff F stated she had never given Resident #34 a shower. Staff F explained she had only given Resident #34 a bed bath. Staff F thought maybe some staff had one time given Resident #34 an actual shower. Staff F stated the facility had ordered Resident #34 more slings so he can get in the shower. Staff F said there were only 2 slings at the facility that were the correct size for Resident #34. Staff F explained there were 2 residents at the facility that required a sling of that size. Staff F stated Resident #34 did not get showers because the facility does not have enough slings to give him a shower. Staff F acknowledged there were 2 residents that required that size slings. On 3/3/26 at 12:21 PM the DON stated she had worked at the facility since the last week of February. The DON stated if baths are missed then staff would attempt the next shift and then the next day. The DON stated unfortunately baths are missed at times and not made up. The DON explained the residents are scheduled to have a bath at least twice a week. The DON stated the bath sheet was supposed to be put under her door or Staff A, MDS Coordinator's door daily. The DON stated the baths that were missed were highlighted and moved it over on the graph to the next day. The DON acknowledged baths are missed and not made up. The DON stated the refusal should be documented on a piece of paper or in POC in the resident's EHR. On 3/5/26 at 2:35 PM the Administrator stated she had just been made aware that Resident #34 had not been given showers but only bed baths at the facility. The Administrator stated she would expect that showers would have been available to get in the last month. The Administrator explained residents at the facility should get at least 2 showers a week unless they refused the shower and that should be recorded / documented. Review of a policy revised 2/18 titled, Bath, Shower/Tub documented the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation should include the date and time the shower / tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath. All assessment data of the resident's skin obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. The staff are to notify the supervisor if the resident refuses the shower/tub bath and report any other information in accordance with facility policy and professional standards of practice.

Based on clinical record review, staff interviews, and policy review the facility failed to revise and implement care plans for 1 of 4 residents (Resident #4) reviewed. The facility reported a census of 33 residents. Findings include: Review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed Resident #4 utilized antipsychotic medications during the seven day look back period. Review of Resident #4's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed order for antianxiety medication with no antipsychotic medication listed. Further review of the Clinical Physician Orders revealed an order for Buspirone HCL oral tablet 10 MG (Antianxiety medication). Give 1 tablet by mouth in the morning. There was no antipsychotic medication listed. Review of Resident #4's Care Plan with a revision date of 1/20/26 revealed #4 was utilizing antipsychotic medications. The Care Plan further revealed that antianxiety medications were not listed. Interview on 3/3/26 at 3:47 PM with the MDS coordinator confirmed Resident #4 was not taking antipsychotic medication, and actually taking antianxiety medication. The MDS coordinator further revealed that the care plan should have been updated as this would be her expectation. Interview on 3/3/26 at 4:22 PM with the Director of Nursing (DON) confirmed that Resident #4 was on anti-anxiety medication, and this was not on the care plan. The DON further revealed that Resident #4's antipsychotic medication should not be on the care plan, and that care plans should be updated and revised in an appropriate time frame. The DON revealed her expectation would be for care plans to be revised and developed accordingly. Review of a facility provided policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed:a. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, clinical record review, resident interview, staff interviews and policy review the facility failed to provide respiratory services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #34) who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The facility failed to have an order for the CPAP and failed to clean the CPAP. The facility reported a census of 33 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #34 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #34 had a diagnosis of obstructive sleep apnea.On 3/2/26 at 3:38 PM Resident #34 stated he had not had his CPAP machine or mask cleaned by the staff since admission to the facility. Review of Resident #34's Electronic Health Record (EHR) documented no physician's order for use of a CPAP machine or any orders to clean Resident #34's CPAP machine / mask.On 3/4/26 at 4:21 PM Staff D, Certified Nurse Assistant (CNA) stated she had seen a CPAP machine in Resident #34. Staff D stated Resident #34 was usually awake when she left at 10:00 PM so she had never assisted him in the application of the mask. On 3/4/26 at 4:27 PM Staff E, Certified Medication Assistant (CMA) / CNA stated she had worked with Resident #34 several times. Staff E stated she had seen the CPAP machine in Resident #34's room but had never seen him use the CPAP machine. On 3/4/26 at 4:31 PM Staff A, MDS Coordinator stated Resident #34 does wear a CPAP mask at night. Staff A explained that usually there was an order on the Treatment Administration Record (TAR) for cleaning the CPAP machine. Staff A acknowledged Resident #34 did not have an order for use of a CPAP machine or cleaning of a CPAP machine or mask on his TAR. Staff A stated she was not sure who was supposed to clean Resident #34's CPAP. Staff A acknowledged she had never cleaned Resident #34's CPAP machine or mask. On 3/4/26 at 5:01 PM the DON stated Resident #34 should have a physician's order for the use of a CPAP machine and an order for the CPAP machine / mask to be cleaned. The DON explained the CPAP was usually cleaned on the am shift to allow time for the equipment to dry. The DON acknowledged Resident #34 had no physician's order for the use of the CPAP machine and no order for cleaning the CPAP machine / mask on the TAR. Review of a policy revised 3/15 titled, CPAP/BiPAP Support documented the purpose of the policy was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. In preparation, review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure for the CPAP machine. General guidelines for cleaning include obtaining from the manufacturer / supplier of the CPAP device specific cleaning instructions. When cleaning the CPAP machine wipe the machine with warm, soapy water and rise at least once a week and as needed. Masks would be cleaned daily by placing them in warm, soapy water and soaking for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Documentation for use of CPAP in the resident's medical record would include a general assessment prior to procedure, time CPAP was started with duration of therapy, mode and settings for CPAP, how the resident tolerated the procedure.

Based on observation, clinical record review, staff interview and policy review the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter for 1 of 3 reviewed (Resident #10). The facility reported a census of 33 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS also documented utilization of an indwelling catheter. Review of Resident #10's Treatment Administration Record (TAR) documented a physician's order to cleanse suprapubic catheter sites with soap, rinse/dry thoroughly. Apply 4x4 or drain sponge every shift. On 3/4/26 at 10:19 AM an observation of catheter cares and transfer of Resident #10 revealed Staff H, Certified Nurse Assistant (CNA) and Staff G, CNA / Certified Medication Assistant (CMA) completed hand hygiene. Staff G applied gloves, cleansed abdomen with peri wipe, cleansed catheter tubing down about 6-8 inches, completed hand hygiene, applied gloves, applied 4x4 split sponge to catheter tubing. Both staff removed gloves, completed hand hygiene, applied gloves. Staff H applied straps to left side lift straps to the full body mechanical lift, Staff G applied right side lift straps to the full body mechanical lift. Staff H utilized full body lift controls, Staff G assisted Resident #10 and directed the resident in the full body mechanical lift cloth to the wheelchair. Staff H removed lift cloth from the lift, applied blanket to Resident 10, Staff G removed gown and gloves, opened room door, did not complete hand hygiene. Staff G backed Resident #10 from the room, placed Resident #10's feet on the foot pedals, pushed Resident #10 down the hall past the next room on the right room [ROOM NUMBER], obtained hand sanitizer from the wall dispenser, completed hand hygiene. Staff H removed gown, removed gloves, completed hand hygiene, Staff H took lift towards the door, applied gloves, cleansed lift with sanitizing wipes, and placed lift in room across the hallway. On 3/4/26 at 11:27 AM Staff G, stated there was a missed opportunity for hand hygiene when she removed her gown and gloves in the bathroom prior to taking the resident down the hall. Staff G explained she thought when she was walking down the hall that she should have completed hand hygiene in the bathroom when she removed the gloves and gown.On 3/4/26 at 12:23 PM the DON acknowledged concerns when observation was shared with her about hand hygiene not being completed appropriately when Staff G left the room with Resident #10 and did not complete hand hygiene in the room after doffing gloves and gown. The DON stated she expected hand hygiene would be completed whenever gloves were removed.Review of a policy revised 8/19 titled, Handwashing / Hand Hygiene documented the facility considered hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with residents and after removing gloves.

Based on clinical record review, observations, resident interview, and staff interviews, the facility failed to provide the residents with a comfortable / clean homelike environment by not changing soiled sheets for 1 for 20 residents reviewed (Resident #3). The facility reported a census of 33 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 3/3/26 at 9:16 AM Resident #3 stated he had bled on his sheets after he fell on 2/28/26. Resident #3 explained the sheets on his bed had not been changed since the bleeding had occurred. On 3/3/26 at 9:15 AM an observation of three 50 cent sized circular areas of dry red colored fluid.On 3/3/26 11:56 AM Staff F, Certified Nurse Assistant (CNA) stated the CNA's change the bedding usually on the first bath day of the week for that resident. Staff F stated Resident #3 was on the list but had not had a bath yet. Staff F explained she had not got him up or changed the bedding today. Staff F stated if there was blood / urine / debris on the sheets the sheets would be changed immediately. On 3/5/26 at 11:22 AM Staff I, CNA acknowledged she stripped Resident #3's bed and had assisted with getting him out of bed on 3/3/26. Staff I stated the bed was stripped because it was dirty and needed to be changed. Staff I explained Resident #3's sheets looked like there was dried blood on them. Staff I stated Resident #3 did not get up the morning before so she did not know or remember if there was blood on the sheet the day before. On 3/3/26 at 12:09 PM Staff C, Registered Nurse (RN)/Nurse Practitioner (NP) explained Resident #3 had a skin tear to the left posterior of his forearm from a fall back on 2/28/26. Staff C stated she had applied the dressing Resident #3 had on his arm on 2/28/26. Staff C acknowledged the CNA's changed the residents' bedding on their bath days. Staff C stated there was a chance that the blood on Resident #3's sheets had been there since last 2/28/26 because the dressing is still the same that she applied. On 3/3/26 at 12:21 PM the DON stated the sheets are supposed to be changed either on the resident's bath days or at least once a week. The DON stated she expected if the residents' sheets were soiled they would be changed and fresh ones would be applied.

Based on interviews, record reviews, and policy review the facility failed to provide services meeting professional standards for 1 of 3 residents (Resident #2). The facility failed to follow physician orders for completion of labs. The facility had a census of 31. Findings include:Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The document provided the resident had diagnoses of diabetes mellitus, hypertension (HTN) and Type 2 Diabetes Mellitus with unspecified complications. The MDS disclosed the resident received 7 days of insulin injections with 2 days of orders for change of insulin orders during the reporting period. The Care Plan dated 6/20/25 contained a focus area for Diabetes Mellitus initiated 4/6/24. Interventions for staff included medications as ordered by physician, monitoring for and documenting side effects and effectiveness (4/6/24), monitor for side effects (4/6/24) and provide education (4/6/24). A focus area of use of insulin/hypoglycemic medications dated 1/14/23 contained interventions of monitoring blood glucose, side effects, hypo/hyperglycemia and Accu Checks as ordered dated 1/14/23. The electronic medical record (EMR) contained the laboratory results dated [DATE] revealed the resident had an A1c 8.8 (h), estimated average glucose 200. The document provided the provider's acknowledgement with an order to check the resident's A1c in 3 months with a signature of 1/29/24 and noted by an unidentified nurse on 1/29/24. The EMR Physician Notification dated 7/24/24 disclosed an order signed by the provider on 7/25/24 to Discontinue the current A1c every 3 months.Next lab day draw CBC, BMP, A1c, TSH - due Feb/Aug every 6 months.Decrease nighttime Tresiba to 10 units.The document was noted by 1 nurse on 7/25/24 and a second nurse on 8/12/24. The facility's EMR failed to provide documentation that orders for A1c checks dated 1/29/24 and labs 7/25/24 were completed.The EMR Progress Notes revealed the following:7/29/25 Provider note to have routine Accu-Checks and routine labs including TSH.10/1/25 Care Conference held with son concerned about the resident's blood sugars being high.10/7/25 New Order for A1c.The EMR Clinical Physician Orders revealed an order for CBC, BMP, TSH, A1c, every 6 months every day shift every 6 months starting on the 7th related to Type 2 Diabetes Mellitus with unspecified complications, essential HTN and hypothyroidism with an order date of 10/7/25 and start date of 11/7/25.On 10/6/25 at 4:55 PM the Director of Nursing (DON) stated there was no documentation for labs completed after 1/24/24. On 10/7/25 at 10:15 AM the DON confirmed the labs completed on 1/24/24 contained an order for A1c to be completed in 3 months had not been completed. The DON acknowledged an order on 7/25/24 for DC of A1c every 3 months and a new order for the next lab day to draw CBC, BMP, A1c, TSH due Feb/Aug every 6 months had not been completed. The DON confirmed after the request for documents the previous day, the DON contacted the physician and requested new lab orders and entered them into the EMR. The DON stated she would be completing a blood draw shortly, and confirmed it would not be a fasting lab due to the time of day and the resident already having eaten breakfast. On 10/7/25 at 10:43 AM the DON stated she expected staff to put the order into the EMR and complete the order as required.On 10/7/25 at 11:40 AM Staff A, Licensed Practical Nurse (LPN) stated if a fax with an order for lab was received, staff would put in the order or contact the provider for clarification if it was not on document.On 10/7/25 at 11:45 AM the Administrator stated she expected staff to put orders into the EMR so they could be completed as ordered and if they had any questions regarding the orders to contact the DON.The facility's Medication and Treatment Orders: Guiding Principles, dated 9/17, provided significant medication-related concerns will be minimized. The document did not address following physician orders.

Based on clinical record review, staff interview, and policy review the facility failed to provide bathing assistance for 2 of 4 residents reviewed for bathing (Residents #1 and #2). The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified bathing activity for Resident #1 was not applicable/not attempted. Resident #1's MDS included diagnoses of cancer, anemia, atrial fibrillation (irregular heart beat), hypertension (high blood pressure), heart failure (heart does not pump blood well), and end stage renal disease (kidney). The Clinical Census documented Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 6/4/25. The Care Plan with a target date of 6/12/25 identified Resident #1 required assistance of 1 staff member to provide bathing. Review of Point of Care (POC) Tasks in the electronic medical record revealed Resident #1 was scheduled for a sponge bath or shower on Monday and Thursday. The bathing records lacked documentation Resident #1 received a bath during her stay at the facility from 5/28 to 6/4/25. The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #1 to shower or bathe. 2. Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a BIMS score of 11, indicating moderately impaired cognition. The MDS identified Resident #2 required substantial/maximal assistance with shower/bathing. Resident #2's MDS included diagnoses of hypertension (high blood pressure), peripheral vascular disease, diabetes mellitus, and cerebrovascular accident (CVA) (stroke) affecting the right side. The Care Plan with a target date of 7/1/25 identified Resident #2 required substantial assistance of 1 staff member to provide bathing Review of POC Tasks in the electronic medical record revealed Resident #2 was scheduled for a bath or shower on Wednesday and Saturday. The facility electronic form title Shower/Bath for the last 30 days documented Resident #2 received a bath on 5/17, 5/28 and 6/8. The form documented a shower/bath was refused on 6/4 and not applicable on 6/7. A facility paper form titled Baths for the week of 5/26 to 6/1 documented Resident #2 received a bath or shower on 5/28 and 5/31. The bathing form directed the staff to write down their initials next to each bath/shower that was given. The form documented that any shower/bath not given needed to be reviewed with the charge nurse and communicated to leadership, as each resident was to be offered bathing two times per week. The form indicated if a resident refused their shower, the staff was to try and offer again the next day. A facility paper form titled Baths for the week of 6/2 to 6/8 documented Resident #2 refused a bath on 6/4 and received a bath on 6/7. Review of the Clinical Record and bathing forms revealed Resident #2 did not have a bath or shower from 5/31 to 6/7. The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #2 to shower or bathe. On 6/10/25 at 4 PM, Resident #2 reported he got a bath about once per week and would prefer to have three baths per week. On 6/11/25 at 10:10 AM, Staff A, Certified Nursing Assistant (CNA) reported she was normally scheduled to do baths/showers. Staff A reported the bathing documentation was completed in the resident's electronic medical record. In addition, she said there was a paper list in the shower house that she highlighted when the baths were completed along with documenting her initials next to the resident name. She said she gave the paper list to the DON when she was done. When asked about Resident #2 baths, she reported he refused to take a bath last Wednesday (6/4). She reported when a resident refused to take a bath the staff were to tell the nurse, then ask the resident one more time, then after that the resident had the right to refuse the bath. When asked when not applicable would be charted for bathing, she said it would be charted when the staff did not get the bath done that day as scheduled instead of charting refused. On 6/11/25 at 11:09 AM, the Director of Nursing (DON) reported she had reviewed the paper documentation for bathing for Resident #2 and acknowledged the documentation in POC did not match the paper documentation. The DON reported she was auditing the bathing documentation on paper and it was a work in progress for the staff to document in POC accurately and consistently all the time. She reported if a resident did not get a bath, she expected the resident to be the first one completed the next day and the staff needed to chart the bath was offered. On 6/11/25 at 3:10 PM, the DON verified Resident #1 did not have a bath during her stay from 5/28 to 6/4/25. In addition, the DON acknowledged Resident #2 refused his bath on 6/4/25. The DON verified Resident #2 did not have a documented bath between 5/31 and 6/7. The DON reported she expected staff to re-approach, offer a bath the following day, and document the attempt. A facility policy title Activities of Daily Living (ADLs), Supporting revised March 2018 documented the facility would provide appropriate care and services for the residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene that include (bathing, dressing, grooming and oral care).

Based on clinical record review, resident and staff interviews and facility policy review the facility failed to maintain complete and accurate records for 7 of 7 residents reviewed (Resident #2, #3, #4, #5, #6, #7, #8). The facility reported a census of 31 residents. Findings include: 1. Review of Resident #2's shower/bath documentation from 2/1/2025 until 5/15/2025 revealed she was to receive a shower or bath on Mondays and Thursdays during the day shift. The documentation revealed the following: 2/3/2025-resident refused 2/10/2025-not applicable 2/13/2025-not applicable 2/24/2025-not applicable 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025-resident refused 3/31/2025-resident refused 4/7/2025-not applicable 4/14/2025-not applicable 4/17/2025-not applicable 4/28/2025-resident refused 5/1/2025-not applicable 5/8/2025-not applicable 5/15/2025-not applicable Record review revealed there were only two notes documented about her bathing refusals on 4/8/2025 and 4/29/2025. The progress notes lacked documentation about other bathing refusal and the reason for not applicable being documented. Review of Resident #4's bath/shower documentation from 2/1/2025 through her discharge date of [DATE] revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 2/1/2025-resident refused 2/8/2025-resident refused 2/12/2025-resident refused 2/15/2025-resident refused 2/19/2025-resident refused 2/22/2025-resident refused 3/1/2025-resident refused 3/8/2025-resident refused 3/12/2025-resident refused Record review revealed there was only one not documenting her bath refusals on 2/9/2025. The progress notes lacked documentation about other bathing refusals. Review of Resident #5 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Tuesdays and Fridays day shift. The documentation revealed the following: 2/14/2025-resident refused 2/16/2025-he received a bath 2/18/2025-he received a bath 2/21/2025-resident refused 2/25/2025-he received a bath 3/18/2025-resident refused 3/21/2025-not applicable 4/11/2025-not applicable 4/29/2025-not applicable 5/2/2025-not applicable Record review of Resident #5's Progress Notes from 2/1/2025 through 5/15/2025 revealed it lacked documentation of bath refusals and reason for not applicable documentation. Review of Resident #6 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Wednesdays and Saturdays. The documentation revealed the following: 3/1/2025-resident refused 3/8/2025-resident refused 5/7/2025-not applicable Record review of Resident #6's Progress Notes from 2/1/2025 through 5/15/2025 revealed there were no notes about his bath refusals and why not applicable was documented. Review of Resident #7 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 3/1/2025-resident refused 3/8/2025-resident refused 4/12/2025-not applicable 4/25/2025-resident refused 5/1/2025-resident refused 5/7/2025-not applicable 5/10/2025-resident refused 5/14/2025-resident refused Record review revealed there were no notes about his bath refusals and why not applicable was documented. Review of Resident #8 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Mondays and Thursdays. The documentation revealed the following: 2/10/2025-not applicable 2/13/2025-not applicable 2/24/2025-not applicable 2/27/2025--resident refused 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025--resident refused 3/31/2025-not applicable 4/7/2025-not applicable 4/10/2025-resident refused 4/17/2025-not applicable 5/1/2025-resident refused 5/8/2025-not applicable Record review revealed there was only one note documenting her bath refusals on 4/15/2025. The progress notes lacked documentation about other bathing refusals. The facility provided a document titled Bath, Shower/Tub with a revision date of February 2018 documented the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: -If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting: -Notify the supervisor if the resident refuses the shower/tub bath. 2. According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Care Plan Focus Area titled Activities of Daily Living (ADLs) with an initiated date of 11/25/2024 documented #3 required substantial assistance of two staff for transfers, ambulation, mobility and toileting. Review of Resident #3's visual/bedside Kardex Report documented she required substantial assistance of two staff for toileting, transfers, mobility and ambulation. The Clinical Census revealed Resident #3 was discharged on [DATE]. Record review 2/1/2025 thru 2/26/2025 revealed it lacked Progress Notes related to her behaviors that were experienced on 2/23/2025 and 2/24/2025. On 5/13/2025 at 2:09 PM Staff B Licensed Practical Nurse (LPN) stated in February 2025 Staff E Certified Nursing Assistant (CNA) and Staff F CNA had attempted to assist Resident #3 to the restroom. When they advised her, they needed to get the EZ-Stand (mechanical lift to assist a resident to a sitting position) the resident refused to allow this. On 5/14/2025 at 3:55 PM Staff F stated Resident #3 had put her call light on, when her and Staff E went in her room she was attempting to get up and walk. They reminded her they needed to use the EZ stand to assist her to the bathroom. On 5/14/2025 at 2:10 PM Staff E stated in February Resident #3 was being combative and hanging off the side of her bed. She was not able to get up on her own, she required the use of an EZ stand for transfers. The previous shift indicated she was using the lift without issues. She tried to explain to the resident that it was their policy that if they required a lift for transfers, they could not, not use it. On 5/14/2025 at 4:23 PM the Director of Nursing (DON) stated Resident #3 required the use of an EZ stand for transfers or she may have been an assistance of two staff. She knew the resident did not like to use the EZ stand. During a follow-up interview on 5/16/2025 at 11:20 AM she stated the MDS Coordinator completes the main portion of the care plans. If she is not working, anyone can update them as needed. When asked what staff use when caring for the residents, she stated they can use the Kardex, can be pulled up in the resident's Electronic Health Record (EHR), and updated as necessary. Care plans should be updated as needed (PRN), checked quarterly and annually with care conferences. When she was informed that Resident #3's care plan did not reflect the use of an EZ stand for transfers, she stated oh. The DON stated it was not acceptable to update a care plan three months after the resident was noted to be using an EZ stand. On 5/16/2025 at 9:15 AM the DON was asked if they had any documentation about Resident #3 using an EZ Stand for transfers. She said she would look. On 5/16/2025 at 9:23 PM in an email correspondence with Staff A Administrator from a sister facility, sent an email that contain Resident #3's care plan. The care plan attached documented Resident #3 required substantial assistance of two staff and used the EZ stand as needed (PRN). Staff A was asked when the care plan had been updated and she stated it was added on 5/16/2025. On 5/13/2025 at 2:09 PM Staff B Licensed Practical Nurse (LPN) stated she was in with Resident #3's roommate when Staff E Certified Nursing Assistant (CNA) and Staff F attempted to assist her. The resident was sitting on the edge of the bed when the CNAs came in to the room. She let them know she wanted to go to the bathroom. When they informed her, they needed to get the mechanical lift, the resident refused to use it. The resident became upset when they would not transfer her without the mechanical lift. The CNAs asked Staff B if she was going to help them. She told them no because she was already upset. When the CNAs asked for help she knew Resident #3 was not going allow her to help her because she was already upset. She indicated Resident #3 can be naughty a times, will cuss and hit the staff members. When helping her it's all about the approach you take with her. During a follow up interview on 5/16/2025 at 10:42 AM Staff B stated when a resident has behaviors and she is aware of them, she is to chart them in a behavior note and intervene. When asked if she documented on the weekend in February when Resident #3 was refusing cares, she indicated she could not remember if she charted that weekend on her behaviors. She added, she does not believe she charted because she thought her behaviors were justified on her behalf. On 5/14/2025 at 3:55 PM Staff F stated when her and Staff E reminded Resident #3 they needed to use the mechanical lift to transfer her to the bathroom she started to tell them they did not know what they were doing and was dumb founded at the request. The resident began to call them incompetent and used curse words. When they told Staff B about Resident #3 refusing to use the mechanical lift, she went in and told the resident they needed to use the mechanical lift as it's their job, then she walked out. For the rest of the night Staff E and Staff F would go in and check on Resident #3 but she refused to be checked and changed even when she was soiled. Resident #3 was adamant about walking and not waiting to use the mechanical lift, then would not let them change her. Staff B knew everything that was going on with Resident #3 but she did not go in to see if Resident #3 would allow her to assist her. When asked where staff are to document these kinds of behaviors, she stated there is a behavior task that the CNAs can chart on. On 5/14/2025 at 2:10 PM Staff E stated Resident #3 was being combative and refused to allow her and Staff F to help her to the bathroom. When her and Staff F went in to the resident's room, she was hanging off the bed. When asked what she was doing and where she was going, she wanted to go to the bathroom. She was not able to get up on her own and required an EZ stand, which she had used that day just fine according to the staffing report. When they informed her they needed to use the mechanical lift, she did not want to use it. Staff E left the resident know per the facility's policy they were not allow to no use the mechanical lift for the transfer. The nurse, Staff B, was in the room with the resident's roommate at the time. Staff B told Staff E and F they have done what they could do. Staff E said she was like what are we supposed to do if she needs to go to the bathroom and Staff B said you done what you can. Staff B added if she is refusing to do anything, we can't do anything but document it. The rest of the night Resident #3 was very agitated and continue to not let them do anything such as checking and changing her, she was hanging on her wheelchair, not wanting to be in bed. Every time they would try to check and change her she would scratch and hit at staff. Staff E added the nurse had a whatever type of attitude that night. She felt the nurse should have been able to do more especially since the CNAs worked directly under the nurse. Staff E and F offered to change Resident #3's brief but she would not allow them to complete their check and changes, in fact she barely allowed them to get her back in bed. Staff E stated this was not the first time the resident has had behaviors like this but they were usually able to deescalate the situation. The CNAs can document in the tasks tab but they also told the nurse about more of her behaviors and assumed she would have done it too. On 5/16/2025 at 11:20 PM the DON indicated there is a supplemental tab for behaviors that nurses will use to document behaviors and in the progress notes. The CNAs can chart as well. She acknowledged the behaviors that Resident #3 had experienced on the weekend of 2/22/2025 should have been documented by the nurse and CNAs. When asked what should have been documented she stated what was offered, refusals, should have showed the refusal of any interventions that were attempted and what ever they did to assist the resident. The facility provided a document titled Problematic Behavior Management with a revision date of September 2017 documented problematic behavior and psychiatric symptoms will be identified and managed appropriately. The staff will seek to identify pertinent non-pharmacological interventions to try to address behavior and psychiatric symptoms. 3. Record review revealed Resident #5's Progress Notes lacked documentation of failed attempts to set up Telehealth appointments with his endocrinologist. On 5/15/2025 at 10:37 AM Resident #5 stated he was supposed to be seen by the Endocrinologist but have since tried to get him to be seen via Telehealth. He has since been on a Telehealth call with an Endocrinologist. The facility has told him they got a letter that the Endocrinologist has discontinued his services because he has not been to the clinic. The facility has also told him the clinic is refusing to assist with setting up the Telehealth appointments. On 5/16/2025 at 9:00 AM management was asked if they had any documentation for Resident #5's Telehealth meetings with his Endocrinologist. The MDS Coordinator stated she dropped the ball on the documentation part. She has been in contact with the clinic and given them various options to set up Telehealth meetings but they are not being receptive.

Based on observations, review of resident council notes, review of grievances and resident and staff interviews the facility failed to ensure they had adequate staff members to answer resident's call lights, provide baths, and assist with toileting needs. The facility reported a census of 31 residents. Findings Include: 1. According to the quarterly MDS assessment tool with a reference date of 4/11/2025, Resident #8 had a BIMS score of 15. A BIMS of 15 suggested no cognitive impairment. The MDS documented he had an impairment on one side of his lower extremity and utilized a wheelchair. Resident #8 required partial/moderate assistance with upper body dressing, was dependent of staff for lower body dressing and required substantial/maximal assistance with personal hygiene. The MDS documented a toilet transfer was not attempted due to his medical condition. Resident #8 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS documented the following diagnoses for the resident: diabetes mellitus, anemia, depression, weakness, insomnia, and left below the knee amputation. The Care Plan Focus Area with an initiation date of 1/8/2025 documented he required substantial assistance of one staff for bathing and moderate assistance of one staff for upper and lower body dressing. On 5/14/2025 at 11:28 AM Resident #8 was sitting in his wheelchair in his room, playing a game on his phone. He stated he is supposed to get a bath two times a weeks but at this time he is only getting one a week for a month. He required a mechanical lift to a chair, then uses a slide board to get in the shower chair. Once staff realize the process they will run off and will not hear back from them on why he did not receive a bath. He indicated there are two staff members that will give him his bath. If they don't have enough staff members they will skip over his bath. Resident #8 stated he has not had a shower in two weeks. Resident #8 stated the wait time for help depends on how many staff members are working. He has had to wait 45 minutes during the day shift when they have two CNAs on the floor. Resident #8 stated he has issues with his bowels and at times he can't hold it while waiting for help on the bed pan. He has had a lot of accidents, more that it should happen. Some of his accidents happen because no CNAs come in to help. This happened at night; he would push his call light, but would fall asleep waiting for someone to come. When he wakes up, he already had an accident and his call light was off. They would come in and shut if off because he was sleeping. 2. According to the quarterly MDS assessment tool with a reference date of 5/9/2025 documented Resident #5 had a Brief Interview of BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented Resident #5 did not refuse evaluations or care during the 7-day review period. The MDS documented Resident #5 had no lower or upper extremity impairments and utilized a wheelchair. Resident #7 was dependent on staff to shower or bathe and upper body dressing. The MDS documented the following diagnoses: cerebrovascular disease, anemia, neurogenic bladder, obstructive uropathy, diabetes mellitus, aphasia, anxiety, depression, schizophrenia, morbid obesity, and stroke. The Care Plan Focus Area with an initiation date of 10/9/2023 documented he was dependent on one staff for bathing, upper body dressing and required substantial assistance of two staff for lower body dressing. On 5/15/2025 at 10:37 AM Resident #5 was lying in bed. His finger nails were long, the nails were passed his fingertips. Some of his finger nails were dirty with brown/black debris in his nail beds. When asked how often he received a bath he indicated once a month. He added his last bath was this previous Friday. This was not his choice as he preferred to receive a bath once a week. Resident #5 stated he would like his bath more often. When asked if the facility trims his fingernails he indicated they are supposed to trim them but the podiatrist will trim his toe nails every 3 months. Resident #5 added he will tell staff when his nails need to be trimmed. He stated when they are short staffed he will not get his bath. He added that if they don't have both of the slings they use for his bath cleaned they will not bath him. When they bathe him they leave one lift under him. After his bath is done, they will put a clean and dry sling under him to get him dressed and ready. If that second sling is not available then he will not get a bath. He added when they are short staffed call lights can take 10 minutes to 1 hour, but not certain how often has happened. At night it seems to be bad. He uses a bedpan to have a bowel movement and when a he has to wait up to an hour for them to answer his call light, he will have an accident. When this happens, Resident #5 stated this makes him feel uncomfortable. Once staff come to his room and notice he had an accident they will ask why he didn't say something. He would tell them he had his call light on for help. Response time all depends on who is working. At 11:09 AM observed Staff I Certified Nursing Assistant, Staff J non-Certified Nursing Assistant (NA), and Staff B Licensed Practical Nurse (LPN) assist Resident #5 with getting dressed and transferred to his wheelchair. When Staff I and Staff J removed his sheets and provided cares a strong odor was present. 3. Record review revealed the following Progress Note for Resident #5: -On 2/10/2025 at 1:30 PM activities staff member went in to the resident's room and begged him to come to an activity; he would not get up and come down. I let him know that we have the accurate number of staff to get him up; he still declined. Review of the Resident Council Notes revealed the following: -During a meeting dated 2/6/2025 staff documented concerns on showers. -During a meeting dated 2/19/2025 staff documented concerns on showers. -During a meeting dated 3/5/2025 staff documented concerns about needed more Certified Nursing Assistants (CNA). -During a meeting dated 4/2/2025 staff documented trim nails. Review of Grievances filed revealed the following: -Resident Council on 2/6/2026-call light times, it takes them too long to get to us. -Resident #11 filled out the form stating she needs more baths. Family member questioned why are they not getting done, residents need care first. Filled out on 2/13/2025. -Resident #12 filed out the form stating she does not get a bath when she is supposed to. Filled out on 2/13/2025. On 5/13/2025 at 1:19 PM Staff I Certified Nursing Assistant (CNA) stated they need more staff here, staffing can be difficult at times. When asked if baths are getting done, she stated if they have enough people they will get done. They do have an extra staff member that will come in to give baths but when she comes in it varies. If they have three CNAs they can do baths but if it's less than that on the morning shift, they do not get done. She indicated having three CNAs on the morning shift happens maybe once a week. Staff I stated when she comes in for her 6:00 AM -2:00 PM shift after Staff N has finished her overnight shift, she finds residents soaked in bed. She has noticed this happens more when there is only one CNA and one nurse on the overnight shift. On 5/13/2025 at 3:40 PM Staff K Licensed Practical Nurse (LPN) laughed when asked how staffing was at the facility. She added when they hire people they do not last long. When asked when they are short staff are baths getting done, she stated that is iffy. On 5/14/2025 at 9:54 AM the Housekeeping Supervisor and Staff M Laundry Aide stated they have noticed residents mainly on the 200 hall to be soaked in bed in the mornings after the night shift has left. They stated it happens a lot with Resident #2 and at times Resident #6. On 5/14/2025 at 12:53 PM Staff L Certified Medication Aide (CMA) stated staffing is good for the most part. When asked if there was enough staff to get their tasks done every day, she stated it depended on the day. She added baths are hard to do but will pick it up on the next stuff but sometimes they get missed. She has come into work a few times to residents soaked in bed. She worked the 2:00 PM-10:00 PM shift. On 5/16/2025 at 9:02 AM Staff D CNA stated they are provided weekly bath sheet that is kept under a clipboard in the tub room. Once they are completed and documented on the sheet, they go to the Director of Nursing. CNAs that completed the bath/shower will document in the residents' Electronic Health Record (EHR). When asked why staff would document non-applicable (NA) on a resident's bath day, she stated she would assume the bath was not done. She added they have been told to document NA when they don't have staff to complete the baths or if they were not done, then they would do them on the next shift. They have been told not to leave the bath day blank, something has to be documented. When a bath is given on a non-bath day, they can add an as needed (PRN) bath so it's documented that one was completed. If a resident refuses a bath Staff D stated the CNA attempting the bath is to go back and after the bath three separate times. If they are still unsuccessful, they have to tell the nurse so they can offer the bath for the resident and then document their attempts and refusals. Staff D stated baths getting done is dependent on the number of staff working. If they have two staff on the morning shift, they will look to see who is working the next shift and if it's more than two staff members, they will pass the baths on to the next shift. They have a staff member that has come in to complete baths. Staff D stated she has spoken to the DON about coming in after the overnight shift to residents being soaked in bed. She added recently, it has gotten better. Staff D indicated it happened a lot when Staff N was working. On 5/16/2025 at 10:42 AM Staff B LPN stated the CNAs will ask the resident if they want a bath. If they refuse after being offered a bath a couple of times, they will come to her, then she will try to talk with them about taking a bath. If the resident continues to refuse, she will chart it. She will chart a progress note in the resident's Electronic Health Record (EHR). They will rely the information to the next shift to see if the resident will allow the bath to be completed. If not, they will attempt the following day. On 5/16/2025 at 11:20 AM the Director of Nursing (DON) stated the CNAs will have a bathing schedule that she puts in a book on Monday mornings. The staff will highlight the resident's name if the bath was completed. If the name is not highlighted the bath was either refused or not completed. If the bath was refused, would like staff to notify the nurse so they can intervene, see if they would like it completed later. If the bath is still not completed, it needs to be charted why it was not completed. They can leave the list in the bath house, so the staff coming in the next day can see which baths were not done from the previous shift. They will start with completing those baths first before moving to the baths scheduled that day. When asked what happens when a resident refuses a bath she indicated staff are to notify the nurse, the nurse can attempt to assist with getting the bath done. If the bath continues to be refused notify management or see if another CNA can assist. If the resident refuses three times, the nurse will need to document why and reason they do not want to take a bath, in a progress note. The DON stated staff would document NA in the bathing task if the resident is not in the building, did not have the bath done in the morning shift. Will chart NA on the bath day then ask the evening shift to complete the bath. If they are successful they can chart the bath in an as needed (PRN) section of their chart. These PRN baths would be on the documents provided to the surveyor. Staff could also chart NA if they did not have a bath aide that day. When asked how the staffing was in her facility, she stated it could be better, they need more staff but some days they have a good amount of staff on duty. When they don't have adequate staff, baths do get pushed to back a day or two. When asked what staff are to do if a resident falls back asleep after they activate their call light, she stated they should go in the resident's room, ask if they need anything, wake them up to find out.

Based on observations, clinical record review, resident council notes, grievances, staff and resident interviews, and facility policy review, the facility failed to ensure residents received baths twice a week or per their requested amount a week for 6 of 6 residents reviewed (Resident #2, #4, #5, #6, #7, and #8). The facility also failed to offer toileting assistance for 2 of 4 resident reviewed (Resident #5 and #8). The facility reported a census of 31 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/21/2025, documented Resident #2 had severely impaired cognitive skills for daily decision making. The MDS documented she required partial/moderate assistance for toileting hygiene, lower body dressing, personal hygiene and toilet transferring. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #2: dementia, hyperlipidemia, dementia, malnutrition, and depression. The Care Plan Focus Area Activities of Daily Living (ADLs), with an initiation date of 10/5/2023 documented she required moderate assistance of one staff for bathing. At times she does refuse. Review of Resident #2's shower/bath documentation from 2/1/2025 until 5/15/2025 revealed she was to receive a shower or bath on Mondays and Thursdays during the day shift. The documentation revealed the following: 2/3/2025-resident refused 2/10/2025-not applicable 2/13/2025-not applicable 2/16/2025-she received a bath 2/17/2025-she received a bath 2/24/2025-not applicable 2/27/2025-she received a bath The February bathing record revealed a bath was not documented as being offered from 2/3/2025 to 2/10/2025 and 2/17/2025 to 2/24/2025. The record also revealed she was not offered a bath after she refused or after not applicable was documented. 3/13/2025-resident refused 3/17/2025- she received a bath 3/24/2025-not applicable 3/25/2025 resident received a bath 3/27/2025-resident refused 3/31/2025-resident refused The March bathing record revealed a bath was not documented as being offered from 2/27/2025 to 3/13/2025, 3/17/2025 to 3/24/2025. The record also revealed she was not offered a bath after she refused or after not applicable was documented. 4/7/2025-not applicable 4/10/2025-she received a bath 4/14/2025-not applicable 4/17/2025-not applicable 4/24/2025- she received a bath 4/28/2025-resident refused 4/29/2025-she received a bath The April bathing record revealed a bath was not documented as being offered between 4/17/2025 to 4/24/2025. The record also revealed she was not offered a bath after she refused or after not applicable was documented, with the exception of when she received a bath on 4/29/2025. 5/1/2025-not applicable 5/8/2025-not applicable 5/10/2025-she received a bath 5/14/2025-she received a bath 5/15/2025-not applicable The May bathing record revealed a bath was not documented as being offered between 5/1/2025 to 5/8/2025. 2. According to the significant change MDS assessment tool with a reference date of 3/6/20205 Resident #4 had a BIMS score of 11. A BIMS score of 11 suggested moderate cognitive impairment. The MDS documented she was dependent on staff for toileting hygiene and personal hygiene. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #4: debility, Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, Alzheimer's, dementia, anxiety, and depression. The Care Plan Focus Area ADLs with initiation date of 10/9/2023 documented she required the assistance of 1 staff for bathing. The Care Plan documented she will refuse her baths multiple times in a row. She has been educated multiple times regarding the importance of good hygiene. She will state I don't care, just leave me alone. Record review revealed the resident was discharged from the facility on 3/16/2025. Review of Resident #4's bath/shower documentation from 2/1/2025 through her discharge date of [DATE] revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 2/1/2025-resident refused 2/8/2025-resident refused 2/12/2025-resident refused 2/15/2025-resident refused 2/19/2025-resident refused 2/22/2025-resident refused The February bathing record revealed a bath was not documented as being offered between 2/1/2025 to 2/8/2025 and 2/22/2025 to 2/28/2025. The record also revealed she was not offered a bath after she refused a bath. The resident did not receive a bath in February. 3/1/2025-resident refused 3/8/2025-resident refused 3/12/2025-resident refused The March bathing record revealed a bath was not documented as being offered between 3/1/2025 to 3/8/2025 and 3/12/2025 to her discharge date of [DATE]. The record also revealed she was not offered a bath after she refused a bath. The resident did not receive a bath in March. 3. According to the quarterly MDS assessment tool with a reference date of 5/9/2025 documented Resident #5 had a Brief Interview of BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented Resident #5 did not refuse evaluations or care during the 7-day review period. The MDS documented Resident #5 had no lower or upper extremity impairments and utilized a wheelchair. Resident #7 was dependent on staff to shower or bathe and upper body dressing. The MDS documented the following diagnoses: cerebrovascular disease, anemia, neurogenic bladder, obstructive uropathy, diabetes mellitus, aphasia, anxiety, depression, schizophrenia, morbid obesity, and stroke. The Care Plan Focus Area with an initiation date of 10/9/2023 documented he was dependent on one staff for bathing, upper body dressing and required substantial assistance of two staff for lower body dressing. Review of Resident #5 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Tuesdays and Fridays day shift. The documentation revealed the following: 2/14/2025-resident refused 2/16/2025-he received a bath 2/18/2025-he received a bath 2/21/2025-resident refused 2/25/2025-he received a bath The February bathing record revealed a bath was not documented as being offered from 2/1/2025 to 2/14/2025 and on 2/28/2025 his bath day. The record also revealed he was not offered a bath after he refused. 3/18/2025-resident refused 3/21/2025-not applicable 3/28/2025-he received a bath The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/18/2025, 3/21/2025 to 3/28/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. 4/8/2025-he received a bath 4/11/2025-not applicable 4/15/2025-he received a bath 4/29/2025-not applicable The April bathing record reviewed a bath was not documented as being offered between 4/1/2025 to 4/8/2025, 4/15/2025 to 4/29/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. 5/2/2025-not applicable 5/7/2025-he received a bath The May bathing record reviewed a bath was not documented as being offered between on 5/6/2025 and from 5/7/2025 to 5/15/2025. The record also revealed he was not offered a bath after not applicable was documented. On 5/15/2025 at 10:37 AM Resident #5 was lying in bed. His finger nails were long, his nails were passed his fingertips. Some of his finger nails were dirty with brown/black debris in his nail beds. When asked how often he received a bath he indicated once a month. He added his last bath was this previous Friday. This was not his choice as he preferred to receive a bath once a week. Resident #5 stated he would like his bath more often. When asked if the facility trims his fingernails he indicated they are supposed to trim them but the podiatrist will trim his toe nails every 3 months. Resident #5 added he will tell staff when his nails need to be trimmed. He stated when they are short staffed he will not get his bath. He added that if they don't have both of the slings they use for his bath cleaned they will not bathe him. When they bathe him they leave one lift under him. After his bath is done, they will put a clean and dry sling under him to get him dressed and ready. If that second sling is not available then he will not get a bath. He added when they are short staffed call lights can take 10 minutes to 1 hour, but not certain how often has happened. At night it seems to be bad. He uses a bedpan to have a bowel movement and when a he has to wait up to an hour for them to answer his call light, he will have an accident. When this happens, Resident #5 stated this makes him feel uncomfortable. Once staff come to his room and notice he had an accident they will ask why he didn't say something. He would tell them he had his call light on for help. Response time all depends on who is working. At 11:09 AM Staff I Certified Nursing Assistant, Staff J non-Certified Nursing Assistant (NA), and Staff B Licensed Practical Nurse (LPN) assisted Resident #5 with getting dressed and transferred to this wheelchair. When Staff I and Staff J removed his sheets and provided cares a strong odor was present. 4. According to the quarterly MDS assessment tool with a reference date of 3/7/2025, Resident #6 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #6: heart failure, aphasia, stroke, seizure disorder, depression, schizophrenia, and atrial fibrillation. The Care Plan Focus Area titled ADL's with an initiation date of 5/17/2024, documented Resident #6 was dependent on one staff member for bathing. Review of Resident #6 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Wednesdays and Saturdays. The documentation revealed the following: 2/8/2025-he received a bath 2/12/2025-he received a bath 2/15/2025-he received a bath 2/22/2025-he received a bath 2/27/2025-he received a bath The February bathing record revealed a bath was not documented as being offered from 2/1/2025-2/8/2025 and 2/15/2025 to 2/22/2025. 3/1/2025-resident refused 3/8/2025-resident refused 3/12/2025-he received a bath 3/19/2025-he received a bath 3/27/2025-he received a bath The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/8/2025, 3/12/2025 to 3/19/2025, and 3/19/2025 to 3/27/2025. The record also revealed he was not offered a bath after he refused a bath. 4/2/2025-he received a bath 4/9/2025-he received a bath 4/24/2025-he received a bath 4/26/2025-he received a bath The April bathing record reviewed a bath was not documented as being offered between 4/2/2025 to 4/9/2025, 4/9/2025 to 4/26/2025 and 4/26/2025 to 4/30/25. 5/1/2025-he received a bath 5/7/2025-not applicable 5/10/2025-he received a bath 5/14/2025-he received a bath The May bathing record reviewed a bath was not documented as being offered between on 5/1/2025 and from 5/7/2025 to 5/15/2025. The record also revealed he was not offered a bath after not applicable was documented. 5. According to the quarterly MDS assessment tool with a reference date of 3/14/2025 documented Resident #7 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented not applicable in the shower/bathe self-portion of the assessment. The resident was dependent on staff for upper and lower body dressing. The following diagnoses were listed for Resident #7: right ankle contracture, malnutrition, and depression. The Care Plan Focus Area with an initiation date of 10/11/2023 documented Resident #7 required moderate assistance of one staff for bathing. Review of Resident #7 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 2/9/2025-resident received a bath 2/12/2025-resident received a bath 2/19/2025-resident received a bath 2/22/2025-resident received a bath 2/26/2025-resident received a bath The February bathing record revealed a bath was not documented as being offered from 2/1/2025 to 2/9/2025 and 2/12/2025 to 2/19/2025. 3/1/2025-resident refused 3/8/2025-resident refused 3/19/2025-resident received a bath 3/22/2025-resident received a bath 3/26/2025-resident received a bath 3/29/2025-resident received a bath The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/8/2025, 3/8/2025 to 3/19/2025. The record also revealed he was not offered a bath after she refused a bath. 4/9/2025-resident received a bath 4/12/2025-not applicable 4/25/2025-resident refused The April bathing record reviewed a bath was not documented as being offered between 4/1/2025 to 4/9/2025, 4/12/2025 to 4/25/2025, and 4/25/2025 to 4/30/2025. The record also revealed she was not offered a bath after he refused a bath or after not applicable was documented. 5/1/2025-resident refused 5/7/2025-not applicable 5/8/2025-resident received a bath 5/10/2025-resident refused 5/14/2025-resident refused The May bathing record reviewed a bath was not documented as being offered between on 5/1/2025 to 5/7/2025. The record also revealed she was not offered a bath after not applicable was documented. On 5/14/2025 at 11:04 AM observed the resident lying in bed, resting. Resident #7 indicated she is supposed to get a bath on Wednesdays and Saturdays but lately she has been getting a bath once a week. She has not received a bath yet today. She would preferred to be offered a bath between 10:00 AM and 6:00 PM; she does not like to have a bath earlier than 10:00 AM. She stated there was one month where she did not receive a bath for 3 weeks and she shared that was disappointing to her. She denied being offered wash clothes to freshen up when this happened. She would like to have more baths. 6. According to the quarterly MDS assessment tool with a reference date of 4/11/2025, Resident #8 had a BIMS score of 15. A BIMS of 15 suggested no cognitive impairment. The MDS documented he had an impairment on one side of his lower extremity and utilized a wheelchair. Resident #8 required partial/moderate assistance with upper body dressing, was dependent of staff for lower body dressing and required substantial/maximal assistance with personal hygiene. The MDS documented a toilet transfer was not attempted due to his medical condition. Resident #8 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS documented the following diagnoses for the resident: diabetes mellitus, anemia, depression, weakness, insomnia, and left below the knee amputation. The Care Plan Focus Area with an initiation date of 1/8/2025 documented he required substantial assistance of one staff for bathing and moderate assistance of one staff for upper and lower body dressing. Review of Resident #8 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Mondays and Thursdays. The documentation revealed the following: 2/3/2025-received a bath 2/10/2025-not applicable 2/13/2025-not applicable 2/17/2025-received a bath 2/24/2025-not applicable 2/27/2025--resident refused The February bathing record revealed a bath was not documented as being offered from 2/3/2025 to 2/10/2025 and 2/17/2025 to 2/24/2025. The record also revealed he was not offered a bath after he refused and not offered a bath after not applicable was documented. 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025--resident refused 3/31/2025-not applicable The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/13/2025 and 3/13/2025 to 3/24/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. Resident #8 did not receive a bath in March. 4/7/2025-not applicable 4/10/2025-resident refused 4/14/2025-received a bath 4/17/2025-not applicable 4/28/2025-received a bath The April bathing record reviewed a bath was not documented as being offered between 4/1/2025 to 4/7/2025, 4/17/2025 to 4/28/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. 5/1/2025-resident refused 5/8/2025-not applicable The May bathing record reviewed a bath was not documented as being offered between on 5/1/2025 to 5/8/2025 and from 5/8/2025 to 5/15/2025. The record also revealed he was not offered a bath after not applicable was documented. The resident had not received a bath in the first 15 days of May. On 5/14/2025 at 11:28 AM observed Resident #8 sitting in his wheelchair in his room, playing a game on his phone. He stated he is supposed to get a bath two times a week but at times he will only get one a week for a month. He required a mechanical lift to a chair, then uses a slide board to get in the shower chair. Once staff realize the process they will run off and he will not hear back from them on why he did not receive a bath. He indicated there are two staff members that will give him his bath. If they don't have enough staff members they will skip over his bath. Resident #8 stated he has not had a shower in two weeks. Resident #8 stated the wait time for help depends on how many staff members are working. He has had to wait 45 minutes during the day shift when the have two CNAs on the floor. Resident #8 stated he has issues with his bowels and at times he can't hold it while waiting for help on the bed pan. He has had a lot of accidents, more than it should happen. Some of his accidents happen because no CNAs come in to help. This happened at night; he would push his call light, but would fall asleep waiting for someone to come. When he wakes up, he already had an accident and his call light was off. They would come in and shut if off because he was sleeping. Review of the Resident Council Notes revealed the following: -During a meeting dated 2/6/2025 staff documented concerns on showers. -During a meeting dated 2/19/2025 staff documented concerns on showers. -During a meeting dated 4/2/2025 staff documented trim nails. Review of Grievances filed revealed the following: -Resident #11 filled out the form dated 2/13/25 stating she needs more baths. Family member questioned why are they not getting done, residents need care first. -Resident #12 filed out the form dated 2/13/25 stating she does not get a bath when she is supposed to. On 5/13/2025 at 1:19 PM Staff I Certified Nursing Assistant (CNA) stated they need more staff here, staffing can be difficult at times. When asked if baths are getting done, she stated if they have enough people they will get done. They do have an extra staff member that will come in to give baths but when she comes in varies. If they have three CNAs they can do baths but if it's less than that on the morning shift, they do not get done. She indicated having three CNAs on the morning shift happens maybe once a week. Staff I stated when she comes in for her 6:00 AM -2:00 PM shift after Staff N has finished her overnight shift, she finds residents soaked in bed. She has noticed this happens more when there is only one CNA and one nurse on the overnight shift. On 5/13/2025 at 3:40 PM Staff K Licensed Practical Nurse (LPN) laughed when asked how staffing was at the facility. She added when they hire people they do not last long. When asked when they are short staff are baths getting done, she stated that is iffy. On 5/14/2025 at 9:54 AM the Housekeeping Supervisor and Staff M Laundry Aide stated they have noticed residents mainly on the 200 hall to be soaked in bed in the mornings after the night shift has left. They stated it happens a lot with Resident #2 and at times Resident #6. On 5/14/2025 at 12:53 PM Staff L Certified Medication Aide (CMA) stated staffing is good for the most part. When asked if there was enough staff to get their tasks done every day, she stated it depended on the day. She added baths are hard to do but will pick it up on the next shift but sometimes they get missed. She has come into work a few times to residents soaked in bed. She worked the 2:00 PM-10:00 PM shift. On 5/16/2025 at 9:02 AM Staff D CNA stated they are provided weekly bath sheet that is kept under a clipboard in the tub room. Once they are completed and documented on the sheet, they go to the Director of Nursing. CNAs that completed the bath/shower will document in the residents' Electronic Health Record (EHR). When asked why staff would document non-applicable (NA) on a resident's bath day, she stated she would assume the bath was not done. She added they have been told to document NA when they don't have staff to complete the baths or if they were not done, then they would do them on the next shift. They have been told not to leave the bath day blank, something has to be documented. When a bath is given on a non-bath day, they can add an as needed (PRN) bath so it's documented that one was completed. If a resident refuses a bath Staff D stated the CNA attempting the bath is to go back after the bath three separate times. If they are still unsuccessful, they have to tell the nurse so they can offer the bath for the resident and then document their attempts and refusals. Staff D stated baths getting done is dependent on the number of staff working. If they have two staff on the morning shift, they will look to see who is working the next shift and if it's more than two staff members, they will pass the baths onto the next shift. They have a staff member that has come in to complete baths. Staff D stated she has spoken to the DON about coming in after the overnight shift to residents being soaked in bed. She added recently, it has gotten better. Staff D indicated it happened a lot when Staff N was working. On 5/16/2025 at 10:42 AM Staff B LPN stated the CNAs will ask the resident if they want a bath. If they refuse after being offered a bath a couple of times, they will come to her, then she will try to talk with them about taking a bath. If the resident continues to refuse, she will chart it. She will chart a progress note in the resident's Electronic Health Record (EHR). They will relay the information to the next shift to see if the resident will allow the bath to be completed. If not, they will attempt the following day. On 5/16/2025 at 11:20 AM the Director of Nursing (DON) stated the CNAs will have a bathing schedule that she puts in a book on Monday mornings. The staff will highlight the resident's name if the bath was completed. If the name is not highlighted the bath was either refused or not completed. If the bath was refused, she would like staff to notify the nurse so they can intervene, see if they would like it completed later. If the bath is still not completed, it needs to be charted why it was not completed. They can leave the list in the bath house, so the staff coming in the next day can see which baths were not done from the previous shift. They will start with completing those baths first before moving to the baths scheduled that day. When asked what happens when a resident refuses a bath she indicated staff are to notify the nurse, the nurse can attempt to assist with getting the bath done. If the bath continues to be refused they are to notify management or see if another CNA can assist. If the resident refuses three times, the nurse will need to document why and reason they do not want to take a bath, in a progress note. The DON stated staff would document NA in the bathing task if the resident is not in the building, did not have the bath done in the morning shift. Will chart NA on the bath day then ask the evening shift to complete the bath. If they are successful they can chart the bath in an as needed (PRN) section of their chart. These PRN baths would be on the documents provided to the surveyor. Staff could also chart NA if they did not have a bath aide that day. When asked how the staffing was in her facility, she stated it could be better, they need more staff but some days they have a good amount of staff on duty. When they don't have adequate staff, baths do get pushed back a day or two. When asked what staff are to do if a resident falls back asleep after they activate their call light, she stated they should go in the resident's room, ask if they need anything, wake them up to find out. The facility provided a document titled Bath, Shower/Tub with a revision date of February 2018 documented the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath.

Based on clinical record review, facility investigative file review, staff interviews and policy review the facility failed to implement their abuse policies. The facility's staff member with concerns about the treatment of Resident #3 was not reported within two hours of the concerns. The facility also failed to complete a thorough investigation. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Clinical Census revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative file contained the following statement from Staff B Licensed Practical Nurse (LPN): -On 2/22/25 (Saturday) I worked the nightshift 10:00 PM-6:00 AM. Staff E Certified Nursing Assistant (CNA) and Staff F CNA were the aides and around 10:30 PM-11:00 PM a resident had her call light on. Staff E heard the call light looked down the hall and stated oh hell no, I am not doing this tonight. When Staff B looked at her, she went down and answered the call light. Both CNAs would leave call lights go for long periods of time, while sitting at the desk talking. Staff B stated she watched and waited to see when rounds were going to be done, rounds were not done until 3-3:30 AM. The was the only time rounds were done, hospice residents were not turned, ice waters were not passed out to the residents, nor were linens. -On 2/23/25 (Sunday) I again worked the night shift 10:00 PM-6:00 AM with Staff E and F. They again were reluctant to answer call lights. The call lights would stay on for more than 5 minutes, while the CNAs sat at the desk talking. A resident had started to open her door and both CNAs yelled from the desk for the resident to lay back down and go to sleep, while pointing into the resident's room, this happened at least two times. A different resident came out of his room in his wheelchair and Staff F grabbed the resident's wheelchair and stated he had to go back to bed. The resident was taken to his room and placed back in bed. Rounds were again started at 3:00 AM and that was the only time rounds were done. Staff B stated she went into Resident #3's roommate's room to do a pre-assessment on the dialysis patient. Resident #3 was sitting up on the side of the bed. She stated she was exercising and was asked if she needed to go to the bathroom. She stated yes and this nurse pulled the call light for the resident. As she was completing the assessment on Resident #3 roommate, Staff E and Staff F came into the room and asked the resident what she was doing, the resident stated she was exercising, both aides started laughing loudly in a condescending manner, and said sure you are. Staff B told the aides that the resident needed to go to the bathroom. The EZ stand (mechanical lift) was brought in to the room and both aides were rude. They stated if she had to go to the bathroom she would need to use the lift. The resident kept stating she did not need to use the lift and that she had gone to the bathroom three other times during the night, by herself. Staff B stated both aides were talking in a manner to which she would not want her loved one being talked to. Resident #3 got more upset and aggressive towards the aides and the aides were telling Resident #3 that they could not take her to the bathroom without the lift but the resident stated she was not going to use the lift. The aides lifted the resident's legs back in to bed and stated then you aren't going to go to the bathroom. The aides did ask Staff B to help them talk to her but she stated that they had already made her mad, she would not listen to her and the resident stated no she wasn't. The statement was signed by Staff B on 2/25/2025 (Tuesday). During an email correspondent with the State Agency's Complaint Intake Specialist on 5/13/2025 at 10:06 AM, she provided the facility initially reported the concern to the State Agency on 2/25/2025 at 5:01 PM. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H Registered Nurse (RN) that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. Staff B stated she had Monday, 2/24/25 off but the next day she said something to the Director of Nursing (DON). When asked if the facility had an abuse coordinator to report abuse concerns to, she stated she was not sure. The DON was just starting in the facility. They usually have something written down to indicate who is on call, but does not recall if they had done that that weekend. She alleged the concerns took place that Sunday in to Monday morning about 4:30/5:00 AM. Staff B stated she did not know who to call at the time of her concerns, but acknowledged she should have called someone. She thought Staff H would tell Staff G previous Administrator. Staff B stated when she came to work on 2/25/2025 she provided her statement and was written up for not reporting her concerns sooner. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/14/2025 at 4:23 PM the DON stated Staff B gave her written statement the same day she reported her concerns on 2/25/2025. The DON acknowledged it was not timely reporting on Staff B's part and she was educated on reporting concerns immediately. When asked who Staff B should have reported her concerns to, the DON stated she should have reported them to the Administrator and/or DON right away. She added they have their phone numbers posted at the nurse's station. The facility provided a document titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, with a revision date of April 2021, documented all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, federal agencies, and thoroughly investigated by facility management, findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 3.Immediately is defined as within two hours of an allegation involving abuse. Review of the facility's investigative file included a page of resident questions that was filled out by various staff members. Question #6 asked Do you have any type of mistreatment to report to me now? The Social Worker documented the following information that was provided by Resident #3: I was abused, left hanging on the side of my bed. It was in the middle of the night. I was told by the aide I will not be helping you. I sat there for 2 hours. It caused me great pain. I've never been physically abused. The investigative file lacked any follow up with Resident #3 about her response to question #6. Resident #3's roommate was asked the same question but the file failed to include an interview with the roommate pertaining to the morning in question. The investigative file included interviews with the following staff members: Staff B, Staff E and Staff F. The investigative file failed to include interviews with staff members that took care of the resident on all shifts after the alleged incident occurred as well as no interview with Staff H Registered Nurse (RN) The investigative file also lacked any follow up interview(s) with Resident #3 after the alleged incident to check on her psycho-social status. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/16/2025 at 10:48 AM the Social Worker acknowledged she interviewed Resident #3 using the resident questions sheet. When asked what she did with the information after her interview, she stated she gave her interview sheets to the DON. She indicated she did not ask further questions and could not remember if other residents had concerns in regards to the care they received. She would not have asked further questions with Resident #3 because she did not like upsetting her. When asked if the DON said anything when she handed her Resident #3's responses she stated she just handed her the paper and the DON said thank you. On 5/16/2025 at 11:20 AM the DON was read Resident #3's response to the questionnaire completed by the Social Worker. She was asked if she followed up with Resident #3 after the Social Worker had completed her questionnaire with her. The DON denied being aware of that statement. Those concerns should have been reported to her and another investigation should have been started. If they were reported to her, she would have found out more information. The DON indicated she followed up with Resident #3 after the alleged incident to see how she was doing, she checked on her a lot but did not document it anywhere. When she followed up with her the resident was fine, some days she was confused others she was not. When asked if the Social Worker could have followed up with Resident #3 she stated oh absolutely. When asked why the roommate was not asked questions specific to the alleged incident, she stated she should have been asked questions. She acknowledged Staff H was not interviewed. Investigating allegations: 1. All allegations are thoroughly investigated. The Administrator initiates investigations. 7. The individual conducting the investigation as a minimum: e. interviews any witnesses to the incident; f. interviews the resident; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate l. documents the investigation completely and thoroughly. The facility provided a document titled Protection of Residents During Abuse Investigations, with a revision date of April 2021, documented the victim is evaluated for his or her feelings of safety.

Based on record review, facility investigative file review, staff interviews and policy review the facility failed to report concerns about the treatment of Resident #3 within two hours of the alleged concerns observed. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Clinical Census revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative file contained the following statement from Staff B Licensed Practical Nurse (LPN): -On 2/22/25 (Saturday) I worked the nightshift 10:00 PM-6:00 AM. Staff E Certified Nursing Assistant (CNA) and Staff F CNA were the aides and around 10:30 PM-11:00 PM a resident had her call light on. Staff E heard the call light looked down the hall and stated oh hell no, I am not doing this tonight. When Staff B looked at her, she went down and answered the call light. Both CNAs would leave call lights go for long periods of time, while sitting at the desk talking. Staff B stated she watched and waited to see when rounds were going to be done, rounds were not done until 3-3:30 AM. The was the only time rounds were done, hospice residents were not turned, ice waters were not passed out to the residents, nor were linens. -On 2/23/25 (Sunday) I again worked the night shift 10:00 PM-6:00 AM with Staff E and F. They again were reluctant to answer call lights. The call lights would stay on for more than 5 minutes, while the CNAs sat at the desk talking. A resident had started to open her door and both CNAs yelled from the desk for the resident to lay back down and go to sleep, while pointing into the resident's room, this happened at least two times. A different resident came out of his room in his wheelchair and Staff F grabbed the resident's wheelchair and stated he had to go back to bed. The resident was taken to his room and placed back in bed. Rounds were again started at 3:00 AM and that was the only time rounds were done. Staff B stated she went into Resident #3's roommate's room to do a pre-assessment on the dialysis patient. Resident #3 was sitting up on the side of the bed. She stated she was exercising and was asked if she needed to go to the bathroom. She stated yes and this nurse pulled the call light for the resident. As she was completing the assessment on Resident #3 roommate, Staff E and Staff F came into the room and asked the resident what she was doing, the resident stated she was exercising, both aides started laughing loudly in a condescending manner, and said sure you are. Staff B told the aides that the resident needed to go to the bathroom. The EZ stand (mechanical lift) was brought in to the room and both aides were rude. They stated if she had to go to the bathroom she would need to use the lift. The resident kept stating she did not need to use the lift and that she had gone to the bathroom three other times during the night, by herself. Staff B stated both aides were talking in a manner to which she would not want her loved one being talked to. Resident #3 got more upset and aggressive towards the aides and the aides were telling Resident #3 that they could not take her to the bathroom without the lift but the resident stated she was not going to use the lift. The aides lifted the resident's legs back in to bed and stated then you aren't going to go to the bathroom. The aides did ask Staff B to help them talk to her but she stated that they had already made her mad, she would not listen to her and the resident stated no she wasn't. The statement was signed by Staff B on 2/25/2025 (Tuesday). During an email correspondent with the State Agency's Complaint Intake Specialist on 5/13/2025 at 10:06 AM, she provided the facility initially reported the concern to the State Agency on 2/25/2025 at 5:01 PM. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H Registered Nurse (RN) that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. Staff B stated she had Monday, 2/24/25 off but the next day she said something to the Director of Nursing (DON). When asked if the facility had an abuse coordinator to report abuse concerns to, she stated she was not sure. The DON was just starting in the facility. They usually have something written down to indicate who is on call, but does not recall if they had done that, that weekend. She alleged the concerns took place that Sunday into Monday morning about 4:30/5:00 AM. Staff B stated she did not know who to call at the time of her concerns, but acknowledged she should have called someone. She thought Staff H would tell Staff G the previous Administrator. Staff B stated when she came to work on 2/25/2025 she provided her statement and was written up for not reporting her concerns sooner. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/14/2025 at 2:54 PM Staff G indicated he reported the concerns to the State Agency he believed immediately. On 5/14/2025 at 4:23 PM the DON stated Staff B gave her written statement the same day she reported her concerns on 2/25/2025. The DON acknowledged it was not timely reporting on Staff B's part and she was educated on reporting concerns immediately. When asked who Staff B should have reported her concerns to, the DON stated she should have reported them to the Administrator and/or DON right away. She added they have their phone numbers posted at the nurse's station. The facility provided a document titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, with a revision date of April 2021, documented all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, federal agencies, and thoroughly investigated by facility management, findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 3.Immediately is defined as within two hours of an allegation involving abuse.

Based on record review, facility investigative file review, staff interviews and policy review the facility failed to complete a thorough investigation. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. Record review revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative file contained the following statement from Staff B Licensed Practical Nurse (LPN): -On 2/22/25 (Saturday) I worked the nightshift 10:00 PM-6:00 AM. Staff E Certified Nursing Assistant (CNA) and Staff F CNA were the aides and around 10:30 PM-11:00 PM a resident had her call light on. Staff E heard the call light looked down the hall and stated oh hell no, I am not doing this tonight. When Staff B looked at her, she went down and answered the call light. Both CNAs would leave call lights go for long periods of time, while sitting at the desk talking. Staff B stated she watched and waited to see when rounds were going to be done, rounds were not done until 3-3:30 AM. The was the only time rounds were done, hospice residents were not turned, ice waters were not passed out to the residents, nor were linens. -On 2/23/25 (Sunday) I again worked the night shift 10:00 PM-6:00 AM with Staff E and F. They again were reluctant to answer call lights. The call lights would stay on for more than 5 minutes, while the CNAs sat at the desk talking. A resident had started to open her door and both CNAs yelled from the desk for the resident to lay back down and go to sleep, while pointing into the resident's room, this happened at least two times. A different resident came out of his room in his wheelchair and Staff F grabbed the resident's wheelchair and stated he had to go back to bed. The resident was taken to his room and placed back in bed. Rounds were again started at 3:00 AM and that was the only time rounds were done. Staff B stated she went into Resident #3's roommate's room to do a pre-assessment on the dialysis patient. Resident #3 was sitting up on the side of the bed. She stated she was exercising and was asked if she needed to go to the bathroom. She stated yes and this nurse pulled the call light for the resident. As she was completing the assessment on Resident #3 roommate, Staff E and Staff F came into the room and asked the resident what she was doing, the resident stated she was exercising, both aides started laughing loudly in a condescending manner, and said sure you are. Staff B told the aides that the resident needed to go to the bathroom. The EZ stand (mechanical lift) was brought in to the room and both aides were rude. They stated if she had to go to the bathroom she would need to use the lift. The resident kept stating she did not need to use the lift and that she had gone to the bathroom three other times during the night, by herself. Staff B stated both aides were talking in a manner to which she would not want her loved one being talked to. Resident #3 got more upset and aggressive towards the aides and the aides were telling Resident #3 that they could not take her to the bathroom without the lift but the resident stated she was not going to use the lift. The aides lifted the resident's legs back in to bed and stated then you aren't going to go to the bathroom. The aides did ask Staff B to help them talk to her but she stated that they had already made her mad, she would not listen to her and the resident stated no she wasn't. The statement was signed by Staff B on 2/25/2025 (Tuesday). Review of the facility's investigative file included a page of resident questions that was filled out by various staff members. Question #6 asked Do you have any type of mistreatment to report to me now? The Social Worker documented the following information that was provided by Resident #3: I was abused, left hanging on the side of my bed. It was in the middle of the night. I was told by the aide I will not be helping you. I sat there for 2 hours. It caused me great pain. I've never been physically abused. The investigative file lacked any follow up with Resident #3 about her response to question #6. Resident #3's roommate was asked the same question but the file failed to include an interview with the roommate pertaining to the morning in question. The investigative file included interviews with the following staff members: Staff B, Staff E and Staff F. The investigative file failed to include interviews with staff members that took care of the resident on all shifts after the alleged incident occurred as well as no interview with Staff H Registered Nurse (RN). The investigative file also lacked any follow up interview(s) with Resident #3 after the alleged incident to check on her psycho-social status. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/16/2025 at 10:48 AM the Social Worker acknowledged she interviewed Resident #3 using the resident questions sheet. When asked what she did with the information after her interview, she stated she gave her interview sheets to the DON. She indicated she did not ask further questions and could not remember if other residents had concerns in regards to the care they received. She would not have asked further questions with Resident #3 because she did not like upsetting her. When asked if the DON said anything when she handed her Resident #3's responses she stated she just handed her the paper and the DON said thank you. On 5/16/2025 at 11:20 AM the DON was read Resident #3's response to the questionnaire completed by the Social Worker. She was asked if she followed up with Resident #3 after the Social Worker had completed her questionnaire with her. The DON denied being aware of that statement. Those concerns should have been reported to her and another investigation should have been started. If they were reported to her, she would have found out more information. The DON indicated she followed up with Resident #3 after the alleged incident to see how she was doing, she checked on her a lot but did not document it anywhere. When she followed up with her the resident was fine, some days she was confused others she was not. When asked if the Social Worker could have followed up with Resident #3 she stated oh absolutely. When asked why the roommate was not asked questions specific to the alleged incident, she stated she should have been asked questions. She acknowledged Staff H was not interviewed. The facility provided a document titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, with a revision date of April 2021, documented investigating allegations: 1. All allegations are thoroughly investigated. The Administrator initiates investigations. 7. The individual conducting the investigation as a minimum: e. interviews any witnesses to the incident; f. interviews the resident; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate l. documents the investigation completely and thoroughly.

Based on observations, interviews and record review the facility failed to monitor and prevent the worsening of pressure sores for 1 of 2 residents. Resident #9 was admitted on [DATE] with a chronic skin issue on his left heel. It wasn't identified or documented until 6/20 and staff failed to get an order for treatment until 8/3. He also had an open sore on his right foot that had not been identified or documented until 8/3. The facility also failed to implement preventative interventions to facilitate healing. The facility reported a census of 36 residents. Findings include: The MDS (Minimum Data Set) 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. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to the Admission Minimum Data Set (MDS) dated [DATE], Resident #9 was admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. The MDS indicated that the resident did not have any pressure ulcers at the time of admission. The Care Plan dated 6/20/23 showed that he was unable to transfer independently, he had a urinary catheter and was at risk for falls. Diagnosis included; type 2 diabetes with diabetic polyneuropathy, chronic kidney disease, Parkinson's disease, long term use of insulin, peripheral vascular disease, chronic ulcer of other part of left foot with necrosis of muscle. In an observation on 8/1/23 at 7:55 AM, Resident #9 was in his bed on his back, was wearing gripper socks and his heels were resting on the bed. The resident said he had a sore on his left heel. A review of the clinical record revealed an After-Visit Summary faxed from the hospital on 6/12/23 at 8:25 AM contained admission orders to the nursing home with directions to staff to apply Alevyn dressing (foam dressing used for fluid absorption and management of partial full-thickness wounds) to the left foot every 5 days. A skin observation dated 6/18/23 at 10:41 AM indicated that the resident did not have any skin issues. Skin and Wound Observations and nursing documentation included the following: a. On 6/20/23 at 7:48 PM. Injury to the left heel, present upon admission, scabbed with no drainage. Foam dressing intact. Area measured 5.5 centimeters (cm) total area, x 3.1 cm (length) x 2.9 cm (width). b. On 7/7/23 at 3:22 PM Injury measured 8.5 cm x 2.6 cm x 5.0 cm. No dressing in place at time of assessment. c. On 7/7/23 at 3:45 PM a fax sent to the doctor indicated previous area to left heel had an open area and Mepilex applied with weekly monitoring. The doctor signed the fax on 7/10/23. The electronic chart lacked an order entry for the treatment. d. The chart lacked documentation of monitoring from 7/7 - 7/25. On 7/25 at 10:56 AM the injury measured 7.3 cm x 4.5 cm x 2.1 cm. There was no documentation of drainage or description of the peri wound area. No dressing present upon assessment. e. On 7/31/23 at 2:18 PM, the heel ulcer measured 8.2 cm x 3.8 cm x 2.4 cm, granulation with slough, moderate drainage, peri wound with rolled edges. Wound cleanser used with island dressing. On 8/1/23 at 7:55 AM, Resident #9 was in his bed on his back. He was wearing gripper socks and he said that he had a sore on his left heel. The heel was resting on the bed and there was no protective boot in the room. On 8/3/23 at 1:30 PM, Registered Nurse, Staff J removed the residents gripper stockings to reveal that he had the toes on both feet amputated. The resident said that the ulcer on his left heel had been so bad that there was a 2 inch hole. Staff J removed the bandage from his heel, it was undated and soiled with fluids and blood. She said that there was no order for treatments on his foot but she had been changing it every day that she had been working. She said that she had requested an order but hadn't gotten a response from the doctor. She then removed a bandage from the right foot and revealed an open sore on the outer edge of his foot, where the fifth digit would have been. She put a bandage on it and the resident said that happened when something came down on his foot. The following was included in the Skin and Wound Documentation in the electronic chart: a. On 8/3/23 at 4:16 PM left heel, identified as a stage 4 pressure measuring 1.4 cm x 1.1 cm x 1.8 cm, with slough and 10% filled eschar of 80% of wound, light drainage, no dressing applied, wound deteriorating. Physician contacted. b. On 8/3/23 at 4:18 PM, right dorsum 5th digit, in house acquired on 7/18/23 trauma. Measured 1.5 cm x 1.1 cm x 1.0 cm with light drainage, superficial loss tissue, primary care physician was contacted. The chart lacked documentation of the trauma that happened on 7/18/23. The resident reported that something fell on his right foot. On 8/3/23 at 2:05 PM Licensed Practical Nurse (LPN) Staff D said that on 7/11/23 when she got the fax for the Mepilex treatment on the heel was the first that she knew that he had this sore. There was no report from nurse to nurse about a pressure sore. On 8/3/23 at 2:15 PM the Assistant Director of Nursing (ADON) acknowledged that said that she had completed the skilled assessments for Resident #9 on the 10th and 11th because she was helping out the nurse on the floor. She said that she would not have looked at the resident's feet at that time because the nurse would have assessed him. She didn't recall every having seen his feet upon admission. On 8/3/23 at 2:22, RN Staff J, said that she had just started working at the facility the beginning of July, and she would not have provided treatments before 7/11/23 because she was unaware of the sores. On 8/3/23 at 4:00 PM, the Director of Nursing (DON) said that she was not aware of an open area on the resident's right foot and she would follow through with orders and documentation. On 8/8/23 at 7:30 AM, a nurse for the facility Physician said that as soon as the facility noticed a change in a wound, the doctor would have wanted to be contacted. The resident had an appointment with the doctor on 6/27 but it had been canceled, she did not know the reason or who canceled it. According to the doctor note on 6/12 he was aware of a spot on his left heel but they did not have documentation that the facility contacted him when it got worse or when he acquired the wound on his right foot. On 8/8/23 at 9:07 AM, the DON provided a dressing change for the left heel and right foot. He had pressure preventative boots on both feet and the dressings included a medication to promote healing. A facility policy titled: Pressure Ulcers/Skin Breakdown - Clinical Protocol 2018 showed that the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The staff would examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.

Based on observations, clinical record review, and staff, resident and family interviews, the facility failed to ensure that based on a comprehensive assessment, staff provided care consistent with professional standards to prevent pressure ulcers from developing unless the individual's clinical condition demonstrated that they were unavoidable. The facility also failed to ensure residents with existing pressure sores received necessary treatment, care, and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 4 residents reviewed (Resident #1, #5, #9, and #15). The facility did not have a comprehensive system that staff used to prevent, track, monitor, identify, evaluate, and treat pressure ulcers, which resulted in new wound formation and/or deterioration of existing wounds for multiple residents with no on-going or cohesive plan for wound care or monitoring that staff followed. This constituted an Immediate Jeopardy in resident health and safety. The facility identified a census of 39 residents. Findings include: The MDS (Minimum Data Set) assessment identified the definition of pressure ulcers: Stage I as 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 with 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 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. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. According to the MDS dated [DATE], Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 12 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS also documented Resident #5 required extensive assistance of 2 staff for bed mobility and transfers and extensive staff assist with personal hygiene. The assessment identified the resident as at risk for pressure ulcers but with no actual pressure ulcers. The MDS revealed the resident was not on a turning/repositioning program and received no treatments. The resident's care plan did not address any risks or potential for skin problems and did not contain documentation of any actual skin problems. A Braden Scale for Predicting Pressure Sore Risk form dated 12/29/21 at 11 a.m. documented the resident as at high risk for pressure ulcers. According to a hospital History and Physical (H & P) form dated 2/17/22, Resident #1 admitted to the hospital with a Stage IV coccyx wound that measured 5.0 cm x 4.0 cm, depth unable to determine, and wound bed with 100% necrotic tissue. Review of Resident #5's clinical record revealed no pictures, additional measurements, or assessments of the resident's pressure ulcers to indicate staff further assessed, tracked, or monitored the resident's coccyx wound. During an interview on 3/10/22 at 8:39 a.m. the Director of Nursing (DON) confirmed that the nurses did not complete the entire evaluation/assessment, but noted they did measure the resident's wound and so they were apparently aware of the ulcer. A typed statement dated 3/10/22 and signed by the Director of Nursing (DON) and the Regional Director of Clinical Services included the following documentation: On March 1, 2022, the DON and the Regional Director of Clinical Services conducted an interview with Staff D, a Licensed Practical Nurse (LPN) from a staffing agency regarding Resident #5 and any dressing changes or skin assessments she might have possibly conducted. Staff D reported she did assess the area and change the dressings according to the orders. When asked if she noticed any changes in the wound, she stated she noticed changes but did not document her observations because she had assumed the skin nurse was doing that. Staff D also verified she had not notified the physician, family/resident representative, or management personnel from the facility, but added that she should have. During an interview on 3/9/22 at 4:47 p.m., the physician stated that obviously, if staff had treated the resident's ulcer it would have kept the areas from worsening, but staff did not bring the ulcer to his attention. 2. An MDS dated [DATE] documented Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 11 of 15 possible points on the BIMS test (moderately impaired cognitive abilities). The MDS also documented Resident #1 did not walk and required extensive assist of 2 staff for bed mobility and toilet use and extensive assistance of 1 staff for personal hygiene. The assessment documented the resident as at risk for pressure ulcers but without current pressure ulcers, not on a turning and repositioning program but received application of ointments/medications other than for feet. A Care Plan revised 10/28/21 documented the resident was at risk for skin impairment and directed staff to: a. Monitor for and document the location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (revised 10/28/21). b. Complete weekly treatment documentation including a measurement of each area of skin breakdown, the type of tissue and exudate, and any other notable changes or observations. (revised 10/28/21) Review of the resident's electronic medical record revealed documentation of the resident's Stage III sacral pressure ulcer assessments as follows: a. On 2/26/22 - 4.33 centimeters (cm) by (x) 2.35 cm with no depth, undermining, or tunneling documented and/or addressed, 10% granulation tissue in the wound base, and no further documentation present. b. On 3/8/22 - 2.77 cm x 1.74 cm with no depth, undermining, or tunneling documented and/or addressed, 90% eschar in the wound base, bleeding, no exudate or drainage, peri-wound edges attached, surrounding tissue contained erythematous and a normal peri-wound temperature. c. On 3/8/22 (same area as above) - 1.03 cm x 0.88 cm - no depth, undermining or tunneling documented and/or addressed, 90% eschar in the wound base, no exudate, peri-wound edges attached, surrounding tissue erythematous, no induration or swelling and a normal peri-wound temperature. d. The Progress Notes documented Resident #1 hospitalized from 3/9/22 to 3/17/22. e. On 3/17/22 - 1.72 cm x 1.63 cm with no further assessment or documentation present. f. On 3/23/22 - 0.85 cm x 1.47 cm with no further assessment or documentation present. 3. An MDS dated [DATE] documented Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident scored 15 of 15 possible points on the BIMS test, which indicated the resident experienced intact cognitive abilities. The MDS identified the resident did not walk and required extensive assistance of 2 staff for transfers, bed mobility, dressing, and toilet use, and had impairment to her bilateral lower extremities. The MDS documented the resident as at risk for pressure ulcers, with no current pressure ulcers or skin problems, and identified the resident as not on a turning a repositioning program. The resident's Care Plan did not contain any documentation that addressed any skin concerns or impairment. An observation on 3/10/22 at 10 a.m. revealed Staff A, Certified Nursing Assistant (CNA) and Staff F, CNA as they positioned Resident #9 with the open area on her left posterior thigh visible. The resident said the ulcerated area had been present since January 2022, but the nurses failed to treat the area. During an interview on 3/16/22 at 10:06 a.m., Staff A stated she had not only reported the open area on Resident #9's left posterior thigh to Staff G, Licensed Practical Nurse (LPN) on 3/10/22 following the above observation, but had also told Staff D, LPN over a month ago. During an interview on 3/16/22 at 11:16 a.m., Staff A and Staff F reported they were present and observed Staff A tell Staff G about the open area on 3/10/22 at approximately 10 a.m. and reported Staff G stated, Oh, really. 4. An MDS dated [DATE] documented Resident #15 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 points on the BIMS test (intact cognitive abilities) and did not walk. The MDS revealed Resident #15 required extensive assist of 2 staff for bed mobility, transfers and toilet use and extensive assistance of 1 staff for personal hygiene. The MDS identified the resident as at risk for pressure ulcers but with no current pressure ulcers and as not on a turning and repositioning program. A Care Plan dated 1/21/22 documented the resident had a skin impairment (surgical incision and bruising) and directed staff to: a. Monitor for and document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] b. Complete weekly treatment documentation to include measurements of each area of skin breakdown, the type of tissue and exudate, and any other notable changes or observations. (dated 1/21/22) An Admission/Readmission Evaluation form dated 1/19/21 at 11:11 p.m. documented the resident had no pressure injuries. A Fax form dated 1/26/22 (no time) documented the resident with (2) Stage II pressure ulcers on his right and left buttock and requested a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident Report form dated 1/27/22 at 10:22 a.m. documented the resident had pressure areas on his right and left buttocks; staff cleansed the areas and applied Allevyn (dressing). Review of the resident's electronic record documented information related to the Stage II pressure area on the resident's right ischial tuberosity pressure ulcer as follows: a. 1/26/22 - 0.47 cm x 0.13 cm with no further documentation/assessment present. b. 2/4/22 - 0.84 cm x 0.35 cm with no further documentation/assessment present. c. 2/7/22, 2/14/22, and 3/1/22 - no documentation of assessment present d. 2/23/22 - 0.95 cm x 0.42 cm with 10% slough, wound edges attached, and surrounding tissue intact. No further documentation/assessment present. Resident #15's Progress Notes revealed the following information related to the Stage II pressure ulcer entries regarding the Stage II pressure ulcer on the resident's right ischial tuberosity: 1/26/22 at 12:34 p.m. - Facility acquired, Stage II partial thickness skin loss with exposed dermis, that measured 0.50 cm x 0.10 cm, depth, undermining and tunneling not applicable, Staff documented that after they cleansed the wound they noted an odor - no further documentation present. 2/4/22 at 12:42 p.m. - Facility acquired, Stage II partial thickness skin loss with exposed dermis that measured 0.8 cm x 0.4 cm, depth, undermining and tunneling not applicable, odor noted after cleansing the area and no further documentation present. 3/1/22 at 11:09 a.m. - Facility acquired Stage II partial thickness skin loss with exposed dermis - no further assessment present. Review of Resident #15's Progress Notes revealed the following documentation related to the resident's pressure area on the left buttock: a. 1/26/22 at 12:34 p.m. - Facility acquired Stage II partial thickness skin loss with exposed dermis, that measured 0.8 cm x 0.2 cm depth, undermining and tunneling not applicable, odor present after cleansing. No further documentation present. b. 2/23/22 at 5 p.m. - Facility acquired Stage II partial thickness skin loss with exposed dermis, that measured 0.3 cm x 0.1 cm, depth, undermining and tunneling not applicable, odor present after cleansing, peri-wound edge appeared flush with the wound bed or as a sloped edge, surrounding skin intact. The entry noted the wound had deteriorated although there was no documentation to show staff had notified the physician. A Five Minute Meeting for Employees form dated 3/6/22 documented the topic and key points as follows: It is all nursing department personnel's (nurses, CNA's and TNA's (trained nurse's aides) responsibility to report any skin conditions (skin tear, bruise, skin breakdown) to the nurse. Then, the nurse's responsibility is to take a picture and complete the change of condition evaluation along with the risk management for that resident. The facility was notified of the Immediate Jeopardy on 3/10/22. The IJ was removed on 3/16/22 when the facility wrote the following summary and implemented the following measures: A resident (# 9) with a pressure ulcer, failed to receive appropriate documentation, evaluation, and follow through. Additionally, an area identified by the surveyor was not identified by the facility staff that completed the head-to-toe [assessment] nor identified by the daily checks, or the facility's wound clinic staff. The resident discharged home on 3/13/22. 1. Full head to toe assessment on all residents by management team with continued monitoring by CNA's, CMA's and bath aides with cares. 2. Education of all Nursing staff 3. Review of residents with current skin issues have had their physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Added documentation to the Skin and Wound Module in PCC. 5. DON/Designee would review the 24-hour report/dashboard in PCC each morning with the clinical morning meeting. 6. Non-compliance with the plan identified through monitoring and presented at QAPI for any additional recommendations. 7. Obtain treatment or new treatment orders PRN. 8. Notification of the resident's physician and responsible party. These actions lowered the IJ from a K severity level to an E with ongoing monitoring required.

Based on clinical record review, staff and physician interview, and facility policy review, the facility failed to provide the necessary assessments and timely interventions for 2 of 5 residents reviewed that experienced a significant change in their physical, mental, or psychosocial condition (Resident #5 & #8). The facility identified a census of 39 residents. Findings include: According to the MDS assessment tool dated 1/21/22 Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident demonstrated severe cognitive impairment by scoring 0 of 15 possible points on the Brief Interview for Mental Status (BIMS) test. The MDS also documented Resident #8 required extensive assistance of 2 staff members for bed mobility, transfers and dressing. The Care Plan with a revision date of 12/9/21 documented Resident #8 had impaired cognitive function or impaired thought process. Resident #8's progress notes documented the following: - Late Entry for 1/11/22 at 2:42 PM documented by the Regional Nurse Consultant on 3/17/22: Resident #8 had a change in condition. He had experienced abdominal pain, abnormal vital signs, and shortness of breath. His oxygen (O2) saturation was 83% on room air on 1/11/22 at 7:15 AM. Under the recommendation section of the assessment the facility documented emergency room (ER). - On 2/4/22 at 1:28 PM, the facility received an order response from Resident #8's primary care provider that directed staff to apply supplemental oxygen: titrate to keep oxygen saturations above 90%. - On 2/4/22 at 4:07 PM, Resident #8 readmitted from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #8's speech therapy notes from 1/19/22 at 12:50 PM documented upon entering the room, the Occupational Therapist (OT) checked the resident's O2 saturations which read 81% and 82%. The OT told the nurse who responded it was likely due to him being at rest. The Speech Therapist encouraged nursing to continue to check O2 saturation checks due to the resident's low percentages identified by the OT. The resident's son reported the resident used O2 in the hospital as needed (PRN). The resident's clinical record lacked the following: documentation after the resident's readmission from the hospital on 1/17/22 and follow up documentation after the OT reported the resident had O2 sats of 81 and 82% on 1/19/22 at 12:50 PM. The resident's vitals documentation record failed to contain a record of the resident's O2 sats from 1/19/22 at 12:50 PM taken and reported to nursing by the OT. The form showed staff checked and documented the resident's O2 sats once daily: 1/19/22 at 6:40 AM: 92% and 1/20/22 at 6:45 AM 97%. On 3/18/22 at 11:58 AM Staff A Agency Certified Nursing Assistant (CNA) stated Staff B, the Speech Therapist (ST) that worked with Resident #8 had reported to Staff C Registered Nurse (RN) that his oxygen levels were low and wanted her to recheck them. Staff C said the resident ran low because he was recovering from pneumonia. Staff A said she did not think that Staff C had rechecked or monitored Resident #8 after the therapist reported the resident's low O2 sats to her. On 3/18/22 at 12:22 PM Staff B, ST reported she had gone into Resident #8's room on 1/19/22 at 12:50 p.m., found him difficult to arouse, and then unsuccessfully tried a sternal rub. This led Staff B to check the resident's O2 sats and she identified they were in the low 80's. She then sat him up in bed and told the nurse, who commented that that he just got back from the hospital for pneumonia and had lain in a flat position, so his lungs were probably working too hard and it was probably why he had low levels. Staff B added the resident could be hard to wake up, but that day it seemed different. Attempts made to contact Staff C, RN for an interview were unsuccessful. On 3/22/22 at 10:28 AM, the Director of Nursing (DON) stated when a resident returns from the hospital, staff should complete a head-to-toe assessment. When asked what is expected of staff when someone reports a resident with low O2 sats in the 80's, the DON said that the nurse should follow up on that. When informed that Staff C, RN had not completed an assessment, she replied that Staff C should have evaluated the situation and sent a request for orders for supplemental oxygen. 2. An MDS assessment form dated 12/27/21 documented Resident #5 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment documented the resident demonstrated moderately impaired cognition with a BIMS score of 12, was non-ambulatory, and remained dependent on staff for toilet use. The MDS revealed Resident #5 required extensive assist of 2 staff with bed mobility and transfers and extensive assistance of staff with personal hygiene. The assessment documented the resident as at risk for pressure ulcers but without pressure ulcers and not on a turn/repositioning program and/or a treatment. A Care Plan failed to address any potential for and/or skin issues. A Braden Scale for Predicting Pressure Sore Risk form dated 12/29/21 at 11 a.m. documented the resident as high risk for pressure ulcers. Record review of the facility's skin and wound tab in PCC resulted in no pictures and/or assessments of the resident's wound. A History and Physical form from a hospital dated 2/17/22 at 9:45 a.m. documented the resident as admitted to the hospital with the following: a. Chronic stasis ulcers to the resident's bilateral lower legs. Ulcers reviewed and stable. During an interview on 3/10/22 at 8:39 a.m. the Director of Nursing (DON) confirmed the nurses did not complete the entire evaluation/assessment of the resident's wounds while he was in the facility, but they did measure the resident's wounds. This led her to believe they were apparently aware of the wound. A Care Plan failed to address any potential for and/or skin issues. A Braden Scale for Predicting Pressure Sore Risk form dated 12/29/21 at 11 a.m. documented the resident as high risk for pressure ulcers. Record review of the facilities skin and wound tab in PCC resulted in no pictures and/or assessments of the resident's pressure ulcers. A History and Physical form from a hospital dated 2/17/22 at 9:45 a.m. documented the resident as admitted to the hospital with the following: a. Chronic stasis ulcers to the resident's bilateral lower legs. Ulcers on the feet looked at and stable. Wound on buttocks described as a stage IV. During an interview 3/10/22 at 8:39 a.m. the Director of Nursing (DON) confirmed the nurse's measured the resident's wounds, but failed to complete the entire evaluation/assessment. This led her to believe they were apparently there had been aware of the ulcers. A typed statement dated 3/10/22 and signed by the Director of Nursing (DON) and the Regional Director of Clinical Services included the following documentation: On March 1, 2022, an interview with Staff D, LPN/agency nurse, the DON, and the Regional Director of Clinical Services regarding dressing changes and skin assessments for Resident #5 was conducted. The staff member stated she assessed and changed the dressings according to the orders. When asked if she noticed any change(s) in the wound, she stated she noticed it had changed, but she did not document it because she had assumed the skin nurse was doing that. Staff D also verified she had not notified the physician, family and/or resident representative, or management at the facility, but stated I should have. During an interview on /9/22 at 4:47 p.m., the physician reported that if staff had treated the resident's ulcerated area it obviously would have kept it from worsening. The physician added that staff did not bring the area to his attention. A Change of Condition/Hot Chart Protocol form dated 1/2015 documented its purpose was to provide care to residents through nursing assessments, interventions, and appropriate follow up. The protocol documented a condition change meant an alteration from normal status which included but was 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, cognitive changes in the resident, and emotional changes in the resident. The Documentation section directed staff that observation/assessment of the resident included responses to interventions until the problem resolved.

Based on clinical record review, facility policy review and family, Nurse Practitioner and staff interviews, the facility failed to follow the standards of practice to prevent the development of a pressure ulcer for 1 of 3 sampled residents (Resident #1). The facility reported a census of 35 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment documented he required the assistance of two for most ADLs (activities of daily living), including being repositioned in bed. Resident #1 did not walk during the assessment period and depended on staff to push his wheelchair for mobility. The BIMS (brief interview for mental status) assessment noted Resident #1 scored 5 out of 15, indicating severely impaired cognition. Resident #1 had limited range of motion (ROM) on both sides of the upper and lower extremities. According to the MDS, Resident #1 had a urinary catheter and always had episodes of bowel incontinence. The MDS documented Resident #1 had one stage 2 pressure ulcer, the risk of developing further ulcers and a weight of 284 pounds. The MDS assessment identifies the following definitions of pressure ulcer staging: Stage 1 Pressure Ulcer: An observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage 2 Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister. Stage 3 Pressure Ulcer: 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. (MONTH) include undermining or tunneling. Stage 4 Pressure Ulcer: 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. Unstageable due to Suspected Deep Tissue Injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Resident #1's Baseline Care Plan dated [DATE] documented his cognition as confused and that he had advanced dementia. The Care Plan noted a current ulcer on his buttocks and frequent turning and repositioning as interventions. An [DATE] revision identified a left heel pressure ulcer with direction for heel float boots at all times and Allevyn (a type of dressing) as interventions for the new wound. The (MONTH) (YEAR) Prevention of Pressure Ulcers guideline noted its purpose as: 1. To promote good skin integrity. 2. To relieve pressure, restore circulation and promote skin protection. Possible choices of equipment: - Skin lotion. - Elbow protector. - Heel protector. - Pressure reduction mattress. - Pressure reduction wheelchair cushion. - Foot or bed cradle. - Positioning pillows/wedges. Guidelines: Point # 6. Utilize pressure-reduction devices on bed and chair as necessary. Point # 7. Reposition resident routinely and position with pads and pillows to protect bony prominences and maintain proper alignment. Point # 11. Use bed cradle to prevent pressure from as needed. Resident #1's Discharge Summary dated [DATE] at 7:55 a.m. documented Resident #1's discharge [DIAGNOSES REDACTED]. Nurse's Note dated [DATE] at 11:15 a.m. documented Resident #1 admitted to the facility. Staff documented he was alert and oriented to himself only and required the use of a Hoyer lift (mechanical lift) with assistance of 2 staff for transfers. The nurse also assessed Resident #1 with 2+ pedal [MEDICAL CONDITION] (slight indentation) to both lower extremities. Fax correspondence to Resident #1's primary care provider dated [DATE] at 9:00 p.m. noted all the skin issues identified during admission which included 6 bruises in various places and 1 pressure ulcer on Resident #1's left buttock. According to a Nurse's Note dated [DATE] at 2:35 p.m. Resident #1 continued to be alert and oriented to himself only and to require the use of a Hoyer lift (mechanical lift) with assistance of 2 staff for transfers. The nurse assessed Resident #1 with 2+ [MEDICAL CONDITION] to both lower extremities. Resident #1 he needed staff to push him back and forth to the dining room in the wheelchair and did not attempt to propel his wheelchair by himself. According to the [DATE] Braden Scale For Predicting Pressure Sore Risk, Resident #1's score of 13 indicated a moderate risk for developing pressure sores. A Nurse's Note dated [DATE] at 8:45 a.m. noted Resident #1 needed staff assistance with ADLs, transferred with an EZ stand (mechanical sit to stand device) and used a wheel chair for mobility. The nurse assessed Resident #1 with 2 to 3+ [MEDICAL CONDITION] to both lower extremities. A Progress Note by Primary Care Provider (PCP) on [DATE] documented the resident's family requested to leave Resident #1's catheter in for a while longer to enable his buttocks to heal more. The PCP assessed Resident #1's skin as warm, dry and swollen. The PCP ordered to leave the resident's catheter in and apply [MEDICATION NAME] (skin barrier ointment) to the healed areas on his buttocks. The ED (emergency department) Provider Notes dated [DATE] at 6:05 p.m. indicated Resident #1 presented with concerns about low urine output. According to the Physician's Assistant (PA), Resident #1 had a chronic indwelling catheter due to urinary incontinence causing skin breakdown issues on his buttocks. The PA's physical exam assessed a 1 cm superficial open wound on Resident #1's buttocks near his coccyx. The PA discharged Resident #1 to the facility at the same level of care. A Nurse's Note dated [DATE] (no time listed) recorded Resident #1 had a pressure area to his left heel with redness surrounding it. The Pressure Ulcer Healing Record documented a 5.1 cm x 8.3 cm Stage 2 left heel pressure ulcer with a small amount of drainage and bright red surrounding skin identified on [DATE]. A Nurse's Note dated [DATE] at 2:00 p.m. recorded staff transferred Resident #1 with a sit/stand lift and pushed him to and from meals in a wheelchair. The nurse assessed Resident #1 with 3+ pedal [MEDICAL CONDITION] to both lower extremities and he complained of left heel pain. Fax correspondence to Resident #1's PCP on [DATE] notified him of an open pressure ulcer to the resident's heel, a blister that opened, measuring 5.1 cm x 8.3 cm with a red surrounding area measuring 4 x 14.3 cm. The nurse requested the provider to authorize an order for [REDACTED]. A Nurse's Note dated [DATE] at 2:45 p.m. documented receipt of a new order to apply Allevyn and change the dressing every 3 days and as needed (PRN). The (MONTH) (YEAR) Treatment Record recorded staff applied Allevyn to Resident #1's left heel on [DATE], to be changed every 3 days and PRN. Review of a Nurse's Note dated [DATE] at 7:30 p.m. revealed Resident #1 complained of left heel pain. The Pressure Ulcer Healing Record documented the weekly assessment dated [DATE] as a 7 cm x 8 cm Stage 2 left heel pressure ulcer with a slightly odorous, moderate amount of drainage with a black wound bed and white surrounding skin. A Nurse's Note dated [DATE] at 10:45 a.m. recorded Resident #1's physician authorized a wound consultation for the left heel ulcer. The nurse recorded the wound increased in size from 5.1 cm x 8.3 cm to 7 cm x 8 cm. A Nurse's Note dated [DATE] at 6:30 p.m. noted a very odorous left heel dressing with red colored drainage. The nurse documented that Resident #1 complained of pain. Fax correspondence to Resident #1's PCP on [DATE] informed the pressure ulcer to Resident #1's heel increased in size that week from 5.1 cm x 8.3 cm to 7 cm x 8 cm with black eschar noted. The nurse requested the PCP to authorize a wound consultation. Resident #1's PCP saw the resident on [DATE]; the resident's family requested the visit regarding a left heel ulcer identified about a week before. The PCP documented the wound as pretty large, concerning and mildly tender. The PCP assessed the wound as a 5 cm necrotic Stage 3 ulcer and noted that although Resident #1 wore protective boots, the wound still hit the wheelchair and bed due to his weight. Resident #1 seemed more confused during the visit and gave inappropriate answers to questions. The PCP's ordered: - A referral to the wound nurse. - The resident must have the extremity elevated with no pressure on it. - Recommendation to have a pillow behind the calf while in the chair or bed to keep pressure off his heel. A Urology Clinic Note dated [DATE] at 4:49 p.m. noted that Resident #1's spouse accompanied him and reported he is less alert, his overall activity has decreased and he had difficulty with pressure ulcers due to his inability to move about in bed. The urologist assessed Resident #1 with a decreased level of consciousness from the many times he had seen him before and recorded worsening of the left heel ulcer compared to the last evaluation. The urologist indicated the ulcer may have an active infection based on its foul smell. He discussed a Hospice consultation with Resident #1 and his wife. New orders included: - Hospice consultation. - Wound nurse consultation. - Keep pressure off by putting pillow/s under the calf so his heels do not touch the mattress. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. A Nurse's Note dated [DATE] recorded Resident #1 had pain when she changed his left heel dressing. She documented that both lower extremities were floated with a pillow and heel boots were in place. On [DATE], staff sent a fax to Resident #1's PCP regarding very painful dressing changes to his heel and the PCP ordered [MEDICATION NAME] 50 milligrams by mouth 3 times a day for the pain. Fax correspondence dated [DATE] to Resident #1's PCP documented orders for a Hospice consult and a wound care consult for the left heel. The orders also directed staff to place a pillow under Resident #1's calf so his heels did not touch the mattress. The physician's orders [REDACTED].#1. The nurse noted a 4.5 cm x 7.0 cm left heel pressure ulcer with black eschar (dead tissue) in the center of the wound. The upper edge of the eschar was soft - boggy, with a necrotic (dead) smell present. The nurse recommended: - Discontinue Allevyn. - Applying gauze dampened with a solution of ½ [MEDICATION NAME] (antiseptic) and ½ saline and wrapped with gauze daily. - Continue bilateral heel pressure relief. - Dietary staff to evaluate Resident #1's nutritional needs for vitamins and supplements. The (MONTH) (YEAR) MAR indicated [REDACTED]. A Nurse's Note dated [DATE] at 8:00 p.m. recorded Resident #1 had difficulty standing with the use of the sit to stand lift. The nurse assessed Resident #1 as only oriented to person and he moaned when he spoke. The nurse documented the resident's catheter drain bag contained dark brown urine. The note dated [DATE] at 11:15 a.m. recorded Resident #1 had been moaning and non-responsive to verbal cues. Orders were obtained to send Resident #1 to the ER. A Resident Transfer Form dated [DATE] noted that Resident #1 transferred to the hospital with a left heel wound after moaning, not responding, not eating and not acting like himself. The ED Provider Notes dated [DATE] at 12:38 p.m. documented Resident #1 had a recent episode of altered mental status secondary to urosepsis and had a left heel pressure sore. The physical exam documented Resident #1 looked frail and chronically ill. The resident had a 6 cm x 5 cm necrotic pressure sore on the left heel surrounded by redness, swelling and tenderness with purulent drainage a bad smell. Resident #1's PCP note dated [DATE] at 9:56 a.m. documented Resident #1 presented to ER the previous evening with a progressively worsening status. Resident #1 had not been eating, had poor mental status and had physically declined in his work with therapy since Wednesday. The PCP offered concern about infection of the malodorous and slightly reddened ulcer. She indicated Resident #1 moaned in pain, but was still poorly responsive. Resident #1 had poor ROM and very advanced [MEDICAL CONDITION] where stiffness predominates. Resident #1's eyes opened, but he did not really respond to commands. The PCP documented that although his ulcer was dry on Tuesday when she saw him, the large black ulcer was now malodorous and draining. The Certificate of Death filed on [DATE] documented Resident #1 died on [DATE] at 2:27 p.m. with an immediate cause of death [MEDICAL CONDITION] due to or as a consequence of urine and wound infection and end stage [MEDICAL CONDITION] with immobility. An interview on [DATE] at 1:45 p.m. with Staff B, LPN (Licensed Practical Nurse) revealed that she changed Resident #1's left heel dressing on [DATE] and [DATE]. Staff B thought the wound bed was necrotic and had an odor to it. Resident #1 depended on staff for a lot. Staff B said the resident was too weak and lacked the cognitive ability to do much of anything for himself. Staff got him up for breakfast and lunch, but otherwise they had to reposition him every 2 hours. Staff B said Resident #1's size alone should have prompted someone to implement the use of protective boots and/or floating his heals as a way of trying to prevent pressure ulcers. The LPN said they started floating his heels on [DATE]. On [DATE] at 2:35 p.m. Staff A, LPN stated she assumed Resident #1 came to their facility with the pressure ulcer on his heel, but nobody identified it because of the swelling on his feet and legs. Staff A believed the sore had been there for some time before they identified it based on its severity when discovered. Staff A stated nurses have discretion to implement the use of protective boots for residents at risk. They try to do that if a resident has reddened skin, but she did not think Resident #1 had reddened skin. An interview on [DATE] at 3:15 p.m. with Staff C, LPN/Wound Nurse revealed she first saw Resident #1's left heel pressure ulcer when an aide reported it to her. Staff C described it as an unopened purple blister about 6 cm in diameter. Although some pressure sores can develop quickly, Staff C said she wondered why nobody identified it sooner based on the severity of the wound when she first saw it. Staff are supposed to report skin issues to her as soon as possible, although some do and some do not. Staff C assesses wounds on Tuesdays and Wednesdays. Nurses are supposed to start a skin sheet whenever they identify a wound and Staff C said if its in the book, she would see it although she may not realize it for up to a week. Staff C offered that other staff are pretty good about letting her know if they are not comfortable with their assessment/opinion of what should be done. Staff should use the Daily Documentation of Wound Care form to track wounds on a daily basis, but Staff C said she did not find that documentation in Resident #1's chart. Staff C stated the facility should have been floating Resident #1's heels [MEDICATION NAME] (preventatively) and that is just common practice unless are resident is independent. Staff C thought Resident #1's wound developed from too much pressure on his heel. An interview on [DATE] at 8:45 a.m. with Staff D, CNA (certified nursing assistant) revealed that she reported to the nurse the first time she saw the pressure ulcer on Resident #1's heel. Staff D said it looked like a reddish fluid filled blister that covered his whole heel. The CNA said bath aids are supposed to check everyone's skin and tell the nurse about anything they find. Staff D recalled that Resident #1 spent quite a bit of time in bed for about the first week because his family had not brought a recliner in for him yet. The got him up for meals, but that was about it for the first week. Staff D said she put pillows under his legs to float his feet, but she doubted that everyone did that. The CNA remembered sometimes seeing him without his feet floated. Staff D thought the sore developed because his heels were not always being floated and had had too much pressure on them. An interview on [DATE] at 1:15 p.m. with the Physician's Assistant (PA) who assessed Resident #1 in theER on [DATE] revealed she did not look at his feet during the encounter. Resident #1 presented to the ER for issues with his catheter. Unless he or his family mentioned the pressure ulcer on his heel, the PA focused primarily on the issues he presented with. The PA expected every nursing home to give a high standard of care according to each resident's needs to prevent a worsening condition. An interview on [DATE] at 2:00 p.m. with the Nurse Consultant revealed the facility did not have a general pressure ulcer protocol. Staff used individualized interventions according to each resident's specific needs. On [DATE] at 2:25 p.m. the Director of Nursing (DON) stated the expectation that all changes in condition of a resident's skin should be reported.

Based on observation, record review and staff interview, the facility failed to ensure that the resident environment remained as free from accident hazards as possible; and each resident received adequate supervision to prevent accidents for 1 of 5 residents reviewed that used mechanical lifts. Resident #1 fell from an EZ lift when agency staff improperly hooked the sling to the bar and started the transfer without a second staff present. There was no evidence the facility provided the agency staff with orientation before working with the resident. The facility census was forty-four (44) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 7/13/17, assessed Resident #1 with short and long term memory problems and severely impaired decision making. The resident had the following indicators of delirium that were continually present: inattention and disorganized thinking. The resident did not have behavior symptoms. The resident was totally dependent on two staff for transfers, locomotion on unit, dressing, toileting personal hygiene and bathing. The resident required extensive staff assistance for eating and bed mobility. The resident had functional range of motion limitations of both upper and lower extremities. The resident did not ambulate and used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The resident had no prior falls identified since the previous assessment. The MDS revealed Resident #1 weight at 192 pounds and his height at 6 feet tall. A fall risk evaluation dated 7/10/17 identified the resident with a fall risk score of 8. A score of 10 or above represented high risk. A care plan dated 2/26/16 that identified the resident at risk for falls due to impaired balance and non-weight bearing due to advanced dementia. The care plan directed staff to transfer the resident with 2 staff via EZ lift (mechanical lift). An addendum to the care plan dated 8/18/17 directed staff to ensure they correctly placed straps on EZ lift prior to transfer. A nurses note entry dated 8/18/17 at 1 p.m. and documented by Staff A RN (registered nurse), revealed the resident laid on the floor underneath the mechanical lift. The resident appeared in pain with red face, grunting and moaning loudly. The resident's vital signs were: blood pressure 112/52, pulse 125, temperature 95.7 degrees. The resident's right leg appeared shortened. A CNA (certified nurse aide) reported the resident did not hit his/her head. The facility notified the physician and the resident transported to the ER (emergency room ) for evaluation. On the same date at 5:10 p.m., the resident returned from ER. On the same date, an entry at 5:20 p.m. identified the resident's activity level as complete bed rest for 8 weeks. An ER report dated 8/18/17, revealed the [AGE] year old non-verbal resident with advanced dementia presented to the ER after being dropped from a mechanical lift. The resident was elevated on a mechanical lift when the strap broke loose, dropping the resident to the floor and the resident landed on the right side. The resident moaned with pain but could not tell anyone the location of the pain due to the resident's nonverbal status. The resident's right hip appeared shortened. The x-ray revealed no evidence of an acute hip, pelvis and or ankle fracture/s.The report indicated the resident had rib fractures which placed him/her at risk for pneumonia. The report documented the resident had prior hip fracture after a fall at the nursing home approximately a year ago. A radiology report dated 8/18/17 revealed the resident had mildly displaced fractures of the right 4th, 5th, 6th and 7th ribs without apparent complication. On 8/23/17 at 7 p.m. the physician identified the injury as NOT a major injury. An incident/accident/unusual occurrences form dated 8/18/17 at 1:45 p.m. revealed the resident fell during a transfer from wheelchair to bed. The medical device involved in the incident was a mechanical lift. The fall investigation for nurses dated 8/18/17 revealed the staff did not use the mechanical lift correctly. The mechanical lift strap came loose and the resident slid out of the sling. The resident fell out of the lift when staff transferred the resident from wheelchair to bed. The internal quality investigation form identified the staff responsible for care at the time as Staff B CNA. In the area preventive measures implemented, Staff B received education on the mechanical lift. Staff B CNA documented on a fall investigation for CNAs dated 8/18/17 that she hooked the resident up to the lift and as she began lifting the resident, Staff C (the other CNA in the room) approached the chair. In midair the right shoulder strap popped off and the resident fell to the floor. In the area what factors could have contributed to the fall?, Staff B documented she could have double checked the straps and could have waited until both staff had hands on the resident before lifting. In the area, what new interventions would you suggest to prevent the fall from happening?, Staff B documented wait until both staff have hands on resident and double check straps. On 10/10/17 at 1:05 p.m. Staff B CNA stated she finished caring for the residents on her hall when Staff C called for help with a transfer. They placed Resident #1's roommate in the bathroom and Staff C stayed in the bathroom to finish assisting the roommate. While Staff C was in the bathroom, Staff B went over to Resident #1 and hooked the sling pad to the mechanical lift in preparation for the transfer. Staff B stated she waited for Staff C and when Staff C came out of the bathroom, Staff B pressed up on the lift as Staff C came towards her. When Staff C was an arms length away, Staff C had Resident #1 suspended in the lift. The resident's weight shifted and when it shifted, the loop came over the bar and it came right off. The resident fell to the floor. Staff B stated she should have double checked the sling straps as the resident rose up from the wheelchair. Staff B stated she received no orientation that morning. She had worked at the facility twice before a year ago and had not returned to the facility since. On 8/18/17, she received a sheet of paper and went to work on the floor. The paper had resident names and if they used an EZ stand. It did not contain the number of staff needed for the transfer. Staff B denied anyone told her the facility policy was to have 2 staff for all lifts and stated she wasn't told that until after Resident #1's incident. Staff B stated she did gave another staff present who was an arms length away. When asked if she could do anything over, what would it be? , Staff B stated she would make sure Staff C had her hands on the resident and she would double check the straps. Staff B stated nothing on the sling was torn or frayed. Review of an updated transfer list, updated on 9/26/17 identified mechanical lift by Resident #1's name with no number of staff included. On 10/10/17 at 1:32 p.m. the ADON (assistant director of nursing) stated the transfer list did not have the number of staff listed by the mechanical lift directive because it is facility policy to use 2 staff with all lifts. Staff C CNA documented on a fall investigation for CNAs dated 8/18/17 that she lowered Resident #1's roommate on the toilet from the sit stand and made sure the resident was secure. As she walked out of the restroom to assist Staff B with Resident #1, Staff B already had the resident rising up in the mechanical lift and the resident fell out. In the area which factors could have contributed to the fall? Staff C documented 2 aides were not present for the transfer. In the area what new interventions would you suggest to prevent the fall from happening? Staff C documented to make sure 2 aides are present during transfer. On 10/5/17 at 1:50 p.m. Staff C CNA stated after lunch they placed Resident #1's roommate on the toilet because the resident liked to sit there while they got Resident #1 in bed. Staff C stated after they placed the roommate on the toilet, Staff B left the bathroom to hook up Resident #1 while Staff C finished situating the roommate. When Staff C exited the bathroom, Staff B had Resident #1 1/2 to 3/4 suspended up in the mechanical lift. Staff C began to walk over to help and didn't make it in time. The resident fell . Staff C stated the resident fell because one of the sling straps wasn't hooked on. She stated it didn't break and nothing was torn or frayed. Staff C stated agency staff are supposed to come to the facility on e hour early to get information and they do rounds. Agency staff gets a sheet that tells them resident transfer needs. Now agency staff gets a checklist and watches a video before starting work. On 10/10/17 at 12:05 p.m. Staff A RN identified self as charge nurse when Resident #1 fell from of the mechanical sling. Staff called her to Resident #1's room and the resident was on the floor. Staff B was panicking and hysterical. Staff B stated the resident fell out. Staff A stated Staff B didn't hook up the sling correctly. Staff A looked the sling over and did not observe rips or tears. Staff B thought she hooked the strap on the bar but it was not hooked. Staff B also transferred the resident by herself. Staff A stated Staff B was aware she should use 2 staff for the transfer because Staff A told her that morning. Staff A told her to get Staff A if she couldn't find someone to assist her with transfers. Staff A stated other staff also informed Staff B that she needed to use 2 staff with a mechanical lift transfer. On 10/11/17 at 8:26 a.m. Staff F CNA stated at 6:20 a.m. on 8/18/17 Staff B told her she transferred a resident alone with the stand. At that time, Staff F stated she informed Staff B that two staff are used with all lifts. Staff B's information: Information from the staffing agency showed Staff B only worked on 8/18/17 (the day of the incident) in 2017. A weekly time sheet showed Staff B clocked in at 6 a.m. and out at 1:35 p.m. on 8/18/17. There was no orientation checklist to show Staff B received orientation. Records from the staffing agency showed Staff B passed a skills test for mechanical lift transfers on 10/1/14. On 10/11/17 at 2:27 p.m. the Director of Nursing (DON) stated Staff C was in the room with Staff B. They put Resident #1's roommate on the toilet and Staff C got the roommate situated. When Staff C exited the bathroom, Staff B had hooked up Resident #1 and he/she was already falling out if the sling. The sling strap was not hooked to the bar. She stated she examined the sling approximately 15 minutes after the incident and there was no fraying or tearing. She stated procedure for agency staff at the time of the incident was that they were to come in 1 hour early and train with staff and go through a checklist. She stated Staff B did not get a checklist because facility staff thought Staff B worked there before. Staff B just happened to pick up the shift on 8/18/17 at the last minute and staff did not orient her. The DON stated she wasn't sure if Staff B got any training. After the incident, they decided agency staff should not perform lift transfers until they watched a video and had an audit with management. Staff B told her she did not wait for Staff C to assist her with the transfer. After the incident: On 10/11/17 at 9:20 a.m. the Administrator stated the facility implemented the following after the 8/18/17 incident: From 8/18/17 to 8/25/17 agency staff could not use lifts. At that time, the facility decided agency staff could use lifts if they went through orientation and watched a video. The agency staff came in early for the orientation and video. When asked about audits to ensure their new policies were implemented, the corporate nurse stated on 10/11/17 at 11:25 a.m. that there was nothing in writing. On the same date at 11:36 a.m. the ADON stated she works the floor so she watches staff and had not caught anyone not following policy. Agency staff interviews: On 10/10/17 at 4:19 p.m. Staff H (agency CNA) stated she worked at the facility 3 or 4 times, used lifts and had not seen the video yet. Staff H's orientation checklist contained a checkmark by watch EZ lift video, Staff H stated it was checked because it was something she was supposed to complete and had not completed it yet. On 10/10/17 at 4:17 p.m. Staff E (agency CNA) stated she worked with Resident #1's roommate after the 8/18/17 incident and did not have a second staff present. The resident told her that she should use 2 staff for the transfer after she placed him on the toilet. She stated she worked at another facility prior to coming to the Avoca facility where it was Ok to transfer EZ lift residents with one staff. She could not remember if anyone at the Avoca facility told her to use 2 staff. She did not watch the training video until after that incident. In a written statement dated 10/10/17 the Administrator documented that a CNA (Staff F) asked Staff E if Staff E was certified for lifts at the facility and if Staff E watched the video. Staff E replied yes. On 9/27/17 Resident #1's spouse told Staff F that Staff E transferred Resident #1's roommate by self. Staff F informed the Administrator and then Staff E watched the training video. Policies: Facility Policy for Mechanical Lift dated January 2015 revealed the lift was used to provide safe transfer for non-ambulatory residents. The policy directed 2 staff perform mechanical lift transfers. The policy also directed staff to check to ensure all straps were secured and evenly placed. On 10/11/17 at 1:55 p.m. the corporate nurse stated the facility did not have policies for agency staff including training/orienting agency staff to facility rules, policies procedures. Agency Agreement: An agreement with the agency dated 2/16/16 revealed the facility would orientate agency staff to their facility including its rules, regulations, policies, procedures, physical layout, emergency protocol, emergency evacuation and equipment on any unit to which the agency staff is assigned. The facility will complete an orientation checklist for the agency staff upon completion of the orientation and fax the completed checklist to the agency. The agreement revealed the facility will be responsible for the establishment of staff competences during the initial orientation period and on an ongoing basis during the contact period. On 10/11/17 at 9:36 a.m. the Administrator stated Staff B did not have an orientation sheet. On 10/11/17 at 12:30 p.m. the corporate nurse stated Staff B did not turn in a checklist to the agency and there was no checklist available to indicate Staff B completed orientation. He stated the facility audits all staff in mechanical lift skills quarterly, upon orientation and with their annual review. The last audits done were last quarter and the facility is now starting their 4th quarter audits of all staff. The EZ Way Smart Lift Operator's Instructions revised on 7/5/17 revealed the lift was designed to lift persons from the bed, chair, toilet and or floor safety with precautions to follow including warnings and operating instructions. A safety note and warning behoove persons using the lift be trained before using with residents. The lift noted one caregiver can operate the lift however, depending on the situation, facility policy, and resident's condition, two caregivers may be necessary for operating the lift safely. The operating instructions revealed steps for attaching the sling to the lift and instructed staff to make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars before lifting the resident. The step for lifting the resident included the following: push the UP button on the hand control to initiate the upward motion of the lift; continue the upward motion until there is tension on the legs of the sling, making sure all the loops on the sling are securely hooked on the hanger bars. The operating instructions included a safety checklist to assist in proper training. Observation: On 10/5/17 at 1:05 p.m. observation showed 3 staff transfer the resident to bed via full body sling. There were no fraying or tears observed on the sling. Observation showed staff hooked up the sling and transferred the resident appropriately to the bed. The resident showed no signs/symptoms of pain and stared straight ahead and remained nonverbal when the surveyor spoke to him/her.

Based on record review, staff and family interviews, the facility failed to investigate, assess, timely report and suspend suspected staff related to an allegation of neglect for 1 of 6 residents (Resident #1) reviewed for a fracture sustained in the facility. The facility reported a census of 41 residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] documented [MEDICAL CONDITION] as Resident #1's diagnosis. The BIMS (Brief Interview for Mental Status) assessment described the resident's cognitive status as severely impaired. According to the MDS, Resident #1 depended on staff for extensive assistance for all transfers and most ADLs (activity of daily living) skills, had absence of spoken words and rarely or never understood others or made him/her understood. The Care Plan dated September 2016 indicated Resident #1 depended on 2 staff members for repositioning, dressing, hygiene, bathing and transfers with an EZ lift (mechanical lift). The Care Plan also indicated that first aid should be administered in the event of a fall. The Investigation of Injuries of Unknown Origin section of the revised August 2016 policy and procedures titled, Dependent Adult Abuse Policy, instructed to immediately investigate injuries of unknown origin to rule out abuse. A type of injury of unknown origin could be a complaint of un-explainable pain and/or signs and symptoms of new onset pain. According to the policy, following the initial assessment of the injury, a prompt investigation must be started. Investigation of injuries of unknown origin must include the initiation of the facility's Incident/Accident/Unusual Occurrence form. The Timely Reporting section of the policy instructed staff to immediately notify the person in charge or the person's designated agent who shall then notify DIA within 24 hours of such allegation, even on weekends and holidays. The AccuNurse (electronic charting system) documentation dated 9/1/16 noted Staff A, bath aid/CNA (certified nursing assistant) charted at 2:37 p.m. she had bathed Resident #1 that day. The Daily Staff Sheet dated 9/1/16 documented that Staff A had been scheduled as the designated bath aide that day. The Daily Staff Sheet dated 9/1/16 through 10/31/16 documented the assigned roles Staff A had been schedule to provide in that time frame. The Daily Staffing Sheets dated 9/1/16 through 10/31/16 documented where Staff A had been scheduled on those days. The Pay Summary Report documented Staff A worked in the facility for 41 days between the 9/1/16 alleged incident and 10/31/16 at which time she had been suspended. The Nurse's Notes dated 9/1/16 at 5:45 p.m. documented a telephone order obtained to administer 1000 mg (milligrams) Tylenol three times a day as needed for pain. The September 2016 MAR (Medication Administration Record) documented the 1st dose of Tylenol 1000 mg was administered on 9/2/16. The physician's orders [REDACTED].'s routine 60 day visit. According to the document, [MEDICATION NAME] (muscle relaxer) 5 mg had been prescribed every morning and bedtime and [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5/325 mg ordered to be administered at bed time and every six hours as needed for pain. According to the Dr.'s notes, Resident #1 had increased stiffness and pain of unknown origin, and winced and groaned when his/her right lower extremity moved. The Nurse's Notes dated 9/3/16 at 5:00 p.m. documented the Dr. had prescribed [MEDICATION NAME] and [MEDICATION NAME] after he visited Resident #1 on rounds. The September 2016 MAR indicated [REDACTED]. The Nurse's Notes dated 9/5/16 at 10:30 a.m. indicated Resident #1 appeared stiff but not showing signs of pain when adjusted in the wheel chair. The Nurse's Notes dated 9/6/16 at 8:45 a.m. indicated Resident #1 continued with stiffness and does not appear to be in pain. The Nurse's Notes dated 9/7/16 at 7:20 a.m. indicated the staff faxed the physician to report Resident #1 groaned in pain when the staff moved the right leg. The leg continued to be stiff as normal for the resident. A fax dated 9/7/16 at 7:25 a.m. notified the Dr. that Resident #1 continued the new order for [MEDICATION NAME] without signs or symptoms of adverse reactions. According to the fax, staff reported the resident continued to be stiff and groan out when moved, especially when the right leg moved. Staff suggested monitoring should be discontinued unless the Dr. had any new orders. The Dr. ordered an increase from 5 mg to 10 mg of [MEDICATION NAME] twice a day. The Nurse's Notes dated 9/7/16 at 6:30 p.m. documented an order had been obtained to increase [MEDICATION NAME] to 10 mg twice a day. The Nurse's Notes dated 9/8/16 at 9:45 a.m. documented the bath aide reported Resident #1 had increased stiffness but no signs and symptoms of pain. Nurse's Notes dated 9/9/16 at 4:15 p.m. indicated Resident #1 continued to have increased stiffness. The Concern Investigation Form initiated and dated 9/11/16 at 11:15 a.m. by Staff D, LPN (licensed practical nurse) noted Staff B, CNA and Staff C, CNA reported they overheard Resident #1 may have been dropped in the shower room. The LPN notified the on call nurse manager, who in turn notified the Administrator. According to the document, both CNAs completed statements for the investigation. On 9/14/16, the Administrator added information to the Form that said Staff A, bath aid/CNA and Staff E, CNA scooted the resident back after he/she had slipped to the edge of the chair. The facility reported the injury of unknown origin to the DIA (Department of Inspections and Appeals) on 9/15/16. The document dated 9/11/16 and signed by Staff C noted that Staff B confided in her on 9/7/16 or 9/8/16 about information related to an accident that involved Resident #1 a week before. According to Staff C, Staff B confided that Staff A called her and said she dropped Resident #1 in the tub room as she transferred the resident by herself. After thinking about it for a few days, the two CNAs decided to report it to Staff D. The document dated 9/11/16 and signed by Staff B noted that she received a call from Staff A on 9/1/16. According to Staff B, the bath aide told her Resident #1 slid out of the chair onto the floor while reaching for her pop. Staff B stated that Staff A seemed to be very upset and begged her not to tell anyone. Staff B said she confided in Staff C when she realized Resident #1 had not been acting like him/herself. The CNAs decided to report it to Staff D on 9/11/16. The Nurse's Notes dated 9/11/16 at noon indicated Resident #1 rubbed his/her right leg that morning, and winced when his/her right leg slightly lifted. The staff administered pain medication ([MEDICATION NAME]). A fax dated 9/11/16 at noon, indicated the nurse notified the Dr. that a CNA reported Resident #1 rubbed his/her right leg that morning, and winced when right leg slightly lifted. The Nurse ' s Notes identified the following: On 9/11/16 at 3:20 p.m. Resident #1 experienced discomfort when ROM (range of motion) to the right leg. The resident had received medication for the pain. On 9/12/16 at 3:10 p.m. Resident #1 grimaced when staff palpated (touched) his/her right leg. Medication had been administered. On 9/13/16 at 12:10 a.m. the Dr. discontinued daily monitoring, but authorized the administration of [MEDICATION NAME] to continue. The nurse sent a fax to the physician and informed him of the resident ' s pain in the right leg. On 9/13/16 at 8:05 a.m. the staff reported slight grimacing as they got the resident up for breakfast. On 9/14/16 at 5:30 p.m. the nurse noted prior to the resident being transported to the ER (emergency room ) a 12 cm (centimeter) by 4.5 cm yellow bruise was located on the resident ' s right inner thigh. According to the documentation, the right leg was slightly larger than the left, and the resident exhibited pain with touch and movement. The staff received education about transfers. A Resident Transfer Form dated 9/14/16 indicated Resident #1 had to be transported to the ER for increased right leg pain. The Radiology Report dated 9/14/16 diagnosed Resident #1 with an impacted intertrochanteric [MEDICAL CONDITION] proximal femur (upper thigh bone). The Nurse's Notes dated 9/14/16 at 6:30 p.m. noted ER notified the facility that Resident #1 had been admitted and scheduled for surgery related to a right [MEDICAL CONDITION]. Records of the facility's interviews with staff related to the 9/1/16 alleged incident dated 9/14/16 through 9/16/16 was submitted. The Radiology Report dated 9/15/16 documented that fluoroscopy (imaging technique with use of x-ray) had been used during the open reduction internal fixation (surgical repair with hardware) of Resident #1's right hip. An interview on 10/25/16 at 3:00 p.m. and subsequent interviews with the DON revealed the following information. According to her, details of an alleged fall in the tub room on 9/1/16 that involved Resident #1 had finally been reported to the facility on [DATE]. According to the DON, Staff B alleged that Staff A called her on 9/1/16 because Resident #1 had fallen in the tub room, and Staff A needed her assistance. Since Staff B had already left the facility, Staff A told the DON she contacted Staff E for assistance in repositioning the resident. The DON stated Staff B failed to report what she knew for about 1 ½ weeks. According to the DON, Staff B confided in Staff C on 9/7/16 or 9/8/16, and both of the CNAs finally reported what they knew to Staff D on 9/11/16. According to the DON, Staff D reported to the on call Nurse Manager. During the interview, the DON was informed of the Nurse Manager ' s interview content which revealed once Staff D reported information about the alleged 9/1/16 incident on 9/11/16, she reported what she knew to the Administrator and was told the DON would do the head to toe assessment. The DON interjected she had been gone until 9/14/16. The Nurse Manger said she had been kept out of the loop because she had already resigned. In response to what the DON had been told about what the Nurse Manager said, she stated that was her job. The DON said, as the Nurse Manager on call, she had an obligation to instruct Staff D to do a complete head to toe assessment, notify the Dr. of the alleged incident and increased pain, and ask the Dr. if an x-ray had been warranted. The DON indicated there had been lot of animosity between her and the Nurse Manager before she left. According to the DON, she had not been informed of the 9/1/16 change in Resident #1's status, and did not realize it until she input the 9/3/16 Dr's order for [MEDICATION NAME] and [MEDICATION NAME]. The DON stated a head to toe assessment had not been done on 9/1/16 or on 9/11/16 when the facility had been informed of the alleged incident. The DON mentioned the Dr. also knew the resident exhibited pain of unknown origin during his assessment on 9/3/16. The DON stated an x-ray should have been ordered at that point too. She stated she relied on the Dr's expertise since he had just done an assessment. The DON said nobody informed her. The DON simply stated the resident should have been sent out sooner and the doctor should have been more clearly informed. The DON said there had been missed opportunities, and something should have been done sooner. According to the DON, Staff A had not been suspended at any time during the investigation. After speaking to everyone at the All Staff meeting on Monday 9/19/16, the investigation had been closed. In a subsequent interview, the DON stated Staff O contacted her and said she had not been completely truthful. The DON apologized that some of her staff had lied. She expressed her disappointment by saying she could not believe they still lied after they had the opportunity to come clean. An interview on 10/26/16 at 7:40 a.m. with Staff B revealed Staff A called her on her cell phone. According to the CNA, Staff A used her cell phone because the batteries in her headset went dead. She said Staff A stated Resident #1 had almost slid out of the tub chair, and she needed her help. When questioned about conflicting information Staff B had previously given in an interview with the facility, Staff B stated she had been mistaken and meant to say the bath aid told her the resident slid out of the chair and onto the floor. Staff B stated Staff A asked her not to tell anyone. When asked, Staff B stated she had been at the day care picking up her kids when Staff A called. An interview on 10/26/16 at 10:10 a.m. with Staff C revealed she knew the resident had not been acting quite right before Staff B told her on 9/7/16 or 9/8/16 that Staff A called her and stated she needed help getting the resident up off the floor in the tub room. According to Staff C, Staff B confided that Staff A told her she tried to transfer Resident #1 alone and the resident fell . Staff C failed to immediately report what she knew, but stated after thinking about it for a couple days, she and Staff B reported it to Staff D on 9/11/16. Staff C said she had not actually witnessed anything. An interview on 10/26/16 at 11:35 p.m. with Staff E revealed Staff A called her on 9/1/16 about 2:15 p.m. She stated Staff A needed help in the tub room because Resident #1 started to slide out of the tub chair. According to Staff E, when she entered the tub room, Resident #1's tailbone was on the edge of the tub chair. She said Staff A stood on the left side of the tub chair with her left hand on Resident #1's chest holding him back and the other hand on the back rest of the tub chair. According to Staff E, both of them repositioned the resident back up in the chair. When asked at a later time, Staff E revealed when she entered the tub room, the tub chair seat belt had not been fastened around Resident #1's waist, which accounted for him/her sliding to the edge of the seat. According to Staff E, the bath aid should have recruited the help of a second person before unfastening the lap belt. An interview on 10/26/16 at 1:15 p.m. with the Corporate Nurse Consultant revealed that on 9/14/16, he first realized an alleged incident that involved Resident #1 reported to the facility on [DATE]. The Nurse Consultant went with another staff to assess Resident #1 and noticed how the resident grimaced when they moved the resident. The Nurse Consultant said they immediately decided to send the resident for an x-ray, and he wished the facility had notified him sooner. An interview on 10/26/16 at 2:00 p.m. with Staff A revealed she had finished bathing Resident #1 and pulled the tub chair out of the tub to dry him/her off. According to Staff A, the resident became rigid and started to slide. She stated she panicked and grabbed her cell phone because her headset went dead. She called Staff B, who had already left the facility. Staff A stated Staff B apparently misunderstood what she had told her because Staff B reported Staff A said the resident had fallen. The bath aide said Staff B was at the day care picking up her kids when she called, and could hear a lot of noise in the background. According to Staff A, Staff B seemed to be stressed. Then Staff A said she called Staff E, who helped scoot the resident back from the edge of the chair. Staff E then left the room until the resident had been dried and dressed as completely as Staff A could do by herself. Once Staff A completed drying the resident she called Staff E to assist with the EZ Lift (mechanical lift) transfer of Resident #1 from the bath chair to the wheelchair. The CNAs wheeled the resident to his/her room and EZ Lifted him/her back to bed. According to Staff A, Resident #1 had not exhibited any signs of pain or injury from the time she started the bath until the time the resident had laid back down. The bath aid stated she recalled Resident #1's spouse being in the room when the resident returned. Staff A stated she first heard the resident experienced pain a couple days later. The bath aid said she could not imagine why someone would say they heard her say the resident fell or why they would say she begged them to not to tell on her. At a later time, Staff A revealed that the lap belt had not been fastened around Resident #1, and she might have turned for a second to grab something when the resident started to slide out of the tub chair. According to the bath aid, she stood in front of the resident with her leg in between his/hers so the resident could not slide all the way out of the chair. When asked if Staff E assisted her to lift Resident #1 off the floor, she stated no, because the resident had not fallen out of the chair. An interview on 10/31/16 at 9:00 a.m. with Staff F, CNA, revealed she worked with Resident #1 for the first time after the alleged incident about 2 days later. The CNA stated she noticed a black/gray bruise with a green/yellow tint about the size of a golf ball on the resident's right hip. Staff F stated she told Staff G, LPN and Staff H, RN about the bruise. According to Staff F, either Staff B or Staff I, CNA worked with her when she saw the bruise. Staff F did not know if her co-worker saw the bruise too. According to Staff F, the resident groaned and grimaced every time staff moved him/her from the time of the alleged incident until he/she had been sent for an x-ray. Once the DON and Administrator heard about the alleged incident, they spoke to her about what she heard and what she knew. An interview on 10/31/16 at 9:25 a.m. with Staff J, CNA revealed her shift began at 2:00 p.m. Staff J stated her and Staff K, CNA worked with Resident #1 that day. When they went to get the resident up, he/she groaned and made facial expressions as they rolled him/her. As Staff J went to summon Staff L, LPN, she saw and spoke to Staff E on the way to get the nurse. According to Staff J, she told Staff E Resident #1 seemed to be in pain, and asked Staff E if she noticed anything unusual with Resident #1 that day. Staff E said she had not noticed anything. Staff J stated she had worked with the resident that day as a restorative aide, and thought the resident might have been sore from the range of motion she provided. Staff J proceeded to find Staff L and reported her findings to the nurse. Staff J stated Resident #1 had typically been pretty quiet and never seemed to have pain prior to that day. Staff J said she overheard them say he did not even have Tylenol, so an order to administer Tylenol had been obtained. Staff J stated she worked 2:00 p.m. to 10:00 p.m. the night before, and seemed sure she had not noticed anything peculiar about the resident when she put him to bed that night. According to Staff J, the resident seemed to have pain whenever staff moved him/her for the 2 weeks between when the alleged incident occurred on 9/1/16 until they sent him/her for an x-ray. Staff J never noticed a bruise at any time. Staff J stated when she heard Staff A dropped the resident in the shower, she told the DON. The DON said it had already been reported. Staff J said they called all of the staff in to account for what they knew once they realized the resident had a broken hip. On 10/31/16 at 10:30 a.m. Staff G, LPN was interviewed and stated she had not worked at the facility since 10/6/16, but stated she worked with Resident #1 frequently before she left. Staff G said nobody reported a bruise on the resident ' s right hip, and she had not seen one when she did the head to toe assessment. According to the LPN, pain had been the only thing reported to her. She stated the resident moaned during the assessment. The resident did not have any pain medication because they had no history of pain before the alleged incident. An order to administer Tylenol had to be obtained from the physician. According to Staff G, though the resident had not been able to state the location of the pain, the lower part of the femur and lower back seemed to be tender. The resident moaned the entire time. Staff G stated she had been in the room, but he/she also grimaced when those areas were touched. The Tylenol seemed to help, but the resident continued to moan and grimace when staff moved him/her. According to According to Staff G, the resident had been somewhat stiff before the alleged incident due to arthritis and contractures, but was significantly stiffer afterwards, almost like a board. Staff G stated Staff M, CNA once asked for help as she bathed the resident because she thought he might slide off the tub chair because of being so stiff. An interview on 10/31/16 at 4:45 p.m. with Staff H, RN revealed when she returned to work on 9/1/16, she realized Resident #1 had been added to the hot chart (identifies a change in the resident) related to acute pain. The RN stated her assessment of the resident included PROM to the right hip. Resident #1 became tenser and expressed facial grimacing as an indication of pain. According to the RN, when she returned to work the following week, the Nurse Manager said someone had dropped Resident #1. Staff H stated nobody reported a bruise on the resident's right hip, and anytime she had moved him during an assessment between 9/1/16 - 9/14/16, the resident expressed facial grimacing. An interview on 11/1/16 3:00 p.m. with the Nurse Manager revealed that she no longer worked at the facility. The Nurse Manager said Staff D called her on 9/11/16 and reported that Staff B and Staff C told her someone told them Resident #1 had fallen. Supposedly, the resident slid out of the chair in the bath house when the resident reached for a pop. The Manager thought it must have been Staff A's pop. The Manager said she told them to write up a statement and then she called the Administrator. According to the Manager, the Administrator said she was on her way in and she would address it afterwards. The Nurse Manager stated the Administrator told her she did not need to do anything else because she would handle it later. According to the Nurse Manager, she never saw any of the paper work or anything related to the alleged incident because she had already given her resignation and felt like she had been kept out of the loop. According to the Manager, the Administrator said she would have the DON come in to assess the resident. The Manager said she went to work the following day. According to the her, because the Administrator had been working as the Administrator in a sister facility that day, she emailed her. The Nurse Manager stated she inquired about what became of the incident she reported the day before. She said she did not get a response from the Administrator. The Manager said she saw the Administrator the next day, and asked again about the investigation. She said the Administrator told her that she and the DON were developing their investigative plan. On Wed, the Nurse Consultant came in and the Manager said she spoke to him about it. According to the Manager, he knew nothing about it, so they went and assessed the resident and sent the resident for an x-ray. According to the Manager, the DON was responsible for the list of hot charts, so the Manager did not know anything about the resident's pain at first. She stated 10 days after the alleged incident she became aware of the resident's pain. At that time, they put the sign in sheet for Resident #1's new narcotic prescription in my inbox, and then I realized the resident had been prescribed a pain medication. The Nurse Manager stated she first realized the investigation had been initiated when the nurse consultant was there. On 11/1/16 at 3:45 p.m. Staff O, CNA was interviewed and stated she had worked at the facility since April 2016, and off and on for 1 ½ years. The CNA stated she worked 10:00 p.m. - 6:00 a.m. shift. Staff O said when she came in at 10:00 p.m.; she did not think she heard anything about Resident #1's pain during report. She stated she remembered telling the nurse of the resident's pain that night. Resident #1 moaned and grimaced while being moved. The nurse stated Tylenol would be administered to the resident. Either the next night or a couple of nights later, Staff O said she worked 6:00 p.m. - 6:00 a.m. She said whenever she checked and changed the resident's brief; she never saw a bruise on the resident's right hip or any other visible signs of injury. Staff O said shortly after it happened, she had been gone for a week because there weren't any hours for her. She said she worked on an as needed basis with the intention of returning full time. Upon her return on 9/15/16, the resident had already been sent out for an x-ray. An interview on 11/1/16 5:15 p.m. with Staff K, CNA, revealed she could not recall specific dates, but recalled when she went to give out snacks and fresh ice water, Resident #1's spouse had been in the room alone. The resident's spouse said they took the resident for a bath. After leaving the room, Staff K said she saw Staff A wheeling the resident back to his/her room. When asked if Staff A needed help to transfer the resident back to bed, Staff A stated Staff E would help her once she got there. According to Staff K, she and Staff Q, CNA returned about 3:45 p.m. to get the resident ready for supper. They realized the resident ' s right thigh caused pain whenever they turned the resident, transferred him or changed him. Staff K stated she thought Staff L had been the nurse she reported the pain to. According to Staff K, from the time of the alleged incident until the resident had been sent for an x-ray, he/she had a loss of appetite and continued showing signs of pain like wincing, grabbing and moaning. On 11/2/16 at 9:20 a.m. Resident #1's spouse was interviewed and stated when Staff A returned the resident after the bath on 9/1/16, the spouse had been there waiting since about 1:00 p.m. According to the spouse, nothing peculiar had been noticed when they first returned to the room. The spouse said early that afternoon, the resident started to moan and make faces, even while laying still. According to the spouse, nothing could have happened after the resident returned because the spouse had been with the resident until staff returned about 4:45 p.m. to take the resident to supper. The nurse said she would call the Dr. and get something for pain. According to the resident's spouse, after the pain medication was administered, the resident did not exhibit signs of pain unless they moved him/her. The Dr. visited the resident on 9/3/16. The resident moaned and grimaced when the Dr. moved his/her right leg. The Dr. told the spouse he did not think he would order any tests. The spouse told the Dr. they thought the resident got hurt during the bath, because the pain started just afterwards. The spouse stated the resident laid there for 2 weeks before anything had been done. According to the spouse, the facility never acknowledged anything had happened, and didn't say they were sorry. The spouse said if someone would have admitted that something happened, the resident might have been sent to the hospital sooner. According to the spouse, the resident exhibited pain from 9/1/16 until the Nurse Consultant assessed the resident on 9/14/16 and decided to send the resident for an x-ray. At one point, a nurse spoke about decreasing the resident's pain medication until the spouse verbally disapproved. The spouse stated the nurse had been told the resident had been in pain every time staff moved the resident since that Thursday after his/her bath. According to the spouse, the nurse stated she apparently had not always been told about the resident ' s pain. According to the spouse, the resident could not possibly have fallen on his/her own because he/she cannot roll, sit up or walk because of being a total invalid. An interview on 11/2/16 at 1:00 p.m. and subsequent interviews with the Administrator revealed she would have sent the resident out right away, started the investigation and reported it to the DIA if she had known about the alleged incident. She said she apparently had not always been fully informed about the severity of Resident #1's condition from the very beginning. The Administrator said she expected staff to report anything they either witnessed or had knowledge of. Once the alleged incident had been reported on 9/11/16, the Administrator stated she wanted to talk to Staff A. According to the Administrator, she and the DON had both been off of work on Monday, and the DON had been gone until 9/14/16, but Staff A had been assigned as the restorative aide instead of the bath aide until then. When asked, the Administrator said they determined that Staff A had no longer been considered suspect and therefore her suspension would not be warranted. When asked how she reconciled the discrepancy between Staff B's allegation and Staff A's denial of the allegation, the Administrator said Staff A could not have possibly transferred Resident #1 off of the floor and back into the chair by herself due to their size difference. When asked about the possibility that both Staff A and Staff E transferred the resident off of the floor and back into the tub chair, the Administrator stated it was possible. At a later interview, the Administrator stated she would have expected Staff A to use the lap belt on the tub chair when she bathed Resident #1 on 9/1/16. According to the Administrator, all staff should use the tub chair seat belt whenever they bathe a resident. The Administrator said the facility did not have a policy regarding the tub chair seat belt. A phone interview on 11/11/16 at 2:15 p.m. with Resident #1's primary care physician revealed that the resident had been experiencing pain when he saw the resident on 9/3/16. According to the Dr., nobody seemed to have any idea what happened. The Dr. said when the resident had been sent to theER on [DATE], he still had not been informed about the alleged incident. Once an x-ray revealed the resident had a [MEDICAL CONDITION], the Dr. stated they began hearing rumors about the resident being dropped in the shower. According to the physician, once the facility learned of the alleged incident he would have expected them to notify him with the results of a complete and accurate head to toe assessment. Note: At the time of the complaint investigation, the complaint was coded at a L, immediate and serious jeopardy. By 11/2/16, the facilty had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to E level. The facility began in-servicing staff on 9/19/16 and on 11/2/16 had educated 29 of the 60 employees regarding appropriate transfer techniques. The staff were trained to follow the care plan with appropriate number of staff required to transfer the resident. The facility reviewed the Dependent Adult Abuse policy/procedures. As of the 11/14/16 exit conference, the facility continued to need to: · Ensure the remaining 31 staff members receive in-service/education on proper transfer techniques per resident care plans, · Ensure the staff are are following the Dependent Adult Abuse policy/procedures, · Monitor to ensure the staff are using safe and planned transfer techniques.

Based on record review, facility and family interviews, the facility failed to ensure resident #1 received kind and considerate care and free from neglect. The resident sustained [REDACTED]. The sample consisted of 6 residents and the facility reported a census of 41 residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] documented [MEDICAL CONDITION] as Resident #1's diagnosis. The BIMS (Brief Interview for Mental Status) assessment described the resident's cognitive status as severely impaired. According to the MDS, Resident #1 depended on staff for extensive assistance for all transfers and most ADLs, had absence of spoken words and rarely or never understood others or made him/her understood. The Care Plan dated September 2016 indicated Resident #1 depended on 2 staff members for repositioning, dressing, hygiene, bathing and transfers with an EZ lift (mechanical lift). The Care Plan also indicated that first aid should be administered in the event of a fall. AccuNurse (electronic charting system) documentation dated 9/1/16 noted Staff A, bath aid/CNA (certified nursing assistant) charted at 2:37 p.m. she had bathed Resident #1 that day. The Daily Staff Sheet dated 9/1/16 documented that Staff A had been scheduled as the designated bath aide that day. Nurse's Notes dated 9/1/16 at 5:45 p.m. documented a telephone order had been obtained to administer 1000 mg (milligrams) Tylenol three times a day as needed for pain. The September 2016 MAR (Medication Administration Record) documented that the 1st dose of Tylenol 1000 mg had been administered on 9/2/16. The physician's orders [REDACTED].'s routine 60 day visit. According to the document, [MEDICATION NAME] (muscle relaxer) 5 mg had been prescribed every morning and bedtime and [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME] (pain medication)) 5/325 mg had been ordered to be administered at bed time and every six hours as needed for pain. According to the Dr.'s notes, Resident #1 had increased stiffness and pain of unknown origin, and winced and groaned when his/her right lower extremity had been moved. Nurse ' s Notes dated 9/3/16 at 5:00 p.m. documented the Dr. had prescribed [MEDICATION NAME] and [MEDICATION NAME] after he visited Resident #1 on rounds. The September 2016 MAR indicated [REDACTED]. Nurse's Notes dated 9/5/16 at 10:30 a.m. indicated Resident #1 appeared stiff. Nurse's Notes dated 9/6/16 at 8:45 a.m. indicated Resident #1 continued with stiffness. Nurse's Notes dated 9/7/16 at 7:20 a.m. indicated the Dr. had been faxed to report Resident #1 groaned in pain when the right leg had been moved. A fax dated 9/7/16 at 7:25 a.m. notified the Dr. that Resident #1 continued the new order for [MEDICATION NAME] without signs or symptoms of adverse reactions. According to the fax, staff reported that the resident continued to be stiff and groan out when moved, especially when the right leg had been moved. Staff suggested that monitoring should be discontinued unless the Dr. had any new orders. The Dr. ordered an increase from 5 mg to 10 mg of [MEDICATION NAME] twice a day. Nurse's Notes dated 9/7/16 at 6:30 p.m. documented an order had been obtained to increase [MEDICATION NAME] to 10 mg twice a day. Nurse's Notes dated 9/8/16 at 9:45 a.m. documented that the bath aide reported Resident #1 had increased stiffness. Nurse's Notes dated 9/9/16 at 4:15 p.m. indicated Resident #1 continued to have increased stiffness. The Concern Investigation Form initiated and dated 9/11/16 at 11:15 a.m. by Staff D, LPN (licensed practical nurse) noted Staff B, CNA and Staff C, CNA reported they overheard that Resident #1 may have been dropped in the shower room. The LPN notified the on call nurse manager, who in turn notified the Administrator. According to the document, both CNAs completed statements for the investigation. On 9/14/16, the Administrator added information to the Form that said Staff A, bath aid/CNA and Staff E, CNA scooted the resident back after he/she had slipped to the edge of the chair. The document dated 9/11/16 and signed by Staff C noted that Staff B confided in her on 9/7/16 or 9/8/16 about information related to an accident that involved Resident #1 a week before. According to Staff C, Staff B confided that Staff A called her and said she dropped Resident #1 in the tub room as she transferred the resident by herself. After thinking about it for a few days, the two CNAs decided to report it to Staff D. The document dated 9/11/16 and signed by Staff B noted that she received a call from Staff A on 9/1/16. According to Staff B, the bath aide told her Resident #1 slid out of the chair onto the floor while reaching for her pop. Staff B stated that Staff A seemed to be very upset and begged her not to tell anyone. Staff B said she confided in Staff C when she realized Resident #1 had not been acting like him/herself. The CNAs decided to report it to Staff D on 9/11/16. Nurse's Notes dated 9/11/16 at noon indicated Resident #1 had been rubbing his/her right leg that morning, and winced when his/her right leg had been slightly lifted. Pain medication had been administered. A fax dated 9/11/16 at noon notified the Dr. that a CNA had reported Resident #1 had been rubbing his/her right leg that morning, and winced when his/her right leg had been slightly lifted. Pain medication had been administered. Nurse's Notes dated 9/11/16 at 3:20 p.m. noted Resident #1 experienced discomfort when ROM (range of motion) to the right leg had been provided. Medication had been administered. Nurse's Notes dated 9/12/16 at 3:10 p.m. noted Resident #1 grimaced when staff palpated (touched) his/her right leg. Medication had been administered. Nurse's Notes dated 9/13/16 at 12:10 a.m. noted the Dr. discontinued daily monitoring, but authorized the administration of [MEDICATION NAME] to continue. A fax had been sent to the Dr. which notified him that Resident #1 had pain in the right leg. Nurse's Notes dated 9/13/16 at 8:05 a.m. noted staff reported slight grimacing as they had gotten him/her up for breakfast. Nurse's Notes dated 9/14/16 at 5:30 p.m. noted that prior to being transported to the ER (emergency room ) a 12 cm (centimeter) by 4.5 cm yellow bruise to Resident #1 ' s right inner thigh had been identified. According to the documentation, the right leg was slightly larger than the left, and the resident exhibited pain with touch and movement. Transfer education had been provided to staff. A Resident Transfer Form dated 9/14/16 indicated Resident #1 had to be transported to the ER for increased right leg pain. The Radiology Report dated 9/14/16 diagnosed Resident #1 with an impacted intertrochanteric [MEDICAL CONDITION] proximal femur (upper thigh bone). Nurse's Notes dated 9/14/16 at 6:30 p.m. noted ER notified the facility that Resident #1 had been admitted and scheduled for surgery related to a right [MEDICAL CONDITION]. The Radiology Report dated 9/15/16 documented that fluoroscopy (imaging technique with use of x-ray) had been used during the open reduction internal fixation (surgical repair with hardware) of Resident #1's right hip. An interview on 10/26/16 at 10:10 a.m. with Staff C revealed she knew the resident had not been acting quite right before Staff B told her on 9/7/16 or 9/8/16 that Staff A called her and stated she needed help getting the resident up off the floor in the tub room. According to Staff C, Staff B confided that Staff A tried to transfer Resident #1 alone and the resident fell . Staff C failed to immediately report what she knew, but stated after thinking about it for a couple days, she and Staff B reported it to Staff D on 9/11/16. Staff C said she had not actually witnessed anything. An interview on 10/26/16 at 11:35 p.m. with Staff E revealed Staff A called her on 9/1/16 about 2:15 p.m. She stated Staff A needed help in the tub room because Resident #1 started to slide out of the tub chair. According to Staff E, when she entered the tub room, Resident #1's tailbone was on the edge of the tub chair. She said Staff A stood on the left side of the tub chair with her left hand on Resident #1's chest holding him back and the other hand on the back rest of the tub chair. According to Staff E, both of them repositioned the resident back up in the chair. When asked at a later time, Staff E revealed when she entered the tub room, the tub chair seat belt had not been fastened around Resident #1's waist, which accounted for him/her sliding to the edge of the seat. According to Staff E, the bath aid should have recruited the help of a second person before unfastening the lap belt. An interview on 10/26/16 at 1:15 p.m. with the Corporate Nurse Consultant revealed that on 9/14/16 he first realized an alleged incident that involved Resident #1 had been reported to the facility on [DATE]. The Nurse Consultant went with another staff to assess Resident #1 and noticed how the resident grimaced when they moved the resident. The Nurse Consultant said they immediately decided to send the resident for an x-ray, and he regretted the facility had not notified him sooner. An interview on 10/26/16 at 2:00 p.m. with Staff A revealed she had finished bathing Resident #1 and pulled the tub chair out of the tub to dry him/her off. According to Staff A, the resident became rigid and started to slide. She stated she panicked and grabbed her cell phone because her headset went dead. She called Staff B, who had already left the facility. Staff A stated Staff B apparently misunderstood what she had told her because Staff B reported Staff A said the resident had fallen. The bath aide said Staff B was at the day care picking up her kids when she called, and could hear a lot of noise in the background. According to Staff A, Staff B seemed to be stressed. Then Staff A said she called Staff E, who helped scoot the resident back from the edge of the chair. Staff E then left the room until the resident had been dried and dressed as completely as Staff A could do by herself. Once Staff A completed drying the resident she called Staff E to assist with the EZ Lift (mechanical lift) transfer of Resident #1 from the bath chair to the wheelchair. The CNAs wheeled the resident to his/her room and EZ Lifted him/her back to bed. According to Staff A, Resident #1 had not exhibited any signs of pain or injury from the time she started the bath until the time the resident had been laid back down. The bath aid stated she recalled Resident #1's spouse being in the room when the resident had been returned after being bathed. Staff A stated she first heard the resident had been experiencing pain a couple days later. The bath aid said she could not imagine why someone would say they heard her say the resident fell or why they would say she begged them to not to tell on her. At a later time, Staff A revealed that the lap belt had not been fastened around Resident #1, and she might have turned for a second to grab something when the resident started to slide out of the tub chair. According to the bath aid, she stood in front of the resident with her leg in between his/hers so the resident could not slide all the way out of the chair. When asked if Staff E assisted her to lift Resident #1 off the floor, she stated no, because the resident had not fallen out of the chair. An interview on 11/2/16 at 9:20 a.m. with Resident #1's spouse revealed that when Staff A returned the resident after the bath on 9/1/16, the spouse had been there waiting since about 1:00 p.m. According to the spouse, nothing peculiar had been noticed when they first returned to the room. The spouse said early that afternoon, the resident started to moan and make faces, even while laying still. According to the spouse, nothing could have happened after the resident returned because the spouse had been with the resident until staff returned about 4:45 p.m. to take the resident to supper. The nurse said she would call the Dr. and get something for pain. According to the resident's spouse, after pain medication had been administered, the resident did not exhibit signs of pain unless they moved him/her. The Dr. visited the resident on 9/3/16. The resident moaned and grimaced when the Dr. moved his/her right leg. The Dr. told the spouse he did not think he would order any tests. The spouse told the Dr. they thought the resident got hurt during the bath, because the pain started just afterwards. The spouse stated the resident laid there for 2 weeks before anything had been done. According to the spouse, the resident exhibited pain from 9/1/16 until the Nurse Consultant assessed the resident on 9/14/16 and decided to send them for an x-ray. At one point, a nurse spoke about decreasing the resident's pain medication until the spouse verbally disapproved. The spouse stated the nurse had been told the resident had been in pain every time staff moved the resident since that Thursday after his/her bath. According to the spouse, the nurse stated she apparently had not always been told about the resident's pain. According to the spouse, the resident could not possibly have fallen because he/she cannot roll, sit up or walk because of being a total invalid. An interview on 11/2/16 at 1:00 p.m. and subsequent interviews with the Administrator revealed she would have sent the resident out right away, started the investigation and reported it to the DIA if she had known about the alleged incident. She said she apparently had not always been fully informed about the severity of Resident #1's condition from the very beginning. The Administrator said she expected staff to report anything they either witnessed or had knowledge of. Once the alleged incident had been reported on 9/11/16, the Administrator stated she wanted to talk to Staff A. According to the Administrator, she and the DON had both been off of work on Monday, and the DON had been gone until 9/14/16, but Staff A had been assigned as the restorative aide instead of the bath aide until then. When asked, the Administrator said they determined that Staff A had no longer been considered suspect and therefore her suspension would not be warranted. When asked how she reconciled the discrepancy between Staff B's allegation and Staff A's denial of the allegation, the Administrator said Staff A could not have possibly transferred Resident #1 off of the floor and back into the chair by herself due to their size difference. When asked about the possibility that both Staff A and Staff E transferred the resident off of the floor and back into the tub chair, the Administrator stated it was possible. At a later interview, the Administrator stated she would have expected Staff A to use the lap belt on the tub chair when she bathed Resident #1 on 9/1/16. According to the Administrator, all staff should use the tub chair seat belt whenever they bathe a resident. The Administrator said the facility did not have a policy regarding the tub chair seat belt. A phone interview on 11/11/16 at 2:15 p.m. with Resident #1's primary care physician revealed that the resident had been experiencing pain when he saw the resident on 9/3/16. According to the Dr., nobody seemed to have any idea what happened. The Dr. said when the resident had been sent to theER on [DATE], he still had not been informed about the alleged incident. Once an x-ray revealed the resident had a [MEDICAL CONDITION], the Dr. stated they began hearing rumors about the resident being dropped in the shower. According to the physician, once the facility learned of the alleged incident he would have expected them to notify him with the results of a complete and accurate head to toe assessment.

Based on record review and family and staff interviews, the facility failed to adequately supervise and use designated precautions for securing one resident in the bath chair and inappropriately transferred 4 out of the 6 residents reviewed (Residents #1, #3, #5 and #6). The facility reported a census of 41 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 8/18/16. The MDS identified the resident had Alzheimer ' s disease and the BIMS (Brief Interview for Mental Status) described the resident ' s cognitive status as severely impaired. According to the MDS, Resident #1 depended on staff for extensive assistance for all transfers and most ADLs (activities of daily living skills), had absence of spoken words and rarely or never understood others or made him/her understood. The Care Plan dated September 2016 indicated Resident #1 depended upon 2 staff members for repositioning, dressing, hygiene, bathing and transfers with an EZ lift (mechanical lift). The AccuNurse (electronic charting system) documentation dated 9/1/16 noted Staff A, bath aid/CNA (certified nursing assistant) charted at 2:37 p.m. she had bathed Resident #1 that day. The Daily Staff Sheet dated 9/1/16 documented that Staff A had been scheduled as the designated bath aide that day. The Concern Investigation Form initiated and dated 9/11/16 at 11:15 a.m. by Staff D, LPN (licensed practical nurse) noted Staff B, CNA and Staff C, CNA reported they overheard that Resident #1 may have been dropped in the shower room. The LPN notified the on call nurse manager, who in turn notified the Administrator. According to the document, both CNAs completed statements for the investigation. On 9/14/16, the Administrator added information to the Form that said Staff A, bath aid/CNA and Staff E, CNA scooted the resident back after he/she had slipped to the edge of the chair. The document dated 9/11/16 and signed by Staff C noted that Staff B confided in her on 9/7/16 or 9/8/16 about information related to an accident that involved Resident #1 a week before. According to Staff C, Staff B confided that Staff A called her and said she dropped Resident #1 in the tub room as she transferred the resident by herself. After thinking about it for a few days, the two CNAs decided to report it to Staff D. The document dated 9/11/16 and signed by Staff B noted that she received a call from Staff A on 9/1/16. According to Staff B, the bath aide told her Resident #1 slid out of the chair onto the floor while reaching for her pop. Staff B stated that Staff A seemed to be very upset and begged her not to tell anyone. Staff B said she confided in Staff C when she realized Resident #1 had not been acting like him/herself. The CNAs decided to report it to Staff D on 9/11/16. Nurse's Notes dated 9/11/16 at noon indicated Resident #1 had been rubbing his/her right leg that morning, and winced when his/her right leg had been slightly lifted. Pain medication had been administered. A fax dated 9/11/16 at noon notified the Dr. that a CNA had reported Resident #1 had been rubbing his/her right leg that morning, and winced when his/her right leg had been slightly lifted. Pain medication had been administered. Nurse's Notes dated 9/11/16 at 3:20 p.m. noted Resident #1 experienced discomfort when ROM (range of motion) to the right leg had been provided. Medication had been administered. Nurse's Notes dated 9/13/16 at 8:05 a.m. noted staff reported slight grimacing as they had gotten him/her up for breakfast. Nurse's Notes dated 9/14/16 at 5:30 p.m. noted that prior to being transported to the ER (emergency room ) a 12 cm (centimeter) by 4.5 cm yellow bruise to Resident #1's right inner thigh identified. According to the documentation, the right leg was slightly larger than the left, and the resident exhibited pain with touch and movement A Resident Transfer Form dated 9/14/16 indicated Resident #1 was transported to the ER for increased right leg pain. The Radiology Report dated 9/14/16 diagnosed Resident #1 with an impacted intertrochanteric fracture of the right proximal femur (upper thigh bone). Nurse ' s Notes dated 9/14/16 at 6:30 p.m. noted ER notified the facility that Resident #1 had been admitted and scheduled for surgery related to a right hip fracture. The Radiology Report dated 9/15/16 documented that fluoroscopy (imaging technique with use of x-ray) had been used during the open reduction internal fixation (surgical repair with hardware) of Resident #1's right hip. An interview on 10/25/16 at 3:00 p.m. and subsequent interviews with the DON revealed the details of an alleged fall in the tub room on 9/1/16 that involved Resident #1. According to the DON, Staff B alleged that Staff A called her on 9/1/16 because Resident #1 had fallen in the tub room, and Staff A needed her assistance. Since Staff B had already left the facility, Staff A then contacted Staff E for assistance with repositioning the resident. The DON stated Staff B failed to report what she knew for about 1 ½ weeks. According to the DON, Staff B confided in Staff C on 9/7/16 or 9/8/16, and both of the CNAs finally reported what they knew to Staff D on 9/11/16. According to the DON, Staff D reported to the on call Nurse Manager. An interview on 10/26/16 at 7:40 a.m. with Staff B revealed Staff A called her on her cell phone. According to the CNA, Staff A used her cell phone because the batteries in the headset she wore went dead. She said Staff A stated Resident #1 had almost slid out of the tub chair, and she needed her help. When questioned about conflicting information Staff B had previously given in an interview with the facility, Staff B stated she had been mistaken and meant to say the bath aid told her the resident slid out of the chair and onto the floor. Staff B stated Staff A asked her not to tell anyone. An interview on 10/26/16 at 10:10 a.m. with Staff C revealed she knew the resident had not been acting quite right before Staff B told her on 9/7/16 or 9/8/16 that Staff A called her and stated she needed help getting the resident up off the floor in the tub room. According to Staff C, Staff B confided that Staff A tried to transfer Resident #1 alone and the resident fell . Staff C failed to immediately report what she knew, but stated after thinking about it for a couple days, she and Staff B reported it to Staff D on 9/11/16. Staff C said she had not actually witnessed anything. An interview on 10/26/16 at 11:35 p.m. with Staff E revealed Staff A called her on 9/1/16 about 2:15 p.m. She stated Staff A needed help in the tub room because Resident #1 started to slide out of the tub chair. According to Staff E, when she entered the tub room, Resident #1's tailbone was on the edge of the tub chair. She said Staff A stood on the left side of the tub chair with her left hand on the resident's chest holding them back and the other hand on the back rest of the tub chair. According to Staff E, both of them repositioned the resident back up in the chair. When asked at a later time, Staff E revealed when she entered the tub room, the tub chair seat belt had not been fastened around Resident #1's waist, which accounted for him/her sliding to the edge of the seat. According to Staff E, the bath aid should have recruited the help of a second person before unfastening the lap belt. An interview on 10/26/16 at 2:00 p.m. with Staff A revealed she had finished bathing Resident #1 and pulled the tub chair out of the tub to dry him/her off. According to Staff A, the resident became rigid and started to slide. She stated she panicked and grabbed her cell phone because her headset went dead. She called Staff B, who had already left the facility. According to Staff A, Staff B seemed to be stressed. Then Staff A said she called Staff E, who helped scoot the resident back from the edge of the chair. According to Staff A, Resident #1 had not exhibited any signs of pain or injury from the time she started the bath until the time the resident had been laid back down. At a later time, Staff A revealed the lap belt had not been fastened around Resident #1, and she might have turned for a second to grab something when the resident started to slide out of the tub chair. According to the bath aid, she stood in front of the resident with her leg in between his/hers so the resident could not slide all the way out of the chair. When asked if Staff E assisted her to lift Resident #1 off the floor, she stated no, because the resident had not fallen out of the chair. An interview on 10/31/16 9:00 a.m. with Staff F, CNA, revealed she worked with Resident #1 for the first time after the alleged incident about 2 days later. The CNA stated she noticed a black/gray bruise with a green/yellow tint about the size of a golf ball on the resident's right hip. Staff F stated she told Staff G, LPN and Staff H, RN about the bruise. According to Staff F, either Staff B or Staff I, CNA worked with her when she saw the bruise. Staff F did not know if her co-worker saw the bruise too. According to Staff F, the resident groaned and grimaced every time staff moved him/her from the time of the alleged incident until he/she had been sent for an x-ray. An interview on 11/2/16 at 1:00 p.m. and subsequent interviews with the Administrator revealed Staff A could not have possibly transferred Resident #1 off of the floor and back into the chair by herself due to their size difference. When asked about the possibility that both Staff A and Staff E transferred the resident off of the floor and back into the tub chair, the Administrator stated it was possible. At a later interview, the Administrator stated she would have expected Staff A to use the lap belt on the tub chair when she bathed Resident #1 on 9/1/16. According to the Administrator, all staff should use the tub chair seat belt whenever they bathe a resident. The Administrator said the facility did not have a policy regarding the tub chair seat belt. 2. The MDS assessment dated [DATE] documented diabetes, depression, osteoarthritis and myalgia as Resident #3's diagnoses. The BIMS assessment rated the resident as completely cognitive as indicated by a score of 14 out of 15. According to the MDS, Resident #3 depended on staff for extensive assistance for all transfers and most ADLs. The Need Care Plan dated September 2016 indicated Resident #1 depended on 2 staff members for repositioning, dressing, hygiene, bathing and transfers with an EZ lift. 4. The MDS assessment dated [DATE] documented dementia, [DIAGNOSES REDACTED] and early onset cerebellar ataxia disease as Resident #5's diagnoses. The BIMS assessment described the resident's cognitive status as severely impaired. According to the MDS, Resident #5 depended completely on staff for all transfers and extensive assistance for all ADLs. The Care Plan dated November 2016 indicated Resident #5 had poor balance related to ataxia, depended on 2 staff members for all transfers with an EZ (mechanical) lift. 5. The MDS assessment dated [DATE] documented dementia, depression and polyosteoarthritis as Resident #6's diagnoses. The BIMS assessment described the resident ' s cognitive status as severely impaired. According to the MDS, Resident #6 depended on staff for extensive assistance for all transfers and ADLs. The Care Plan dated August 2016 indicated Resident #6 depended on 2 staff members for transfers with an EZ lift. A document provided by the facility titled Mandatory CNA Meeting 9/19/16 noted resident transfers as the subject matter. The document indicated the facility recently discovered inappropriate resident transfer techniques had been used, and went on to chastise staff by noting we know you've all been doing some of them wrong! This is unacceptable. It is a risk not only to you, but to our residents as well. These are not canned goods and bags of flour at Wal-Mart these are peoples ' lives. The document had 18 signatures of those that attended on 9/19/16. The facility provided twenty four documents signed and dated 9/19/16 regarding education provided to staff for the recent discovery that inappropriate resident transfer techniques had been used. The document noted: It has been brought to our attention that we have an issue in our facility where for some reason, staff is under the impression that we can utilize any lift or transfer for residents. This is NOT the case. Residents need to be transferred per their care plan. If the care plan states they are an EZ Stand/Sit-stand, they must be transferred with an EZ Stand/Sit-stand. If they are listed as an EZ Lift/Hoyer, they are to be transferred with an EZ Lift/Hoyer. ALL lifts must be used by TWO staff members. There are NO exceptions to this. If a resident is listed as a two assist, two staff must be present and a gait belt must be used for ALL transfers. If the person is a one assist, one staff member must use a gait belt with ALL transfers. This is black and white. If a resident is not doing well with the transfer they are, talk with your charge nurse immediately, and you may use greater assistance. For example: if a resident is a one assist, but they are having trouble, you can use two staff. If a resident is a two person transfer, you can use a lift, if a resident is an EZ stand, you can use and EZ lift. But this is something that must be communicated to the nurse and therapy. You can NEVER use less assistance than what is care planned, only more. The January 2015 addition of Lift Sit to Stand procedure documented: Purpose: to provide safe transfer for non-ambulatory resident. Equipment: 2 staff members required. Guidelines: resident care plan will include the number of staff members needed for transferring with the use of sit to stand. The April 2015 revised Lift - Mechanical procedure documented: Purpose: to provide safe transfer for non-ambulatory resident. Equipment: 2 staff members required. During observations at various times from 10/26/16 through 11/7/16, all transfers had been done according to the care plan. However, when conducting interviews, staff revealed the facility had a serious problem where most CNAs had improperly transferred Residents #1, #3, #5 and #6 on multiple occasions. An interview on 10/25/16 at 3:00 p.m. and subsequent interviews with the DON revealed someone admitted improper transfer techniques had been used by most staff. As a result, the DON stated an in-service had been held to re-educate people. According to her, for whatever reason, they thought it was OK to transfer residents in ways other than what was care planned. During the in-service, the DON asked for anyone who had not participated in an improper transfer technique to raise their hand, and nobody raised their hand. An interview at a later time revealed the DON had knowledge that Residents #1, #3, #5 and #6 had all been inappropriately transferred on numerous occasions. The DON named Staff A as someone that had transferred Resident #6 by standing and pivoting the resident with the assistance of a 2nd person instead of with the EZ lift per the care plan. Next the DON named Staff B as someone that had transferred Resident #6 by standing and pivoting the resident with the assistance of a 2nd person on multiple occasions, and utilized an EZ stand to transfer Resident #6 a couple times instead of with the EZ lift per the care plan. The DON named Staff M and Staff R, Housekeeping Supervisor/CNA as staff that transferred Resident #1 by standing and pivoting the resident instead of using the EZ lift per care plan. The DON named Staff S, CNA as someone that transferred Resident #6 and Resident #5 by standing and pivoting them on numerous occasions instead of using the EZ lift per their care plans. The DON named Staff J as someone that transferred Resident #1 with an EZ lift without the assistance of 2nd person, and stood and pivoted Resident #5 with the assistance of a 2nd person instead of using the EZ Lift per care plan. Staff J revealed to the DON that she also 2 manned Resident #6 with the assistance of a 2nd person, and said she never sees anyone using the EZ Lift for Resident #6. The DON named Staff T, CNA as someone that transferred Resident #1 by standing and pivoting them once with Staff Q instead of using the EZ lift per the care plan. The DON named Staff U, CNA as someone that transferred Resident #3 with the EZ Stand by herself instead of with assistance of a 2nd person per care plan. The DON named Staff V, CNA and Staff E as people that transferred Resident #1 by standing and pivoting them on about 9/2/16 instead of using the EZ Lift per care plan. The DON said Staff V admitted that she ' bear hugged' resident #5 to stand and transfer them by herself. According to the DON, everyone knew the residents well enough to know they jeopardized the residents ' safety. The DON said the AccuNurse system provided prompts for staff. They have the option to review which cares should be provided, and are also prompted to acknowledge they provided cares appropriately. If staff selected they transferred with 2 assist, AccuNurse also inquires if a lift had been used. Staff have always charted that transfers had been done appropriately. Not once did anyone record that they did it wrong. Some staff admitted they put lift slings behind residents and placed lifts in residents ' rooms to make it appear as if transfers had been done appropriately, even when they had not. They worked harder at staging the rooms than they would have if they actually did the work. The DON stated that she went back and checked for any inconsistencies between the care cards and care plans because so many CNAs had spoken of inconsistencies. According to the DON, she had not found any, but eliminated the care cards from the residents ' closets because they could easily be altered. The DON said many of the CNAs tried to excuse the improper transfers they did by saying there had been inconsistencies between care cards and care plans. An interview on 10/31/16 at 3:00 p.m. with the Corporate Nurse Consultant revealed that he did not believe Resident #1 had gotten injured in the tub room on 9/1/16. He believed the resident's injury occurred during an improper transfer. He stated they all admitted they were transferring residents in ways other than what was care planned, including Resident #1. The Nurse Consultant stated that some staff admitted they stood and pivoted Resident #1. According to him, it seemed more plausible that a fracture occurred if the opposing force of someone trying to pivot him/her against the resistance of his/her own rigidity. He also stated that Staff A worked at the facility for many years and had helped train staff. He repeatedly said what a good CNA Staff A had been, and thought that anyone that injured the resident during and improper transfer could have diverted the attention to Staff A. An interview on 11/1/16 at 7:55 a.m. with Staff J revealed that she had done improper transfers before. According to the CNA, she used an EZ Lift by herself to transfer Resident #1. She stated she believed that all other staff had done improper transfers before. Staff J explained there used to be care cards in resident ' s closets that staff was supposed to reference to know which method of transfer should have been used. They told us at the meeting that not all cards were correct, so they took them out of the rooms. The CNA stated she had seen others using EZ Stands alone, and emphasized that they are only to be used when 2 staff are present. An interview on 11/1/16 at 8:00 a.m. with Staff C revealed that she had done improper transfers before. The CNA explained that she had transferred residents by standing and pivoting them with assistance of a 2nd person instead of using an EZ Lift according to the care plan. According to her, she had never transferred Resident #1 that way before. An interview at a later time revealed that care cards had previously been kept inside of residents' closets for staff to reference to know which transfer method should be utilized. Now they are kept in a book at the nurses' station. The DON revises those as necessary. According to the CNA, there were some inconsistencies. She stated that she could not recall what Resident #6's card said before, but admitted that she and other staff placed an EZ Lift sling behind Resident #6 in the wheelchair to make it look like an appropriate transfer had been done. Instead, she said they stood and pivoted him/her with a gait belt. An interview on 11/1/16 at 8:30 with Staff B revealed she had used an EZ Stand to transfer Resident #3 by herself, despite knowing it required the assistance of 2 people. She stated she had seen people that transferred Resident #1 by standing and pivoting them instead of using an EZ Lift per care plan. The CNA stated Resident #6's care card said the resident should be stood and pivoted with assistance of 2 (staff). According to the CNA, she and a lot of other people transferred Resident #6 that way instead of the EZ Lift per care plan. There were care cards in the residents ' closets that instructed staff how to transfer the resident. The CNA stated she informed Administration of the inconsistencies at the in-service about a month and a half ago, and they took them out of the rooms. They said the care cards were not all correct. An interview on 11/1/16 at 9:30 a.m. with Staff M revealed that she used improper transfer techniques with Resident #6 before. The Care Plan in the resident's closet instructed that he/she should be transferred by standing and pivoting with assistance of 2 and a gait belt, or by EZ lift with assistance of 2. Once the facility had been informed of the inconsistency, they changed the care card to transfer the resident with an EZ Lift only. Prior to the alleged incident on 9/1/16, care plans in residents ' closets were meant to be referenced. Since then, only the care plan at the nurses ' station should be referenced. I have never knowingly transferred anyone improperly because of Resident #6's inaccurate care card. An interview at a later time revealed that once Staff M had time to think about it, she recalled that she and Staff R used an EZ Stand to transfer Resident #1 in the tub room instead of using the EZ Lift per care plan. Staff M stated the improper transfer must have occurred on 9/8/16 because that coincides with Resident #1's bath day. An interview on 11/1/16 at 1:30 p.m. with Staff E revealed that shortly after Resident #1's transfer status changed from an EZ Stand to an EZ Lift, the CNA admitted that she used the EZ stand because she failed to read the CNA book to know the current status. According to the CNA, staff had been told to use the care cards in the residents' closets to know how they should be transferred. Staff had also been told to read the staff book at the nurses ' station every morning before shift. The CNA stated the care cards and the staff book were the same information. She could not recall why the care cards in the closets had been eliminated. Staff E said she had seen others staff doing improper transfers too. She stated she had stood and pivoted Resident #6 on numerous occasions with various other staff members, despite knowing an EZ Lift should have been used instead. According to Staff E, on one occasion, Staff A also helped to stand and pivot Resident #6, but she could not recall when that occurred. The CNA stated that she always charted the transfers had been done appropriately instead of how they were actually done. An interview on 11/1/16 at 2:12 p.m. with Staff U revealed that when she floated as a CNA one day during the 2nd week of September, she witnessed Staff M and Staff R as they removed the EZ Stand sling from behind Resident #1, and moved the EZ Stand away from the wheelchair. Staff U said she told Staff M that she thought for sure that Resident #1 should have been transferred with an EZ Lift. According to Staff U, Staff M just looked at her. Staff U admitted she had made improper transfers too. According to the CNA, she stood and pivoted Resident #6 with another person on a couple occasions after physical therapy said the resident had been changed back to an EZ Lift. Another time, Staff U confided that she transferred Resident #3 from the wheel chair to the toilet with the use of an EZ Stand by herself. She stated she had always charted transfers had been done appropriately, instead of how they had actually been done. An interview on 11/1/16 at 3:45 p.m. with Staff O revealed that she had never used any improper transfer techniques with lifts, but had probably not used a gait belt when she should have. An interview on 11/1/16 at 5:15 p.m. with Staff K revealed she had never transferred Resident #1 or anyone else using improper transfer techniques. She stated she heard of other people doing it, but had never witnessed it. The CNA mentioned one exception. She stated there had been a problem with a care card for Resident #6. According to her, the care card noted that an EZ Lift/ 2 person assist with walker should be used to transfer the resident. She said that she and other people stood and pivoted Resident #6 instead of using the EZ Lift for at least 10 months. Because the card confused her, she said she asked Staff U, the person that trained her. Staff U stated she did not know. And although the card confused her, Staff K stated she did not see any reason to get clarification. An interview on 11/7/16 at 2:00 p.m. with Staff Q revealed that she 2 manned Resident #6 with a gait belt. The CNA stated this had been her 1st job as a CNA, and she had only worked at the facility for about 3 months. Staff Q said she had been trained to transfer the resident by Staff J and Staff K, amongst others. She stated that she had been told to refer to the care cards in their closets, but did not refer to them. The CNA stated she had seen Resident #5 being 2 manned by Staff T and Staff J. The CNA admitted whenever she charted transfers, she charted what was supposed to be done rather than what was actually done. An interview on 11/7/16 at 12:46 p.m. with Staff A began with her stating, I won't say that I've never transferred anyone improperly. She said she stood and pivoted Resident #6 with a gait belt and the assistance of another person. According to Staff A, the resident's care card indicated the resident could be transferred as a 2 person assist with a gait belt or an EZ Lift. She admitted she had not thought very carefully when she did it. She stated even though the care card seemed confusing, she knew the resident should have only been transferred with an EZ Lift and not stood and pivoted. The CNA stated she could not recall which staff member assisted her.

Based on record review and staff and resident interviews, the facility fail to transfer a resident as directed by the interventions of the care plan in order to prevent accidents and injuries (Resident #1). The sample consisted of 7 residents and the facility identified a census of 36 residents Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 10/25/2012. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. The resident required extensive assistance of 2 staff members for transfers and toilet use and the assistance of 1 person for personal hygiene. Resident #1 did not ambulate. The resident had unsteady balance with all activities and limited range of motion of 1 side of the body. The care plan with a goal date of 2/13 revealed the resident transferred him/herself with assistance of 2 staff and the use of a gait belt. The resident could transfer him/herself to the toilet but required assistance of 2 persons and a gait belt to get off the toilet. The review of the care plan posted in the resident's bathroom directed staff that the resident needed to be transferred with assistance of 2 staff persons and to use an EZ lift for all transfers. The review of the Incident/Accident/Unusual Occurrences Form dated 12/14/12 at 8:50 a.m. revealed the CNA (Certified Nursing Assistant) helped the resident off the toilet and the resident became irritated because the CNA did not wipe /clean the resident well enough and the resident purposely sat on the floor. The observation of the resident revealed the staff did not see any injuries. The Nurse's Notes dated 12/14/12 at 11:50 a.m. reflected the resident as very upset and irritable that day. After breakfast at approximately 8:50 a.m., the CNA from a staffing agency attempted to transfer the resident off the toilet as a 1 person assist. The resident became very irritated and said, "she had not cleaned him/her up right". The resident then told the CNA he/she planned to sit down. The resident sat on the floor and the CNA could not get the wheelchair under the resident. The nurse did not see any injury at the time of the incident. The resident asked for acetaminophen (Tylenol) before lunch for general achiness which had been normal and consistent for the resident. The nurse's assessment showed no injury. The resident remained very irritable and demanding. The Incident/Accident/Unusual Occurrences Form dated 12/14/12 at 5:30 p.m. documented Staff C (CNA) tried to transfer the resident to the spouse's personal vehicle, the resident could not successfully complete the transfer and the CNA caught the resident to prevent a fall. The resident did not complain of pain at the time. The Nurse's Notes dated 12/15/12 at 1 a.m. documented the resident complained of his/her leg being sore where the strap of the right leg brace is located. Staff saw no bruising, but the resident complained of soreness to the touch. Staff administered Tylenol. The Nurse's Notes dated 12/15/12 at 11:15 a.m. documented the resident complained of pain to the right leg, rating 10 out of 10 (the worst pain). The resident described the pain as tingling and of weakness and difficulty in standing. Staff noted the leg as slightly swollen and tender to touch and staff called the resident's primary care physician. At 12:30 p.m. the resident's family transferred the resident to the emergency room . The hospital Discharge Summary dated 12/22/12 documented during transfer from the bathroom, the resident's wheelchair was not locked and Resident #1 suffered a fall to his/her right side. The resident has chronic right-sided weakness and decreased sensation secondary to a CVA (stroke), therefore did not notice the pain right away. The next day, Resident #1 complained of achy pain in the right leg, went to the hospital and diagnosed with [REDACTED]. Staff A, (Agency CNA), stated on 1/2/13 at 3:10 p.m. that she had not been assigned to Resident #1. Staff A stated she worked with another aide and that aide had been helping another resident. Resident #1 sat on the toilet, Staff A took the resident's gait belt, the resident held onto the grab bar and she helped the resident to stand. She stated the resident then stated she had not cleaned the resident well enough and as she grabbed another wipe, the resident got mad and sat down on the floor. Staff A got help while the resident sat on the floor. Staff A stated she did not know he/she required 2 staff to assist. She stated that everyone transferred the resident with assistance of 1. She also stated that the afternoon shift got the resident up with 1 assist and a sit-stand on the toilet and the resident already had his/her gait belt on. Staff A again stated she did not know the resident required a 2 person transfer. Staff A stated she did not have time to look at the care card because the resident tried to stand and had been screaming so she grabbed the gait belt while he/she stood him/herself up. The Director of Nursing was interviewed on 1/2/13 at 4:15 p.m. and stated the agency CNA, Staff A, should have known the resident required 2 people to assist as the CNA had been in the facility quite a bit. Staff B (Certified Medication Aide) was interviewed on 1/3/13 at 11:38 a.m. and stated that Staff A had worked at the facility for about 6 weeks. When agency staff came to work at the facility, the staff gave them a sheet with the resident's cares on it for the hall the agency staff had been assigned to. Staff B also stated the facility had care plan cards in each resident's bathroom. Staff B stated Staff A should have known the resident required 2 people for transfers. The Care Plan nurse was interviewed on 1/3/13 at 11:15 a.m. and stated she did not remember when the resident had been a 1 person transfer. Staff C (CNA) was interviewed on 1/2/2013. Staff C stated on 12/14/2012, the resident ' s daughter convinced the resident to attend the Christmas party. Staff C and Staff D (CNA) transferred the resident to his/her wheelchair to go to the party. After the party in the facility, the resident sat in the wheelchair at the nurse's station until 5:15 p.m. when his/her ride came to take him/her to the resident's family's Christmas party. The resident kept reminding Staff C not to forget to go back at 5:15 p.m. to help the resident. Staff C and Staff E CNA took the resident out to his/her ride. Staff C stated when they lifted the resident, Staff E pushed the wheelchair back out of the way and when he went to turn with the resident, the resident fell and the staff caught the resident due to the resident losing his/her footing or just being too weak. Staff E helped Staff C to get the resident back up and they put him/her back into the wheelchair. The resident's wife did not want to take the resident to the party as no one could lift him/her, being too weak. The facility Administer provided a facsimile dated 1/7/2013 from the staffing agency. The facsimile indicated that on 11/6/12, the Administrator notified the staffing agency that Staff A had transferred a resident by herself and the resident had required a 2-person transfer. The staffing agency gave Staff A a verbal warning that she should never transfer a 2-assist resident by herself. Staff A stated she did not know the resident was a 2-person assist and she would not knowingly transfer a 2-assist by herself. They let Staff A know that had been a verbal warning and she needed to be certain that she know who is a single transfer and who are 2 assist transfers. The resident stated on 1/2/13 at 5:00 p.m. that he/she had put him/herself onto the toilet as allowed. The resident stated that he/she put on the call light and that girl answered it. The resident told the aide that she needed to get another person to help and the aide told her/him, she could do it without another person. The resident stated after she/he tried to stand up the aide, cleansed him/her and pulled pants up at the same time. The resident told the aide he /she needed to sit down. The aide had the wheelchair and tried to pull it closer but could not. As he/she started to sit down on the toilet, the aide pushed the resident towards the wheelchair and the resident fell . The resident stated he/she had pain right away. On 1/17/13 at 2:45 p.m., the resident ' s primary physician was interviewed. The physician stated he felt the resident's leg had been fractured with the first fall when the agency staff transferred the resident by herself. The resident wore a brace on the right leg and the break had been a spiral break above where the brace ended. The physician continued to state the break had been severe and according to the resident and his/her spouse the resident could not transfer well after the initial fall in the morning.