Every finding on record at Azria Health Clarinda

Based on observation, staff interviews, resident interviews, clinical review and policy review. The facility failed to respond to call lights in a timely manner for 4 of 4 residents reviewed (Resident #1, #15, #14, and #47). The facility reported a census of 60 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 00 that indicated severe cognitive impairment. The MDS further indicated that Resident #1 was dependent on staff for toileting hygiene, personal hygiene and transfers. On 5/4/26 at 12:35 PM a continuous observation revealed Resident #1's Wife turned the call light on. At 12:40 PM a Certified Nursing Assistant (CNA) entered the room Resident #1's Wife stated to that CNA Resident #1 wanted assistance to lay down in bed. That CNA stated she had to go find a lift and another staff member first. That CNA exited the room and went into room [ROOM NUMBER]. A second CNA entered the room, stated she needed to get a lift, a second staff and exited the room. At 12:46 PM Staff J, Licensed Practice Nurse (LPN) entered the room and turned off the call light. At 12:47 PM Resident #1's Wife turned the call light back on. Resident #1 remained in the wheelchair. At 12:54 PM Staff C, CNA and Staff D, CNA entered Resident #1's room with hoyer lift and assisted Resident #1 from wheelchair into bed. Continuous observation revealed the request for transfer assistance was not completed for a total of 19 minutes. 2. The MDS dated documented Resident #15 had a BIMS of 15 that indicated no cognitive impairment. The MDS further indicated that Resident #15 was dependent on staff for toileting hygiene, personal hygiene and transfers. On 5/4/26 at 11:37 AM Resident #15 stated the facility needed more help because they are so short staffed. Resident #15 explained she frequently had to wait over 20 minutes for the call light to be answered. She continues to explain that the staff would shut the light off, say they will come back and not return. Resident #15 had a sign documented to not shut my light off until you have met my needs. On 5/7/26 at 9:07 AM the Director of Nursing (DON) stated her expectation was the call light response time to be less than 15 minutes. The DON acknowledged a concern with staff shutting off the call light before the residents' needs were met and stated she expected the call light to remain on until the resident was cared for. 3. Review of Resident #14's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. Interview on 5/4/26 at 11:41 AM with Resident #14 revealed that call lights often take up to 30 minutes to be answered. Resident #14 then revealed that he watches the clock, and can read the time to tell how long it takes. 4. The MDS dated [DATE] documented Resident #47 had a BIMS of 11 indicating moderate cognitive impairment. On 5/4/26 at 2:17 PM Resident #47 stated on the PM shift it took up to an hour at times but longer than 15 minutes almost nightly to respond to the call light. Review of document dated 3/19/26 and 4/16/26 titled, Resident Council Minutes recorded concerns with call light times / length of time for call light response. Review of policy revised 9/22 titled, Answering the Call Light documented the purpose of the procedure was to ensure timely responses to the resident's requests and needs. Staff were to answer the resident call system timely. When staff answer an auditory request for assistance, identify yourself and politely respond to the resident by his/her name. If the resident needed assistance, indicate the approximate time it would take for the response.

Based on observations, staff interviews, clinical record review, and policy review, the facility failed to ensure universal infection control measures and Enhanced Barrier Precautions (EBP) were maintained. The facility failed to ensure appropriate hand hygiene was completed during personal care for Resident #1, during wound care for 1 of 2 residents (Resident #41), during medication administration and during catheter care for 1 of 2 residents (Resident #5). The facility also failed to ensure appropriate Personal Protective Equipment (PPE) was worn for a resident that required EBP during catheter care (Resident #37). The facility reported a census of 60 residents.Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief interview for Mental Status (BIMS) of 00 that indicated severe cognitive impairment. The MDS documented Resident #1 was dependent on staff for all Activities of Daily Living (ADL) and was always incontinent. On 5/4/26 at 12:54 PM an observation of a transfer completed by Staff C, Certified Nurse Assistant (CNA) and Staff D, CNA revealed Staff C and Staff D transferred Resident #1 with a hoyer lift into bed. Hand hygiene was performed and gloves were applied by both Staff C and Staff D. Both staff repositioned Resident #1, removed the hoyer sling and removed the resident's pants. Staff C grabbed a brief off the bedside table, Staff D removed Resident #1's brief and placed a towel in between the residents legs. Staff C completed personal care to buttocks, applied a clean brief and cream to buttocks without changing gloves or performing hand hygiene. Staff C repositioned the resident onto his back and continued with personal care to his groin and applied cream to the inner groin. Staff C secured Resident #1's brief and both Staff C and Staff D removed gloves. Staff D lifted Resident #1's legs while Staff C placed a pillow under them both. Staff C and Staff D performed hand hygiene. Staff D lowered the bed and placed the call light on the resident's chest. 2. The Minimum Date Set (MDS) dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 5 indicated severe cognitive impairment. The MDS documented a diagnoses of diabetes, that the resident has an open area and recieves application of nonsurgical dressings and ointments/medications. On 5/6/26 at 2:01 PM an observation revealed Staff E, Licensed Practical Nurse (LPN) entered Resident #41's room, completed hand hygiene, applied a gown, applied gloves and laid a barrier on resident #41's bedside table. Staff E opened supplies and laid them on the barrier. Staff E placed foam dressing, silicone faced foam border dressing and a sterile water bottle on the barrier. Staff E removed gloves and performed hand hygiene. Staff E applied new gloves and prepped two washcloths, one with soap and water and one with just water. Staff E cleansed the wound to the left shoulder of Resident #41. Staff E took the glove that was holding the dirty washcloth, turned the glove into itself keeping the washcloth inside the glove and placed it onto the back of the toilet. Staff E applied a new glove to that hand without performing hand hygiene. Staff E utilized the second washcloth with the opposite hand with only water to cleanse the wound and turned the glove inside itself, keeping the washcloth inside the glove and placing the glove onto the back of the toilet. Staff E applied a new glove to that hand without completing hand hygiene. Staff E opened the blue foam dressing and cut into the shape for the wound. Staff E poured sterile water, wrung out the dressing and applied blue foam dressing to the wound bed and covered it with a foam border dressing. Staff E removed gloves and performed hand hygiene. Staff E applied new gloves, opened skin prep packaging, pulled down Resident #41's sock and applied skin prep to the left outer ankle. Staff E grabbed white heel protectors out of the closet, applied them to both feet, removed the barrier from the bedside table, removed the gown, removed gloves and performed hand hygiene. On 5/5/26 a continuous observation of medication administration revealed Staff F, Licensed Practice Nurse (LPN) performed medication administration to 6 residents in a row without performing hand hygiene before or after medications were gathered and administered. On 5/6/26 a continuous observation of medication administration revealed Staff G, Certified Medication Aide (CMA) performed medication administration without performing hand hygiene before administering medications to a resident. On 5/6/26 at 12:06 PM, an observation of Staff H, Licensed Practical Nurse (LPN) revealed Staff H removed the medication from the narcotic box. Staff H counted the medication and documented the count in the narcotic book on the medication cart. While attempting to dispense the medication into a medication cup, the tablet dropped onto the narcotic book and fell onto the top of the medication cart. Staff H picked up the tablet with an ungloved hand and placed it into the medication cup. Staff H proceeded to administer the medication to the resident without replacing the medication and without performing hand hygiene before, during or after the medication was administered. On 5/7/26 at 9:07 AM the Director of Nursing (DON) acknowledged concerns when staff did not complete appropriate hand hygiene with catheter care, medication administration, personal care and wound care. The DON acknowledges concerns with EBP not being worn during catheter care. The DON stated medication should be discarded once it had been contaminated from falling onto the narcotic book and a new medication administered to the resident. 3. The MDS dated [DATE] documented Resident #5 had a BIMS of 3 indicating severe cognitive impairment. The MDS documented Resident #5 was dependent on staff for toileting. Observation on 5/6/26 on 2:04 PM of Resident #5's catheter emptied by Staff I, CNA/Bath aide. Observed Staff I completed hand hygiene, donned gown, applied gloves, and applied a gait belt around the waist of Resident #5. Staff I assisted with standing in the bathroom with stand bars on the wall, assisted Resident #5 when turned to the left to sit on the toilet. Staff I removed Resident #5's sweat pants, removed gloves, with no hand hygiene completed. Staff I adjusted catheter leg bag, applied gloves, placed barrier on the ground, placed a graduated cylinder on a barrier, cleansed catheter bag tip, emptied urine from catheter bag with 25cc emptied from the bag. Staff I removed gloves with no hand hygiene, applied gloves, cleansed buttocks, pulled brief up, pulled sweat pants up, and assisted resident in turning to the right to sit in the wheelchair. Staff I removed gloves, removed gait belt, and completed hand hygiene. Staff I applied gloves, emptied graduated cylinder into the toilet, cleansed graduated cylinder, graduated cylinder placed in a plastic bag, doffed gown, removed gloves and hand hygiene completed. On 5/7/26 at 9:07 AM the Director of Nursing (DON) stated she expected hand hygiene to be completed when staff moved from a contaminated body site to a clean body site during resident care and with glove changes as well. Review of policy revised 8/19 titled, Handwashing / Hand Hygiene documented hand hygiene should be completed before and after direct contact with residents, before preparing or handling medications, before performing any non-surgical procedures, before and after handling an invasive device (e.g., urinary catheters), before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with resident's intact skin, after contact with blood or bodily fluid, after handling used dressings, after handling contaminated equipment, before entering isolation precaution settings and after entering isolation precaution settings. 4. The MDS assessment dated [DATE] revealed Resident #37 had diagnoses of obstructive uropathy (a blockage in the urinary tract backing urine into the kidney) and a multi-drug resistant organism (MDRO) (a superbug; germs or bacteria that are resistant to three or more families of antibiotics). The MDS recorded the resident did not have an indwelling catheter. The Care Plan revised 4/1/26 revealed Resident #37 had an indwelling catheter and had recurrent urinary tract infections related to a MDRO ESBL (extended-spectrum beta-lactamase) (a bacteria). A foley catheter placed by urology was added to the care plan on 4/24/26. The Care Plan directed staff to use enhanced barrier precautions (EBP's) in accordance with Centers for Disease control (CDC) guidelines, and use the appropriate personnel protective equipment. Resident #37's Electronic Health Records revealed Special Instructions:Use EBP's for ESBL in the urine. The Order Summary revealed to do catheter care every shift. Observation on 5/4/26 at 12:01 PM revealed an EBP sign on the door by Resident #37's room. A plastic bin containing gowns sat by the wall in the room. During observation on 5/5/26 at 1:24 PM, Staff A, certified nursing assistant (CNA) washed her hands and donned a pair of gloves. Staff A drained the urine contents from Resident #37's catheter bag into a graduate container. Staff A clamped the catheter port, took an alcohol swab and cleansed the end of the port. Staff A emptied the graduate into the toilet, turned the sink faucet on with her gloved hand and rinsed the graduate with water. Staff A placed the graduate on the back of the toilet, removed her gloves, turned the sink faucet on, and washed her hands. Staff A did not wear a gown for EBP's. In an interview on 5/5/26 at 1:45 PM, Staff A reported she had worked at the facility for 2 to 3 weeks and she was shown how to do things during orientation. Staff A reported a gown and gloves worn for EBP's whenever a resident had a catheter. In an interview on 5/6/26 at 10:52 AM, Staff B, CNA, reported Resident #37 had bacteria in her urine. Staff had to wear a gown and gloves when they took care of Resident #37 or handled the catheter. In an interview on 5/6/26 at 12:26 PM, the Infection Preventionist (IP) reported she completed hand hygiene, EBP and peri care audits monthly. The IP stated she expected a gown worn whenever staff performed catheter care and wound care. An EBP policy dated 9/2024 revealed EBP's utilized to prevent the spread of MDRO's. A gown and gloves are used during high contact care activities such as handling a catheter.

Based on clinical record review, facility investigation review, staff interviews and policy review the facility failed to report a reportable event to the appropriate facility staff members after the alleged event took place. Which lead to the facility failing to report to the State Agency within 2 hours of the alleged event. The facility reported a census of 52 residents.Findings include:According to the Annual Minimum Data Set (MDS) assessment tool, with a reference date of 5/8/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 2. A BIMS score of 2 suggested severe cognitive impairment. The MDS documented she experienced hallucinations, delusions, displayed physical and verbal behavioral symptoms for 1-3 days during the 7-day review period. Resident #1 did not exhibit rejection of evaluation or care and did not wander. Resident #1 utilized a wheelchair for mobility and was always incontinent of urine and bowel. She was dependent of staff for eating, oral hygiene, toileting hygiene, shower/bathing, personal hygiene, toilet transfers. The MDS indicated Resident #1 received the following medications during the 7-day review period: antianxiety, antidepressant, and an opioid. The following diagnoses were listed for Resident #1: stroke, coronary artery disease, thyroid disease, Alzheimer's disease, anxiety, glaucoma, insomnia, and cellulitis.The Care Plan focus area with an initiation date of 5/20/2024 documented she was dependent on staff for meeting emotional, intellectual, physical, spiritual and social needs related to physical limitations.A second Care Plan focus area with an initiation date of 5/22/2024 documented Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit related to stroke, anxiety, macular degeneration. The Care Plan documented she did not ambulate, utilized a wheelchair for locomotion, and was dependent on staff for mobility. She was dependent on staff to make significant position changes while in bed; she required the assistance of tow staff with bed mobility. She was also totally dependent on two staff for toilet hygiene and incontinence management. The Care Plan directed staff to check and change her in the morning, before and after meals, before bed and as needed. Resident #1 did not use the toilet, she was incontinent. Staff are to encourage the resident to participate to the fullest extent possible with each interaction.A third Care Plan focus area with an initiation date of 5/28/2024 documented Resident #1 had impaired cognitive function/dementia or impaired thought processes related to short term memory loss.A fourth Care Plan focus area with an initiation date of 6/10/2024 and revision date of 6/9/2025 documented Resident #1 had alteration in her mood and behaviors as evidenced by yelling out to staff, disrobing, confusion (not knowing where she is) and worried/anxious feelings related to stroke and anxiety, cursing, grabbing, hitting and spitting at staff during cares. On 6/3/2025 resident made a comment about wanting someone to shoot her. Resident was sent to the emergency room (ER) to make sure she was not a danger to herself. She was sent back after being evaluated and determined she was not a danger to herself. Staff were directed to provide an opportunity for positive interaction, attention and to stop and talk with her as they pass by her. Staff were also encouraged to provide redirection to resident when using foul language. Staff are to use a clam approach, tell her what is being done prior to providing cares. If the resident is punching and hitting staff during cares, staff are to monitor for agitation and if save, step back to allow her to calm down. The nurse is to be updated to assess her if she's in pain and give an as needed (PRN) pain medication. Staff are encouraged to talk through what is bothering the resident. Staff are to introduce themselves, speak slowly and clearly so that the resident understands staff when providing cares/speaking with resident.A fifth Care Plan focus area with an initiation date of 5/12/2025 documented Resident #1 had delirium or an acute confusion episode related to acute disease process, dementia. Staff are to redirect and provide gentle reality orientation as required.The facility investigative file contained the following summary:On 7/9/2025 at approximately 4:30 PM the Director of Nursing (DON) was notified by the Assistant Director of Nursing (ADON) that on 7/6/2025 Staff A Certified Nursing Assistant (CNA) witnessed Staff B CNA forcefully grab Resident #1's arm and push it down then stated stop hitting me while completing cares on Resident #1. Staff A stated she immediately reported the incident to Staff C Registered Nurse (RN), the charge nurse. The facility was unable to review the incident with the resident due to a BIMS score of 2. The DON notified the Administrator after the incident was reported to her on 7/9/2025. Staff B was immediately suspended pending the investigation. During the investigation, initially it was reported the incident happened on 7/6/2025. Follow up with Staff A, she stated it did not happen on 7/6/2025 it happened on 7/2/2025. Facility staff were all educated on what abuse is, the different kinds of abuse and how to properly report abuse.The facility investigative file included the following statement from Staff A:On Sunday 7/6/2025 we were laying Resident #1 down after dinner. She was being combative and attempting to hit us. While doing so, Staff B grabbed her arm, forced it down and said stop hitting me b*tch. I finished cares and went to report it to my charge nurse, Staff C.On 8/5/2025 at 12:09 PM Staff A stated on Wednesday, July 2nd her and Staff B completed cares on Resident #1. The resident was being very combative but barely hits when she does. Staff A was on the right side of the resident and Staff B was on the left side of the resident. Resident #1 was doing her normal stuff by calling them fat and telling them to get out of her room. Resident #1 swung at Staff B and Staff B grabbed her left forearm/wrist and said don't hit me b*tch. After cares were completed, they left the room and she told Staff B that as not acceptable, we should not be acting like that; Staff B just rolled her eyes. Staff A reported this incident to her charge nurse, Staff C. Staff A stated she had not heard anything about the incident for a few days so she went the ADON and DON about what had happened. They both told her neither of them knew about the incident. She stated her statement does say the 6th but it happened on the 2nd. She indicated since this took place they facility has educated staff on what types of abuse, how to report it and who to report it to.On 8/5/2025 at 2:20 PM Staff C stated Staff A reported to her another aide, Staff B had called Resident #1 a name because she was trying to hit her. Staff A reported that aide stopped the resident from hitting her by holding her arm then called her a b*tch. The other aide was Staff B. It happened about 7:00 PM, after dinner as they were assisting residents. Staff C stated Staff A came up to her said she has had it and went to break. When she returned from her break, that's when Staff C stated Staff A reported the incident to her. She stated it was about 7:30 PM because Staff A usually took her break after dinner. When asked what she did after this alleged incident was reported to her, she indicated she was dealing with another conflict and asked Staff A to report her concerns to the Administrator and through she did, but apparently, she did not. When asked why she did not tell the Administrator herself, she stated she went and took care of a different situation, honestly it slipped her mind and did not doing anything about it. After this incident Staff C stated they facility provided education to all staff on the policies and procedures if this kind of incident should happen again, who to call with abuse concerns and what abuse it.On 8/5/2025 at 2:34 PM the ADON stated Staff A came to her office on the 7th and stated she needed to talk to her about something. Staff A said her and Staff B were in Resident #1's room assisting her with cares when Staff B called the resident a b*tch. The ADON questioned if she reported this and why was this the first time she was hearing this. Staff A told her after she left Resident #1's room that day she reported this to her charge nurse, Staff C. They went to the DON with the information. The ADON stated they should have called her, the DON and/or the Administrator so they were not hearing it after the fact.On 8/5/2025 at 2:59 PM the DON stated the alleged event took place on Wednesday the 2nd. The dates got mixed up during the investigation process. The incident was reported to Staff C on the same day of the incident, the 2nd. When they spoke to Staff A she reported Staff C told her to go tell someone, but Staff A indicated you are the charge nurse, I am supposed to report these things to you. They later found out Staff A reported alleged incident to Staff C after she went on break; because Staff A was upset she needed to take a break. When she spoke to Staff C, she indicated she told Staff A she needed to tell someone. The DON informed her that someone was you, you are the charge nurse. Staff C was to make sure the resident was safe then contact the DON or the Administrator. The DON added, as a charge nurse, this is part of her job. Staff C was educated on proper reporting procedures.The facility provided a document titled Identifying Types of Abuse, with a revision date of September 2022. The policy statement included: as part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.The facility also provided a document titled Abuse, Neglect, Exploitation and Misappropriation-reporting and investigating with a revision date of September 2022. The policy statement included all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) 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 state laws.2. The Administrator or the individual making the allegations immediately reports his or her suspicion to the following persons or agencies:a) The state licensing/certification agency responsible for surveying/licensing the facility3. Immediately is defined as:a) Within two hours of an allegation involving abuse or result in serious bodily injury; orb) Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on clinical document review, staff interviews, provider interview and policy review the facility failed to provide appropriate assessments, implementation of the bowel managment plan and physician notification for 1 of 3 Residents (Resident #1) reviewed. The facility reported a census of 61 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #1 dated 10/9/24 revealed Resident #1 had severely impaired cognitive skills. The MDS further revealed diagnosis of traumatic brain injury, profound intellectual disabilities, and slow transit constipation. Review of the Electronic Health Record (EHR) page titled, Physician's orders revealed orders for Sennosides oral tablet (Laxative) 8.6mg give 1 tablet by mouth at bedtime for constipation (hold if having loose stools), Miralax oral packet (Laxative) 17 grams give 17 grams by mouth one time a day for constipation (hold if having loose stool), Linzess oral capsule 72mcg (gastrointestinal agent) give 1 capsule by mouth one time a day for bowel function (Give 30 minutes before breakfast), Fiber oral tablet (Laxative) give 2 tablets by mouth one time a day for constipation (hold if having loose stools). This page further revealed the following as necessary (PRN) orders Fleet Enema (Laxative) insert 1 dose rectally every 24 hours as needed for constipation, Biscaodyl laxative rectal suppository (Laxative) 10mg insert 1 suppository rectally every 24 hours as needed for constipation, prune juice 4-8 ounces to promote bowel movement every 24 hours as needed for constipation, Milk of Magnesia suspension 400mg/5ml (Laxative) give 30ml by mouth every 24 hours as needed for constipation. Review of a document titled Monthly Bowel Tracker provided by the facility dated December 2024 revealed that Resident #1 did not have a bowel movement from 12/1/24 through the morning shift of 12/9/24. Review of the Medication Administration Record (MAR) dated 12-1-24 through 12-31-24 revealed that suppositories were given 12/5/24, and 12/9/24 and were ineffective. No other PRN medications were given during this time to help promote bowel movement. Interview on 1/6/25 at 2:38 PM with Staff A Licensed Practical Nurse (LPN) revealed that nightshift nurses are to run a bowel movement list every night and identify if someone needs medication. Staff A then revealed nightshift nurses will make a list of residents needing the medication and pass it on to day shift for MOM and so forth. Staff A then revealed that nightwatch generally gives the suppositories. Staff A then revealed nursing should be reporting to the physician if medications given to promote bowel movement are not effective. Staff A then revealed she was unsure on the facility policy, but if medications are being given, and not effective then they need to be followed up with the physician. Interview on 1/7/25 at 10:00 AM with Staff B LPN revealed she would check the bowel movement book, and if a resident had not had a bowel movement in 3 days she would give a suppository if they had an order. Staff B then revealed that a new bowel protocol took effect about two weeks ago. Staff B then revealed the bowel protocol was changed to get all staff on the same page and run reports. Staff B then elaborated revealing nightshift nurses run a report and make out a list of residents needing to have a bowel movement. Staff B then revealed that if residents are day 3 without a bowel movement then an assessment should be completed, and the physician should be called. Staff B revealed she has listened to the abdomen of residents, and can't recall charting a bowel assessment. Staff B further revealed she had seen residents get to day five without having a bowel movement. Staff B further revealed that by day four of a resident not having a bowel movement she would reach out to the physician, but by then she stated she would have given the prn suppository if they had an order for it. Staff B then revealed that she would document notification to the physician if it was completed in the EHR. Interview on 1/7/25 at 10:20 AM with Staff C Director of Nursing (DON) revealed that the bowel movement protocol was changed after she had found a discrepancy with a resident not having bowel movements. Staff C then revealed that she noticed on a report that Resident #1 hadn't had a bowel movement. Staff C then revealed she was also notified by an outside worker via email that Resident #1 hadn't had a bowel movement in quite awhile. Staff C then confirmed that eight days to not have a bowel movement was way too long. Staff C then revealed that it was in the norm for Resident #1 to go for 4 or 5 days without a bowel movement, and then have a very large bowel movement. Staff C further revealed that the bowel movement protocol is Day 2 give Prune juice/or Miralax, Day 3 give milk of magnesia, Day 4 give a suppository with an assessment, Day 5 a fleet enema is to be given and to call the physician, and complete an assessment. Interview on 1/7/25 at 11:05 AM with the Physician, Staff D, revealed he is unsure of the bowel protocol at the facility, but does know that the facility has one. The Physician confirmed that Resident #1 had a lot of medical issues such as rectocele, slow transit constipation, intellectual disabilities, and was non-verbal. The Physician then confirmed that Resident #1 had not had a BM for almost 9 days, and he was not notified of this, but the facility could have notified the other on-call physician. He further revealed that there would definitely be a potential for harm after 8 days with no bowel movement but he did not think this had anything to do with the resident passing away. Interview on 1/7/25 at 11:30 AM Staff E Assistant Director of Nursing (ADON) revealed that the bowel protocol was changed on the 20th of December. Staff E then revealed that Resident #1 had not had a bowel movement for several days at the beginning of December, it was identified to them by Resident #1's Social Worker. Staff E revealed her expectation would be for the bowel protocol to be followed, and for the physician to be notified when residents have not had a bowel movement. Staff E further revealed her expectation for assessments to be completed per the bowel protocol as well. Review of a facility policy titled, Bowel Disorders Clinical Protocol, with a revised date of September 2017 revealed: 1. The nurse shall assess and document/report the following: a.Vital signs; b. Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistency, etc.); c. Change in mental status or level of consciousness; d. Presence of fecal impaction; e. Signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output); f. Abdominal assessment; g. Digital rectal examination; h. Onset, duration, frequency, severity of signs and symptoms; i. All current medications; j. All active diagnoses; and k. Recent labs.

Based on electronic health record (EHR) review, resident interview, staff interviews and facility policy review the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of a resident and/or resident representative to allow developing the care plan and making decisions about his or her care to 1 of 5 residents reviewed (Resident #6). The facility reported a census of 66 residents. Finding include: The Minimum Data Set (MDS) assessment for Resident #5 dated 5/13/24 documented a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. On 6/10/24 at 1:25 PM Resident #5 stated she had not been to a care plan meeting. Resident #5 stated her Power Of Attorney had not been invited either. Review of EHR titled, AZH Multidisciplinary Care Conference V1.0 revealed the last care conference was completed 2/8/24. On 6/11/24 at 11:51 AM Staff I stated normally she was on top of care conferences meetings, but had doubled the census at the facility in the last month. Staff I stated she spoke with the MDS coordinator about how to get caught back up and they had developed a plan. Staff I stated care conferences should be completed at least quarterly every 90 days with resident and/or resident representatives allowed to participate. Staff I stated Resident #5 was due for a care conference. Staff I stated Resident #5's care conference should have been completed in May but was not. On 6/11/24 at 12:22 PM the DON stated the facility's expectation was care conferences would have been completed with the resident and/or resident representative every 90 days. Review of Policy titled, Care Planning - Interdisciplinary Team revised 3/22 documented that comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. The IDT was to include but was not limited to the resident and/or the resident's representative.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to maintain Activities of Daily Living (ADLs) by failing to provide restorative aid for 1 of 1 resident reviewed (#46). The facility reported a census of 66 residents. Findings include: The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated severely impaired cognition. It revealed the resident required supervision or touching assistance with eating; moderate assistance with oral hygiene, toileting hygiene, and upper body dressing; and maximal assistance with bathing, lower body dressing, and putting on and removing footwear. The quarterly MDS assessment dated [DATE] indicated the resident still had a BIMS score of 0 out of 15. It revealed the resident required supervision or touching assistance with eating; maximal assistance with lower body dressing; and was dependent with all other aspects of ADLs. On 6/11/24 at 12:56 PM, Resident #46 observed having difficulty eating lunch in the dining room. The Electronic Health Record (EHR) included a restorative therapy progress note that revealed the resident not able to participate in restorative therapy due to a lack of available staff to help him ambulate. On 6/12/24 at 9:36 AM, Staff A, Certified Nursing Assistant (CNA) stated the resident required a second staff member to assist with ambulation by following the resident with a wheelchair. She stated Staff B, CNA used to assist but hasn't been available due to a change in residents' shower schedules. She stated resident restorative therapy is documented in the resident's EHR. A document titled Restorative list indicated the resident was to be walked to the dining room for one (1) meal. On 6/12/24 at 9:49 AM, Staff C, Physical Therapy Assistant (PTA) stated the resident discharged from Occupational Therapy on 4/01/24 and from Physical Therapy (PT) on 4/02/24. A document titled Therapy to Nursing Restorative Nursing Program Communication dated 4/02/24 directed staff to ambulate the resident 60 - 90 feet. Staff C stated staff was to ambulate the resident to the dining room for one (1) meal every day. On 6/12/24 at 10:02 AM, Staff D, CNA stated resident walking would be documented under 150 feet walking task in the EHR. The Review of the 150-feet walking task list indicated the resident was ambulated 11 times since 4/03/24 and 3 times between 5/01/24 and 5/31/24. On 6/12/24 at 10:51 AM, the Director of Nursing (DON) stated the resident would sometimes refuse to allow anyone to ambulate him. She also stated if the resident had been ambulated, it would appear in the response section of the 150-feet walking task report. She stated a not applicable response indicated the task was not done. A policy titled Restorative Nursing Services revised 7/2017 revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. It indicated residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care and included restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. On 6/13/23 at 7:32 AM, the DON stated the staff should have documented the resident's refusal to participate in restorative therapy.

Based on clinical record review, resident interview, staff interviews, and policy review, the facility failed to document an administered medication into the resident's medical record for 1 of 1 resident reviewed (Resident # 53). The facility reported a census of 66 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Diabetes Mellitus, hypertension, anxiety, and depression. It also indicated the resident had not vomited during the 7-day look-back period. On 6/10/24 at 3:12 PM, Resident #53 stated she was sent to the hospital on 4/15/24 due to a Urinary Tract Infection (UTI) and Clostridium Difficile (C-Diff) infection. The Electronic Health Record (EHR) Progress Notes dated 4/15/24 at 11:43 PM revealed the resident complained of nausea at 6:00 PM and had emesis at 7:00 PM. It also revealed the resident was sent to the Emergency Department (ED). The Care Plan included a history of Gastroesophageal Reflux Disease (GERD). The EHR included orders for the resident to take one (1) 4 milligram (mg) Ondansetron tablet by mouth every six (6) hours as needed for nausea. On 6/12/24 at 8:03 AM, Staff G, Licensed Practical Nurse (LPN) stated she was told during shift report the resident complained of not feeling well all day and the resident already received medication for nausea. On 6/12/24 at 8:22 AM, Staff H, Registered Nurse (RN) stated she didn't remember the resident complaining during her shift. She stated as-needed (PRN) medications are usually documented on the Medication Administration Record (MAR) accompanied by a progress note that would include attempted, non-pharmacological interventions. The MAR lacked documented administration of Ondansetron medication on 4/15/24. The hospital medical record indicated the resident admitted she received Zofran at 7:00 PM. A document titled Administering Medications revised 4/2019 directed staff to initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. On 6/13/24 at 7:32 AM, the DON stated Staff G contacted her and stated that she gave the resident Zofran shortly after 6:00 PM when the resident complained of nausea. The DON stated the staff should have documented the medication administration.

Based on clinical record review, resident interview, observation, staff interview, and policy review the facility failed to implement appropriate infection control practices to prevent cross contamination by failing to perform hand hygiene during resident care. The facility reported a census of 66 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Diabetes Mellitus, anxiety, depression, and the need for assistance with personal care. It also revealed the resident required set-up assistance with eating; moderate assistance with oral hygiene; maximal assistance with upper body dressing and personal hygiene; and was dependent with toileting hygiene, bathing, lower body dressing, and putting on and removing footwear. The Care Plan initiated 5/16/24 revealed the resident was dependent on two staff assistance with toileting. It also directed staff to provide pericare after each incontinent episode and observe enhanced barrier precautions for infection control. On 6/10/24 at 3:12 PM, Resident #53 stated she was sent to the hospital on 4/15/24 due to a Urinary Tract Infection (UTI) and Clostridium Difficile (C-Diff) infection. On 6/12/24 at 10:45 AM, Staff E, Certified Nurse Aide (CNA) and Staff F, CNA performed incontinence care for Resident #53. An observation of the incontinence care revealed the resident was sitting on the bedside commode with her pants and disposable brief pulled down to her mid-thigh level and a blanket covered her lower abdomen and mid-thighs. Staff E, CNA already had gloves on and removed the blanket and repositioned the resident's pants and briefs. Staff F, CNA raised the resident with an E-Z stand transfer device. Staff E, CNA took a hygiene wipe and wiped the resident from behind and used a front-to-back method to perform urinary incontinence care. No hand hygiene was performed while she performed the resident's incontinence care. A policy titled Standard Precautions revised 10/2022 indicated hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water and directed staff to perform hand-hygiene after contact with items in the resident's room. It also indicated gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another. On 6/13/24 at 7:32 AM, the Director of Nursing (DON) stated the staff should not have touched anything else after gloving their hands.

Based on clinical record review, observation, staff interviews, facility investigative file review, and policy review the facility failed to treat 1 of 3 residents with dignity and respect (Resident #1). The facility reported a census 36 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool with a reference date of 1/25/24 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he did not refuse care during the review period and had the following diagnoses: atrial fibrillation, heart failure, fracture of first lumbar vertebra, malignant neoplasm of kidney and a stroke. The Care Plan focus area with an initiated date of 1/18/24 documented Resident #1 had increased risks for actual/potential limitation(s) in his ability to perform his activities of daily living (ADLs) and had impaired balance. The Care Plan documented he required assistance of two staff with a walker and gait belt. During an observation on 3/1/24 at 12:00 PM observed Resident #1 in his wheelchair in his room. The bedside table placed in front of him and the resident eating his lunch. The Progress Notes documented the following: a) On 2/2/24 at 3:04 PM facility attempted to contact Power of Attorney (POA) multiple times since this morning regarding an allegation. b) On 2/2/24 at 3:58 PM Resident #1's wife called the facility back and spoke to the Administrator regarding the incident this morning. The facility provided the following summary: a) On 2/2/24 at appropriately 8:20 AM Resident #1 asked Staff C Certified Nursing (CNA) if she had heard the nurse this morning and did not understand why she was acting that way. Staff C told the resident she did hear that they were speaking loud but did not hear the conversation. Staff A then immediately reported this information to the Administrator and the Social Worker then interviewed Resident #1. b) Per interview with Resident #1 he stated the nurse Staff A Licensed Practical Nurse (LPN) and Staff B CNA came in his room this morning before breakfast (approximately 6:45 AM) and the nurse told him he had to go to the dining room. He told the nurse he did not want to go to the dining room and the nurse told him he had to go anyway, that his wife said he had to go. The nurse and the CNA then picked him up from under his arms and threw him in his wheelchair without his permission, then took him to the dining room. c) On 2/2/24 Resident #1's POA was notified. During the phone call with the Administrator, she stated she hoped what she told Staff A to do did not cause the incident. She stated she told Staff A that she wanted Resident #1 to go to all meals and if he says no he needs to go anyway. She felt that with him going to all meals, it will help him get stronger and enable him to return to home sooner. At this time, the Administrator educated the POA regarding resident rights and let her know the facility will do everything they could to encourage and provide education for Resident #1 to come to meals. Resident #1 does have the right to refuse and the facility will honor his wishes. The POA voiced that she understood. d) Per interview with Staff A, she reported that Staff B came and told her that Resident #1 did not want to go to the dining room. She then went to Resident #1's room with Staff B and told the resident per his wife, he had to go to the all meals regardless of what he says. The resident again said he did not want to go to the dining room. Staff A and Staff B then assisted him under his arms and transferred him to his wheelchair from the recliner. e) Per interview with Staff B, she reported that she was in with Resident #1 and he stated he did not want to go to the dining room. She then went and notified Staff A that he did not want to go to the dining room. Staff A then told Staff B that he has to go to the dining room and asked Staff B to come help her assist him to his wheelchair. They both went to Resident #1's room and the nurse told him that his wife wanted him to come home so he had to go to the dining room. The nurse then put the foot stool down on his recliner and put her arm under the resident's right arm. Staff A was adamant that the resident transfer to the wheelchair so Staff B went to assist with the transfer and she knew the resident was an assist of two staff, if she did not help the resident would fall. Staff B put her arm under his left arm and they both stood the resident up but he sat back down in his recliner. They stood him up again and pivot transferred him from his recliner to wheelchair with the wheelchair right next to his recliner. On 3/1/24 at 9:26 AM observed resident lying in his bed. When asked if anyone had ever been mean or unkind to him, he stated no. Resident #1 could not recall if staff had ever made him get up and go to the dining room when he did not want to. He fell asleep during the interview, the interview concluded at that time. On 3/1/24 at 10:22 AM Staff C stated Staff B told her she had asked Resident #1 if he wanted to go to the dining room for breakfast and he stated he did not. Staff C told her to go talk to Staff A to see what to do. Staff C continued to assist other residents to the dining, as she walked passed Resident #1's room she heard an argument and raised voices. She carried on with what she was doing because there was a nurse and CNA in there. After she took another resident to the dining room, she informed the Administrator that she heard an argument and loud voices coming from Resident #1's room while Staff A and Staff B were in his room. She was not sure what was said but it sounded like Staff A because she was normally loud. She added she did not know if the resident could not hear Staff A talking or if she was trying to encourage him to go the dining room. After this happened, Resident #1 had his call light on, her and Staff D went in to assist him to the restroom. While they were assisting him Resident #1 stated he did not know who that lady was or why she had to be that way. Staff C asked if he wanted to talk to the Administrator or Director of Nursing (DON) and he did, so she went and got the Administrator. Staff C stated it's not her job to make someone leave their room. She had heard Staff A act this way with other residents but was unsure if she was trying to encourage them to go or if she was doing it because she's the nurse and she made the residents go to the dining room anyway. Staff A had mentioned before she likes to see all the residents while they eat so they don't choke on their food. On 3/1/24 at 10:32 AM Staff D stated after breakfast Resident #1 needed to go to the bathroom. He looked at her and Staff C and asked if there was something wrong with her and wanted to talk to someone. When asked who, she assumed Staff A, she was the only one on that hall at that time. Staff C got the Administrator for him. When asked if Resident #1 would normally refuse to get up for meals, she stated he would, he was not a morning person. Staff A was big on everyone going to the dining room for their meals so she could supervise them while they ate and how much they ate. When asked if it was appropriate to force a resident to go to the dining room for a meal when they do not want to, she stated no. On 3/1/24 at 12:32 PM the Administrator stated Staff C came to her about an incident. She had the Social Worker and Regional Nurse Consultant complete the interviews. They did end up terminating Staff A's employment because she did not follow the facility's resident rights policy when Resident #1 did not want to go to breakfast. She added it was the choice of Resident #1 on what he wants to do. On 3/1/24 at 12:55 PM the Social Worker stated she talked with Resident #1 about the incident after Staff C reported he was upset. He explained he did not want to go down to the dining room for breakfast. The nurse told him he had to go down there, that his wife wanted him to go, he needed to go and he made him go down to the dining room for breakfast. She told the Administrator and the nurse consultant what had happened and they started their investigation. The Social Worked indicated it was his right to go to the dining room for breakfast or refuse. She stated if that was the case, staff are to encourage the resident to get up and go down for meal but they are not to be forced. On 3/1/24 at 2:29 PM Staff B stated Resident #1 was in his recliner and when asked if he wanted to go to breakfast he stated no. When she told Staff A that he did not want to go down to the dining room for breakfast she told Staff B no, he has to go down. Staff B told Staff A again, he did not want to go down. Staff A started to go in to his room when she told Staff B she needed to help her transfer him. She followed Staff A in there and she stated you have to go down to the dining room, your wife wants you to, then they started to argue. When asked what was said, she could not recall but knew he clearly did not want to go. Staff A told him again that his wife wants him to go and wants him home so you have to go to the dining room. Staff A then linked arms with Resident #1 and asked if Staff B was going to help. Staff B stated she only helped because she did not want him to fall. Staff B linked arms with him and they assisted him to stand but he sat back down in the recliner. Staff B indicated she unlinked her arm from the resident's arm and Staff A stated ok we are going to do this again. Staff B linked her arm with the resident's arm, stood the resident up to pivot transfer him to his wheelchair. She indicated they transferred him as safely as they could, then she took him down to the dining room. As she took him to the dining room, Staff B stated she apologized to Resident #1 because what they did was stupid. When asked if the resident said anything while they tried to transfer him, he called them a bunch of idiots. When asked why she did not speak up for the resident before they transferred him she stated because had she done that, it would have made the situation with Staff A ten times worse. Staff A has an attitude that it is her way or the highway. On 3/1/24 at 2:47 PM Staff A stated Staff B indicated Resident #1 did not want to go to breakfast. His wife had asked Staff A to make sure he got up and did not stay in his room, so he could get stronger; she was consistent on pushing him to get better. She told Resident #1 his wife wanted him to go to the dining room, he had fallen and she was worried about him being along in his room. She went to get him into his wheelchair anyway and he told her again he did not want to go to breakfast. Staff B assisted with the transfer to his wheelchair and took him to breakfast. When asked if it was his right to refuse breakfast and or getting up for the day, she stated it is to a certain point but Staff A indicated she did not want him left alone since he was on neurological checks due to a recent fall. He had no safety awareness, he would just get up on his own and attempt to go. From a safety stand point, she wanted him to go to breakfast where staff could supervisor him. Staff A acknowledged she is kind of pushy but not in a mean manner. The facility's Resident Rights Policy stated employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a) a dignified existence, b) be treated with respect, kindness and dignity, c) exercise his or her rights as a resident of the facility, d) be supported by the facility in exercising his or her rights. 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on clinical record review, staff interviews and policy review the facility failed to follow 1 of 5 resident's (Resident #1) care plan during transfers. The facility reported a census of 36 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool with a reference date of 1/25/24 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he did not refuse care during the review period and had the following diagnoses: atrial fibrillation, heart failure, fracture of first lumbar vertebra, malignant neoplasm of kidney and a stroke. The Care Plan focus area with an initiated date of 1/18/24 documented Resident #1 had increased risks for actual/potential limitation(s) in his ability to perform his activities of daily living (ADLs) and had impaired balance. The Care Plan documented he required assistance of two staff with a walker and gait belt. On 3/1/24 at 2:29 PM Staff B Certified Nursing Assistant (CNA) stated on 2/2/24 her and Staff A Licensed Practical Nurse (LPN) each stood on Resident #1's sides, linked their arms under his, stood him and assisted with a pivot transfer from his recliner to his wheelchair. When asked how Resident #1 usually transferred, she stated with two staff, walker and a gait belt. When asked if they had a gait belt during this transfer, she stated they did not. She added Staff A did not grab one when she went in to his room to transfer him but there should have been one in his room for them use. On 3/1/24 at 2:47 PM Staff A stated when her and Staff B transferred Resident #1 on 2/2/24 from his recliner to his wheelchair they did not use a gait belt. She acknowledged it was their mistake to not use the gait belt but they were rushing. She added things just happen when you are working and the hall he lived on was busy. On 3/1/24 at 12:44 PM the Regional Nurse Consultant stated they completed education to staff because they did not use the gait belt when they transferred Resident #1. The facility's Care Plans, Comprehensive Person-Centered policy with a revision date of March 2022 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. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons.

Based on clinical record review, facility records, hospital records, staff, family, and physician interviews, and facility policy review the facility failed to have a nurse assess 1 of 3 residents (Resident #1) after two Certified Nursing Assistants (CNA) reported the resident had experienced a change in condition. On [DATE] two CNAs reported to the nurse at about 6:30PM-7:00 PM they noted her oxygen saturation was 63% on room air, blood pressure (BP) was ,d+[DATE], they rechecked it and it was ,d+[DATE]. When the nurse on duty was notified she told the CNAs to put oxygen on her via oxygen concentrator at 2 liters (L). The CNAs rechecked Resident #1's oxygen saturation 20 minutes later and it was 92% but the resident seemed confused, not very aware and appeared to be in pain. The CNAs reported their concerns to the nurse again but she did not seem worried or concerned. The CNAs checked on Resident #1 around 8:00 PM-8:30 PM and her oxygen saturation went back down to 72%. The nurse told them to turn her oxygen up to 3L. They did that and reported the resident's vitals never got better than that for the rest of their shift. When the overnight nurse came on shift at 10:00 PM, the CNAs reported their concerns about Resident #1 and that she needed to go to the hospital. The oncoming nurse agreed and the resident was sent to the emergency room (ER) at approximately 10:30 PM, 4 hours after staff first reported her change in condition. The resident passed away on [DATE] at the hospital with a cause of death documented as congestive heart failure. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety. The State Agency informed the facility of the IJ that began as of [DATE] on [DATE] at 12:09 PM. The immediacy was removed on [DATE] at 5:03 PM when the facility submitted an acceptable removal plan. The facility's removal plan documented the following actions: 1. Resident was discharged on [DATE]. 2. Will educate nurses in regards to assessments and interventions. 3. Will educated CNAs to report to another nurse in the facility or notify on call nurse if they feel the resident's change in condition is not appropriately addressed. 4. Facility will review progress notes in order to identify change in condition and implemented interventions were appropriate. 5. Director of Nursing (DON)/Designee will review any change in condition 3 days per week for one month then weekly for one month. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 39 residents. Findings include: The annual Minimum Data Set (MDS) with a reference date of [DATE] documented Resident #1 required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, and personal hygiene. She also required limited assistance of one staff for walking in her room and in the facility while using a walker or wheelchair. The quarterly MDS with a reference date of [DATE] documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 out of 15 suggested no cognitive impairment. The following diagnoses were documented for Resident #1: hypertensive heart failure, coronary artery disease, anxiety, depression, history of falling, urine retention, and thrombocytopenia. The Care Plan focus area with an initiation date of [DATE] documented Resident #1 was on an anti-coagulant therapy to manage her diagnosis of atrial fibrillation. Staff were encouraged to observe, document, report as needed (PRN) any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. The Progress Notes documented the following for Resident #1: -On [DATE] at 10:12 PM follow-up from a fall today. This nurse checked on her after receiving report at 10:00 PM. Resident #1 would moan when she was asked questions, would not open her eyes. This nurse noticed increased edema in her feet and hands. Vital signs as follows: temperature 97.7 F, pulse ,d+[DATE] beats per minute (BMP), respirations 20, blood pressure (BP) ,d+[DATE] and oxygen saturation 94% on 3L of oxygen. Oxygen saturation would go back down in low 70's when they would take off the oxygen. The nurse on call was notified at 10:15 PM and the resident was sent to the ER to be evaluated and treated. Resident #1 left the facility by ambulance at 10:30 PM. Her family was notified and would like updates when received. This progress note was documented by Staff A Licensed Practical Nurse (LPN). -On [DATE] at 4:11 AM this nurse called to get an update on Resident #1. The hospital staff stated her head scans were clear, was admitted for respiratory acidosis and is currently on BiPAP (machine to provide different air pressure levels for inhalation and exhalation). Review of Resident #1's [DATE] Treatment Administration Record (TAR) revealed she had an as needed (PRN) oxygen order at 2 liters via nasal cannula for signs and symptoms of hypoxia with a start date of [DATE]. The Clinical Report from theER on [DATE] documented the following: -On [DATE] at 10:34 PM Resident #1 arrived to the ER by ambulance. She fell earlier today, on warfarin (blood thinner) and start noted she was having altered mental status, hypoxia (low oxygen), low blood pressure. Resident obtunded (diminished responsiveness to stimuli) since this afternoon. She required oxygen, normally does not require it and not responsive to questions. Her son reported he saw her around 1:00 PM and was able to verbalize about the fall and what happened. Tonight, she is unable to verbalize what happened. -Physical exam: she is obtunded, appears uncomfortable, pale, dehydrated and appears elderly. Respiratory distress, decreased breath sounds, wheezing is present. -Clinical impression: acute mental status change with lethargy, respiratory acidosis, hypercapnia (carbon dioxide build up in bloodstream), hypoxia, and fall. -Resident was admitted to the medical/surgical unit. The History and Physical with a date of service of [DATE] documented the following: -Past medical history of chronic heart failure, atrial fibrillation, anticoagulated use, presenting with altered mental status and hypoxia from the nursing home after a fall. The nursing home stated that she fell today and did not do neurological checks on the resident. The night nurse noticed that she was not acting right. The family would like a do not resuscitate (DNR) do not intubate (DNI) status, no transferring, would like fluids but no lines or tubes. Resident does not use oxygen a home. -Physical exam: mild wheezing on the left side, +4 pitting edema to extremities -Assessment/Plan: acute hypoxic respiratory failure. Resident has been on 10L high flow oxygen with current oxygen saturation of 99%, on diuretics and does have +4 pitting edema so this likely chronic heart failure exacerbation. Review of the Certificate of Death with a date filed of [DATE] documented Resident #1 expired on [DATE] at 8:12 PM with an immediate cause of death documented as congestive heart failure. Review of the nurse communication reports revealed no report found for [DATE] from Staff B Licensed Practical Nurse (LPN). Staff A LPN documented on [DATE] at 2:15 AM Resident #1 sent to the ER at 10:30 PM due to low blood pressure, pulse, oxygen saturation, and unresponsive. Resident did have a fall earlier in the day. The resident admitted for respiratory acidosis and x-ray pending to check for chronic heart failure. On [DATE] at 8:24 PM Staff A documented resident passed away. Review of clinical and facility records revealed the facility could not locate the CNA assignment sheet and vitals sheets for [DATE]. On [DATE] at 11:29 AM Staff D CNA stated she worked the evening shift on [DATE] with Resident #1. She stated they were doing vital signs on her every 2 hours because of a fall that occurred earlier in the shift. At about 6:30 PM-7:00 PM she noted her oxygen saturation was 63%, blood pressure was ,d+[DATE] and when she checked it again it was ,d+[DATE]. She stated when she told Staff B Licensed Practical Nurse (LPN) about the resident's vitals, the nurse told her to put oxygen on at 2L. Roughly ,d+[DATE] minutes later Staff D rechecked the resident's oxygen saturation and it went up to 92%. Staff D stated while attempting to talk to the resident to see how she was doing, she was confused, not aware and complained of being in pain. She stated she used the Hoyer lift with Staff C to get her to bed. Staff D again told Staff B her concerns but she did not seem worried or concerned, and just said ok. Staff D stated her and the other aide continued to check on her more frequently, and that was their own choice to do that. At about 8:00 PM-8:30 PM the residents oxygen saturation was at 72% and when they told Staff B, she told them to turn her oxygen up to 3L. The residents vital signs did not get better nor did they get worse. When the overnight nurse came in, Staff D pulled her aside, told her what was going on and that she needed to go to the hospital. Staff A told her she would send her out right away. Staff A sent the resident to the hospital 4 hours after they let Staff B know of her decline. On [DATE] at 12:17 PM Resident #1's emergency contact #1 stated when he visited with his mom that afternoon she was fine. She was sitting in her chair and talked about her fall. The staff came to get her for lunch and he said his goodbyes. He added that was the last time he talked to her. On [DATE] at 2:46 PM Staff B denied being told any concerns about Resident #1 from the CNAs that evening. When asked if anyone reported Resident #1's BP being low on [DATE], she said no. When asked if anyone reported her oxygen saturations being low she said no, then said maybe they did. She stated staff had put the resident in bed that night and her saturation was low so she told them to put her as needed (PRN) order of oxygen on. Staff B indicated about 20 minutes after she advised staff to put her oxygen on she went to check on the resident and her levels were about 94%. Staff B stated the resident passed away at the hospital that night and she was not sure why. At 10:00 PM she told the oncoming nurse, Staff A, she should send the resident to the hospital but was sent out about 1:00 AM because she was unconscious. On [DATE] at 4:01 PM Staff C CNA stated she came in to work at 6:00 PM on [DATE] and when she went in to Resident #1's room she was not her normal self. Staff C stated Resident #1 usually would call Staff C by her name, talk about her kids but she could not tell her own name or Staff C's name and it was just not normal conversation. At about 6:30 PM-6:45 PM Staff C stated the resident's oxygen saturation was alarming, not sure on the number but remembered it was less than 90% as she sat in her wheelchair. Resident #1 did not have oxygen on at that time but when they told Staff B about her oxygen saturation she told her to put it on, so they did. Staff C stated roughly 45 minutes later she went back in to Resident #1's room and her oxygen saturation was a bit better, not good and was still alarming. The resident continued to not be herself. She wanted to lay in bed when normally she would want to talk about her day, ask to change the television and eat a snack. She stated she used the Hoyer lift with Staff D to put the resident in bed so it would be easier to check on her. She was very tired and out of it. About an hour after they put her oxygen supplement on they checked her again; she was not responding, they would say her name, she would say huh and not answer. They continued to check on her until the overnight nurse came on at 10:00 PM and sent the resident to the ER. When they told Staff B about their concerns, she indicated she assessed her and she was fine. Her and the other CNA were assisting other residents so she was unsure if Staff B actually went in to assess Resident #1. Staff B reported she was fine and awake but when her and Staff D went back in the resident's room she was still not responding. She felt Staff B could have done more. Staff C stated she documented her vitals on her CNA assignment sheet that they give to the DON to have on file. On [DATE] at 7:02 PM Staff A stated she worked on [DATE] from 6:00 PM until 6:00 AM on [DATE]. She stated she was working in the building the day Resident #1 had a decline. She was working on the other side of the building from 6:00 PM-10:00 PM and at 10:00 PM she went to get report from Staff B so she could go home. Staff B stated the resident had fallen earlier in the day was lying in bed and was out of it. Staff B stated earlier in the shift her blood pressure and pulse bottomed out and her oxygen was really low. Staff B reported the resident was now on oxygen because her oxygen saturation dropped to 60% after supper and was doing fine. After Staff A completed report she went straight to Resident #1's room to do an assessment. The resident would not open her eyes or wake up, just moaned, her oxygen saturation was ,d+[DATE]% and her blood pressure was ,d+[DATE]. The evening shift CNAs also reported to her the resident's blood pressure and oxygen was low. As soon as she heard that information in report she knew the resident was not ok and that is why she went down to her room right away. Resident #1 was sent to theER on 10:30 PM. Staff A stated based on what information was given to her during report and what the CNAs reported to her, the resident should have been sent out sooner. On [DATE] at 10:30 AM the Director of Nursing (DON) stated Staff A called her on the night of [DATE] and informed her she was sending the resident to the ER. When asked what was going on Staff A told her the resident had edema in her feet, her oxygen saturations were low and she wanted to send her for evaluation. The next day the DON called to get an update and the hospital informed her the resident was on BiPAP, and waiting for family to arrive. She learned later that Resident #1 had passed away. When asked if she spoke to the CNAs that worked the evening she stated she only spoke to Staff A. The DON was informed of what the CNAs had observed from 6:00 PM until 10:00 PM on [DATE] and she denied being aware of the events that took place. She indicated it was normal for Resident #1 to have edema to her feet. The DON was informed the CNAs felt Staff B did not do enough for the resident, she stated if the resident had a decline a total assessment should have been completed. The DON stated the physician should have been notified and they would go from there but she was not aware the resident had experienced a change in condition at that time. The DON felt their facility had open lines of communication and has had staff members text her with issues. The DON stated Staff B never said anything to her and she was unsure how to dispute the concerns if she did not know what was going on. She denied receiving information about Resident #1's low oxygen, low pulse and low blood pressure. She acknowledged there would have been another nurse in the building at that time that the CNAs could have reported their concerns to. The DON was notified of the missing CNA assignment and vital sheet from [DATE]. She was unsure why that particular sheet was missing. On [DATE] at 1:47 PM when asked the Medical Director if a resident experienced confusion and disorientation if that would require a call to the physician, he stated that would be a significant change in condition that would require a call to the physician. The facility's Change in a Resident's Condition or Status Policy with revised date of February 2021 documented the following policy statement: out facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician on call when there has been a(an): a. Accident or incident involving the resident d. Significant change in the resident's physical/emotional/mental condition Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications will be made with in twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on clinical record review, staff interviews, family interview, physician interview, and facility policy review the facility failed to notify 1 of 3 resident's (Resident #2) family member of a fall. The facility also failed to notify 1 of 3 resident's (Resident #2) physician when Resident #2 fell and experienced 5 out of 10 pain to her shoulder. The facility reported a census of 39 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) with a reference date of 8/16/23 documented Resident #2 required limited assistance of one person for dressing, toilet use and supervision with set up help only for transfers. The quarterly MDS with a reference date of 11/16/23 documented Resident #2 had a Brief Interview of Mental Status (MDS) score of 9. A BIMS score of 9 out of 15 suggested mild cognitive impairment. The MDS documented she utilized a walker and wheelchair. The following diagnoses were listed for Resident #2: myasthenia gravis without exacerbation, renal failure, stroke, dementia, anxiety, depression, and insomnia. The Care Plan focus area with an initiation date of 5/12/23 documented Resident #2 had increased risk for actual/potential limitation in her ability to perform her activities of daily living (ADLs) due to confusion and impaired balance. The care plan documented she required assistance of one staff for toileting, assistance of two staff with a walker and gait belt for ambulation and transfers. The Care Plan focus area with an initiation date of 5/12/23 documented Resident #2 had an actual fall with no injury due to poor balance and unsteady gait. Interventions documented two staff to assist her with transfers and ambulation, with a walker and gait belt and staff not to leave her unattended in the bathroom. The following Progress Note documented on 12/30/23 at 2:23 PM: staff assisted Resident #2 back to her recliner from the bathroom, when she lost balance and fell . Resident did have a gait belt on, active range of motion completed without difficulty. She did complain of left shoulder pain, no temperature change, color change or other signs and symptoms of a fracture noted. Tylenol and ice pack applied for discomfort. Family updated. The facility Incident Report dated 12/30/23 on 2:11 PM documented the resident lost her balance and fell while returning from using the bathroom; she fell after breakfast at 8:18 AM. Resident #2 had a pain rating of 5 out of 10 at her right shoulder (front). Staff E Licensed Practical Nurse (LPN) documented she notified the resident's physician, Power of Attorney (POA) on 12/30/23 at 2:22 PM and a family member on 12/31/23 at 1:39 PM. On 1/3/24 at 12:42 PM Resident #2's POA stated on the day her mother fell the facility did not contact her until 7:19 PM that evening. Resident #2's other daughter, whom is not an emergency contact, called the facility about 9:00 AM that morning to let them know she would be picking up the resident for a family visit. The nurse on the phone stated she was just getting ready to call her about the resident's fall and that she had some shoulder pain with no injuries observed. The facility called the POA at 7:19 PM to let her know they were sending her to the emergency room to get x-rays of her arms because the resident could not move them. On 1/4/24 at 10:21 AM Resident #2's daughter stated she called on a Saturday morning about 9:00 AM to let staff know she would be picking up the resident for their family Christmas and lunch about 11:30 AM-12:30 PM. The nurse she spoke to stated she was about to call her to let her know the resident fell that morning. The daughter stated she is not on the contact list and was not her POA. On 1/4/24 at 10:30 AM the physician's nurse stated the fall took place on a Saturday so she would need to see who was on call that day. During a follow-up phone call at 2:20 PM the nurse stated she was able to speak with the on-call doctor from that day. He told her after looking through his phone he got a call after midnight on 12/30/23 that lasted 30 seconds. He was unable to recall the nature of the call but did remember seeing the resident when she went to the ER. On 1/4/23 at 1:09 PM Staff E stated there was a call at the nurse's station and it was Resident #2's family letting them know they were going to take her out for a family Christmas around 11:30 AM. While she had the family member on the phone she let them know she had fallen, complained of shoulder pain but no signs and symptoms of an injury, just had the pain. Staff E stated she thought she was talking to the resident's POA, she could not remember the name of Resident #2's POA. The resident was given Tylenol for discomfort, even after that was given she was still complaining of pain so she had staff put an ice pack on the area. Staff E stated since the resident did not have a major injury she put in a facsimile (fax) to the resident's physician. When asked if the resident had a pain rating of 5, as documented, should the physician have been called Staff E acknowledged he should have been called. She should have called her physician to let them know. On 1/9/24 at 2:08 PM the Director of Nursing (DON) stated when notified of Resident #2's fall, the nurse told her she goofed up when the family called to tell them they were taking the resident out for a family outing. The nurse reported she told that family member of the fall and learned it was not the POA. The DON acknowledged the nurse should have called the physician when the resident reported pain of 5 out of 10 after her fall. The facility's Assessing Falls and Their Causes policy with a revision date of March 2018 documented the purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying the causes of the fall. Staff are to notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. When a fall does not result in a significant injury or change in condition, notify the practitioner routinely (by fax or phone). Staff are to notify the following individuals when a resident falls: a. The resident's family. b. The attending physician.

Based on clinical record review, staff and physician interviews the facility failed to ensure competent staff members increased 1 of 3 resident's (Resident #1) supplemental oxygen as directed by the nurse. The facility reported a census of 39 residents. Findings include: The annual Minimum Data Set (MDS) with a reference date of 4/6/23 documented Resident #1 required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, and personal hygiene. She also required limited assistance of one staff for walking in her room and in the facility while using a walker or wheelchair. The quarterly MDS with a reference date of 10/12/23 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 out of 15 suggested no cognitive impairment. The following diagnoses were documented for Resident #1: hypertensive heart failure, coronary artery disease, anxiety, depression, history of falling, urine retention, and thrombocytopenia. The Care Plan focus area with an initiation date of 6/13/22 documented Resident #1 was on an anti-coagulant therapy to manage her diagnosis of atrial fibrillation. Staff were encouraged to observe, document, report as needed (PRN) any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of Resident #1's November 2023 Treatment Administration Record (TAR) revealed she had an as needed (PRN) oxygen order at 2 liters via nasal cannula for signs and symptoms of hypoxia with a start date of 6/3/22. The following Progress Note was documented for Resident #1: -On 11/27/23 at 10:12 PM follow-up from a fall today. This nurse checked on her after receiving report at 10:00 PM. Resident #1 would moan when she was asked questions, would not open her eyes. This nurse noticed increased edema in her feet and hands. Vital signs as follows: temperature 97.7 F, pulse 50-53 beats per minute (BMP), respirations 20, blood pressure (BP) 90/40 and oxygen saturation 94% on 3L of oxygen. Oxygen saturation would go back down in low 70's when they would take off the oxygen. The nurse on call was notified at 10:15 PM and the resident was sent to the ER to be evaluated and treated. Resident #1 left the facility by ambulance at 10:30 PM. Her family was notified and would like updates when received. This progress note was documented by Staff A Licensed Practical Nurse (LPN). On 1/2/24 at 11:29 AM Staff D CNA stated she worked the evening shift on 11/27/23 with Resident #1. She stated they were doing vital signs on her every 2 hours because of a fall that occurred earlier in the shift. At about 6:30 PM-7:00 PM she noted her oxygen saturation was 63%, blood pressure was 79/39 and when she checked it again it was 88/68. When she told Staff B Licensed Practical Nurse (LPN) about the resident's vitals, she told her to put her oxygen on at 2L. Roughly 20-30 minutes later Staff D rechecked the resident's oxygen saturation and it went up to 92%. While attempting to talk to the resident to see how she was doing, she was confused, not aware and complained of being in pain. Her and Staff C used the hoyer lift to get her to bed. Staff D again told Staff B her concerns but she did not seem worried or concerned, just said ok. Staff D stated her and the other aide continued to check on her more frequently, that was their own choice to do that. At about 8:00 PM-8:30 PM her oxygen saturation was at 72% and when they told Staff B, she told them to turn her oxygen up to 3L. Staff D stated she was unsure if it was within her scope of practice to change the oxygen level on the resident's concentrator if there was no order. On 1/2/24 at 2:46 PM Staff B was asked if anyone reported her oxygen saturations being low she said no, then said maybe they did. Staff had put the resident in bed that night and her saturation was low so she told them to put her as needed (PRN) order of oxygen on. When asked if CNAs are allowed to adjust a resident's oxygen level higher than what is ordered she stated no. On 1/2/24 at 4:01 PM Staff C CNA stated she came in to work at 6:00 PM on 11/27/23. When she went in to Resident #1's room she was not her normal self because usually Resident #1 would call Staff C by her name, and talk about her kids but she could not tell her own name or Staff C's name; just not normal conversation. At about 6:30 PM-6:45 PM Staff C stated the resident's oxygen saturation was alarming, not sure on the number but remembered it was less than 90% as she sat in her wheelchair. Resident #1 did not have oxygen on at that time but when they told Staff B about her oxygen saturation she told her to put it on, so they did. On 1/2/24 at 7:02 PM Staff A stated she does not let the CNAs adjust the oxygen levels on a concentrator while a resident is utilizing it. She also stated she would not allow the CNAs to adjust the oxygen level higher than what is ordered. On 1/4/24 at 1:09 PM Staff E LPN stated CNAs cannot apply a resident's as needed (PRN) oxygen. She added oxygen is like a medication, they can change out the oxygen tank but they can't bump the level up to 3 liters if the order reads for 2 liters. On 1/9/24 at 1:47 PM when asked the Medical Director if a CNA was able to increase a resident's supplement oxygen level or if a nurse was to do that, he stated he believed that was a nurse's doing. On 1/9/24 at 2:08 PM the Director of Nursing (DON) stated she thought it would be the nurse's responsibility for the nurse to increase a resident's supplemental oxygen.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop a baseline care plan related to smoking for 1 (Resident #198) of 3 residents reviewed for accidents. Findings included: A review of the facility policy [Facility Name] Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 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. Review of Resident #198's Admission Record revealed the facility admitted Resident #198 with diagnoses that included acute respiratory failure, chronic obstructive pulmonary disease (COPD), and nicotine dependence disorder. A review of Resident #198's Smoking and Safety Evaluation, dated 03/21/2023 revealed the resident used tobacco products and smoked cigarettes, was not on a smoking cessation plan, and was not interested in quitting smoking. The evaluation revealed the resident was a safe smoker, knew how to safely dispose of their tobacco products in the proper receptacle, and agreed to the smoking rules of the facility. The facility deemed the resident able to smoke safely with a safe smoking service/care plan and the use of a smoking apron. A review of Resident #198's care plan, revealed there was no documented evidence the facility developed a safe smoking care plan with measurable goals, objectives, and interventions to address Resident #198's current use of tobacco products. During an interview on 03/28/2023 at 8:53 AM, Resident #198 stated the nurse did a safe smoking assessment when they admitted to the facility and informed the resident where and when they could smoke. Resident #198 stated they wore a smoking apron while smoking and a staff member was always close by. Resident #198 stated their smokes were kept at the nurse's station. The surveyor observed Resident #198 request a cigarette and lighter and a staff member accompanied the resident outside for a smoke break. On 03/28/2023 at 9:03 AM, Resident #198 was observed in the designated smoking area with two staff members present. The resident wore a smoking apron and staff provided assistance for the resident when requested. During an interview with the Social Service Director (SSD) on 03/29/2023 at 2:35 PM, she stated care plans covered everything about the resident and were completed by her, Registered Nurse (RN) #1, the Minimum Data Set (MDS) Coordinator, and the Dietary Manager. The SSD stated care plan objectives were added in the admission care plan meeting. According to the SSD, smoking should be covered in the care plan; however, she was unable to find a care plan that addressed smoking for Resident #198. The SSD stated she was not sure why it was missing because the resident had a safe smoking evaluation completed within 24 hours of admission to the facility. During an interview on 03/29/2023 at 2:43 PM, RN #1 stated a resident's care plan was initiated upon admission and included the resident's daily living needs, fall risk, safety measures, and care objectives for the certified nursing assistants. RN #1 stated smoking also should be included on the resident's care plan. Per RN #1, she completed Resident #198's admission and completed the resident's safe smoking assessment. RN #1 stated she could not find a smoking care plan for Resident #198 and had overlooked updating the resident's baseline care plan for smoking. During an interview with the MDS Coordinator on 03/29/2023 at 3:02 PM, she stated RN # 1 completed the resident's baseline care plan upon admission to the facility and worked with the SSD and Dietary Manager to create the care plan. The MDS Coordinator stated a safe smoking evaluation would be completed for residents who wished to smoke and would be included in the communication notes which she reviewed and used to develop the care plan. The MDS Coordinator explained that she reviewed the resident's medical record and communication notes to develop a care plan, but missed the notes about the resident smoking. During an interview on 03/28/2023 at 3:27 PM, the Director of Nursing (DON) stated development of the resident's care plan started upon admission and was ongoing through the resident's stay. The DON stated smoking should be added to the resident's care plan right away. Per the DON, Resident #198's desire to smoke was communicated to all departments and should have been added to the resident's care plan. During an interview with the Administrator on 03/28/2023 at 3:44 PM, she stated she expected to be able to read the resident's care plan and know who the resident was. She stated smoking should be added to a resident's care plan as soon as the facility knew the resident smoked. According to the Administrator, Resident #198 admitted to the facility during the evening hours and the resident's safe smoking evaluation was completed the following morning. The Administrator stated Resident #198's desire to smoke was communicated to all departments and should have been added to the resident's care plan.

Based on record review, interviews, and facility policy review, the facility failed to develop a comprehensive care plan for the care and treatment of an indwelling urinary catheter for 1 (Resident #98) of 2 residents reviewed for indwelling urinary catheters. Findings included: A review of the facility policy [Facility Name] Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, 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 policy indicated, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR [Preadmission Screening and Resident Review] recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and c. reflects currently recognized standards of practice for problem areas and conditions. A review of the Admission Record revealed the facility admitted Resident #98 with diagnoses that included urinary tract infection, retention of urine, and benign prostatic hypertrophy (BPH) with lower urinary tract symptoms. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #98 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #98 required limited assistance with toilet use and had an indwelling catheter. A review of Resident #98's care plan initiated 03/10/2023, revealed the resident had limitations in their ability to perform activities of daily living. The care plan interventions indicated the resident had an indwelling urinary catheter in place. There care plan did not include measurable objectives or the care and treatment of the resident's indwelling urinary catheter. In an interview on 03/29/2023 at 9:58 AM, Licensed Practical Nurse #2 (LPN) stated the MDS Coordinator was responsible for care planning the indwelling urinary catheter for Resident #98. LPN #2 reviewed Resident #98's care plan and stated she did not see the resident's catheter stated as a problem on the care plan with interventions to change, provide care, or prevent infections. During an interview on 03/29/2023 at 11:41 AM, the Director of Nursing stated the MDS nurse was responsible for care planning the catheter. In an interview on 03/30/2023 at 8:38 AM, the MDS Coordinator stated she typically care planned indwelling urinary catheters for residents. The MDS Coordinator added that she could not say why Resident #98's catheter had not been addressed on the resident's care plan. During an interview on 03/30/2023 at 9:20 AM, the Administrator stated she expected the care plan to reflect the resident and it should be clear enough to guide the direct care staff on how to care for the residents.

Based on observations, interviews, and review of the facility policy, the facility failed to obtain a physician's order and provide treatment to pressure ulcers for 1 (Resident #25) of 2 residents reviewed for pressure ulcer/injury. Findings included: The facility's policy titled, [Facility Name] Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018 indicated, 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment as needed; c. Resident's mobility status; d. Current treatments including support surfaces; and e. All active diagnoses. The facility's policy, titled [Facility Name] Wound Care revised October 2010, indicated the facility should 1. Verify that there is a physician's order for this procedure. The policy specified, The following information may be recorded in the resident's medical record: 1. The type of wound care given. The date and time the wound care was given. The position in which the resident was placed. The name and title of the individual performing the wound care. Any changes in the resident's condition. All assessment data obtained when inspecting the wound. How the resident tolerated the procedure. Any problems or complaints made by the resident related to the procedure. If the resident refused the treatment and the reason(s) why. The signature and title of the person recording the data. A review of the Admission Record revealed the facility admitted Resident #25 with diagnoses that included fracture of the right humerus (large bone in the arm), malnutrition, osteoarthritis, and bladder cancer. A review of Resident #25's Weekly Skin Check dated 01/16/2023, indicated the resident had a right elbow abrasion that measured 1.7 centimeters (cm) length by (x) 1.6 cm width and bruising to the right shoulder and right elbow. A review of Resident #25's care plan initiated 01/18/2023, revealed the resident had limitations with activities of daily living due to limited range of motion, trauma, and pain in their right arm/shoulder due to a right arm fracture. The care plan interventions indicated the resident had a sling/brace to their right arm/shoulder that was to always remain on and the staff could remove the sling/brace during bathing, dressing, and skin assessments. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene and was totally dependent on staff for bathing. Per the MDS, Resident #25 was at risk of developing pressure ulcers/injuries, had moisture associated skin damage, but no unhealed pressure ulcers/injuries. A review of Resident #25's Skin Alteration Evaluation dated 02/15/2023 indicated on 02/13/2023, Resident #25 was identified to have a stage III right upper and lower elbow pressure ulcer. The upper elbow pressure ulcer measured 1 cm length x 1 cm width. The lower elbow pressure ulcer measured 2 cm length x 2 cm width. The evaluation revealed, Stage III pressure related ulcers noted to left elbow, originally reported on 2-13-2023. Upper area is moist with intact covering of thick, yellow slough. Edges are dark pink with moderate amount of serous drainage noted. Surrounding tissue is pink and intact without excessive warmth or streaking noted. No odor noted or reported. Lower area is moist with intact covering of thick, yellow slough. Copious amount of serosanguinous drainage noted. Surrounding tissue is pink and intact without excessive warmth or streaking noted. No odor noted or reported. The evaluation further revealed the areas were gently cleaned and a protective dressing applied. Review of Resident #25's Skin Alteration Evaluation dated 02/25/2023, indicated the resident had a right heel pressure ulcer that measured 2.1 cm length x 1.4 cm width with non-blanchable erythema. Per the evaluation, there was no stage identified for the right heel pressure ulcer. The staff documented a chemical debriding agent, and a padded dressing was applied, and the staff notified the primary care physician for orders. A review of Resident #25's Treatment Administration Record (TAR) for February 2023 revealed collagen and a silicon padded dressing was applied to the resident's right elbow every three days from 02/17/2023 to 02/23/2023. The TAR indicated a chemical debriding agent, fluff and a padded dressing was applied to the resident's right elbow on 02/24/2023 - 02/27/2023. Per the TAR, a chemical debriding agent was applied and secured with a silicone bordered form dressing to the resident's right elbow on 02/28/2023. A review of Resident #25's TAR for March 2023 revealed a chemical debriding agent was applied to the resident's right heel on 03/02/2023 - 03/27/2023 and to the right elbow twice a day 03/01/2023 - 03/27/2023. During an observation on 03/29/2023 at 9:25 AM, the Assistant Director of Nursing (ADON)/Treatment Nurse provided wound care for Resident #25 and no concerns were identified. Per the ADON/Treatment Nurse, the resident's right upper elbow pressure ulcer measured 0.3 cm length x 0.2 cm width; the right heal wound measured 0.8 cm length x 0.6 cm width x 0.2 cm depth, and the right lower elbow wound had healed. During an interview on 03/29/2023 at 9:49 AM, Certified Nursing Assistant (CNA) #3 stated she removed Resident #25's splint/brace for bathing and dressing and stated when in bed, the resident's heels were propped up and pillows were used for positioning. CNA #3 added when the resident sat in a recliner, the resident's heels hung over the end of the recliner's footrest. In an interview on 03/29/2023 at 10:13 AM, Licensed Practical Nurse (LPN) #2 stated on admission Resident #25 had an abrasion on their right elbow. LPN #2 added the resident's right elbow continued to receive pressure due to Resident #25 leaning to their right side. She stated since admission, pillows were used to help position the resident. LPN #2 stated the facility had standing orders for treating abrasions, which included the use of a topical antibiotic ointment (TAO) and a band-aid. She stated any treatment provided to a resident's wound would be captured on the resident's TAR. LPN #2 stated the initial treatment for a wound was expected to start the day the wound was identified. LPN #2 stated Resident #25 had been in the facility about a week when she saw the abrasion and initiated the treatment of TAO and a band-aid. LPN #2 stated the treatment should have started when the abrasion was first seen, the treatment order should have been added to the TAR, and nurses should have signed the treatment when completed. She reviewed the January 2023 TAR and acknowledged she did not see a treatment for the skin abrasion. LPN #2 stated she was the nurse that discovered the wound on Resident #25's right heel and described the area as a stage II pressure ulcer. Per LPN #2, she started a treatment of a chemical debriding agent and fluffed gauze with a padded dressing, but did not write the order on the TAR until the physician responded on 03/02/2023. The Director of Nursing (DON) was interviewed on 03/29/2023 at 11:53 AM. The DON stated she expected all skin alterations to include abrasions, skin tears, and pressure ulcers to be reported to the physician and treatment started immediately. The DON confirmed the resident was found to have an abrasion on 01/16/2023. The DON reviewed the resident's February 2023 TAR and stated it was unacceptable to wait days before a treatment began. In a telephone interview on 03/29/2023 at 1:25 PM, the Medical Director stated he had assessed Resident #25 on 02/23/2023 and ordered a chemical debriding agent to be used on the resident's wounds. During a telephone interview on 03/29/2023 at 1:41 PM, LPN #4 stated she was the nurse that completed the resident's weekly skin check on 02/13/2023 and identified an open area on Resident #25's right elbow. LPN #4 stated at the time the area was discovered, it was approximately one inch from the pointed part of the elbow, was about pea sized, and looked like an abrasion. The LPN stated she notified the Assistant Director of Nursing (ADON) and thought the ADON had assessed the area and started treatment the same day. LPN #4 stated the ADON would have been responsible for entering a treatment order and documenting the completion of the treatment. The ADON/Treatment Nurse was interviewed on 03/29/2023 at 2:41 PM. The ADON confirmed Resident #25 was admitted with an abrasion on their right elbow. She stated if an abrasion was dry, no treatment was needed. If an abrasion was moist, standing orders would be used as a treatment. The ADON added that weekly skin alteration evaluations were not completed for abrasions. The ADON stated if other treatment orders were received, the person who received the order would enter the order on the resident's TAR. The ADON stated she recalled LPN #4 reported the area to Resident #25's right elbow on 02/13/2023 to her. The ADON stated she assessed the area on 02/13/2023, but did not document her assessment because she thought the nurse who found the wound had documented an assessment. The ADON stated she started a treatment of collagen and a padded, silicone bordered dressing on Resident #25's right elbow but was unable to answer why she had not documented the treatment. The ADON stated she found out she had been staging wounds incorrectly on 03/29/2023 from the regional nurse consultant and now she knew if a wound was covered with slough, the wound was unstageable, not stage III. Furthermore, the ADON reviewed the February TAR for Resident #25 and stated she could not answer why she had waited two days after the wound was identified to obtain a treatment order from the physician. She confirmed no treatment was provided for the resident's right elbow wounds until 02/17/2023, four days after the wounds were identified. The ADON reviewed the February 2023 and March 2023 TARs and acknowledged there was no documentation that treatment was provided to the resident's right heel until 03/02/2023, five days after the wound was identified. The ADON had no explanation for the lack of treatment. In an interview on 03/30/2023 at 9:23 AM, the Administrator stated she expected pressure ulcers to be identified early, notification given to the physician and resident representative, and the treatment started as soon as possible. During an interview on 03/30/2023 at 10:20 AM, CNA #5 stated when she bathed Resident #25, the resident's sling was removed from the resident's right arm. In a follow-up interview with the DON on 03/30/2023 at 10:40 AM, she stated staff nurses only described wounds and did not stage wounds. The DON stated on 02/15/2023, the ADON applied a dressing to the resident's elbow, but did not document the provision of the treatment in the resident's medical record. In an interview with Resident #25 on 03/30/2023 at 10:55 AM, the resident confirmed staff removed the sling (splint/brace) on the right arm for baths and showers. Resident #25 stated pillows had been used since admission to elevate their heels off the bed. The resident did not know the reason for the development of the pressure ulcer to their right heel. The surveyor observed a sling in place on Resident #25's right elbow that rested on a soft, foam surface. The resident's heels were off-loaded on a pillow.

Based on clinical record review, staff interviews, clinic staff interview, and ARNP (Advanced Registered Nurse Practitioner) interview, the facility failed to assure staff completed a complete and thorough physical assessment with a timely identification of a change of condition which required transfer to the local emergency room (ER) for 1 of 2 residents reviewed (Resident #200). The facility failed to complete a thorough physical assessment with an identified change of condition or notify the physician until the resident transferred to the localER on [DATE] at 7:55 PM. Once in the ER, Resident #200 required intubation (tube placement to maintain open airway) and air lift transfer to a Level III hospital (intensive care or trauma hospital, requiring mechanical ventilation). Resident #200 died in transit to the Level III hospital on [DATE] at 11:18 PM, less than 4 hours after being transferred from the facility. The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) assessment tool dated [DATE], identified Resident # 200 as able to make herself understood and as able to understand others. Resident # 200 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident's cognition, mood and behaviors were not assessed. Resident # 200 required the assistance of 2 staff with bed mobility and transfers and the assistance of 1 staff with dressing, toilet use and personal hygiene. The resident did not walk. The resident's Care Plan, revised on [DATE], identified she required special precautions related to possible COVID-19 exposure. The Care Plan included the following interventions: a. Appropriate PPE (personal protective equipment) would be worn by staff providing both indirect and direct care per the facility, CDC (Centers for Disease Control), and CMS (Centers for Medicare and Medicaid Services) guidance; refer to signage as needed b. Lab or testing (as) ordered with results to the physician. c. Monitor for signs and symptoms of COVID-19 including fever, cough, shortness of breath, sore throat, etc. Notify the provider if signs and symptoms are observed. d. Report worsening signs/symptoms of infection or lack of improvement from treatment and promptly report any of the following: trouble breathing, oxygen saturation of less than 90%, persistent pain or pressure in the chest, new confusion or inability to arouse, blush lips or face. The resident's Care Plan, revised on [DATE], identified she had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 200's Progress Notes revealed the following information: a. A Health Status Note (HSN) dated [DATE] at 7:24 AM recorded the resident's temperature during the night measured 100.9 degrees Fahrenheit (F). Staff performed a COVID-19 test and she tested positive. Staff transferred the resident to the COVID-19 wing, to isolate her per the facility protocol. The resident presented with a decline prior to bed and staff assisted her with the use of the sit-to-stand lift (a mechanical lift device) due to complaints of increased body pain. Staff placed oxygen on the resident due to a decline in her oxygen levels and inability to maintain an oxygen level greater than 90% on room air. b. The HSN dated [DATE] at 10:47 PM documented staff updated Resident # 200's responsible party on the resident's condition. c. An HSN dated [DATE] at 7:23 PM documented Resident # 200 continued on room air, without the use of oxygen and her oxygen saturations measured 95%. She denied pain or discomfort. d. An HSN dated [DATE] at 1:44 PM recorded Resident # 200 received infusion treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] e. A Weekly Medicare Note (late entry) dated [DATE] at 10:28 AM recorded the resident's therapy services were on hold due to the resident being in the red zone, testing positive for COVID-19. f. The Interdisciplinary Team Note of [DATE] at 4:57 PM documented staff updated the resident's responsible party that due to the rise in COVID-10 cases, Resident # 200 would be moved to a different room. Staff informed the responsible party the resident did not have an elevated temperature. g. The HSN dated [DATE] at 6:54 PM recorded staff notified the residents' responsible party the resident displayed confusion, wore oxygen on and was eating. h. The Communication with Family note of [DATE] at 7:33 PM documented staff updated the resident's responsible party of the resident's condition. i. The Communication with Family note of [DATE] 3:13 PM recorded staff updated the resident's responsible party of her condition. j. A HSN dated [DATE] at 4:04 AM documented Resident # 200 yelled out in her sleep most of the shift. Staff placed pressure relieving devices and assisted the resident to reposition every 2 hours and as needed with cares. The resident's head of bed was elevated and she received oxygen at 2 liters per nasal cannula. Staff documented the resident's lung sounds as clear with decreased breath sounds in the bases. The resident had an occasional dry, non-productive cough without shortness of breath or difficulty breathing noted or reported. The resident had no signs or symptoms or complaints of discomfort. Staff offered fluids and encouraged them frequently. Staff would continue to monitor. k. The HSN dated [DATE] 1:53 PM recorded staff notified the resident's responsible party with an update. Resident # 200 wore continuous oxygen, displayed confusion, and had no cough or congestion. l. The HSN of [DATE] at 9:52 AM documented staff provided the resident with a drink and Tylenol for her temperature m. The HSN dated [DATE] at 7:52 PM documented that at 7:15 PM, staff notified the local ER of the resident's condition and reported the had been unresponsive since after breakfast. The on-call doctor suggested an ER visit for evaluation. Staff notified the resident's responsible party at 7:25 PM of the resident's condition and transfer to the local ER. The resident left the facility at 7:55 PM. Resident # 200's condition remained the same, she was not talking or responding to a change of position. The resident's food intake showed 50% at breakfast and 50 cubic centimeter (cc, liquid measurement) consumption of fluids. The resident had no intake of fluids or food after breakfast. n. The HSN dated [DATE] at 10:38 PM recorded staff received call from the local ER. Resident # 200 required intubation and life flight to a Level III hospital. o. The HSN On [DATE] at 1:36 AM documented notice at 12:30 AM, by the Level III hospital ER staff, that Resident # 200 passed away in transit. The resident's COVID Surveillance Expanded form dated [DATE] at 9:02 AM recorded the following: Vitals, GI (gastrointestinal): a. New or worsening nausea or vomiting - No. b. New or worsening diarrhea - No. c. New or increased cough - No. d. Signs and symptoms or verbalization of increased or new onset of fatigue or malaise - Yes. e. Reported loss of taste or smell - No. Vital signs: a. Most recent temperature - 100.7 F (normal ,d+[DATE]) on [DATE] at 7:18 AM. b. Most recent oxygen saturations - 95% on room air (normal 90% or higher) on [DATE] at 7:18 AM. The resident's Episodic COVID Positive form dated [DATE] at 9:07 AM recorded the following: Vitals, GI: a. Nausea or vomiting - No. b. Diarrhea - No. c. Physician contacted - Not applicable (NA). d. Cough - No. e. Lung sounds - Wheezes. f. Cough present or abnormal lung sounds, Provider notified - Left blank. g. New orders - No new orders. h. Reported loss of taste or smell - No. i. Decreased oral intake - Present. j. Monitor for signs of dehydration - Blank, no response. k. Physician contacted - Blank, no response. l. Activities of daily living decline - Yes Vitals: a. Most recent temperature - 100.7 F on [DATE] at 7:18 AM. b. Most recent oxygen saturation - 95% room air on [DATE] at 7:18 AM. c. Respirations - 18 breaths per minute. d. Pulse - 68 beats per minute. e. Blood pressure - ,d+[DATE]. The typed statement from Staff H, RN (Registered Nurse) dated [DATE] recorded that Staff H confirmed worked the COVID Red Zone on [DATE] with Resident # 200. Staff H stated at approximately 10:30 or 11:00 AM, she was informed Resident # 200 ran a temperature and received Tylenol that had been effective; her temperature was normal. Staff H stated that later, the Certified Nurse's Aide (CNA) reported Resident # 200 did not want to wake up for lunch and did not verbally respond. Staff H stated this was unusual behavior for Resident #200 and she went to the resident. Staff H noted the resident to be less responsive than normal but the resident took a few sips of water. Staff H stated she talked to the resident in an attempt to get her to wake up to eat. Staff H stated allowed the resident to rest and attempted several times to wake up her to eat, however, the resident would only take a small sip of water. Staff H stated staff monitored Resident #200 throughout the afternoon, repositioned her often, and the resident accepted a small sip of water. Staff H stated by supper, the resident did not take a sip of water, but her eyes moved underneath her eye lids. Staff H stated the ER was notified due to the resident being less responsive throughout the afternoon. Staff H stated documentation in the resident's clinical record stated she was unresponsive since breakfast, however, the documentation was incorrect. Staff H stated the resident was less responsive, not her normal self, and that should have been how she described the situation. Staff H confirmed she had documented the resident consumed no water or food after breakfast and that was also incorrect. Staff H stated Resident # 200 took a small sip of water off and on throughout the afternoon. The resident became less responsive at supper and could not take a sip of water. Staff H stated she notified ER and the on-call physician thought the resident should be elevated in the ER. The clinical record lacked a complete and through physical assessment, including vital signs after 9:15 AM on [DATE]. The clinical record lacked any communication with the resident's primary care provider prior to the resident being transferred to the local ER at 7:55 PM. Resident # 200's Emergency Medical Services (EMS) Prehospital Care Report dated [DATE] identified: Primary impression: Altered Mental Status Narrative: the local EMS called to the facility for a resident who had been unresponsive since noon. The facility staff stated the resident was normal in the morning and by noon, stopped responding to stimuli. The resident's vital signs measured within normal ranges. EMS staff found the resident in bed and unresponsive to voice, pain, or touch. The facility nurse provided set of vitals they had taken. The resident's blood glucose measured 185. The resident was moved to the cot after initial assessment. Resident # 200's 12-lead EKG (Electrocardiogram) appeared unremarkable. EMS follow up assessment documented no abnormal findings. In route to the ER. an assessment at 7:45 PM documented: Skin - Cold. Mental status - Unresponsive. Chest/lungs - Breath sounds equal. Patient condition - Chief complaint unresponsive with a duration of 8 hours. Vitals: a. 6:20 PM: BP ,d+[DATE], pulse 106, respirations 12, oxygen 96% on low concentration oxygen (,d+[DATE] liters). b. 7:52 PM - BP ,d+[DATE], pulse 108 and irregular, respirations 28, oxygen 98% on low concentration oxygen. c. 8:05 PM - Pulse 104 and irregular, respirations 24, oxygen 94% on room air. Glasgow Coma Scale (GCS, scoring system used to describe the level of consciousness. Severe 8 or less, moderate ,d+[DATE], and mild ,d+[DATE]). a. 6:20 PM - Score 3. No eye movement when assessed, no motor response, and no verbal/vocal response. b. 7:52 PM - Score 3. c. 8:05 PM - Score 3. The resident's Clinical Report - Physicians/Mid-Levels Emergency Department dated [DATE] at 8:09 PM documented the resident's chief complaint as decreased mental status. The resident was found unresponsive, it started today and continued. The resident presented from the nursing home where she had been in the isolation wing being COVID-19 positive [DATE]. The nursing facility reported the resident awake and alert at breakfast and that she ate. At lunch, her blood sugar tested ok; however, the resident did not respond and was allowed to sleep. The resident could not be aroused for supper. Vitals reported at the nursing home included her temperature 99 F, BP ,d+[DATE], heart rate 106. The resident desired to be a full code (full resuscitation) and she was found unresponsive. Physical exam: a. [DATE] at 9:58 PM - BP ,d+[DATE], pulse 83, heart rate 105, respirations 26, oxygen 96%, and temperature 99.6 F. Pain scale ,d+[DATE]. b. Appearance: Not alert. c. Eyes: Pupils sluggish. d. Cardiovascular: [CONDITION(S)], abnormal rhythm (a fast irregular heart rate). e. Respiratory: Breath sounds normal. f. Skin: Warm and dry with mottled distal extremities (this develops with lack of blood flow). g. Neurological: GCS 3. Gag reflex completely absent. Lab tests: a. Sodium 146, normal ,d+[DATE] (elevated indicated dehydration). b. BUN (blood urea [MEDICATION(S)]) 96, normal ,d+[DATE] (elevated indicated dehydration). c. Creatinine 3.6, normal 0.,d+[DATE] (elevated indicated dehydration). d. WBC (white blood count) 21.6 (elevated indicated infection and/or inflammation). The Clinical Report documented a Course of Care: The resident arrived GCS 3, non-responsive. Intravenous line established pre-hospital, with fluids given. Labs sent, chest X-ray without significant finding, and CT scan (computerized tomography) of the head obtained. Upon return from the CT, the resident was intubated due to no gag reflex and unable to protect her airway. The resident was intubated and sedated and the provider documented seeking intensive care transfer placement. The resident transferred to another hospital with a clinical impression of acute mental status change with coma, acute renal failure, and COVID-19. The resident's emergency room Clinical Report for Nurses dated [DATE] documented Resident # 200 arrived at 8:11 PM with unresponsive as the chief complaint. The resident was COVID-19 positive since [DATE] and required oxygen at 2 liters per nasal cannula. The nursing home reported the resident as fine in the morning; she ate breakfast and talked with staff. At lunch the resident appeared more lethargic and did not respond. The nursing home called ER to report the resident as unresponsive to painful stimuli and verbal stimuli which started after lunch. The nursing facility staff reported they waited to call as the resident's vital signs stayed intact. Upon arrival, Resident # 200 was unresponsive to verbal and painful stimuli, did not follow commands, and had sluggish pupils and no gag reflex. The Nurses Clinical Report documented a GCS of 3; eyes not open, no verbal response, and no motor response. The resident's vital signs at [DATE] at 10:58 PM measured her BP ,d+[DATE], pulse 83, heart rate 105, respiratory rate 26, oxygen saturation 96%, temperature 99.6 F and pain scale ,d+[DATE]. The resident was unresponsive with decreased awareness (she did not open her eyes to pain). The resident did not respond verbally. The resident's right pupil was sluggish reactive and left pupil sluggishly reactive. Resident # 200 had mild respiratory distress and decreased breath sounds in the both bases of her lungs. Her cardiac rhythm showed [MEDICATION(S)] [CONDITION(S)] and [CONDITION(S)] (an abnormal heart rhythm). The resident's abdomen felt soft, her skin showed peripheral cyanosis and appeared pale, warm, and dry. Nursing Progress Notes documented the following actions: a. At 8:11 PM - Oxygen administered by nasal cannula at 2 liters. b. At 8:16 PM - Started IV (intravenous) fluids, normal saline, at 1000 milliliters (ml)/hour (hr). c. At 8:18 PM - EKG (electrocardiogram) performed. d. At 8:22 PM - Portable chest x-ray performed. e. At 8:28 PM - EKG performed. f. At 8:38 PM - Resident # 200 transported to the CT by the stretcher with the IV in place. g. At 8:50 PM - The resident returned from the CT scan. h. At 8:55 PM - ER staff intubated the resident by anesthesia. i. At 9:11 PM - [MEDICATION(S)] given IV (medication given to relax her muscles for intubation). j. At 9:18 PM - [MEDICATION(S)] given IV (short acting anesthesia medication). k. At 9:25 PM - [MEDICATION(S)] started IV (sedative). l. At 9:28 PM - ER staff placed a second IV site to the resident's right arm. m. At 9:30 PM - ER staff started IV fluids, normal saline, and 1000 ml/hr with the first bag of IV fluids completed. n. At 9:56 PM - A flight crew worked at the resident's bedside. At 9:56 PM, Resident # 200 transferred to a Level III hospital and with a 10:06 PM departure time. During interview on [DATE] at 9:00 AM, the Director of Nursing (DON) stated that Resident # 200 did not have a physical assessment on [DATE] prior to or upon transfer to the local hospital. The DON stated the nurse could not get into the computer charting system to complete her documentation and documented on paper. Interview on [DATE] at 1:30 PM with Staff H revealed she worked a 12 hour shift on [DATE] when Resident #200 transferred to the local hospital. Staff H stated she'd been in a panic due to not working the floor often and being in the COVID-19 unit with 12 - 14 residents to care for. Staff H received report from the night nurse that Resident #200 had an elevated temperature and received acetaminophen. Staff H stated the night nurse also gave Resident # 200 her morning medications. The CNA's (Certified Nursing Assistants) completed morning rounds and did not report any concerns. Staff H stated that at lunch the CNA's reported Resident # 200 would not wake up. Staff H had checked the resident's blood sugar earlier and the resident would not get insulin until eating her lunch as she as not eating much that day. Staff H stated the resident groaned out during this time and did not verbally respond. When lunch arrived, the CNA's reported the resident did not wake up to eat and was sound asleep. Staff H stated that all the nursing staff went in and out of the resident's room [ROOM NUMBER] - 4 times within 45 minutes to an hour and attempted to assist the resident to eat. The resident was never alert enough to eat, but took sips of water. The CNA's reported the resident slept during position changes and did not voice any complaints. Staff H stated she checked the resident's oxygen saturations and temperature a couple of times throughout day and they measured normal. Resident # 200 had oxygen on throughout the day. Staff H stated that at supper, she explained to the resident that she needed to wake up. The resident appeared less responsive and could not drink through a straw. The resident's primary physician clinic was closed and Staff H notified the ER physician, receiving an order to send Resident # 200 to the ER. Staff H stated the resident had not been unresponsive, but less responsive. Staff H stated the resident took sips of water until suppertime and her oxygen saturations never went below the 90's. Staff H confirmed no documented vital signs for Resident # 200 after completion of the morning COVID-19 assessment. Staff H stated she felt overwhelmed working on the floor and wrote a statement the resident was less responsive, not unresponsive. Staff H did not remember completing a transfer sheet when the resident transferred to the ER and stated she should have. During interview on [DATE] at 1:45 PM the DON stated if a resident had a change in condition, she expected a full assessment to be completed. If a resident transferred out to the hospital, the DON expected resident assessment, bed hold information, detailed documentation, code sheet, medication list, and an Interact transfer form to be completed. The DON stated the transfer form would be completed when a resident transferred out to the hospital and included full assessment with current vital signs. The DON stated at times the nurse could not complete the documentation due to an emergency situation and the need to get the resident out. Interview on [DATE] at 12:20 PM with the Triage nurse at Resident # 200's Primary Care Provider (PCP) Clinic stated that per record review, facility staff had not contacted the clinic on [DATE] related to the resident's change in condition. The Triage nurse stated the resident had a Telehealth visit with the clinic's ARNP on [DATE] and they had no further documentation for Resident # 200 after that date. The Triage nurse stated when Resident # 200 arrived to theER on [DATE], the ER note documented she arrived non-responsive, intubated and was sent out to a Level III hospital. Interview on [DATE] at 1:49 PM with the DON revealed the facility did not have a policy related to a change in resident condition and/or resident transfers. During interview on [DATE] at 2:23 PM, Staff G CNA stated she worked on [DATE] beginning 2:00 PM and cared for Resident # 200. Staff G stated that upon arrival, she learned the resident ate breakfast and then was unresponsive. Staff G stated the resident took sips of water, so Staff G did not feel the resident's condition was that bad. Staff G checked the resident at 2:00 PM, the resident had been incontinent and needed to be repositioned. Staff G checked the resident's vital signs and they measured in the normal range, but did not recall if the vital signs were documented in the resident's clinical record. Staff G stated Resident # 200 drank a full glass water at 2:00 PM, however, she did not verbally respond. Staff G stated the resident continued to drink and the staff member did not think much about it. At 4:00 PM, staff repositioned the resident and provided incontinence care. The resident did not verbally respond or moan out and had no signs of pain. At 5:30 PM, Resident # 200 refused to eat supper, but would take a few sips of water. About 6:30 PM, the resident had no incontinence and felt limp with repositioning. Staff G reported to Staff H, who called the ER and sent the resident out. Staff G stated Resident # 200 had not been as responsive and did not talk or converse with staff as she had prior to COVID-19. Staff G denied the resident moaned or had any response during cares on [DATE]. During interview on [DATE] at 4:38 PM, the ARNP ER Provider stated he provided care for Resident #200 when she arrived in theER on [DATE]. The ARNP stated it would be difficult to confirm if the resident arrived in the ER sooner that her outcome would have been different. The ARNP stated Resident # 200 was absolutely unresponsive and in bad shape. The ARNP could not say how long the resident had been in her current condition. The ARNP stated Resident # 200 had lab results in the ER consistent with dehydration and that would not have occurred quickly. The ARNP stated the resident did not drink well over a period of time. The ARNP recalled being struck at how completely unresponsive the resident had been and in bad shape. The ARNP attempted to get the resident transferred out as quickly as possible due to her poor condition; she was absolutely and completely unresponsive. Upon assessment, Resident # 200 had absolutely no gag reflex and no basic reflexes, which required intubation. During interview on [DATE] at 4:47 PM, Staff I CNA stated she worked 6:00 AM - 9:00 PM on [DATE] and cared for Resident #200. Staff I stated Resident # 200 got up for breakfast, did not have lunch, had been incontinent and staff changed her every 2 hours. Staff I stated the resident's vital signs were normal. Staff G arrived for work at noon and checked the resident's vital signs and they were normal. Staff I stated the resident had water throughout the day and at lunch had a full glass of water. The resident had approximately 600 cc of water throughout the day. Staff I stated she had a conversation with Resident #200 in the morning, but by noon the resident only moaned when spoken to. Staff I stated between 12:00 and 2:00 PM the resident was more drowsy. Staff I assisted to transfer the resident to the gurney for the ambulance crew; they lifted her with a bed sheet as the resident had no response.

Based on observation and facility policy review, facility staff failed to secure medications and label outdates on high risk medications. The facility identified a census of 49 current residents. Findings include: An observation on 1/11/21 at 6:59 AM revealed Staff A, LPN (Licensed Practical Nurse) prepared medications at the cart outside Resident #199's room. Staff A left the cart unlocked and unattended in the hallway beginning at 7:12 AM. The resident's room door was closed which left the cart unable to be seen by Staff A. At 7:14 AM, Staff A returned to the unlocked cart in the hallway. An observation 1/12/22 at 1:30 PM revealed Staff D, LPN walked away from two unlocked medication carts that sat at the nurses station. Staff D entered a resident's room and the carts were out of his line of sight. At 1:34 PM, Staff D returned to the nurses station and locked the carts after the surveyor pointed them out. The facility's policy titled Storage of Medications, dated 4/19, documented under number 9 that all unlocked medication carts would not be left unattended.

Based on clinical record review, observation and staff interview, facility staff failed to provide thorough incontinence care for one (#32) of five residents reviewed. The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #32, dated 12/13/21, documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident needed the assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS identified the resident was always incontinent of urine and bowel. During an observation on 1/11/22 at 9:19 AM, Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA washed their hands and applied gloves. While Resident #32 lay in bed, Staff F and Staff G lowered her pants and tucked the Attends (an incontinence brief) down between the resident's legs. Staff F cleansed the resident's front perineal area using a new wipe or folded wipe for each swipe. Staff F and Staff G rolled resident on her right side and removed the visibly wet Attends. Staff F cleansed the resident's left buttock and hip, wiping back and forth across the area 3 times with the same side of the wipe, contaminating cleansed skin with the soiled wipe. Staff F then cleansed the resident's right buttock, wiping back and forth across the area 2 times with the same side of a wipe, and failing to cleanse the resident's right hip. Staff F removed her gloves, did not perform hand hygiene, and then applied new gloves. Staff F assisted Staff G to apply a new Attends for the resident, pulled up her pants, and covered the resident with a blanket. Staff F and Staff G removed their gloves and washed their hands. During an interview on 1/12/22 at 9:05 AM, the Director of Nursing stated the expectation to use new wipe or fold wipe and use clean side for each swipe.

Based on clinical record review, observations, staff interviews and staff competency directions, staff failed to ensure a medication error rate remained below 5%. Observations of 27 medications revealed 2 errors, resulting in an error rate of 7.4%. The facility identified a census of 49 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #199 had a Brief Interview for Mental Status (BIMS) score 0 out of 15 possible points, indicating severe cognitive impairment. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Order Summary Report dated 1/18/22 documented an order beginning 1/6/22 to administer [MEDICATION(S)] (insulin) via a flex-touch pen injector, 50 units daily in the morning. Observation on 1/11/22 at 6:59 AM showed Staff A LPN (Licensed Practical Nurse) did not prime the injector pen with two units of insulin prior to administering the resident's ordered dose of 50 units. 2. The MDS assessment dated [DATE] documented Resident #3 had a BIMS score of 13, indicating intact memory and cognition. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Order Summary Report dated 1/18/22 documented orders beginning 10/6/21 to administer [MEDICATION(S)] insulin 42 units every morning and [MEDICATION(S)] insulin per Sliding Scale before each meal and at bedtime. Observation on 1/10/22 at 10:52 AM revealed Staff A administered 8 units of [MEDICATION(S)] insulin to Resident #3 for a blood sugar of 346. Staff A did not prime the [MEDICATION(S)] pen with 2 units of insulin prior to administering the ordered 8 units. During interview on 1/12/22 at 10:15 AM, Staff E, LPN identified staff should prime an insulin pen with 2 - 3 units before administering the ordered dose to ensure no air was in the needle and the resident received an accurate dose of insulin. On 1/12/21 at 1:30 PM, the Director of Nursing (DON) stated the expectation that staff prime an insulin pen with 2 units of insulin prior to administration of the ordered dose. The DON reported that education had been provided to nurses regarding the proper administration on insulin pens. The [MEDICATION(S)] [MEDICATION(S)] Insulin Competency checklist, under point #9, instructed to dial a test dose of 2 units of insulin, hold the pen upright and tap it to bring any bubbles to the top.

Based on observations, clinical record review, and staff and family interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent hazards for 2 of 4 residents reviewed (Resident #2 and 5). On 1/31/21, staff found Resident #2 on the floor in the bathroom. Staff A took the resident to the bathroom to use the toilet. Although the resident had a history of falls, experienced cognitive and memory problems, exhibited confusion, and required staff assistance for surface-to-surface transfers, Staff A left the resident in the bathroom and alone and unsupervised on the toilet. While sitting alone, the resident fell and complained of leg, hip, back and ankle pain. Staff sent her to the emergency room for evaluation and the hospital identified the resident sustained a femoral (upper leg bone) fracture. On 2/25/21 at 10:55 PM, the resident passed away. The Death Certificate identified the immediate cause of death was frailty due to or as a consequence of a femur fracture and [CONDITION(S)]. The facility reported a census of 49 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment tool dated 11/22/19 documented Resident #2 had diagnoses that included heart failure, hypertension, [CONDITION(S)], [CONDITION(S)], history of fractured left femur, repeated falls, postural kyphosis, and abnormal posture. The MDS revealed the resident scored 12 out of 15 possible on her Brief Interview of Mental Status (BIMS) test, which indicated the resident demonstrated moderate cognitive impairment. The MDS also documented she required extensive assist of 1 staff for bed mobility, transfers, dressing, and toilet use and experienced occasional bowel and bladder incontinence. The MDS documented she had a history of falls since the last assessment. The Care Plan dated 11/28/19 identified Resident #2 as at risk for falls and required assist of 1 staff for toilet use and transfers related to a diagnosis of [CONDITION(S)]. The care plan also documented the resident experienced memory problems and episodes of confusion. The care plan lacked any documentation to indicate whether or not staff could leave the resident unsupervised while utilizing the toilet. The Fall Risk Evaluation dated 11/22/19 revealed Resident #2 scored 75, which put her at high risk for falls. The evaluation documented she had a history of falls within the last 6 months, had impaired gait, and overestimates or forgets her limits. Resident #2's Progress Notes documented the following: a. On 10/23/20 at 2:14 AM resident fell to the floor when attempting to get out of bed to go to the toilet with the bed in the low position and a mat next to her bed. Staff documented the resident has been confused and mixed up for the past couple days. b. On 11/24/20 at 9:23 AM, staff completed an MDS quarterly review and documented the resident demonstrated increased periods of confusion and hallucinations related to progression of [CONDITION(S)] per her nurse practitioner. c. On 12/29/20 at 2:14 PM, staff documented the resident as very confused with hallucinations today. The resident reported she saw her brother fall outside the dining room, could not find her mother, tried to pick up chocolate chips from the floor, and attempted to get out of her recliner independently. d. On 1/6/20 at 6:25 AM, the resident had lots of hallucinations and confusion and told staff her parents were here and also found in a seated position on the side of the bed because she needed to go help the boy in the other room. e. On 1/6/20 at 2:14 PM, the resident became confused, had hallucinations, and tried to get up independently and clean her room because she believed she could walk and she needed to clean it. f. On 1/6/20 at 7:49 PM, the resident displayed continued confusion with hallucinations. Staff found her prior to supper sitting on only 3-4 inches of the recliner foot rest because she wanted to get up to sweep the floor. Reality orientation not effective. The resident's granddaughter assisted with bedtime cares. Staff checked and noted the bed in low positron with the mat on the floor. g. On 1/9/20 at 9:54 PM, staff documented resident confused today and stated that she was checked for bed bugs today but none were found. h. On 1/15/20 at 7:00 AM, the resident reported tingling in arms and weak upper arm strength and tingling in legs and feet, with legs weak with the left leg weaker than the right. Resident stated she had to use her arms to lift her legs. The nurse documented the resident required 2 staff or a lift to assist the resident. i. On 1/29/20 at 7:00 AM, Resident #2 stated she had tingling and numbness in her upper and lower extremities with leg strength weak with the left leg weaker than the right leg. The resident reported she had to lift her left leg with her arms. Staff documented the resident did not ambulate and required 2 staff assist with gait belt or lift. j. On 1/31/20 at 3:41 PM, resident found sitting on the floor in front of the toilet in the bathroom with her right leg bent under her, sitting on the leg, left leg bent up and toward her chest with the left ankle flexed upward and outward. The resident screamed to get her up off the floor and complained of bilateral hip, back, and ankle pain and she could not straighten her legs due to the pain. Staff called 911 to send the resident to the emergency room , and sent her via gurney and emergency medical team. The Incident Report dated 1/31/20 at 3:57 PM, documented staff found the resident on the floor in her bathroom in front of the toilet. The nurse completed an assessment and Resident #2 reported bilateral hip, back, and ankle pain. Staff sent her to the emergency room for evaluation. The Incident Report also documented her mental status as forgetful with a lack of safety awareness and a diagnosis of [CONDITION(S)] which was progressing, with more frequent periods of confusion and hallucinations. The Radiology Report from the hospital dated 1/31/20 at 4:29 PM revealed Resident #2 sustained a left distal femoral fracture. The History and Physical (H&P) from the hospital dated 1/31/20 at 6:10 PM documented the Resident #2 was using the restroom, attempted to stand up, her legs felt numb and weak, and she fell forward onto her knees. The H&P described the resident as in significant pain when evaluated by the emergency medical responders and they administered 50 micrograms of [MEDICATION(S)]. The H & P revealed Resident #2 sustained a fracture of the distal left femur and subsequently admitted to the hospital for physical therapy, pain control, and anticoagulation. The H & P added the resident was not a surgical candidate related to her age and complicities. During an interview on 5/18/21 at 2:55 PM with the Director of Nursing (DON) she stated staff are not to leave residents on the toilet unassisted if there has been any change in their level of consciousness or confusion. She added that she and the nurses checked on the residents every couple of days and if there has been any changes, they will communicate it to the aides. During an interview on 5/19/21 at 10:30 AM with Staff A, she stated it was the end of her shift around 2:00 PM on 1/31/20 when she took Resident #2 to the bathroom. Staff A stated according to Resident #2's chart, staff could leave the resident on the toilet herself. Staff A stated the resident told her she needed to have a bowel movement and would be awhile. Staff A stated she told the oncoming aide that Resident #2 remained on the toilet and the aide (Staff B) responded, okay I will be there in a minute to get her. Staff A stated she clocked out and went home and added she normally would not leave Resident #2 unattended because she was usually more incoherent, but that day she was more with it. Staff A reported when she left the room, the resident her call light and her wheelchair next to her with the brakes locked. Staff A said she knows the resident should not transfer by herself but she wanted the wheelchair next to her just to be safe. During an interview on 5/19/21 at 10:55 AM with Staff B, she stated she was worked a 12-hour shift that day 1/31/20 doing showers. At 2:00 PM, she went to work as an aide on the resident's hall as scheduled. Staff B stated Staff A told her everything was fine and left. Staff B stated as she passed linens on Resident #2's hall around 3:00 PM, she found the resident on the floor in her bathroom with the bathroom door shut and immediately alerted the nurse to assess her. She reported the resident sat on the floor in front of the toilet, leaning. It was one of the reasons they were not supposed to leave her unattended on the toilet as she leaned, displayed confusion, could not transfer herself independently, and likely could not remember to use the call light. Staff B stated that she could not recall anything being on her chart saying the staff could leave her unattended; she had worked with the resident for over a year and they were never to leave her. The resident had declined a lot, saw things that were not there and showed confusion. Staff B stated she knew to never leave a resident that could not transfer themselves independently and exhibited confusion alone on the toilet. She stated it was around when she was passing linens and found the resident She added that the resident had reported so much pain that they did not transfer her from the floor prior to the time emergency personnel arrived at the building. During a follow up interview on 5/19/21 at 1:25 PM with the DON she stated there was nothing on Resident #2's care plan that directed staff to stay with Resident #2 but she expected Staff B to be with her once Staff A left for the day. She stated that she really expected everyone to be watched in the bathroom unless they are independent. She reported the care plan directed staff to remind the resident to use her call light and commented Staff A insisted she stayed in the doorway of the resident's room until she told Staff B that the resident remained in the bathroom. During an interview with a family member on 5/26/21 at 1:20 PM, she stated after Resident #2 fell and broke her hip, she went to another nursing home and passed away there. She said staff should have supervised the resident in the bathroom at all times due to her confusion. She added if Resident #2 had not fallen, she might still be alive. The State of Iowa Certificate of Death dated 2/29/20 documented Resident #2's date of death was 2/25/20 at 10:55 PM and the immediate cause of death was frailty due to or as a consequence of a femur fracture and [CONDITION(S)]. 2. The quarterly Minimum Data Set (MDS) assessment tool dated 5/4/21 documented Resident #5 had diagnoses that included [CONDITION(S)], cancer, hypertension, peripheral vascular disease, dementia and depression. The MDS revealed the resident demonstrated severe cognitive impairment. The MDS also documented he required extensive assist of 2 staff for bed mobility, transfers, ambulation (walking), dressing, and toilet use with occasional bowel incontinence and frequent bladder incontinence. The MDS revealed Resident #2 had a history of falls since the last assessment; he fell two or more times with no injury and two or more times with minor injury. The Care Plan dated 2/4/21 identified Resident #5 had a risk for falls related to dementia and directed staff to place a fall mat by the bed, apply non-skid strips to the bathroom floor, and ensure the resident wore proper footwear with (initiated 2/4/21). The care plan also contained an update on 2/16/21 that directed remove the strips and floor mat. The Fall Risk Evaluation dated 5/4/21 revealed Resident #5 scored a 17, which meant he was at risk for falling. The evaluation documented he had a history of falling 3 or more times in the past 3 months, was disoriented at all times, had a balance problem while standing, a balance problem while walking, and should wear rubber-soled shoes or non-skid slippers for ambulation (walking). Resident #5's Progress Notes documented: a. On 2/16/21 at 12:24 PM during the telehealth appointment, staff updated the physician regarding the resident's recent falls and reported the resident had been observed stepping over the non-skid strips and fall mats. He told staff he was afraid to step on them because they looked like a hole. Housekeeping team notified to remove the strips and mat, as they seem to be a contributing to the resident falling instead of trying to prevent falls. b. On 2/23/21 at 4:12 AM resident had an unwitnessed fall with injuries and sustained a gash on his right temple, right side of head behind the ear, and large skin tear to the back of his right hand. Resident seen in ER. c. On 2/25/21 at 11:02 AM resident fell while walking in the hall. d. On 2/27/21 at 2:48 PM, staff found the resident on the floor in his room between the wall and the recliner. e. On 3/3/21 at 4:04 PM, staff found the resident was found on the floor in the hallway. f. On 3/11/21 at 10:15 PM, the resident had an unwitnessed fall. g. On 3/12/21 at 7:58 PM, the resident tried to stand up, lost his balance, and fell . h. On 3/19/21 at 10:40 PM, the resident slid out of bed onto the fall mat and re-opened the skin tear on his elbow. i. On 3/28/21 at 3:38 PM, staff found the resident on the floor in his room and noted the floor wet with urine. j. On 3/30/21 at 4:47 PM, staff found the resident on the floor. k. On 4/21/21 at 7:04 PM, the resident fell to the floor in the hallway. l. On 4/22/21 at 3:20 AM, the resident lay in his low bed with a landing mat next to the bed - still on fall follow-up. m. On 4/27/21 at 10:18 PM, staff found the resident on the floor in front of the nurse's station wearing no shoes or socks with gripper tread. n. On 5/9/21 at 4:22 AM, staff found the resident on the floor in the opening of the closet in his bedroom with a skin tear to his left elbow. The resident reported he needed to use the toilet. o. On 5/11/21 at 2:31 AM and 5/13/21 at 3:07 AM, the resident had the low bed in use with landing mat next to the bed - still on fall follow-up. During an observation on 5/18/21 at 11:05 AM, Resident #5 sat in his wheelchair with staff present preparing him for a transfer to the toilet. A fall mat sat on the floor next to his bed with non-skid strips visible on the bathroom floor. During an observation on 5/25/21 at 11:25 AM, Resident #5 sat in his wheelchair right outside his room. A fall mat sat on the floor next to his bed with non-skid strips visible on the bathroom floor. During an interview with the DON on 5/25/21 at 1:55 PM, she stated they should have removed the strips and mat on 2/16/21. She added she alerted the housekeeping staff and they will remove them today.

Based on observations, record review and staff interviews, the facility failed to provide skin assessments for a resident with a high risk for the development of pressure ulcers (Resident #1). Resident #1 was transferred to the hospital for an x-ray and returned to the facility on [DATE] after identification of a fractured femur. The physician identified pressure ulcers located on the buttocks region on 2/3/2011 while the resident was hospitalized . The resident returned to the facility on [DATE] and the transfer sheet instructed the facility to assess the resident ' s skin every shift. The record revealed the staff did not check the skin every shift and did not identify the open wounds on the buttocks until 2/7/2011. An additional wound was identified on the coccyx which revealed an infection. The sample consisted of 5 residents and the facility reported a census of 69 residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment identified the resident at risk for pressure ulcers and had three Stage II pressure ulcers present on admission to the facility (2/4/11). The resident had a urinary catheter and experienced bowel incontinence. The same MDS identified the resident had short/long term memory problems with moderately impaired for decision making and required total dependence of two plus staff persons for bed mobility, transfers, and personal hygiene. physician's orders [REDACTED]. a. Complete a skin assessment every week, b. Apply SSD tube 1% cream ([MEDICATION NAME]) to the right buttock daily until healed. This was discontinued on 1/19/11, c. [MEDICATION NAME] powder, apply to groin and axilla twice daily, d. [MEDICATION NAME] 40%, apply to buttocks each shift. Review of the care plan with a team conference date of 2/10/11 identified the resident with alteration in skin integrity related to immobility. The care plan directed staff to inspect the skin with cares provided and report red/open areas, provide adequate change of position every 2 hours and PRN (as needed), provide optimum nutrition per the Registered Dietician recommendations, provide timely response to incontinence, use moisture barrier as needed, medications and treatments as ordered, podus boots to feet bilaterally (both feet), splint to left/right hand, brace to left leg, foam wedges to left leg for proper alignment. Review of the care plan for wound care dated 2/9/11 directed staff to complete the following treatments to the resident's coccyx, left buttock and right buttock; a. SSD ([MEDICATION NAME] cream) 1% fluff daily and PRN. b. [MEDICATION NAME] Bid (twice daily) and PRN. The Medicare Daily Skilled Nursing Notes from the facility dated 2/3/11 revealed the facility received orders for a transfer to the local hospital for an x-ray of the lower left extremity. The resident left the facility by ambulance at 10:10 A.M. At 10:50 A.M. the notes revealed the resident had a bad left femur fracture, at 1417 (2:17 P.M.) the hospital notified the facility, the hospital sent the resident to a hospital located in Omaha. A physical assessment dated [DATE] from the Omaha hospital documented pressure ulcers present; #1 Ulcer: 0.50 cm (centimeters) by 0.5 cm, Stage II, left ear present on admission. #2 Ulcer: 0.50 cm by 2.00 cm, Stage II, right buttock, present on admission. #3 Ulcer: 5.00 cm by 4.50 cm, Stage I, left buttock, present on admission. #4 Ulcer: Stage I pressure ulcer on nose, present on admission. The Social Worker/Case Manager Note dated 2/3/11 from the Omaha Hospital identified the patient had sores behind ears, nose, buttocks and wrist. The Nursing Facility Transfer Sheet dated 2/4/11 directed staff to apply Sensicare barrier ointment (zinc oxide) to each buttock bid (twice daily) as directed. and to turn the resident every 2 hours. The transfer sheet also directed staff to perform skin assessments every shift, overlay mattress on bed, and decubitus precautions. This direction was signed by the resident's primary care physician. The Medicare Daily Skilled Nursing Notes from the facility dated 2/4/11 at 2200 (9:00 P.M.) revealed the resident returned from the hospital and noted to have scabbed skin tear at right forearm and no other skin issues were noted, pressure relieving devices in place, and assisted to reposition with hygiene/incontinence care given every 2 hours. The assessment did not include a skin assessment of the buttocks. The Medicare Daily Skilled Nursing Notes dated 2/5/11 at 1130 (11:30 A.M.) indicated the staff turned the resident every 2 hours, pressure relieving devices in place, skilled for observation, showed no pain or discomfort, skin pale warm and dry. The assessment did not include pressure sores on the buttocks. The Medicare Daily Skilled Nursing Notes dated 2/6/11 at 2245 (10:45 P.M.) revealed the resident had a large soft BM (bowel movement) once with no note of skin integrity. The cares failed to reveal the pressure sores on the buttock. The Initial Wound Evaluation for Resident #1 dated 2/7/11 revealed Stage III acquired pressure ulcer to the right buttock which measured 6.2 cm by 3.6 cm depth less than 0.3 cm with jagged edge. The assessment also revealed a Stage III acquired pressure ulcer on the left buttock which measured 2.2 cm by 1.7 cm with depth of less than 0.3 cm. Noted at the bottom of the assessment revealed no current treatment. A nurse sent a fax to the physician. The Nursing Home Notes dated 2/8/11 by the resident's primary care physician, revealed the resident had an infected coccyx ulcer that he/she came back from the city with. The area was described as red and hot. The facility staff reported the ulcer to be hospital acquired. The Initial Wound Evaluation dated 2/8/11 revealed Stage II acquired pressure ulcer measured 1.8 cm by 1.2 cm with depth less than 0.2 cm, macerated and red, wound bed purple and beefy red. The Weekly Wound Progress Note dated 2/9/11 revealed a house Stage II pressure ulcer to coccyx which measured 2 cm by 2.1 cm with depth superficial, an acquired Stage II pressure ulcer to left buttock which measured 1.8 cm by 3.1 cm, and an acquired Stage II pressure ulcer to right buttock which measured 7.2 cm by 4.2 cm. The Weekly Wound Progress Note dated 2/16/11 revealed an in house acquired Stage III pressure ulcer to the coccyx which measured 5.8 cm by 2.2 cm with depth superficial, an acquired Stage II pressure ulcer to the left buttock measured 1 cm by 0.3 cm, an acquired Stage III pressure ulcer to the right buttock which measured 6.8 cm by 7.9 cm. Observation on 2/28/11 at 10:10 A.M. revealed the resident lying supine in bed when staff entered the room. The resident had an immobilizer in place to the left leg. No splints were noted in the resident ' s hands (per care plan) and no wedge cushion used to align the left leg (per physician's orders [REDACTED]. After cares completed, the resident placed supine (back position) with head of bed elevated. Observation at 11:00 A.M., 12 noon, and 1:00 P.M. found the resident in the supine position with head facing the window. During an interview on 2/28/11 at 8:00 P.M., the DON (Director of Nursing) stated the facility did not review or update the resident's care plan to reflect his/her care after hospitalization . During an interview on 2/28/11 at 1:40 P.M., Staff A, C.N.A. (Certified Nursing Assistant) stated on 2/2/11 in the evening, when she had the resident positioned in bed, on the right side, Staff B, LPN entered the room and completed the resident's treatments to the buttocks ([MEDICATION NAME] powder) per TAR (Treatment Administration Record). During an interview on 3/1/11 at 4:50 P.M. the resident's primary care physician stated he/she saw the resident on last rounds and stated the pressure ulcers were horrible. The physician stated the nursing staff stated the resident had returned from the hospital with the pressure sores. The physician stated the resident had a [DIAGNOSES REDACTED]. The physician also stated he/she failed to check pedal pulses and did not recall getting a report of poor pedal pulses from the nurses. The physician continued to state to prevent pressure sores, the resident needs adequate nutrition, circulation and positioning. The physician confirmed if the resident had not been repositioned then that could be the cause for the pressure ulcers. During an interview on 3/7/11 at 8:40 A.M., the DON stated the repositioning schedule would be documented by the charge nurse on the C.N.A. (Certified Nursing Assistant) assignment sheet and the C.N.A.'s are expected to follow the schedule. When the resident returned from the hospital, a skin assessment had not been performed for several days.