Every finding on record at Bettendorf Health Care Center

Based on observation, clinical record review, resident, family and staff interviews, the facility failed to answer call lights in a timely manner for 4 of 6 dependent residents reviewed (Resident #6, Resident #9, Resident #13, and Resident #14) for call lights. The facility reported a census of 56 residents. Findings included:1. The Minimum Data Set (MDS), dated [DATE] identified Resident #6 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The list of diagnoses included: cellulitis to the right and left leg and lymphedema. The MDS identified Resident #6 dependent on staff for transfers, and required substantial/maximal staff assistance for toileting and personal hygiene. Review of Resident #6's Care Plan, dated 4/16/26, revealed a Problem area to address [Name redacted, Resident #6] is incontinent of bowels and is at risk for impaired skin, rashes, irritation in the peri-area. Interventions included, in part: Keep call light within reach to use to notify using if [name redacted, Resident #6] needs to use the toilet/has an incontinence episode. During an observation and interview on 4/17/26 at 1:19 PM, Resident #6 sat up in bed, wearing a clean hospital gown and covered with blankets from waist to feet and dressings dry and intact to both feet. She reported on Sundays, she has to wait more than a few hours, sometimes up to 3 hours for staff to answer her call light. They are supposed to check and change her every 2 hours. This usually happens on night shift. She has complained about it before and nothing changes. Resident #6 also reported the staff will usually take more than 15 minutes to answer her call light and this happens at least once a week. They will come in and turn off the call light, say they'll be back and they'll never come back. During an interview on 4/23/26 at 8:46 AM, Staff I, Certified Nursing Assistant (CNA) reported Resident #6 had reported she was not getting her call lights answered in a timely manner, that staff should answer call lights within 15 minutes and that any staff member should be expected to answer a call light. 2. Review of Resident #9's MDS, dated [DATE] identified as cognitively intact with a BIMS score of 15 out of 15. The list of diagnoses included: renal insufficiency (kidney failure), diabetes mellitus and spinal stenosis. The MDS identified Resident #9 dependent on staff for toileting and transfers, and required substantial/maximal assistance with personal hygiene. During an interview on 4/17/26 at 12:52 PM, a family representative for Resident #9's reported the resident had been incontinent with urine and had to wait an hour and a half for staff to come to her room. The family representative reported the staff told Resident #9 they have other patients they have to take care of and she is not the only one. The family representative added another family member called the nurses station to let them know that Resident #9 was ready to get out of bed. There was another time where the resident waited to get into bed, turned on her call light at 8:00 PM and then waited until 11:00 PM to be assisted into bed. During an interview on 4/28/26 at 8:56 AM, Staff H, CNA reported Resident #9 complained to her that she would be left sitting up in her wheelchair until 11:00 PM waiting for help to get to bed. Staff H stated Resident #9 reported she had her call light on for 2 hours before staff helped her and it usually happened on second and third shift. Review of Resident Grievance's revealed on 4/7/26, Resident #9 submitted a Grievance. The Summary of Grievance read: [name redacted, Resident #9] stated she was not put to bed until after 11. States that she called nursing station 3 x (times) before going into the hall to yell for help. 3. Review of Resident #14's MDS, dated [DATE] identified the resident as cognitively intact with a BIMS score of 15 out of 15. The list of diagnoses included: cancer, diabetes mellitus and cerebral palsy. The MDS identified Resident #14 dependent on staff for assistance with all activities of daily living (ADL's), with the exception of eating. Review of Resident #14's Care Plan revealed a Problem area, initiated 12/15/25 to address: [Name redacted, Resident #14] has a self-care deficit as evidenced by requiring assistance with ADL's, impaired balance during transitions requiring assistance and/or walking, incontinence. Interventions included, in part: a. BED MOBILITY: 1 person assist. Date Initiated: 12/15/25. b. TOILETING: 1 person assist. Provide peri-care with every incontinent episode and as necessary. Date Initiated: 12/15/25. c. TRANSFERS: 2 person assist with hoyer (a brand name of a full body mechanical lift which has become a genericized trademark to refer to any full body mechanical lift). Date Initiated: 12/15/25. During a continuous observation that started on 4/21/26 at 9:50 AM, Resident #14 call light activated. At 9:59 AM call light remained on, with an alarm sounded. Call light activated for a total of 9 minutes. At 10:07 AM call light remained on, with an alarm sounded. Staff A, Registered Nurse and the Director of Nursing (DON) walked by the room without checking in with the Resident #14. Call light activated for a total of 17 minutes. At 10:12 AM call light remained on, with alarm sounded. The Human Resources Coordinator walked by the room without checking in with Resident #14. Call light activated for a total of 22 minutes. At 10:14 AM, call light remained on, with alarm sounded. Staff A, RN and the DON walked down the hallway of Resident #14 room and checked with a different resident. Staff A and the DON did not check in with Resident #14. Call light activated for a total of 24 minutes. At 10:15 AM, Staff D, CNA entered Resident #14's room to check on her and turned off the call light. Call light activated for a total of 25 minutes. During an interview on interview on 4/21/26 at 10:29 AM, Resident #14 the longest she had to wait to get her call light answered was 3 hours. Resident #14 stated a lot of staff have quit, and she has to wait for someone to answer her call light 3 to 4 times a week. The resident stated she always waits 2 or 3 hours, it's terrible. During an interview on 4/22/26 at 3:27 PM, Staff C, Licensed Practical Nurse (LPN) stated staff are expected to answer call lights within 15 minutes. When asked if she felt there was enough staff to provide residents with the care they need, she reported there were enough CNAs, however, she felt the nurses could use more help. During an interview on 4/23/26 at AM, Staff B, CNA reported staff should answer call lights within 15 minutes, that any staff member can answer a call light, however, not everyone does. He also reported a few residents have complained that aides will come in, turn off the call light and say they will be back and the aides will not come back During an interview on 4/28/26 at 12:33 PM, the DON stated she would expect the staff to answer call lights within 2 minutes. The DON stated when a resident has their call light on any staff member should be able to answer it. She would expect the staff to check on a resident who has their call light on, rather than walk by without checking on them. Regarding the grievance on Resident #9, she reported she waited as long as 20 minutes to get her call light answered. She did complain that she was left to sit up in her wheelchair until 11:00 PM, but it was actually 9:00 PM, by then she had her call light on for a few hours. The DON explained she terminated a CNA for saying she'll be back and then never came back. She recalled Resident #9 told her she did not mind being up a little bit, but it was ridiculous to be kept up that late. She requested to be assisted to bed by 9:00 PM. Other residents that have also complained to her about their call lights not getting answered in a timely manner were Resident #6 and Resident #14. 4. Review of Resident #13's MDS, dated [DATE] revealed a BIMS of 12 out of 15 which indicated a mild cognitive impairment. The list of diagnoses included: anxiety, depression and asthma. The MDS indicated Resident #13 dependent on staff for all ADL's with exception of substantial/moderate staff assistance required for eating. During a continuous observation that started on 12:48 PM on 4/27/26, Resident #13 in his room, lying in bed. Resident #13 activated his call light. At 12:53 PM, call light remained on. Call light activated for a total 5 minutes. At 12:58 PM, call light remained on. Call light activated for a total 10 minutes. At 1:02 PM, call light remained on. Call light activated for a total 14 minutes. At 1:06 PM, call light remained on. Call light activated for a total 18 minutes. At 1:10 PM, call light remained on. Call light activated for a total 22 minutes. At 1:13 PM, call light remained on. Call light activated for a total 25 minutes. At 1:16 PM, call light remained on. Call light activated for a total 28 minutes. At 1:19 PM, Staff B, CNA and Staff I, CNA entered the resident's room, closed the door, and the call light was turned off. Call light activated for a total of 31 minutes before staff responded. A review of the facility policy titled, Call Lights: Accessibility and Timely Response, dated 2025, revealed a Policy statement which declared: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The Policy Explanation and Compliance Guideline section directed, in part: a. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. b. Process for responding to call lights: 1. Turn off the signal light in the resident's room. 2. Identify yourself and call the resident by name. 3. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. 4. Inform the appropriate personnel of the resident's need. 5. Do not promise something you cannot deliver. 6. If assistance is needed with a procedure, summon help by using the call light. Stay with the resident until help arrives.

Based on observation, clinical record review, resident and staff interviews, the facility failed to treat 2 of 9 residents with dignity and respect when staff did not respond to Resident #6's request to stop washing her hip; and when a staff took Resident #3's cigar from him when he planned to leave the non-smoking facility campus to smoke. The facility reported a census of 56 residents. Findings include:1. Review of Resident #6's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS list of diagnoses included: cellulitis to the right and left leg; and lymphedema. The MDS also identified Resident #6 as dependent on staff for transfers and showers; and required substantial/maximal assistance to roll left and right, and for personal hygiene. Review of Resident #6 Care Plan, initiated: 4/14/25 and revised: 4/7/26 revealed a Problem area to address: [Name redacted, Resident #6] has potential/actual impairment to skin integrity of the (all body regions) r/t (related to) edema. Interventions included, in part: Wash hips with soap and water each shift and change bandages. Do not scrub, wash gently. Revised: 11/11/25. During an observation on 4/21/26 at 7:42 AM, Resident #6 sat up in bed and wore a hospital gown. The resident had dry and intact wound dressings on each of her feet. Resident #6 covered from her waist to ankles with a bath blanket. Staff C, Licensed Practical Nurse (LPN) entered the room to administer medication. The resident asked Staff C to look at the area on her right hip. The area appeared reddened with a scant amount of serosanguinous (watery body fluid, mixed with a small amount of blood and appeared pink in color). Resident #6 informed Staff C, LPN that on 4/17/26 aides were rough when they scrubbed her right hip. The resident stated she asked them to be gentler, however, Staff E, Certified Nursing Assistant (CNA) kept scrubbing hard to the point where the area started to bleed. Resident #6 described the aide as not nice as they were scrubbing roughly. The resident stated she told the aids to stop, but they kept scrubbing. During an interview on 4/22/26 at 1:05 PM, Staff E, CNA reported she bathed Resident #6 on 4/17/26 and washed an open area beneath her abdomen. Staff E stated Resident #6 stated it hurt and Staff E felt this was normal for her. She could not recall if Resident #6 had asked her to stop rubbing so hard. Resident #6 stated Staff F, CNA was gentler. Staff E stated on 4/21/26, the Administrator informed her that Resident #6 reported she had scrubbed too hard when washing her causing her to bleed. Staff E stated she could not recall seeing any blood. Staff E stated that the Administrator sent her home on 4/21/26 pending the completion of the investigation. During an interview on 4/22/26 at 1:25 PM, Staff F, CNA reported on 4/17/26 he had assisted Staff E, CNA when she bathed Resident #6. Staff F explained Resident #6 said Staff E, CNA was rubbing her belly too hard and asked her to stop. Staff F reported this was the only time Resident #6 asked Staff E to stop. During an interview on 4/23/26 at AM, Staff B, CNA reported Resident #6 had complained on 4/17/26 that Staff E, CNA rubbed too hard when she washed up the resident, which caused her sides to bleed. Staff B stated he reported this to the Administrator. During an interview on 4/28/26 at 12:33 PM, the Director of Nursing (DON) stated if a resident complained that an aide was being too rough with cares and asked the aide to stop, she would expect the staff to stop. After the incident with Resident #6, she asked the facility Nurse Practitioner to assess her and she found no markings on her skin or any bleeding. 2. Review of Resident #3 MDS, dated [DATE] revealed a BIMS score of 15 out of 15, which indicated intact cognition. The MDS assessed Resident #3 without symptoms of delirium; always able to be understood by others and always understood others. Review of the electronic health record (EHR) Medical Diagnosis list revealed, in part the following diagnosis: alcoholic polyneuropathy (nerve damage caused by alcohol, which can cause symptoms which can include numbness, extreme sensitivity, and weakness) generalized muscle weakness and unsteadiness on feet. During an interview on 4/21/26 at 11:06 AM, Resident #3 stated he did not understand why other residents and staff are allowed to smoke at the facility, yet he had been told by the Administrator that the facility is non-smoking and he could not smoke. Resident #3 explained there is a covered porch area where people [residents] go to smoke. Resident #3 stated the Administrator did not tell him where he could smoke, or why the other residents could smoke but he was not allowed. Review of the EHR revealed the following: a. A General Progress Note entered on 4/25/16 at 11:37 AM: Resident outside on patio with his mother, resident had an unlit cigar at the time this nurse went out, [CNA name redacted, Staff D] and [name redacted, title or relationship not identified] states they seen him smoking a lit cigar, Both [Resident name redacted, Resident #3] and his mother were reminded that smoking is not allowed on facility grounds. His mother was being very rude to both CNA's making comments that they were both very strange and why are we treating [Resident name redacted, Resident #3] like he is in jail. I asked to lock up cigar, resident refused stated when he comes back in then he will allow me to lock it up and he wants to know why other residents and staff are allowed to smoke but not him. [staff name reacted] medical records and informed [name redacted] Administrator of situation. b. Social Services Note entered on 4/22/26 at 11:52 AM: Social Worker spoke with resident and reminded resident of of non-smoking campus policy. Resident had a cigarillo on person and advised it could be secured in nurse's medication room. Cigarallo provided to nurse [name redacted]. Social Worker will continue to assist as needed. c. General Progress Note entered on 4/17/26 at 12:22 PM: Resident on porch outside dining room smoking with a visitor. Informed resident we are a non-smoking campus and he is not permitted to smoke on the property. During another interview on 4/27/26 at 10:17 AM, Resident #3 stated he was outside with a visitor, with an unlit cigar, they were going to get off the facility property so he could smoke and the Social Worker told him he couldn't have it and had to take it away. The resident stated he gave the cigar to the visitor to hold on to it for him and the Social Worker said she had to take the visitor's cigarettes away, which the visitor refused. The resident stated he now understood that he could smoke off of facility property and felt the staff continued to be demeaning to him and treated him like a child in regard to smoking. The resident stated he had not and would not smoke inside the facility or share his smoking materials with anyone and didn't understand why staff treated him that way. During an interview 4/28/26 at 11:18 AM, the Social Worker stated she took the resident's cigar because the Administrator told her to. When asked if she had removed any other resident's smoking materials, she said she had removed 2 other resident's smoking materials in the past. During an interview on 4/28/26 at 12:33 PM, the Director of Nursing (DON) reported she had heard about the issue with Resident #3 and could not explain why the Social Worker would have taken his cigar away from him. The DON explained residents are not allowed to have cigars or cigarettes on their person and maybe there was not a smoking assessment completed, education completed and care plan updated. The DON stated Resident #3 did not have an assessment done because we did not know he was smoking.

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure 1 of 1 residents (Resident #5) attended dialysis on time and as scheduled, and to complete thorough pre and post dialysis assessments for 1 of 1 resident (Resident #5) reviewed for dialysis related care. The facility reported a census of 56 residents.Findings include:Review of Resident #5's Minimum Data Set (MDS), dated [DATE] revealed a list of diagnoses which included renal insufficiency (kidney failure which required dialysis), diabetes mellitus and paraplegia (paralysis of one half of the body). The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated the intact cognition. The MDS indicated Resident #5 received dialysis while a resident. Review of the April 2026 Medication Administrator Record (MAR) revealed:a. Dialysis Days: MWF (Monday, Wednesday, Friday) time for pick up: 9:30.Start Date: 2/23/26.b. Post-Dialysis: Assess thrill/bruit (common dialysis related assessment for the fistula [a surgically created connection of an artery to a vein used for dialysis access] site. Thrill is a palpable vibration can feel with fingertips, while a bruit is a whooshing sound hear with stethoscope). Chart + if present and - if absent. Notify [redacted name of dialysis provider] if absent. Assess access site fistula and document N for normal, B for s/sx (signs/symptoms) bleeding, or I for s/ss infection and notify dialysis for bleeding or infection. Assess cognition and document A for alert; C for confused, or D for disoriented. One time a day every Mon, Wed, Fri for ESRD (end stated dialysis)/hemodialysis. Start Date: 3/4/26.c. Assess thrill/bruit. Chart + if present and - if absent. Notify [redacted name of dialysis provider] if absent. Assess access site fistula and document N for normal, B for s/sx bleeding, or I for s/ss infection and notify dialysis for bleeding or infection. Assess cognition and document A for alert; C for confused, or D for disoriented. One time a day every Mon, Wed, Fri for ESRD /hemodialysis. Start date: 3/11/26. A review of the April 2026 MAR revealed the following:a. Post Dialysis assessment not thoroughly completed on:1. April 6, 2026 for Cognition, Site, Thrill.2. April 10, 2026 for Bruit, Cognition, Site, Thrill3. April 15, 2026 for Bruit, Cognition, Site, Thrill4. April 17, 2026 for Bruit, Cognition, Site, Thrill5. April 20, 2026 for Bruit, Cognition, Site, Thrillb. Pre-Dialysis assessment not thoroughly completed on1. April 10, 2026 for Thrill2. April 13, 2026 for Thrill3. April 17, 2026 for Site4. April 22, 2026 NA documented for Bruit, Thrill and weight. No documentation in clinical record to explain lack of assessment in these areas. During an interview on 4/17/26 at 12:45 PM, a Dialysis provider staff stated Resident #6 missed her transportation to an appointment due to not being ready on time. During an interview on 4/21/26 at 8:22 AM, Resident #5 stated she is late to dialysis once or twice a week. The resident explained she is supposed to be in her dialysis chair at 10:00 AM, but she often does not get to the center until 10:30 AM. Resident #6 stated the head nurse at dialysis wants her to be at the center by 9:30 AM so she can get started on time. During an interview on 4/23/26 at 8:57 AM, Staff A, Registered Nurse (RN) stated when a resident returned from dialysis, the nurse should assess and document on the Medication Administration Record the resident's vital signs, weight, site for thrill and bruit, appearance and dressings.During an interview on 4/28/26 at 12:33 PM, the Director of Nursing (DON) reported she expected nurses to document post dialysis assessments on the flow sheets on paper. She was not sure if there was anything documented on the MARs and TARs other than checking the fistula. She would expect this to be documented immediately upon return. The DON stated if a resident had dialysis scheduled at 9:30 AM she would expect the resident to be up and ready by 8:00 AM and ready for pick up by 8:4f5 AM. The [NAME] added residents that need dialysis are transported to the center through a transportation service. When asked how many times has Resident #5 been late for dialysis she was not sure. Review of the facility policy titled, Hemodialysis, dated 2025 included a Policy statement which declared: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.The Purpose section directed, in part: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.

Based on observation, clinical record review, resident and staff interviews, the facility failed to follow up on hospital discharge orders for 1 of 1 residents (Resident #3) reviewed. After a September 2025 hospitalization Resident #3 discharged with recommendations to be evaluated by a rheumatologist and podiatrist. The facility reported a census of 56 residents.Findings include:Review of Resident #3, Minimum Data Set, dated [DATE] revealed a BIMS score of 15 out of 15, which indicated intact cognition. The MDS assessed Resident #3 without symptoms of delirium; always able to be understood by others and always understood others. Review of the electronic health record (EHR) Medical Diagnosis list revealed, in part the following diagnosis: alcoholic polyneuropathy (nerve damage caused by alcohol, which can cause symptoms which can include numbness, extreme sensitivity, and weakness) generalized muscle weakness and unsteadiness on feet. Review of hospital discharge records, dated 8/16/25 revealed a History of Present Illness section, which documented, in part.Diffuse psoriasis noted. The Active Problems listed included, in part: hand arthritis and psoriasis. Review of a [name of geriatric clinic redacted] encounter notes, dated 11/12/25, Orders & Requisitions section included, in part: Rheumatology referral – was previously ordered, date is pending, and Podiatry to see patient – order left. During an interview on 4/21/26 at 11:06 AM, Resident #3 stated he had been at the facility for over 7 months and had yet to see a rheumatologist or a podiatrist. Resident #3 noted to have 1 centimeter raised areas, dark pink covering up to 50% of each arm. Resident #3 stated the areas itched and he hoped a rheumatologist could do something to help him. During an interview on 4/21/26 at 11:27 AM, the Administrator stated the order for a rheumatologist was ordered when the resident admitted on [DATE]. She stated she would check into it and provide information; she knew they had worked on it. On 4/21/26 at 1:00 PM, the Administrator stated when the resident admitted to the facility in August of 2025, he had Medicaid in the community but not for the facility. She explained the facility had not been notified Resident #3 had the change in Medicaid in place until January of 2026, which had been made retroactive back to November 2025. The Administrator stated the facility attempted to set up an appointment with the rheumatologist but the process got lost amid other pressing matters which occurred at the time. That being said they did not try to make a Rheumatologist referral until January when he had Medicaid coverage (5 months after his facility admission). During an interview on 4/27/26 at 7:49 AM, the Administrator stated the facility had an appointment with a rheumatologist for Resident #3 on 4/28/26. During an interview on 4/27/26 at 10:17 AM, Resident #3 stated he was also supposed to see a podiatrist During an interview on 4/27/26 at 10:25 AM, the Administrator stated Resident #3 had been scheduled to see a Podiatrist on 1/5/26 but was not seen as he did not have Medicaid approved at the time of the appointment. The Administrator added Resident #3 had an appointment rescheduled for 3/9/26 and was not sure why that appointment did not occur. The Administrator later communicated by email that Resident #3 had an podiatrist appointment scheduled for May 18, 2026 During an interview on 4/27/26 at 12:52 p.m., the Director of Nursing (DON) stated she expected staff to follow physician orders unless clarification was required, and to get the clarification if so. If there was a referral for podiatry, she would expect the resident's name to be put on the Podiatrist's list to be seen at the next visit, unless it was urgent and then they should check to see where they could refer the resident to.

Based on clinical record review, facility policy review, and resident and staff interviews, the facility failed to complete a thorough investigation of an allegation of abuse made by Resident #7. The facility failed to interview all staff working on the night of the allegation and all residents residing in the same hallway to ensure they felt staff and had no concerns with how treated by staff. The facility reported a census of 56 residents. Findings include: Review of a facility self-reported incident, dated 3/29/26, revealed:a. At approximately 3 a.m. on 3/29/26, Administrator was informed by nurse that resident [ Resident #7] had called her daughter who in turn called the nurse because the resident was upset. The resident used her white board to write yell and cut. When asked to show where she was cut she wrote push. She told nurses Black girl and then said push' and pointed to her left shoulder.b. Nurses completed a full body assessment which revealed no injuries or skin concerns. Subsequent skin checks have revealed no injuries or skin concerns. c. In a follow up interview with [name redacted, Resident #7], [name redacted, Resident #7] said the CNA (Certified Nursing Assistant) [name redacted, Staff K] did not change her, but she stood her up out of her recliner. [Name redacted, Resident #7] then said [name redacted, Staff K] pushed her down into her chair using her hands on [name redacted, Resident #7] chest. Upon further questioning, she couldn't remember if [name redacted, Staff K] had changed her or if she even helped her into the chair. She then commented I miss him so much.d. Interview with [name redacted, Staff K] indicates that she responded to resident's call light. [name redacted, Staff K] commented to resident that she had just been changed. The resident yelled at [name redacted, Staff K] that she needed to be changed. [name redacted, Staff K] helped the resident to stand up. The resident was bare footed and began to slip. [name redacted, Staff K] prevented resident from falling. [name redacted, Staff K] changed [name redacted, Resident #7]. [name redacted, Resident #7] then released [name redacted, Staff K] hand and plopped herself down in her chair. Interviews with other CNAs indicate that this is how they assist [name redacted, Resident #7] and that [name redacted, Resident #7] will at times plop herself down into her chair. [name redacted, Staff K] did not realize that [name redacted, Resident #7] was cares in pairs. [name redacted, Staff K] said she was holding onto [name redacted, Resident #7] waist and never touched her above the waist .e. Interviews with other residents on North Hall revealed no concerns regarding any cares received recently.Review of Resident #7's Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included: cerebrovascular accident (a stroke), aphasia (difficulty with speech), hemiplegia (paralysis on 1 side of the body), anxiety and depression. The assessment revealed the resident was usually able to make herself understood and usually understood others. The MDS indicated Resident #7 required substantial/maximal staff assistance for all activities of daily living (ADL's) with the exception of staff supervision/touch assistance required for eating.Review of Resident #7's Care Plan, dated 3/31/26 revealed a Problem area to address [Name redacted, Resident #7] has a self-care deficit as evidenced by requiring assistance with ADL's, impaired balance during transitions requiring assistance and/or walking, incontinence. Interventions included, in part: TOILETING: 1 person assist. Provide peri-care with every incontinent episode and as necessary; and TRANSFERS: 1 person assist stand pivot transfer (SPT). Date Initiated: 3/31/26. During an interview on 4/22/26 at 8:40 AM, Resident #7 became visibly distraught when asked to describe what happened with a staff member during the night on 3/29/26. The resident communicated that the staff member yelled at her, called her names such as stupid, took her pop away from her and poured it out for no reason. She told her she needed to be changed, that she was wet, and the staff member yelled at her, told her she was just changed, then had her stand up from the chair and changed her brief. The resident then said she pushed and pointed to her shoulder area. When asked if the staff member had hurt her, the resident didn't respond or answer. Then the resident held up 1 finger, then shook her finger as if to mean no, no, no, then held up 2 fingers. When asked if she meant there were supposed to be 2 staff in the room, but the staff member was by herself, the resident nodded her head up and down, to indicate yes.During an interview on 4/22/26 at 9:05 AM, a family representative and Power of Attorney (POA) stated they received a phone call from the resident in the middle of the night on 3/29/26. The family representative described Resident #7 as hysterical and crying. The family representative stated they had never heard the resident so upset. The resident reported the staff that took care of her yelled at her, cursed at her, called her stupid, and had pushed her. The family representative was unable to determine if the resident was hurt and called the nurse on duty right away, told her what the resident reported and asked her to go check on the resident.During an interview on 4/22/26 at 9:20 AM, the Administrator provided a copy of the 5-Day investigative report submitted to the State Agency in response to a request for the facility investigative file regarding the 3/29/26 allegations of abuse made by Resident #7. The Administrator stated she spoke to staff and residents and they did not have any concerns. The Administrator stated she did not have the staff provide written statements. The Administrator denied the State Agency access to her investigative file related to the 3/29/26 incident. Upon request, on 4/22/26 at 9:33 AM, via email the Administrator provided a list of three staff she interviewed - Staff K, CNA, Staff J, RN and Staff Q, LPN; and a list of 8 residents who could be interviewed based on their cognitive status. The 7 residents resided on the same hall as Resident #7. During an interview on 4/22/26 at 10:02 AM, the Director of Nursing (DON), stated she had not worked at the facility very long when the alleged incident occurred. The DON stated Staff K, CNA had been directed to leave the facility and suspended at that time, she has not returned to work.Review of the March 2026 Daily Assignments revealed from 10:00 PM on 3/28/26 to 6:00 AM on 3/29/26 the following staff worked: Staff K, Certified Nursing Assistant (CNA); Staff O, CNA; Staff P, CNA; Staff J, Registered Nurse (RN); and Staff Q, Licensed Practical Nurse, LPN.During an interview on 4/22/26 at 12:25 PM, Staff P, CNA confirmed she worked third shift on 3/28/26 which stated at 10:00 PM and ended on 3/29/26 at 6:00 AM. Staff P denied having been interviewed by facility staff about the allegations made by Resident #7 on 3/29/26.During an interview on 4/22/26 at 12:33 PM, Staff J, RN stated she. Staff worked on the night shift that started 3/28/26 and ended at 6 AM on 3/29/26. Staff J stated she had assessed Resident #7, along with Staff Q, Licensed Practical Nurse (LPN). Staff J stated a Resident 7's family representative called and reported the resident was upset. Staff J stated when they entered the room the resident was very upset, she had never seen her that upset before. As they spoke to her the resident kept looking towards the door as if she was afraid. They used a communication board to ease the resident's ability to communicate. Staff J recalled Resident #7 reported that the staff member yelled at her, pushed her in the shoulder area, and said that she cut her. Staff J explained Resident #7 has expressive aphasia and they thought the resident tried to say that she hurt her when she said cut. They did a full body assessment of the resident at that time and did not find any redness, bruises or any signs of injury on her body. They called the administrator and were directed to send Staff K, CNA home. During an interview on 4/22/26 at 1:25 PM, Staff R, CNA, confirmed she worked third shift on 3/28/26 which stated at 10:00 PM and ended on 3/29/26 at 6:00 AM. Staff R denied having been interviewed by facility staff about the allegations made by Resident #7 on 3/29/26.During an interview on 4/23/26 at 11:33 AM, the Social Worker stated she spoke with Resident #7 after she heard about the incident on 3/29/26. The Social Work recalled Resident #7 reported that she was physically hurt and her feelings were hurt by the actions of a staff member. The Social Worker described Resident #7 as tearful as they discussed the issue, and said she wasn't fearful of who hurt her. The Social Worker stated she offered Resident #7 counseling and supportive services from the therapist contracted by the facility, and the resident has had one session with the therapist with more planned. During an interview on 4/23/26 at 6:21 PM, Staff O, CNA, confirmed she worked third shift on 3/28/26 which stated at 10:00 PM and ended on 3/29/26 at 6:00 AM. Staff R denied having been interviewed by facility staff about the allegations made by Resident #7 on 3/29/26.During an interview on 4/27/26 at 3:04 PM, Staff Q, LPN, stated she worked full-time on the on-night shift (6:00 PM to 6:00 AM). Staff Q stated she worked the 3/28/26 to 3/29/26 night shift with Staff K, CNA. Staff Q recalled she got a call from the resident's [Resident #7] family member in the middle of the night, who reported the resident was really upset and asked that I check on the resident. Staff Q, LPN stated she went in the resident's room with Staff J, RN. Staff Q stated Resident #7 had been really upset, and she had not seen the resident that upset before. Staff Q reported Resident #7 said a staff member yelled at her, called her names, then the staff pushed her [Resident #7] on her chest/shoulder area and that she [the staff member] had hurt her [Resident #7]. Staff Q stated Staff K, CNA was identified as the staff member and she had been in the resident's room just prior to the phone call. Staff Q stated she and Staff J, RN completed a head-to-toe assessment, and they did not find any marks anywhere on the resident. She asked Staff K what happened when she was in the resident's room, she said the resident had her call light on, she requested to be changed and she had just changed the resident. Staff K explained that to the resident, and then went ahead and changed her again. Staff K had reported as Resident #7 stood during the process she started to slip. Staff K stated she had to stop the resident from falling, and in the process her hand came in contact with the resident's waist area to prevent a fall, the action was not intended to hurt her. During an interview on 4/28/26 at 2:34 PM, the Administrator stated when she did abuse investigations she followed their checklist, she spoke to staff, anyone around the scene, in the building at that time, and interviewed any residents able to be interviewed from the same hall that would have had care by the identified staff member. The Administrator stated she asked the resident questions do you have concerns about staff being rough, or are you fearful of anyone. The Administrator stated the residents and staff that she interviewed related to the alleged incident did not have concerns for abuse or treatment by staff. The Administrator reviewed her investigative file and reported she conducted the following resident interviews:Resident's name redacted - had no concerns, and said staff don't check on him.Resident's name redacted - said she'd sat in the bathroom for a long time, had no concerns or issues.Resident's name redacted - said everyone was great, she'd received a bed bath that day.Resident's name redacted - said he wasn't feeling well, did not have concerns.Resident's name redacted - said he didn't have concerns, and the 3rd shift CNA's listened to music on their phones.Resident's name redacted - said the aides play music on the night shift and he didn't see staff much at night.Resident's name redacted - said it could take staff some time to get to the residents, family member visited in their room and witnessed her questions.Resident's name redacted - said he was applying to go to another long-term care facility, said he was supposed to get his medication at 10 p.m. and sometimes they were late.During resident interviews conducted by the State Agency, 3 of the 8 residents reported interviewed by the Administrator denied talking to facility staff about any concerns they may have about staff treating them rough or being abusive. All 3 residents denied having any concerns with how staff treated them or reported any abusive incidents.Review of the facility policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated 3/18/26 revealed a Purpose statement which declared: To achieve compliance with state and federal requirements for preventing, identifying, investigation and reporting abuse in all [facility corporate name redacted] facilities.The Rational section of the policy revealed, in part:a. All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .b. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property.c. These procedures shall include the screening and training of employees, protection of Residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation.The Key Definition section revealed, in part: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.The Investigation Protocol sections directed, in part:The Administrator will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident.Attempt to obtain witness statements (oral and/or written) from all known witnesses.The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation.

Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to ensure that a resident with a physician order for a nebulizer treatment scheduled for four times daily had been assessed for the ability to self-administer the medicated treatment for 1 of 15 (Resident #13) reviewed for medication administration. The facility reported a census of 56 residents.Findings include:Review of Resident #13's Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated a mild cognitive impairment. The list of diagnoses included anxiety, depression and asthma. The MDS indicated Resident #13 dependent on staff for all activities of daily living with the exception of substantial/maximal assistance for eating. The MDS indicated Resident #13 received Hospice care. Review of Resident #13 Care Plan, dated 3/26/26 revealed a Problem area to address [Name redacted, Resident #13] has impaired cognitive function though[t] processes as evidenced by short/long term memory deficit, impaired decisions making and/or impaired ability to understand others related to a dx (diagnosis) of HX of CVA (history of stroke) and drug use. HX: metabolic encephalopathy. Interventions included: a. Cue, orient and supervise as needed. Date initiated: 3/26/2026.b. Monitor/document/report as necessary any changes in cognitive function, specifically changes in the following: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date initiated: 3/26/2026.c. Use task segmentation to support short term memory deficits as appropriate. Break them into one at a time. Date initiated: 3/26/2026.Review of Resident #13's Care Plan, dated 3/16/26 included a Problem area to address [Name redacted, Resident #13] has the potential for infection related to a history of upper respiratory infection, pneumonia, cellulitis. Interventions included, in part: Administer treatments as ordered, initiated 3/26/2026.Review of Physician Orders revealed, in part: DuoNeb solution 0.5-2.5 (a mix of Ipratropium 0.5 milligrams (mg) per milliliter (ml) and Albuterol 2.5 mg/ml used to dilate airways and ease breathing) suspended in 3 ml solution inhaled via nebulizer 4 times a day every 6 hours and 6 a.m., 12 noon, 6 p.m. and 12 a.m. Start Date: 3/3/26.During an observation on 4/21/26 at 8:19 AM, Resident #13 in bed, positioned flat. The nebulizer machine on, while the face mask laid on the bed. Duoneb solution observed to be present in the aerosol chamber, and mist noted have moved through the tubing and exited out through the face mask. No staff present. During on observation on 4/22/26 at 2:58 PM, Resident #13 in bed, with the head of the bed at a 30-degree angle. The nebulizer machine sat on the floor, turned on with Duboneb solution visible in aerosol chamber. Resident #13 held the mask with both hands out approximately 20 inches from his mouth. No staff present. At 3:12 PM, Resident #13 remained in bed with nebulizer machine on and the mask rested on the floor. No staff present. During an observation on 4/28/26 at 5:36 AM, Resident #13 in bed. The nebulizer machine on, with the mask positioned on the resident's face. No staff present.During an interview on 4/28/26 at 5:43 AM, Staff M, Registered Nurse stated she had to go back to check on the resident because he had a history of taking the nebulizer mask off during the treatment. Review of the clinical record revealed the lack of a Self-Medication Administration assessment, Care Plan direction to address the self-administration for a Duoneb nebulizer treatment, and a Physician Order for Resident #13 to self-administer his medications. Review of the facility policy, titled Self Administration of Medication Policy, dated 2025, directed staff to:a. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following:b. The medications appropriate and safe for self-administration;c. The resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections;d. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for;e. The resident's capability to follow directions and tell time to know when medications need to be taken;f. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff.g. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs.h. The resident's ability to ensure that medication is stored safely and securely.i. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.j. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR. k. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur:1. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective.2. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.

Based on observation, clinical record review, facility policy review, consulting pharmacy staff interviews and staff interviews, the facility failed to complete disposition of medications by destruction in the facility or return to the pharmacy upon a resident death, resident discharge or change in medication regime for 3 of 4 residents (Resident #6, Resident #7, and Resident #9) reviewed. The facility reported a census of 54 residents. Findings include: Review of a Facility Self-Reported incident, dated [DATE], revealed the facility received an anonymous call placed to their corporate compliance office regarding an alleged theft of resident medications. The facility Five Day Follow-up Investigation determined the facility was unable to determine staff accused of theft removed narcotics, insulin or a blood sugar monitoring device from the facility for her personal or family use. The facility did identify concerns related to facility practices regarding the destruction of discontinued resident medications. Review of the facility consulting providers revealed Pharmacy A discontinued services at the facility on [DATE], and Pharmacy B started on [DATE]. During an observation on [DATE] at 11:52 AM, resident medications dispensed via blister-pack cards. Each card held up to 30 doses, and each individual blister sealed with foil. All medications stored in one of three locked medication carts, with narcotic medications stored in a separate compartment under a double lock system. Other medications stored in a locked medication room. During an interview on [DATE] at 3:21 PM, Staff B, former Assistant Director of Nursing (ADON), explained when a resident is discharged or the resident had a medication change, Staff A, the former Director of Nursing (DON) put the medications in an unlocked cupboard in the DON office. Staff B stated this had been the practice for 2 to 3 years. Staff B stated there had been at least 30 medications in the cupboard. Staff B stated Staff A had said they may as well keep them since they wouldn't get any credit from the pharmacy when returned. Staff B stated Staff A gave the medications to staff when they didn't have insurance, and talked about helping a family member with the medications. Staff B stated she had not seen Staff A take the medications out of the facility. Staff B stated when Staff A was on vacation in December, 2025, Staff B destroyed all the medications stored in the cupboard with Staff L, LPN. Staff B stated when Staff A returned from vacation, she was angry the medications were destroyed. Staff B stated Staff A also kept discontinued narcotics in the top left drawer of the DON desk, which had been kept locked. Staff B stated there was no count of those narcotics, and she thought only Staff A had the key to her desk. However, Staff B explained when Staff A was on vacation the Human Resources (HR) Manager needed documentation regarding employee discipline and used his key to unlock the desk and found the narcotics stored in the desk. Staff B stated she and the HR Manager informed the Administrator of the narcotics in Staff A's desk. During an interview on [DATE] at 1:28 PM, Staff H, LPN, stated some narcotics were kept in the left-hand drawer of the DON's desk, and discontinued resident medications were kept in a cupboard behind the DON's. Staff H stated she is not sure why the discontinued medications were stored in the DON office and desk. During an interview on [DATE] at 1:26 PM, Staff K LPN, stated there was a tote in the med room where they put discontinued meds (either due to a change, a discharge or death). Staff K stated that most of the time the pharmacy refused to accept the medication returns and a nurse had to destroy the medications with the use of a Drug Buster (a system that deactivates the medications). During an interview on [DATE] at 11:34 PM, Staff L, LPN, stated there was a cupboard in the DON's office that contained approximately 25 discontinued resident medications. Staff L stated she destroyed all the medication with the Staff B, LPN in December, 2025 while the former DON [Staff A, ] was on vacation. Staff L reported she also destroyed narcotics stored in the DON's desk with the Staff A on her [Staff A] last day at the facility. Staff L stated the destruction was documented on the respective narcotic inventory control sheets. Staff L stated there wasn't an inventory of what was in the DON's desk, but there were inventory control sheets for every narcotic that was destroyed from the desk that day. A review of the narcotic destruction book on [DATE] at 10:42 AM, with Staff L revealed 11 narcotics destroyed on [DATE] by Staff L and the Staff A. Staff L confirmed the narcotics listed in the destruction book were from the DON's desk. During an interview on [DATE] at 4:58 PM, Staff A, former DON stated resident's discontinued meds were kept in an unlocked cupboard in the DON office since before she started as the DON (more than 2 years ago). Staff A explained the pharmacy would not accept returned medications if as few as 1 pill had been removed from the blister-pack. Staff A stated there were narcotics stored in a locked drawer of the DON desk that required destruction. Staff A explained she kept the narcotics in the drawer until a second RN could be a witness to the destruction as required by the former facility owners. Staff A explained the former owners required destruction be completed by the DON, with a RN or pharmacist as the witness. Staff A explained the discontinued narcotics could not be stored in the narcotic compartment of a medication cart, and there was no inventory or shift to shift count of what was kept in the DON drawer. During an interview on [DATE] at 2:14 PM, the HR Manager stated while the DON had been on vacation several months ago, he unlocked her desk to get something and saw medications stored in the desk. The HR Manager stated he did not know if they were narcotics, and estimated there was at least 20 different medications in the drawer. The HR Manager stated the Administrator was informed and observed the medications in the drawer. During an interview on [DATE] at 11:22 AM, the Administrator stated the corporate investigation completed determined there were medications stored in the DON's office in an unlocked cupboard. The Administrator stated the investigation revealed the DON gave Certified Nursing Assistant (CNA) one of the medications from the cupboard, and the staff member brought the medication back to the facility during the investigation. The Administrator stated in [DATE] while the DON was on vacation, the HR Manager unlocked the DON's desk to get some personnel paperwork and found narcotics in the desk. The Administrator stated there were 2 narcotics in drawer, one of them was a blister-pack card with tablets, and the other was a used bottle of liquid morphine with an unknown small amount remaining in the bottle. The Administrator stated she didn't know what happened to the narcotics in the DON's desk as she didn't direct any staff to take action. The Administrator stated it was not appropriate for the DON to keep narcotics in her desk. The Administrator stated the DON [Staff A] had been terminated after the corporate investigation. The Administrator stated the facility took corrective action and educated the staff. During an interview on [DATE] at 3:05 PM, the Regional Nurse Consultant (RNC) stated she was involved in the investigation initiated [DATE]. During their investigation staff reported medications were stored inappropriately in an unlocked cabinet in the DON's office, Staff A, former DON reported the medications were used as a back-up Emergency Medication supply during the time that they changed pharmacies, and that was not truthful information. The RNC stated she would have expected the Administrator to notify her/their corporation of medications stored inappropriately by the DON, that had not occurred and the corporation learned about that from the complaint received on their Corporate Compliance Hotline. Review of the electronic health record (EHR) revealed the following: a. Resident #6 was admitted to the facility [DATE], and died at the facility on [DATE]. The facility pharmacy at the time, Pharmacy A, provided medications for the resident through an automated medication dispensary machine that dispensed medications daily, and through blister-pack medication cards prepared and delivered to the facility by Pharmacy A. The facility changed to Pharmacy B, on [DATE]. Medications dispensed on the blister-pack medication cards by both Pharmacy A and Pharmacy B included: 1. Atorvastatin (used treat high cholesterol) 80 milligrams (mg) administered oral daily at hour of sleep (HS) ordered [DATE], discontinued [DATE].2. Pantoprazole (used to treat indigestion) 40 mg administered oral daily, ordered [DATE], discontinued on [DATE].3. Warfarin (a blood thinner) 4 mg administered oral daily, ordered [DATE], discontinued on [DATE]; and Warfarin 3.5 mg administered oral daily, ordered [DATE], discontinued [DATE].4. Bumetanide (used to treat fluid retention, often called a water pill) 0.5 mg tablets, administer 2 tablets (1 mg) oral daily, ordered [DATE], discontinued [DATE].5. Carvedilol (used to treat high blood pressure) 12.5 mg tablets, administer 2 tablets (25 mg) oral twice daily, ordered [DATE], discontinued [DATE].6. Hydroxyzine (an antihistamine that is used to retreat allergies, and/or anxiety) 25 mg administered oral 3 times daily, ordered [DATE], discontinued [DATE]. The facility could not provide requested documentation of destruction or pharmacy invoices to indicate return of the for the listed medications upon the Resident #7 death. b. Resident #7 admitted to the facility on [DATE], and discharged from the facility on [DATE]. Medications dispensed to the facility by Pharmacy A included: 1. Lidocaine 5% external patch (patch used to treat pain) applied topical daily, ordered [DATE], discontinued [DATE]. The facility could not provide requested documentation of destruction or a pharmacy invoice to indicate return of the listed medication after Resident #8's discharge. c. Resident #9 admitted to the facility [DATE], and discharged to home on [DATE]. Medications provided by Pharmacy B, dispensed to the facility on [DATE] included: 1. Bumetanide - 1 mg oral daily, ordered [DATE], discontinued [DATE], 14 tablets dispensed.2. Glipizide (used to lower blood sugar) - 2.5 mg oral daily, ordered [DATE], discontinued [DATE], 14 tablets dispensed.3. Lisinopril (used to treat high blood pressure)- 20 mg oral daily, ordered [DATE], discontinued [DATE], 14 tablets dispensed.4. Apixaban (a blood thinner) - 5 mg oral twice daily, ordered [DATE], discontinued [DATE], 28 tablets dispensed.5. Oxybutynin (use to treat over-active bladder) - 5 mg oral twice daily, ordered [DATE], discontinued [DATE], 28 tablets dispensed. The facility could not provide requested pharmacy invoice for documented return of the above medications upon Resident #9's discharge. During an interview on [DATE] at 10:08 AM, Staff Q, Registered Nurse (RN), Nurse Consultant with Pharmacy B stated medications should be returned to the pharmacy when they were discontinued, or if the resident discharged , except for narcotics, topicals, inhalers, vials once they were accessed, or other non-returnable conditions. The medications had to be returned within 45 days of the date they were dispensed to be accepted for credit. During an interview on [DATE] at 8:35 AM, Staff R, Pharmacy A representative stated the State of Iowa is a no return state so facilities could not return resident medications for credit. During an interview on [DATE] at 8:57 AM, Staff S, Registered Pharmacist (RPh), and long-term care (LTC) pharmacist consultant with an Iowa based LTC pharmacy stated facilities could return medications for credit, in blister-packs even when some of the doses had been administered, as long as the seals were intact on the medications that remained, and should do that when the order was discontinued or the resident discharged , that was a common practice in Iowa. Exceptions apply, such as creams/topicals, any vials that had been accessed, inhalers, eye drops or similar medications that had been opened (unless in original sealed package and unused), and narcotics and refrigerated medications would not be returnable. Review of facility policies revealed the following:The Medication Storage policy dated 2025 directed, in part:a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.b. Only authorized personnel will have access to the keys to locked compartments.c. Schedule II narcotics and controlled substances are stored under double lock and key.d. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. The Discarding and Destroying Medications policy, dated as revised October, 2014 directed, in part:a. Medications will be disposed of in accordance with federal, state and local regulations.b. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.c. Non-controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.d. Individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: 1. No medications covered under the Federal Comprehensive Drug Abuse Prevention and Control Act of 1976 are returned;2. All such medications are identified as to lot or control number; and3. The receiving Pharmacist and a Registered Nurse employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned.4. Schedule II, III, and IV controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The Disposal of Medications and Medication-Related Supplies policy dated 12/2017 directed, in part: a. Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit are destroyed. Destruction methods comply with federal and state laws and regulations for medication destruction.b. All medications should be destroyed in a manner that they are unusable.c. All discontinued medications will be immediately removed from the resident's active medication and stored in a separate locked area for up to 90 days or as required by applicable law, and then destroyed by a manner in accordance with applicable state and federal laws.d. Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law.e. The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the Prescription Drug Destruction Inventory form: 1. Date of destruction2. Name and strength of medication3. Prescription number, if applicable4. Amount (Qty) of medication destroyed5. Signatures of witnessesa. Controlled medications may not be returned to the pharmacy

Based on clinical record review, resident and staff interviews and policy review, the facility failed to attempt to educate a resident on potential discharge options prior to his leaving after having signed an Against Medical Advice form for 1 of 1 resident reviewed. The facility reported a census of 63 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: heart failure, neurogenic bladder, diabetes mellitus and persistent mood disorders. The MDS identified Resident #1 required set up/cleanup assistance with eating, oral hygiene, toileting, showers, personal hygiene. The MDS identified the resident had physician orders for the following medications: anti-anxiety, hypnotics, anticoagulant, opioid, hypoglycemic (including insulin) and anticonvulsant.Review of the clinical record revealed Resident #1 had Physician Orders for:a. Jardiance (for Diabetes Mellitus) 10 milligram (mg) one tablet daily.b. Lorazepam (for anxiety) 1 mg tablet daily.c. Metoprolol (for high blood pressure) 25 mg one tablet daily.d. Apixaban (blood thinner for abnormal heart rhythms) 25 mg twice daily.e. Lorazepam 1.5 mg tablet twice daily. f. Glargine insulin (for Diabetes Mellitus) 18 units subcutaneously (injection) at bedtime.g. Lispro Insulin sliding scale four times daily based on blood sugars.The census tab in the electronic medical record revealed Resident #1 was admitted to the facility on [DATE], was hospitalized [DATE], returned to the facility 10/8/25 and discharged [DATE].The Initial Psychiatric assessment dated [DATE] identified Resident #1 had the primary treating diagnosis of generalized anxiety disorder, had the secondary treating diagnosis of Other stimulant abuse and had other specified persistent mood disorders. The Reason for Referral: Agitation, Hallucinations, Grief/Loss Issues, Alcohol or Substance Abuse, High Risk Behavior, Verbal Aggression, Medication Evaluation.The Discharge Planning Form dated 9/16/25 revealed the form was reviewed with the resident, the overall goal was to discharge to another facility and that the plan was to be discharged to a local mental health facility. The form was signed as completed by the facility Social Worker.A review of a Facility Incident Report dated 10/7/25 at 9:00 PM documented that a nurse observed Resident #1 push Resident #2. Resident #2 fell onto the floor and hit her head. Resident #1 reported he did not push Resident #2, that the door pushed her. The Abuse and Neglect Coordinator and Director of Nursing were called, notified 911 to summon police and ambulance. Notified provider and family. Both residents were taken to the hospital for evaluation and neither one had injuries.A review of the progress notes had documentation of the following:a. On10/8/25 at 2:23 AM Resident #1 returned from the hospital via taxi, was pleasant and cooperative.b. On 10/8/25 at 9:17 AM Resident #1 signed the AMA (Against Medical Advice) paperwork in the presence of the Business Office Manager (BOM) and DON (Director of Nursing).c. On 10/8/25 at 10:41 AM Resident #1 called himself a cab, packed some of his belongings and left the facility at this time. Provided medication list to the resident.Review of the clinical record did not reveal documentation to show other alternatives for discharge planning had been discussed with Resident #1 on 10/8/25.A review of the facility AMA (Against Medical Advice) Form had documentation that the resident released the facility of any further responsibility for the resident's care, safety or welfare. It was signed by the resident on 10/8/25 and witness signatures from the DON and the BOM.During an interview on 10/15/25 at 8:47 AM, Resident #1 reported an incident on 10/7/25 where Resident #2 kept trying to enter his room. He had called for the staff 5 different times to keep her away from his room and no one did anything. He reported the next morning the staff woke him up and told him to just sign the AMA (Against Medical Advice) paper. They told him it was because of the incident between him and Resident #2. He was still sleepy and did not really understand what the form was, other than it was to get him kicked out. He admitted he did have plans to eventually leave, but he felt he needed more time to learn how to do things on his own. The day he was discharged (10/8/25), he did not feel he could take care of himself. The staff did not inform him of plans to discharge him until he came back from the hospital (10/8/25) and told him he had to do this on his own and find a place to stay. He was sent to a homeless shelter, he did not have any medications with him and woke up the next morning with a blood sugar between 400 and 500 (a reading he obtained from an internal blood glucose monitor). He reported he did not have any insulin and an ambulance had to take him to the hospital. He did not feel safe in the homeless shelter. A friend of the family took him home from the hospital that day.During an interview on 10/13/25 at 10:25 AM, Staff C, Registered Nurse (RN) reported she did not feel Resident #1 fully understood the AMA form that they had him sign before he was discharged on 10/8/25. Staff C also reported Resident #1 needed to be in a facility so that his mental health and diabetes can be safely managed.During an interview on 10/14/25 at 8:58 AM, the Business Office Manager reported on 10/8/25 Resident #1 reported to her that he did not punch Resident #2 and he was fearful the police were going to come after him which is why he wanted to leave.During an interview on 10/14/25 at 9:31 AM, the Social Worker, reported on 10/8/25 when she spoke to Resident #1, he informed her of the incident between him and Resident #2 and that he wanted to leave. She also reported the Business Office Manager and the Director of Nursing had him sign the AMA paperwork.During an interview on 10/14/25 at 12:12 PM, the DON reported the staff informed her of the incident between Resident #1 and Resident #2 on 10/7/25. The next morning, she, the Social Worker and the Administrator made the decision that a court committal was necessary for resident and staff safety. However, when she came to work 10/8/25, the BOM already had spoken to Resident #1 about discharging. The DON was going to get him court committed so he had a place to go. The Social Worker called a local homeless shelter and found a bed for him. Resident #1 left in a cab the facility paid for to take him to the homeless shelter.During an interview on 10/15/25 at 12:20 PM, the Social Worker reported on 10/8/25, she had called the homeless shelter to see if they had a bed for Resident #1 and they did. She also called the local mental health facility he had been on the waiting list for and still no available bed for him. She also reported she was going to call the local community health clinic to make an appointment for him to get his medications and he informed her that he would go there himself and walk in.During an interview on 10/15/25 at 2:29 PM, the Business Office Manager reported on 10/8/25 at approximately 8:45 AM, Resident #1 approached her and kept saying he didn't punch Resident #2, he slammed the door and she fell. He was afraid he was going to be arrested. The police came in and talked to him after the incident. She explained they would not be coming after him. The only other alternative that was offered was they placed him on a waiting list for a local mental health facility.During an interview on 10/15/25 at 2:43 PM, the Social Worker reported she made arrangements for Resident #1 to be discharged to the homeless shelter after the AMA form was signed. The DON and Business Office Manager reviewed the AMA paperwork with Resident #1.During an interview on 10/15/25 at 3:01 PM, the, DON reported she and the Business Office Manager (BOM) had the resident sign the AMA form after the BOM explained the form to Resident #1. She also reported no one had offered him another alternative discharge plan to evaluate would be suitable within the next 30 days. She was not part of the conversation when he reported he wanted to leave and did not know who he approached first.The facility did not have a policy regarding a Discharge Against Medical Advice.

Based on observation, record review, staff interviews, and the facility policy, the facility failed to clean the ceiling vents and oven hood and maintain the dishwasher sanitizer at the appropriate sanitizing level. The facility reported a census of 66 residents. Findings include: During the initial tour of the kitchen on 9/8/25 at 9:45 AM, the low temperature dishwasher tested for the sanitizer level. The strip tested and the color of the strip was gray and did not rise to the level 25 PPM (parts per million). The Dish machine PH log for September 2025 revealed initial [Initials redacted] on the 8th on the breakfast and lunch times with the number 150 next to the initials. During the initial tour of the kitchen on 9/8/25 at 9:45 AM, observation revealed the ceiling vents had thick dust on and around them above the steam table, and the hood above the oven and stove covered with dust and grime. During an interview on 9/8/25 at 10:07 AM, the Dietary Supervisor informed the dishwasher did not reach the appropriate PPM level. The Dietary Supervisor went and got the Maintenance Supervisor, he changed out the rinse aid, reran the dishwasher, the PPM did not reach 25 PPM, and was still gray in color. The Dietary Supervisor stated she would call someone in and get the machine checked out. The Dietary Supervisor confirmed she would not use the dishwasher until the machine was fixed. During an interview on 9/8/25 at 11:32 AM, the Dietary Supervisor stated Maintenance found a broken hose and fixed it as best as he could. During an interview on 9/8/25 at 11:34 AM, the Dietary Supervisor stated a repair man was coming to the facility to fix the tube and make sure nothing else got cut off. The Dietary Supervisor ran the dishwasher again, the PPM read between 25-50 PPM, and the Dietary Supervisor confirmed the color on the strip needed to be darker and needed to be at least 50 PPM. The Dietary Supervisor confirmed they would not use the dishwasher until the repair man fixed it. During an interview on 9/8/25 at 2:32 PM, the Dietary Manager stated the dishwasher was repaired, and the repair man stated the tubing was bent and the chemicals might have been bad. The dishwasher ran twice, the sanitizer strip checked, and read between 75-100 PPM. The Dietary Manager queried on how long the dishwasher had been broken and the Dietary Manager stated it couldn't of been long because her staff checked it everyday. The Dietary Supervisor queried where the tubing was broken, and she stated the tubing was broken near the end that went into the chemical bottle. The Customer Service Report dated 9/8/25 at 1:30 PM revealed: a. Customer: machine no testing for sanitizer- O PPMb. Solution: Replaced cracked product line, replaced squeeze tube, replaced straw going into bucket, put new jug of [Name Redacted] (sanitizer) on machine, and primed and tested 100 PPM. During an observation on 9/9/25 at 12:18 PM, the kitchen ceiling vents were covered with thick layers of dust and the hood above the stove and oven covered in dust/greasy film. During an observation on 9/10/25 at 11:27 AM, the kitchen ceiling vents were covered with thick dust and a thick film/dust on the hood above the oven and stove. During an interview on 9/10/25 at 7:57 PM, Staff G, Dietary Aide queried on the deep cleaning schedule and Staff G stated they used to deep clean every week. Staff G asked about the ceiling vents and Staff G stated maintenance took care of them. Staff G asked about the stove hood and Staff G stated they used to clean it, but Staff G didn't know how often. Staff G queried how often she checked the sanitizer strip for the dishwasher and Staff G stated everyday. During an observation on 9/11/25 at 8:50 AM, Staff H, Dietary Aide queried when he checked the sanitizer strip for the dishwasher and Staff H stated he checked the strip after Staff H did all the dishes. Staff H queried why he checked after the dishes were all done, and Staff H stated because normally then the sanitizer strip would be in range. When informed the dishwasher sanitizer log was already initialed for the breakfast and lunch on 9/8/25, Staff H confirmed he wrote down the number before tested the strip. Staff H queried on why he continued to do the dishes after the sanitizer test strip color was gray, Staff H stated he didn't know, and he was just finishing the dishes. During an interview on 9/11/25 at 8:54 AM, the Dietary Supervisor queried when the staff checked the dishwasher strips, and the Dietary Supervisor stated before breakfast, lunch, and supper dishes. The Dietary Supervisor asked about the sanitizer strip being logged for breakfast and lunch on 9/8/25 and the Dietary Supervisor stated she already spoken to staff about that. The Dietary Supervisor queried about the thick dust around the ceiling vents above the steam table, and the Dietary Supervisor confirmed she wouldn't want the dust to fall down. The Dietary Supervisor queried on the stove hood, the Dietary Supervisor stated the facility had an outside company come in and clean it, and didn't know the last time they came. During an interview on 9/11/25 at 11:42 AM, the Administrator informed of the dust around the ceiling vents and on the hood above the stove/oven. The Administrator stated she didn't know what the Dietary Supervisor's cleaning schedule looked like, but the Administrator stated she thought the vents and hood should be cleaned weekly or whatever was on the Dietary Supervisor's list. During an interview on 9/11/25 at 1:11 PM, the Administrator stated the dishwasher sanitizer should be between 50-100 PPM.The Facility Nutritional Services Sanitation Policy dated 3/31/21 revealed:a. Cleaning of equipment condensers, lights, vents/fans, ceiling, ice machine, etc. shall be completed by the Maintenance Department as determined by the Administrator and in accordance to meet minimum standards of Federal, State, and Local guidelines and ordinances governing food service.b. Equipment shall be cleaned, sanitized, delimed, etc. in accordance with manufacturer recommendations. Detergents and sanitizers shall be used in the correct dilutions consistent with Federal and State guidelines and ordinances governing food service.c. Exhaust system and hoods shall be clean, operational, and maintained in good repair.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure pureed meat was reheated to 165 degrees for fifteen seconds when held for hot service after the temperature of the pureed meat dropped below 135 degrees Fahrenheit. The facility reported a census of 66 residents. Findings include: During an observation on 9/9/25 at 10:43 AM, Staff A, Dietary [NAME] prepared pureed meat for the lunch service. The turkey slices temped at 181 degrees. After the Staff A finished with her preparation of the puree meat, Staff A placed the prepared meat onto the steam table and did not take the temperatures of the meat prior to placing on the steam table. The Facility Spring/Summer 2025 menu revealed the following menu for Tuesday Week 3: Herbed turkey, baked potato, sour cream, sugar snap peas. During an observation on 9/9/25 at 11:32 AM, Staff A took the temperatures of the foods on the steam table prior to lunch service. The pureed turkey temped at 131.2 degrees. During an observation 9/9/25 at 11:45 AM, Staff A plated 3 pureed meals first. During an observation on 9/9/25 at 12:25 PM, Staff A conducted post temperatures after the lunch service completed. The pureed turkey temped at 141 degrees. During an interview on 9/11/25 at 8:44 AM, Staff A, Dietary [NAME] queried if she needed to reheat the puree up to a certain temperature after she processed it and Staff A stated she didn't know, because she had never been told. Staff A stated she just knew the holding temperatures and thought it was between 135 and 170 degrees. During an interview on 9/11/25 at 8:54 AM, the Dietary Supervisor queried if the pureed meat needed to be reheated to a certain temperature and the Dietary Supervisor stated yes, it the meat was not up to temperature. The Dietary Supervisor queried on what the meat should be brought up to and the Dietary Supervisor stated 140 degrees or higher. The Dietary Manager stated if the meat started out at 165 it just needed to be held at 140 degrees or higher. During an interview on 9/11/25 at 1:11 PM, the Administrator stated the the meat did not have to brought back up to temperature and the holding temperature needed to be 135 or hot items. The Administrator queried if meats needed to be a higher temperature and the Administrator stated it depended on the type of meat.Per email from the Regional Director of Operations on 9/11/25 at 1:20 PM, revealed on the temperature log form it indicates it needs to hold at 135 degrees, and she didn't believe the facility had a separate policy that she could locate for food temperatures.

Based on clinical record review, staff and resident interviews, Payroll Based Journal (PBJ), and facility document review the facility failed to provide enough staff to care the residents for four out of eight residents reviewed Resident #20, #28, #34 and #54). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #34 dated 6/26/25 listed diagnoses of cerebral palsy, cancer and neurogenic bladder. The Brief Interview for Mental Status (BIMS) assessment reflected a score of 15 out of 15, which indicated intact cognition. The MDS revealed Resident #34 was always incontinent of bowel and bladder. On 9/08/25 at 5:10 PM, Resident #34 reported nursing staff were less on the weekends, but her call light could take too long many days of the week, and many times of the day. She revealed the call light could take hours for staff to answer at least 4 times a week. On 9/11/25 at 2:00 PM, the Assistant Director of Nursing (ADON) reported the facility failed to have a staffing problem. She confirmed some of the resident had reported a concern with call lights and they did have resident complaints about staffing. She reported it may be a failure of the charge nurse to make the staff get up from the nurses station and get the call light. She reported staff calling in happened daily, but they got the shifts covered. On 9/11/2025 at 2:04 PM, the ADON reported the facility staffing was based on the census, the Patient Per Day (PPD). She reported the management company increased the PPD at the beginning of the year and she failed to know that until March or April. The ADON reported she put enough staff on the schedule, the staff can get cares done. The ADON said day shift got 5 Certified Nurse Aide (CNA)s, 3 nurses or 2 nurses, a medication aide and the 5 CNAs, at times they get more. She reported the second shift got 4 CNAs, 2 nurses and a medication aide. The night shift got a nurse and medication aide and 3 to 4 CNAs or 3 nurses and 3-4 CNAs a night. On 9/10/2025 at 12:29 PM, the Administer provided her explanation of why the facility triggered for excessively low weekend staffing due to the facility experienced call offs on 1/12/25, 1/25/25, 2/1/25, 2/15/25, 2/22/25, 2/23/25, and 3/15/25. She reported the facility failed to track the hours of staff members that picked up shifts in nursing. She explained the Business office Manager (BOM) was a Certified Medication Technician (CMT), and housekeeping supervisor was a CMT, the transportation person was a CNA, and the activities director was a CNA. The Administrator reported the staff picked up some of the shifts. She revealed those hours were not always adjusted to the PBJ numbers. The PBJ dated Fiscal year (FY) Quarter 2 2025 (January 1 - March 31), triggered for Excessively low weekend staffing and a One Star Staffing Rating. The Facility Assessment updated 6/19/25, reflected the number of full time (FT) licensed nurses staff providing direct care for the building as 15 and the number of FT Nurse Aides (CNA) as 28. The facility failed to identity how many staff were needed on each shift to care for the residents. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 scored a 15 out of 15 on a BIMS exam, which indicated cognition intact. During an interview on 9/8/25 at 1:04 PM, Resident #20 stated her only concern was that some of the shifts didn't come in and check on the residents. Resident #20 stated the other night she was laying on her left side and couldn't reach her call light and called for help and no one came into her room for 4 hours. Resident #20 stated she knew how long it was because she looked at the clock. 3. The MDS assessment dated [DATE] revealed Resident #54 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. During an interview on 9/8/25 at 1:34 PM, Resident #54 stated she had to wait over an hour before for the call light and she knew it was that long because she watched the clock. Resident #54 stated it happened on all three shifts. Resident #54 stated this morning they checked her brief and then she had to tell the staff to change her after lunch. 4. The MDS assessment dated [DATE] revealed Resident #28 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. During an interview on 9/8/25 at 11:11 AM, Resident #28 stated her call light could be on for 45 to 1 hour. Resident #28 stated the third shift was the worst, and last Saturday they only had two aides and one nurse on the third shift. During an interview on 9/11/25 at 9:08 PM, Staff R, CNA queried on the staffing levels on third shift and Staff R stated she thought it was horrible, but the facility said they were fully staffed. Staff R stated they usually had 3 CNA on third shift, but sometimes there were only 2 CNA and it made it harder to get to the call lights. Staff R stated she didn't know how long the call lights would be on if Staff R was in another hall helping another CNA, but Staff R thought she could get to the call lights within 15 minutes.

Based on observation, record review and staff interview that facility failed to provide adequate linens for bariatric beds for 2 out of 2 residents reviewed with bariatric beds (Resident #3, Resident #41). The facility reported 18 residents who utilized bariatric beds in the facility. The facility identified a census of 66 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. Per this assessment, the resident required substantial/maximal assistance to roll left and right. On 9/09/25 at 4:10 PM, Resident #3 in bed with no sheet below him on the mattress. He did have a bath blanket under parts of him but the mattress was exposed. On 9/10/25 at 7:32 AM, Resident #3 remained in bed with no sheet under, and mattress remained exposed. The resident had bath blanket under part of him. 2. On 9/10/25 at 7:49 AM, Resident #41 observed lying in bariatric bed with no sheet on the bed. The resident observed on bath blanket with no sheet on bed. On 9/10/25 at 9:44 AM Staff E, Certified Nursing Assistant (CNA) stated don't have a lot of bariatric sheets, and depended on the laundry and how fast they come back. Staff E explained East Hall had 2 sheets and there were 4 beds on this wing. Observation of the [NAME] hall linen closet with Staff E revealed there were no bariatric sheets in the linen closet.Per review of an email sent by the Regional Nurse Consultant on 9/11/25 at 2:33 PM, she reported the facility did not have inventory sheet for linens.The facility provided a list of residents which indicated 18 residents had bariatric beds in the facility. On 9/11/25 at 9:59 AM Staff O, Certified Medication Technician (CMT) stated ran out of bariatric sheets from laundry pretty frequently, and had a lot more bariatric beds than in the past. Staff O explained would try to use a flat sheet and tuck it in on the corners. On 9/11/25 at 10:05 AM Staff P, Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) stated bariatric sheets were an issue with staying secured, and knew they ordered the full size regular sheets because they fit the beds much better. Staff P estimated had 5 maybe 6 bariatric beds on the [NAME] hall.On 9/11/25 at 11:08 AM, Staff T, Laundry Aide stated had a lot of bariatric sheets. Staff T explained they took them down, put in the linen closet, and further explained the supervisor did inventory of linens. On 9/11/25 at 11:15 AM, the Housekeeping Supervisor stated regarding fitted bariatric bed sheets, they honestly had not counted them, and needed to go through and mark them. The Housekeeping Supervisor explained there had been no complaints of running out of them per the staff, [Houskeeping Supervisor] didn't really know how many had at this time, they should have sheets available during the day, and if not available they could come get what they needed. On 09/11/2025 at 12:09 PM, the Director of Nursing (DON) stated they sent an email today about getting sheets ordered for the bariatric beds, and it was the bariatric beds that seemed to have a problem. Per the DON, the facility did not take inventory of the sheets, and DON would expect them to have sheets on their beds at all times and we should have a 3 day supply of linens. On 09/11/2025 at 1:12 PM, the Administrator stated was not aware of any problems with bariatric sheets, and further explained found out there was linen closets not being filled and was resolved. Per the Administrator, inventory linens were not being done since I have been here.

Based on observation, clinical record review, staff and resident interviews, and facility policy review the facility failed to ensure residents remained free from verbal abuse, mental abuse, and neglect by facility staff for three of five residents reviewed for staff treatment (Resident #6, Resident#28, Resident #34). The facility reported a census of 66 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident#34 dated 6/26/25 listed diagnoses of cerebral palsy, cancer and neurogenic bladder. The Brief Interview for Mental States (BIMS) assessment reflected a score of 15 out of 15, which indicated intact cognition. The MDS revealed Resident #34 was always incontinent of bowel and bladder. Review of documentation dated 6/30/25 provided as part of a Facility Reported Incident regarding Resident #34 revealed, On 6/30/2025, Social Services was given a grievance form from [Name Redacted], Activity Director regarding resident [Resident #34]. Resident reported to Activity Aide that on second shift Sunday night (June 29), [Staff D], CNA (Certified Nursing Assistant) told resident that she had to earn [Resident #34's] respect and that no one liked her. Resident further stated that [Staff D] told her no one was going to come in and take care of her. The resident also said that she doesn't want to get anyone in trouble; she would just like respect. Administrator interviewed resident, [Resident #34]. Resident stated [Staff D] came into her room around 6:45 pm on 6.29.25 and asked [Resident #34] why she was talking to other staff members about her when the resident knows what she is saying is not true. Resident was telling other staff that [Staff D] said, All you do is poop and roll around. According to the resident, [Staff D] proceeded to tell her that no one liked her, and they were not going to come in to care for her. Resident further states that [Staff D] told her that [Staff D] is going to continue to be on East hall and that she was going to write up a grievance on the resident. Resident feels she was verbally and emotionally abused and states that she is afraid of this CNA Resident's roommate was also interviewed who stated that it sounded to her like [Staff D] was badgering the resident. Review of a statement by Staff D dated 7/2/25 revealed, in part, On Sunday 6/29/25 I came to worked about 1/2way through my shift a housekeeper had come to me stating that [Resident #34] was going around to anyone that would listen to her that I was saying all she does is eat (and) poop. I waited untill <sic> the call light came on for that room myself and [Name Redacted] who was training answered the call light I had let [Resident #34] know that I would be filing a grievance on her because she was going around telling any employee who would listen to her [Resident #34] then screamed at me that I dont treat her with respect or dignity I turned and left the room. On 9/08/25 at 4:59 PM, Resident #34 named Staff D, Certified Nurse Aide (CNA) as the staff that failed to treat her with respect and dignity telling others all she did at the facility is eat, poop and roll around. Resident #34 described Staff D as inappropriate and the rudest thing. She felt horrible after she knew that's how Staff D talked about her to other. On 9/09/25 at 11:28 AM, Resident #4 explained she didn't hear the start of [Staff D] and [Resident #34's] conversation, she just heard that [Resident #34] was going to file a grievance on [Staff D]. Then [Staff D] got in [Resident #34's] face within a few feet and said she would file one right back on [Resident #34], then they turned and left the room. On 9/10/25 at 5:40 PM, Resident #34 sat at the table in in the dining room in her wheelchair. On 09/10/25 at 9:29 AM, Staff C, Licensed Practical Nurse (LPN) confirmed she worked on 6/29/25 on Resident #34's hall. She said Staff D worked on Resident #34's hall, and she revealed Resident #34 told her Staff D treated her rudely. On 9/10/25 at 10:21 AM, Staff E, CNA reported Resident #34 told Staff D, she treated her disrespectfully. On 9/10/25 at 10:12 AM, Staff F, CNA confirmed she worked on 6/29/25 with Staff D. She revealed Staff D used the words ate and pooped in reference to Resident #34. She indicated Resident #34 took it the wrong way. Staff F said that Staff D reported Resident #34 ate, pooped and rolled around today. Staff F reflected the CNA meant she ate all her meals and had bowel movements (BM) 3 times today. Staff F reported Resident #34 took the conversation the wrong way. Staff F reported Staff D needed to use better language when talking about residents. On 9/11/25 at 8:28 AM, Staff D, CNA confirmed she worked on 6/29/25. Staff D confirmed Resident #34 went to others in the facility and told them that she was going around telling anyone that Resident #34 just ate and poop. Staff D said she never said that to Resident #34. Staff D reported Resident #34 yelled at her the she failed to respect her and failed to treat her with dignity. Staff D revealed the facility suspended her for incident on 6/29/25 and then the facility terminated her. On 9/11/25 at 2:40 the Director of Nursing reported she expected all the staff to treat resident with respect and dignity. The Progressive Discipline Report & Plan for Staff D, dated 7/8/25, revealed the following date of incident: 6/29/25. The report revealed the employee had been terminated. The Incident Summary revealed the following: [Staff D] was reported by a resident for telling that resident that she did not respect her and that the resident had to earn [Staff D's] respect. [Staff D] also told the resident that none of the employee's at the facility liked her and none of them would even come and provide care for her. [Staff D] then told the resident that she was going to put her to bed at that time, despite protests from the resident saying she did not want to go to bed at that time. [Staff D] then told the resident that she would be filing a report on her for yelling at her. [Staff D] later told the administrator that she heard froother <sic> employees that the resident told them that [Staff H] said to her that all she did was eat and poop. [Staff D] did not deny saying this when she brought it up. The Progressive Discipline Report & Plan further revealed the following per the Code of Conduct and/or Employee Handbook Violations section: #18: Engaging in physical harassment, sexual harassment, disruptive or abusive behavior, or disrespect towards fellow employees, residents, visitors or others. #19. Engaging in resident physical, emotional, or verbal abuse; resident neglect; or by violating any of the Resident Rights. Also written in the section was the following: Violating the [Name Redacted] training on customer service expectations. The Corrective Action Plan section documented, [Staff D] has been coached and warned previously for how she treats others in our building. Due to the continuation of this behavior and the fact this unacceptable attitude was directed towards a resident, it has been decided to terminate [Staff D] at this time. Review of the Facility Policy titled Abuse, Neglect, and Exploitation approved 8/30/18, and revised 4/29/25, revealed the following: Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation including abuse that is facilitated or enabled through the use of technology. 2. The MDS assessment dated [DATE] revealed Resident #28 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The Care Plan revealed a focus area dated 8/11/25 for history/potential for behavior problem and antagonizing other residents. The interventions dated 8/11/25 revealed if reasonable, discuss disruptive behavior(s) and explain/reinforce why behavior is unacceptable; and intervene as necessary to protect the rights and safety of others; and approach/speak in a calm manner; divert attention; and remove from situation and take to alternate location as needed. During an interview on 9/8/25 at 10:53 AM, Resident #28 queried on how staff treated her and Resident #28 stated the receptionist called her a *itch and the receptionist said she would kick Resident #28 in the hip if Resident #28 came around the desk. Resident #28 stated she thought the situation was handled, but she was called up to the office to discuss the receptionist coming about to the facility. Resident #28 stated if the facility let the receptionist come back, Resident #28 would leave the facility because Resident #28 wouldn't tolerate being threatened. During an interview on 9/10/25 at 3:25 PM, Staff J, Receptionist queried on the incident that occurred between Staff J and Resident #28. Staff J stated she thought Staff J and Resident #28 were friends because Resident #28 would come and talk with Staff J at the desk. Staff J stated the day before the incident Resident #28 was upset about another resident being near her cup at that the receptionist desk. Staff J stated the day of the incident Resident #28 came up to Staff J and told Staff J to apologize to Resident #28 and Staff J said she didn't have anything to apologize for. Staff J stated Resident #28 then threaten to punch Staff J in the stomach and Staff J had a [medical condition]. Staff J asked if Staff J yelled or cussed at Resident #28 and Staff J stated no. Staff J stated after the incident she went home and has not worked since. During an interview on 9/10/25 at 3:41 PM, Staff K, CNA stated she witnessed the incident with Staff J and Resident #28. Staff K stated she heard Resident #28 say something about another resident trying to touch her drink on the receptionist's desk and Staff J moved around the desk and said something to Resident #28, but didn't hear it. Staff K said she heard Staff J say, she wasn't going to play like this and lose her job. Staff K stated, Staff J shouldn't of talked like that in front of the residents and Staff J shouldn't of said anything to Resident #28. During an interview on 9/10/25 at 7:48 PM, Staff L, CNA stated she didn't think Staff J raised her voice at Resident #28, but at one point Staff J did tell Resident #28 to get out of her face. During an interview on 9/10/25 at 7:54 PM, Staff G, Dietary Aide queried about the incident with Resident #28 and Staff J and Staff G stated she didn't hear much except both Resident #28 and Staff J yelling at each other. During an interview on 9/11/25 at 10:14 AM, the Housekeeping Supervisor queried on the incident between Resident #28 and Staff J and the Housekeeping Supervisor stated she heard Staff J tell Resident #28 to “get the f**k away from the desk”. During an interview on 9/11/25 at 11:52 AM, the Administrator queried on the thoughts of the incident between Staff J and Resident #28, and the Administrator stated her investigation revealed inappropriate language used by Resident #28 and Staff J. The Administrator stated she concluded that Staff J was trying to do her job and got frustrated and expressed her frustration onto the resident. The Administrator asked if it was appropriate to cuss at residents and the Administrator stated no, she wouldn't say that. The Administrator stated Staff J should have asked for additional assistance or asked the Administrator to come back into work. Review of the Facility Policy titled Abuse, Neglect, and Exploitation approved 8/30/18, and revised 4/29/25, revealed the following: Review of the Facility Policy titled Abuse, Neglect. and Exploitation approved 8/30/18, and revised 4/29/25, revealed the following: Verbal Abuse: Use or oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated cognitively intact. It further indicated diagnoses including: hypertension (high blood pressure), diabetes, anxiety disorder, and depression. The Care Plan created 4/5/22, initiated 8/3/22, and revised 3/11/24 revealed, ADL (activities of daily living) self-care performance deficit Activity Intolerance, Impaired balance, Limited Mobility, Right Below Knee amputation. The Intervention created 4/5/22 and revised on 12/2/24 revealed the following for bed mobility: requires staff assistance to turn and reposition in bed. The Intervention dated 3/11/24 and revised 9/8/25 revealed the following for transfers: 2 assist HOYER (mechanical lift): BLUE SLING ONLY. On 09/09/25 at 8:27 AM, Resident #6 stated on Sunday staff did not get him out of bed at all, they told him they did not have enough staff, and most days it was 10:00 to 10:30 AM before could get up to his chair due to not enough staff. Resident #6 observed in bed waiting for breakfast tray. On 9/10/2025 2:00 PM, Staff I, Registered Nurse (RN) stated she was aware of Resident #6 not getting up on Sunday and staff telling him it was because of low staffing. This was not the case they had a Certified Nursing Assistant (CNA) on the [NAME] hall. Staff I also offered to help get him up but the CNA working did not want to get him up. She stated it was the attitude and the backlash from the CNA on why things didn't get done. She had reported this to the Director of Nursing (DON) and it had not helped. She had not gone further up the chain of command. You can't tell the aides what to do related to the backlash you get from them. On 09/11/2025 at 12:16 PM the Director of Nursing (DON), RN stated even when staff were short they should still get residents up for the day even if they are late, [facility] didn't really run short staff, and administration also had gone out and helped to get residents up. On the weekends there was a manager on duty and were fully staffed. There were three nurses on then and one of the nurses needed to be in the dining room for the meal. We have heard of issues with CNA not doing things and refusing to cooperate with the nurses but it has been addressed or is in the works of being addressed. Review of the Facility Policy titled Abuse, Neglect, and Exploitation approved 8/30/18, and revised 4/29/25, revealed the following: Deprivation of Good and Services: Deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Example includes staff has the knowledge or ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s) which result in care deficits to the resident(s).

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to provide incontinence care for two out of two residents reviewed (Resident #2 and Resident #20). The facility reported a census of 66 residents.Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 listed diagnoses of cerebrovascular accident (CVA),anxiety, and depression. The Brief Interview for Mental Status (BIMS) exam revealed a score of 14 out of 15, which indicated intact cognition. The MDS reflected Resident #2 was always incontinent of bowel and bladder. The Care Plan for Resident #2 initiated 2/9/22, revised 3/1/22, revealed, ADL (activities of daily living) self-care performance deficit Impaired balance, Limited Mobility, stroke. The Intervention dated 12/12/24 directed utilize check and change to manage incontinency. The Intervention dated 12/11/24 directed assist of 1 staff for personal hygiene. On 9/10/25 at 1:09 PM, Resident #2 laid in her bed, Staff B, Certified Nursing Assistant (CNA) washed her groin and turned the resident on her right side. Staff N, Licensed Practical Nurse (LPN) completed wound care. Staff B placed a brief under Resident #2 and rolled her onto her back. At 1:17 PM, Staff B reported Resident # 2 voided urine, she needed to wash her, and changed the brief and the incontinent pad under her. Staff B rewashed the groin, changed the brief and the incontinent pad under Resident #2, and failed to wash her buttocks. On 9/10/25 at 1:25 PM, Staff B, CNA reported she found Resident #2's depend wet when she got in her room. Staff confirmed she washed the front and thought she washed Resident #2's back side. She reported when she turned her for the wound care she voided urine again. Staff B said Resident #2 needed a new incontinence pad and new brief. She reported she failed to wash her back side the last time. On 9/11/25 at 10:21 AM, Staff M, Licensed Practical Nurse (LPN) confirmed incontinence cares were completed after every incontinent episode. She said she expected all parts of the skin washed that came in contact with urine or bowel movement (BM). On 9/11/25 at 10:30 AM, Staff E, CNA reported they complete peri care anytime a resident was incontinent of urine or BM. On 9/11/25 at 2:45 PM, the Director of Nursing (DON) confirmed she expected the staff to complete peri care after each incontinent episode. 2. The MDS assessment dated [DATE] revealed Resident #20 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS indicated the resident dependent with toileting hygiene and always incontinent of bowel and bladder. The MDS revealed diagnoses for depression and Parkinson's disease without dyskinesia, without mention of fluctuations. The Care Plan revealed a focus area dated 8/23/24 for Activities of Daily Living (ADL) self-care performance deficit due to disease process (Parkinson, weakness, history of falls), and limited mobility. The interventions dated 9/10/24 revealed the resident did not use bed pan, toilet or commode and to utilize check and change to manage incontinency. During an interview on 9/8/25 at 1:04 PM, Resident #20 stated it depended on the staff when she got changed every couple of hours. During an interview on 9/10/25 at 10:56 AM, Resident #20 laid in bed and stated staff changed her right before breakfast, which was around 8:30 AM. Resident #20 stated the staff changed her at least twice in a shift. During an observation on 9/10/25 at 12:50 PM, Resident #20 sat up in her chair and ate her lunch. During an observation on 9/10/25 at approximately 1:00 PM, Staff E, CNA took the mechanical lift into Resident #20 room. During an interview on 9/10/25 at 1:35 PM, Staff S, CNA queried on when Resident #20 changed today during Staff S's shift. Staff S stated Resident was checked and changed after breakfast this morning, then Staff S and Staff E didn't realize therapy had gotten Resident #20 up until after Staff E went to get Resident #20 lunch tray. Staff S stated therapy would have gotten Resident #20 up between 9 AM and 11 AM. Staff S stated they were going to change her after lunch, but Resident's bed was deflated and they didn't want to put Resident #20 in bed and hurt her. Staff S stated she wasn't sure if Resident #20 had been changed yet. When asked how often residents were changed in her shift, Staff S stated it depended, but usually in the morning before breakfast, lunch and before shift ended. When asked how often residents needed checked and changed, Staff S stated every 2 hours. During an interview on 9/10/25 at 1:57 PM, Staff E stated check and changes needed done every 2 hours and for some residents more often. Staff E confirmed Resident #20 required check and change. Staff E asked when Resident #20 checked and changed today, and Staff E stated he didn't know when therapy got Resident #20 up and Resident #20 was still eating when he went to get her tray. Staff E stated when he went to get Resident #20 up, Resident #20 bed was deflated and didn't want to lay her on the deflated bed. Staff E asked if Staff E changed Resident #20 brief today and Staff E stated Staff S changed Resident #20 around 10, and then Staff E went into her room around 12:30 to check and change her, but Resident #20 refused. During an interview on 9/11/25 at 11:29 AM, the Director of Nursing (DON) confirmed check and changes needed completed every 2 hours. The DON asked how she thought check and changes were going and the DON stated it depended on the shift and the DON was working with the shifts to make sure the staff knew the policy and procedures. The DON asked how often Resident #20 should be checked and changed and the DON stated Resident #20 always incontinent and needed check at a minimum of every 2 hours. During an interview on 9/11/25 at 2:16 PM, the Regional Nurse Consultant stated the did not have a policy for the time frame of check and changes and to refer to the care plan. The Regional Nurse Consultant stated the professional standard of care is no longer than 2 hours. The Facility Incontinent Cares dated 7/21/22 revealed: a. Cleanse Perineal Area with a Perineal Cleanser. b. Females: Separate Labia, Cleanse one side and then the other, Cleanse center of the Labia wiping towards the Rectal Area. c. Cleanse Perineal Area from Front to Back. d. Cleanse Thighs, Rectal Area & Buttocks.

Based on employee file review, staff interviews, and facility policy review the facility failed to ensure a staff member completed the required Dependent Adult Abuse training withing six months of hire for one of eight staff reviewed (Staff S, Certified Nurse Aide). The facility reported a census of 66 residents.Findings include:Review of Staff S, Certified Nurse Aide (CNA)'s employee file listed she started on 2/27/25. The file failed to include Dependent Adult Abuse (DAA) certificate of training. The facility provided a document that reflected Staff S started on 2/20/25.The Time Card Report dated 9/10/25 revealed Staff S worked 7.75 hours that day.On 9/11/2025 at 9:59 AM, Human Resource Specialist reported new staff were required to complete the DAA training within 6 months of hire.On 9/11/25 at 10:15 AM, the Administrator reported Staff S attempted to complete the training and the system shut down on her. The Administrator confirmed Staff S failed to get the DAA training finished. The facility provided the policy titled Abuse, Neglect and Exploitation dated 4/29/25, directed facility staff shall be provided education upon hire, and at least annually thereafter, regardingResident's Rights, including freedom from abuse, neglect, mistreatment, misappropriation of property, exploitation and the related reporting requirements and obligations.

Based on observation, record review and staff interview the facility failed to utilize proper technique when dispensing oral medications to prevent spread of infections. The facility also failed to maintain a catheter bag off the ground to prevent infections for 1 of 2 residents reviewed for catheters (Resident #3). The facility reported a census of 66 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. It further indicated diagnoses including: atrial fibrillation (irregular heart beat), heart failure, urinary tract infection and chronic obstructive pulmonary disease. Per the assessment, the resident had an indwelling catheter. Review of the Order Summary Report with active orders as of 9/11/25 revealed an order for foley catheter to be changed every 30 days and as needed.The Care Plan for Resident #3, date initiated 7/7/25, indicated the resident needed catheterization. The interventions failed to direct staff for placement of the catheter. On 9/09/25 at 8:09 AM, Resident #3 observed in bed, and resident's catheter bag resting on the ground and no privacy bag covering it. Resident #3 stated staff were too busy to take care of it. On 9/09/25 Resident #3 sat on the side of bed with feet hanging down uncovered, and feet rested on the catheter bag which was on the ground uncovered. On 9/09/25 at 11:52 AM, Resident #3 laid in bed and had catheter bag on the ground not covered.On 9/11/25 at 9:58 AM Staff O, Certified Medication Technician (CMT) stated catheter bags should be maintained below level of the bladder and off the floor, a dignity bag or privacy cover over it at all times, and it should never be on the floor or uncovered. On 9/11/25 at 10:10 AM, Staff P, Licensed Practical Nurse (LPN) , Assistant Director of Nursing (ADON) stated catheter bags at bedside should not touch the floor, should be up on the bed or wheelchair, and should always be covered by a dignity bag. On 9/11/25 at 12:14 PM, the Director of Nursing (DON) stated catheter bags should be maintained below the level of the bladder up off the floor, and covered at all times. The facility provided an undated policy titled Indwelling Urinary Catheter Care and Removal which directed staff to keep the catheter and drainage tubing free from kinks to allow free flow of urine, and keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of urinary tract infections (UTI). Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent UTI. 2.) On 9/10/25 at 8:11 AM Staff O, Certified Medication Technician (CMT) during medication pass she dispensed pill into hand and then placed in a medication cup. On 9/10/25 8:43 AM Staff O, CMT during medication put pills in her hand to administer to a resident. Staff O transferred the pills from the medication cup into her hand to help resident take them and then assisted to put in residents mouth. On 9/11/25 at 9:56 AM Staff O, CMT stated I take medication out of the packs and put directly into the cup. If it is in a bottle put the medication on the lid and then put in the cup. You should not put it in your hand and then put in the cup. On 9/11/25 at 10:07 AM Staff P, Licensed Practical Nurse (LPN) stated medications should be handled with gloved hands or should be punched out of the pack into the medication cup or take from envelope or bottles directly into the medication cup. If assisting a resident to get the medications in their mouth should use a spoon unless a resident requests it in their hands. On 9/11/25 at 12:03 PM the DON stated when staff dispense medication they should never touch with their hands and should put in a medication cup. The facility provided a policy titled Medication Administration - General Guidelines revised 10/2017 failed to address the handling of medications or direct staff how to dispense medications.

Based on staff and resident interviews, Payroll Based Journal (PBJ), and the Facility Assessment the facility failed to assess and identify the number of nursing staff needed during the week, weekends, and the different shifts. The facility reported a census of 66 residents.Findings include: The Facility assessment dated [DATE] reflected the building needed 15 full time (FT) Nurses and 28 FT Certified Nurses Aides. The Facility Assessment lacked the number of nurses and CNAs needed based on days, nights, or weekends to care for the residents. The PBJ Fiscal Year (FY) Quarter 2 2025 (January 1 - March 31) triggered for excessively low weekend staffing. On 9/08/2025 at 5:10 PM, Resident #34 reported nursing staff are less on the weekends, but her call light can take too long many days of the week, and many times of the day. She revealed the call light could take hours for staff to answer at least 4 times a week. During an interview on 9/8/25 at 1:34 PM, Resident #54 stated she had to wait over an hour before for the call light and she knew it was that long because she watched the clock. Resident #54 stated it happened on all three shifts. Resident #54 stated this morning they checked her brief and then she had to tell the staff to change her after lunch. On 9/10/2025 at 12:29 PM, the Administer explained the facility triggered for excessively low weekend staffing due to staff called in. The Administrator reported because of budget changes, they started scheduling more staff in April. On 9/11/2025 at 1:11 PM, the Administrator confirmed the Facility Assessment failed to address the number of staff needed per shift, and reported she edited it. On 9/11/2025 at 1:18 PM, the Administrator reported staffing was based on the number of resident and the type of resident on the halls. The Facility assessment dated [DATE] revealed the following per the Purpose section: The facility assessment . is a complete review of the internal human and physical resources required by the facility to care for the residents completely during the day (including nights and weekends) and emergency operations. The facility assessment identifies your capabilities as a skilled nursing service provider. The Facility Assessment will be the basis for your surveyors to ascertain whether you are prepared to completely take care of the population you have identified that you will serve.

Based on observation, record review, and staff interviews, the facility failed to maintain 3 of 3 Shower Rooms in a functional and sanitary manner. The facility reported a census of 66 residents. Findings include: Observations on 1/12/25 revealed: At 2:12 p.m., the East Hall Shower Room with tiled shower stall that measured approximately 6 feet long by 4 feet wide, with 2 inch square tiles on the floor. Four floor tiles were missing in the shape of a square near the entrance to the stall, 8 floor tiles were missing by the drain in the shape of an L, and 2 floor tiles were missing in a rectangular shape at the rear of the shower stall. The grout between the floor tiles appeared dirty, a dark gray color, and the grout along the floor/wall junction of the left and rear walls with a thick black residue. At 3:03 p.m., the [NAME] Hall Shower Room with tiled shower stall that measured approximately 6 feet long by 4 feet wide, with 2 inch square tiles on the floor that had a dark gray colored build up of residue on the grout between the tiles. The space at the junction between the floor tiles and the left wall had what appeared as caulk that was once white, very dirty in appearance and with orange colored calcium or similar build up that was also present at the floor/wall junction at the rear of the shower stall, and also present from the rear corner to approximately 8 inches of the right wall. The discoloration and build-up was also present on the wall from the floor up to approximately 8 inches high at the 2 rear corners of the stall. At 3:07 p.m., the North Hall Shower Room with tiled shower stall that measured approximately 6 feet long by 4 feet wide, with 2 inch square tiles on the floor, and 6 inch wide by 8 inch high tiles along the wall. The grout between the floor tiles had a dark gray dirty appearance, heavier and black colored in some areas, the area between the floor and right wall appeared to have what was at one time white [NAME], now had several areas of dark gray residue build-up, and a white colored 4 inch high rubber wall base along the right wall had a black colored build up located at the top of it along the front 4 inches of the stall. The wall tiles along the bottom of the wall at the rear and left side of the stall were cut to approximately 3 inches high by 6 inches wide, 3 consecutive tiles were not on the wall at the rear of the stall and laid on the floor, and revealed an exposed crumbling structure that had both black and light colored areas. Six of the wall tiles along the wall/floor junction at the rear of the stall had a thick black residue buildup, and the remaining left wall tiles along the floor either had some black residue, or build up of black residue in the grout areas, or both. The black residue was also present on the floor along the left wall, and measured from 1/2 inch to 1 inches wide. During an interview on 1/12/25 at 2:19 p.m., Staff A, Certified Nursing Assistant (CNA), stated the tiles had been missing from the floor of the East Hall Shower Room for several months, and she thought the Housekeeping Department was responsible for the cleaning required in the Shower Rooms. During an interview on 1/12/25 at 2:56 p.m., the Interim Administrator stated the previous Administrator said something about tiles missing from the wall by the entrance to the East Hall shower stall. She stated Maintenance Staff were supposed to be working on that, and she had been unaware of the missing floor tiles and condition of the grout/build-up of dark gray residue. After the observation of [NAME] Hall Shower Room on 1/12/25 at 3:03 p.m., the Interim Administrator stated she thought Housekeeping cleaned the tile floor in the Shower Rooms but she would check with Maintenance Staff as far as cleaning the grout and who was responsible for that. During an observation on 1/14/25 at 10:10 a.m., a sign posted on the East Hall Shower Room door stated the room closed for repairs. Repairs observed included: all tiles on the floor of the shower stall replaced, the grout between the floor tiles cleaner, and the black colored residue along the edge of the wall in the stall also appeared much lighter in color and amount. During an observation on 1/14/25 at 10:13 a.m., a sign posted on the North Hall Shower Room door the room was closed for repairs. Repairs observed included: new white colored [NAME] applied to the floor/wall junction along the right wall and the black colored area above the wall base had been removed, a new piece of white rubber wall base approximately 4 inches high had been applied to the rear and left walls of the shower stall, and white [NAME] applied to the floor edge along the wall base. The grout of the shower stall floor appeared cleaner. The black colored areas along the left wall had been removed or covered by the rubber wall base. During an observation on 1/23/25 at 9:41 a.m, the floor grout and lower wall area of the [NAME] Hall Shower Room had been cleaned, with the orange discoloration removed; and the floor gout now a light gray color and previously observed build up removed. During an interview on 1/14/25 at 10:19 a.m., the Interim Administrator stated the repairs to the 3 Shower Rooms had been made the day of the initial observation [1/12/25]. She stated staff could use the Shower Rooms that day once the grout had dried, and able to complete the repairs due to a re-prioritization of needs within the facility. A review of the facility policy, reviewed on 4/28/22, titled Safe Homelike Environment included the following Policy statement: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The Procedure section directed staff, in part: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on clinical record review, facility policy review, and resident and staff interviews, the facility failed to provide resident baths/showers twice weekly or as directed by resident preference for 4 of 5 residents (Resident's #2, #3, #4 and #5) reviewed in the sample. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. The MDS diagnoses listed included morbid obesity, depression, and wound infection. The MDS indicated Resident #2 required substantial staff support for bathing. The Care Plan, initiated on 7/10/23, included a Focus area to address ADL (activity of daily living, meaning showers, toothbrushing, etc.) self-care performance deficit Impaired balance, Limited Mobility. The Focus area included I may refuse baths at times. Please offer me a bed bath if I refuse a bath. Interventions, initiated on 7/10/23, included, in part: a. Bathing/Showering: Offer Bathing/Showering twice weekly and as necessary . b. Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated . During an interview on 1/23/25 at 10:40 a.m., Resident #2 stated he refused a shower on a Monday, over a week ago because he didn't feel well. He stated, otherwise he had not refused baths or showers, and had not been offered another bath or shower since that time. The resident stated there for a while, the shower situation had gotten better, but worse again during the last couple of weeks. A review of the facility Shower Book on 1/12/25, revealed the Resident #2 refused a shower on 1/2/25, and no other documentation of completed showers or baths or refusals. 2. The MDS assessment dated [DATE] revealed Resident #3 scored 15 out of 15 on the BIMS which indicated intact cognition. The MDS indicated Resident #3 required moderate staff support for bathing. The MDS listed diagnoses included: chronic obstructive pulmonary disease (COPD), generalized muscle weakness, and morbid obesity. The Care Plan, initiated on 1/31/23, included a Focus area to address ADL self-care performance deficit Activity Intolerance. Interventions revised on 12/12/24, included, in part: a. Resident has refusal of bathing/showering cares b. Resident has voiced that she will only take a shower weekly and will wash self in room as needed. During an interview on 1/23/25 at 7:22 a.m., Resident #3 stated the last shower she received was 1 week ago on 1/16/24 [Thursday] and preferred to be showered 1 time a week,. Prior to 1/16/25 she had not had a shower for 5 weeks, she said something about it to therapy staff, thought they alerted nursing management and that was why she was offered a shower last Thursday. When reviewed on 1/12/25, the facility's Shower Book revealed no documentation of any showers or baths completed for the resident. 3. The MDS assessment dated [DATE] revealed Resident #4 scored 15 out of 15 on the BIMS cognitive assessment, which indicated intact cognition. The MDS diagnoses listed included: muscular dystrophy, weakness and type 2 diabetes. The MDS indicated Resident #4 required substantial staff support for bathing. The Care Plan, initiated on 5/10/24, included a Focus area to address ADL self-care performance deficit. Interventions, initiated on 5/10/24 included, in part: a. Bathing/Showering: 2 Assist - includes Transfer to/from shower chair/whirlpool. b. ADL - Bathing 2x/week and as needed. During an interview on 1/22/24 at 10:52 a.m., Resident #4 stated he couldn't remember exactly the last time he had a bath or shower, but thought it was around Christmas time, and knew he had not had a bath or shower since he returned from the hospital. Record review revealed the resident hospitalized from 1/10/25 to 1/15/25 when he returned to the facility. When reviewed on 1/12/25, the facility's Shower Book revealed the resident hospitalized on [DATE], and no documentation of any showers or baths completed for the resident. 4. The MDS dated [DATE] revealed Resident #5 scored 15 out of 15 on the BIMS cognitive assessment, which indicated intact cognition. The MDS listed diagnoses include: immobility syndrome, type 2 diabetes, chronic obstructive pulmonary disease. The MDS indicated Resident #5 required substantial staff support for bathing. The Care Plan, initiated on 4/19/21 included a Focus area to address ADL self-care performance deficit. Interventions included, in part: a. ADL bathing on Wednesdays and Saturdays, 2nd shift and as needed, initiated 5/30/21. b. Prefers a bed bath, initiated 11/20/23. c. Provide a sponge bath when a full bath or shower cannot be completed, initiated 12/1/23. During an interview on 1/23/25 at 10:18 a.m., Resident #5 stated she was supposed to get bed baths twice a week on Wednesday and Saturday, usually received them 1 time a week on Wednesday, her last bed bath was on 1/22/25, she seldom received her baths on Saturdays and preferred to have bed baths twice weekly, and it had been several years since she had a shower. When reviewed on 1/12/25, the facility's Shower Book revealed the resident had a bed bath on 1/8/25, and a shower on 1/11/25. During an interview on 1/23/25 at 10:21 a.m., Staff C, Assistant Director of Nursing (ADON) stated she monitored the Certified Nursing Assistants (CNA's) completion of assigned showers, and changed the daily staff assignment sheet to include names of the residents that were scheduled for a bath/shower, and the staff assigned to complete the activity, the change was put into place today. A review of the facility policy, last reviewed on 7/21/22, titled ADL Care Bathing Policy revealed a Policy statement: Nursing staff will assist in bathing Residents to promote cleanliness and dignity. The Charge Nurse will be made aware of Residents who refuse bathing.

Based on observation, clinical record review, resident and staff interviews, the facility failed to answer call lights within 15 minutes, with an observation of a staff response time of 32 minutes. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. The MDS diagnoses listed included morbid obesity, depression, and wound infection. The MDS indicated Resident #2 required substantial staff to change positions in bed, transfer to and from bed and chair, dressing toileting and bathing. During an interview on 1/23/25 at 10:40 a.m., Resident #2 stated he used his call light at least 3 or 4 times a day, and staff response times were usually 45 minutes or longer, it didn't matter what time of day or what day of the week. 2. The Daily Assignment Schedule for the Day Shift on 1/14/25 revealed Staff G, Certified Nursing Assistant (CNA), was the CNA assigned to the North Hall. When a call light is activated, a box in the hallway outside of a resident room will illuminate. The call light board by the Nurse's Station will also activate with an illuminated indicator by resident room numbers. A continuous observation on 1/14/25 from 9:54 a.m. to 10:27 a.m. revealed: a. At 9:54 a.m., observed a call light activated by Resident #9 on the North Hall. Resident #9 a resident on the North Hall. Staff D, Registered Nurse (RN), stood at a medication cart for the North Hall, positioned near the Nurse's Station. Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA sat at the Nurses Station. The indicator for the residents who activated illuminated by the resident's room number on the call light board at the Nurse's Station. b. At 9:59 a.m., Resident #9 call light remained activated. Staff E, CNA and Staff F, CNA seated at the Nurses Station. The MDS, dated [DATE], indicated Resident #9 had a BIMS score of 11 out of 15, which indicated a mild cognitive impairment. The diagnoses listed included: chronic obstructive pulmonary disease, psychotic disorder, and non-Alzheimer's dementia. The MDS indicated Resident #9 required assist of one for transfers for chair/bed-to chair, to get on/off toilet, toilet hygiene and mobility. c. At 10:02 a.m., Resident #9 call light remained activated. Staff D, RN at the medication cart near the Nurse's Station preparing medications. Staff E, CNA and Staff F, CNA seated at the Nurses Station. d. At 10:09 a.m., Resident #9 call light remained activated. Staff E, CNA and Staff F, CNA seated at the Nurses Station. e. At 10:14 a.m., Resident #9 call light remained activated. Staff E, CNA and Staff F, CNA seated at the Nurses Station. f. At 10:19 a.m., Resident #9 call light remained activated. Staff E, CNA and Staff F, CNA seated at the Nurses Station. g. At 10:21 a.m., Resident #9 call light remained activated. Staff D positioned at the medication cart by the Nurses Station. Staff E, CNA and Staff F, CNA seated at the Nurses Station. At 10:21 a.m., 2 call lights activated on the East hall. h. At 10:25 a.m., Resident #9 call light remained activated on the North Hall, and the 2 on the East Hall remained activated. During an interview, Staff D stated Staff G, CNA assigned to the North Hall was on a break. Staff E, CNA observed leaving Nurses Station to go to the East Hall. Staff F, CNA remained at the Nurses Station. i. At 10:26 a.m., Resident #9 call light remained activated. Staff D, RN observed knocking on Resident #9 door and entered the room. The call light turned off and Staff D exited the room at 10:27 a.m. During an interview, Staff D stated Resident #9 requested he be changed as he had been incontinent. Staff D left the room door partially open and went back to her medication cart positioned near the Nurse's Station j. At 10:29 a.m., the door to Resident #9 door remained partially opened and no staff had entered the room. k. At 10:31 a.m., staff entered Resident #9's room and closed the door. From the start of the observation until the time staff entered the resident room [ROOM NUMBER] minutes elapsed. During an interview on 1/14/25 at 11:50 a.m., the Director of Nursing (DON) and the Interim Administrator were asked who answers call lights when the assigned CAN is on break or is assisting with a meal service. The DON stated the nurse, another CNA or any staff in the hallway should answer a call light. The Interim Administrator agreed with the DON. The DON stated staff were expected to answer activated resident call lights in a timely manner.

Based on clinical record review, policy review and staff interview the facility failed to ensure a resident received their ordered medications and not someone else for 1 of 5 residents reviewed (Resident #1). On 6/3/24 as the nurse and Certified Medication Aide (CMA) passed the medication to the residents, the CMA delivered the wrong medications to Resident #1. Following the error, the CMA reported the incident to the nurse who notified the appropriate people. After receiving notification, the provider gave the nurse an order to send Resident #1 to the emergency room (ER) for further evaluation. During her stay in the ER, Resident #1 had a change in condition due to the accidental overdose, that resulted in the need to have tube placed down her throat to assist her with breathing (intubated). Due to the severity in her change in condition, the provider admitted her to the intensive care unit (ICU). This resulted in an immediate jeopardy (IJ) situation. The facility reported census of 60. The Department notified the facility of the IJ on 6/18/24 at 8:45 AM. The facility corrected the deficient practice as of 6/4/24 by implementing the following: a. The facility sent Resident #1 to the hospital the night of 6/3/24 at around 10:45 PM and returned to the facility on 6/1 l/24. Resident #1 has since received all scheduled medication as ordered. b. The interview of Resident #5 on 6/4/24 and review of the Medication Administration Record (MAR) reflected she received scheduled medication as ordered since 6/4/24. c. The facility immediately suspended the two employees pending a full investigation of the incident on 6/4/24. The nursing leadership completed a whole house audit on 6/4/24 to ensure the MAR was correct. d. The facility conducted interviews on 6/4/24 of all interviewable residents that the staff involved were responsible for and there were no reports of any other missed medication administration. On 6/7/24 after the completion of the investigation, the facility terminated the employees. On 6/4/24 the facility immediately completed competencies, skills validation and education to all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Medication Technician (CMTs) regarding the policy of medication administration which includes: i) Section 7.2 section A #4 on page 1 of 6 which states the five rights to medication administration. ii) Section 7.2 section B #7 on 4 page of 6 which states 'The person who prepares the dose, for administration is the person who administers the dose. iii) Section 7.2 B # 15 page 4 of 6 which states Medication supplied for one resident are never administered to another resident: All licensed nurses and CMTs who were in house, as well all other licensed nurses and CMTs completing competencies. skills validation and education before the start of their next shift by nursing leadership started on 6/4/2024. Any and all qualified persons will not administer medication before receiving the education provided, including new hires who will have the skills competencies completed before the start of their first shift. The facility will not schedule a RN, LPN, or CMT until they complete their education and skills competencies. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension, renal insufficiency, and a seizure disorder. The MDS listed Resident #1 received dialysis while a resident in the facility. The Medication Administration - Preparation and General Guidelines dated December 2017 instructed the facility have sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions. In addition, the person who prepared the medication must be the person who administers the dose. On 6/13/24 at 12:45 PM Staff B, Certified Medication Aide, stated on 6/3/24, he worked the 6:00 PM to 6:00 AM shift and assisted with passing medications. At around 9:00 PM he finished passing his medications and moved to the East hall to help Staff A finish her medications. Staff A told him the medications in a medication cup sitting on the medication cart belonged to Resident #1, she instructed him to give them to her. Staff B stated he took the medications to Resident #1 and gave them to her. Upon returning to the medication cart, Staff A looked at the computer screen and realized the medications he just gave Resident #1, belonged to Resident #6. Staff B stated Staff A notified everyone and handled the medication error issue. On 6/17/24 at 9:31 AM Staff A, Registered Nurse, stated on the evening of 6/3/24, she finished giving medications on the North and [NAME] halls, then moved to the East hall around 9:00 PM. She asked Staff B to assist with checking blood sugars. Staff A explained she set up Resident #5's and his roommate's medications in medication cups. She placed them on the medication cart. She had Resident #1 on her computer screen, while she searched in the medication cart, when Staff B came over and picked up Resident #5's medication cup, then walked away. Staff A reported she didn't pay attention and didn't recall saying anything at the time. Moments later, Staff B exited Resident #1's room. Staff A asked Staff B if he gave those medications to Resident #1 and he stated yes. Staff A stated she immediately informed Resident #1 that she had received another resident's medications. Staff A stated she checked Resident #1's vital signs which were stable and contacted her physician, leaving a message of the error. Staff A stated another resident fell and she was taking care of her. About 30 minutes later, the physician called and gave an order to have Resident #1 sent to the emergency room for evaluation. Staff A stated she made those arrangements and sent Resident #1 to the hospital. Staff A denied instructing Staff B to give the medications to Resident #1, but admitted she knew he picked up the cup of medications and didn't stop him. The Nurses Note dated 6/3/24 at 11:27 PM reflected Resident #1 received Cefadroxil (antibiotic) 500 milligrams, L-Arginine (supplement) 500 milligrams, Trazadone (antidepressant that improve sleep) 50 milligrams, Tamsulosin (used to treat enlarged prostates in men) 0.4 milligrams (Flomax), Baclofen (muscle relaxant) 20 milligrams and Melatonin (supplements that assists with sleep) 10 milligrams in error. The nurse notified the physician who gave orders to send her to the emergency room (ER) for further evaluation. The nurse notified the resident and the medics. Resident #5's June 2024 Medication Administration Record (MAR) reflected the evening medications Resident #1 received as: a. Tamsulosin HCL Oral Capsule 0.4 milligrams. Give 2 capsules by mouth at bedtime for urinary retention. b. Trazodone HCL tablet 50 milligrams. Give 1 tablet by mouth at bedtime related to depression to promote sleep. c. Cefadroxil oral capsule 500 milligrams. Give 1 capsule by mouth two times a day for bacterial infection prophylactic (preventive). d. L-Arginine oral tablet. Give 500 milligrams by mouth three times a day for promotion of wound healing. e. Baclofen oral tablet 10 milligrams. Give 2 tablets by mouth 4 times a day related to other muscle spasms. f. Melatonin oral tablet 10 milligrams. Give 1 tablet by mouth at bedtime to promote sleep. The Mayo Clinic Website updated 6/1/24 described Baclofen as a medication used to relax certain muscles in your body. The article indicated the present of other medical problems could affect the use of the medication. The medication could cause dizziness, drowsiness, vision problems, clumsiness, or unsteadiness, Tell the physician prior to starting the medication with the following medical problems: a. Epilepsy (seizure disorder) b. Stroke, recent - use with caution. May make the conditions worse. c. Kidney disease - the effect could increase because of the slower removal of the medicine from the body. Avoid use in elderly patients with kidney disease because of increased risk of serious brain problems (example encephalopathy, or brain swelling). The Mayo Clinic Website updated 6/1/24 related to Trazodone documented not recommended for use with Baclofen. The History and Physical dated 6/4/24, indicated Resident #1 came to the ER due to accidentally receiving another resident's medication, the previous evening. She received 50 milligrams Trazodone, 10 milligrams Baclofen, 500 milligrams of Cefadroxil, 0.4 milligrams of Flomax, and 500 milligrams of L-Arginine. In addition, she received her scheduled melatonin but at a higher dose of 9 milligrams instead of 3 milligrams. She reported feeling tired with a frontal headache. Upon the provider's assessment, she appeared sedate and difficult to arouse. During her time in the ER she developed soft blood pressures and a decreased level of responsiveness. The staff could arouse her but only through a sternal rub. She received 500 cubic centimeters (cc) of a fluid bolus (rapid infusion) but continued to have a low blood pressure (hypotensive). Even after starting on medications to raise her blood pressure, she became more sedate and required intubation to maintain her airway. The provider gave an order for admission to the intensive care unit (ICU) for closer monitoring and management. The Assessment/Plan reflected Resident #1 had a medication overdose and the provider contacted poison control who recommended close monitoring for air protection and supportive care. The plan included the following problems: a. Acute encephalopathy secondary to medication overdose. b. Hypotension secondary to medication overdose. c. Urinary tract infection (UTI) d. End stage renal disease (ESRD) on dialysis. Resident #1 presented in the emergency room following reports of receiving another resident's medication in error. While in the emergency room Resident #1 was sedate, difficult to arouse and hypotensive (low blood pressure). Resident #1 remained hypotensive, sedated, and required intubation for airway protection. Resident #1 required admission to ICU for close monitoring and further management. The Discharge Summary dated 6/11/24 identified Resident #1 admitted to the ICU, she saw pulmonology and nephrology. She had a dopamine drip for hypotension and bradycardia (low heart rate less than 60 beats per minute). Through her stay she improved enough to discontinue the dopamine drip. Resident #1 started to have a drop in her hemoglobin (low blood volume) with blood in her stools. The provider had gastroenterology elevate her and did an upper endoscopy (visualization through the throat on the esophagus to the stomach). The endoscopy reveals a gastric ulcer that the provider clipped. Following the ulcer repair, Resident #1 discharged to the nursing home in good condition.

Based on record review, and staff and physician interviews, the facility failed to provide timely assessments and failed to implement appropriate interventions in a timely manner when there was a noted change in a resident's condition, for 1 of 9 resident records reviewed (Resident #1). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 2/6/24 revealed Resident #1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), peripheral vascular disease, aphasia (inability to speak following a cerebrovascular accident, also called a stroke), hemiplegia (paralysis of 1 side of the body) following cerebral infarction that affected the right dominant side of the body, and depression. The resident scored 12 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated mild cognitive impairment, without symptoms of delirium present, the resident usually able to make herself understood and usually able to understand others. The MDS assessment revealed the resident required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed and wheelchair, dressing, toilet use, and personal hygiene, the resident unable to stand or ambulate. The assessment revealed the resident had received other non-pharmacological approaches for pain management when needed over the 5 days that preceded the assessment, for occasional pain rated at a 5 on a 0 to 10 pain scale, with 10 assigned to the worst pain level. The pain rarely or never impacted the resident's ability to sleep or carry out her day-to-day activities. An ADL (Activity of Daily Living) self-care performance deficit problem related to hemiplegia, impaired balance, limited mobility, limited ROM (Range of Motion), musculoskeletal impairment and Stroke, initiated 2/1/2024 on the Nursing Care Plan directed staff: On 2/1/2024, 1 assist for transfer. On 2/26/24, changed to 2 assist for transfer, use elevating foot rest for right leg on wheelchair. Nursing Progress Notes contained the following entries: 2/27/2024 at 5:17 p.m., transcribed as a late entry, entered 2/29/24 at 8:21 a.m., Staff D stated: On Tuesday 2/27 at approximately 5:30 p.m. CNA assigned to north hall reported to this nurse that resident right leg was swollen; reported to on coming nurse and requested Nurse Practitioner see her on next rounds. 2/28/24 at 11:02 a.m., a late entry transcribed by the ADON on 3/11/24 at 12:02 p.m., stated: Resident noted to have bruising present to right trunk area measuring 14 inches by 10 inches, dark purple in color, painful to touch along with bruising present to right lower extremity from knee to ankle with edema noted and painful with range of motion. RN was notified of painful lower right extremity and edema at this time however did not complete full body assessment. 2/28/24 at 11:35 a.m., the note described the resident transferred to the hospital by ambulance due to the bruising, swelling and condition of the right leg. An X-ray report obtained 2/28/24 at 2:14 p.m. in the hospital emergency room revealed both bones of the right lower leg were fractured, identified as a right proximal tibial metaphysis fracture and a right proximal fibular metaphysis fracture (the areas very close to the knee). The resident required hospitalization for the injury until 3/4/24. The facility's Notification of a Change in Condition policy, dated as last reviewed 4/26/23, directed staff to notify the physician or physician extender of a change in resident's condition, that included a significant change, abnormal complaints of pain, or resident unusual behavior. Staff interviews revealed: 3/13/24 at 11:06 a.m., Staff K, Licensed Practical Nurse (LPN) and the facility's MDS Nurse stated she changed the resident's Care Plan to a 2 person assist for transfer on 2/26/24 because staff had approached her and said they weren't comfortable transferring the resident by themselves. 3/19/24 at 12:21 p.m., Staff I, CNA, stated when he worked on 2/26/24, he transferred the resident with Staff O, CNA, for all transfers that day, and had not noticed anything unusual about the resident, there were not signs that she had any pain. 3/12/24 at 2:39 p.m., Staff G, CNA, stated on 2/27/24, she transferred the resident by herself from the bed to the wheelchair for breakfast, back to bed after breakfast, and back to bed after lunch. She stated she had not noticed anything unusual about the resident during the transfers, she did not act like she had any pain, and the resident ate well for lunch that day. 3/13/24 at 1:39 p.m., Staff A, CNA, stated on 2/27/24, she transferred the resident by herself from the bed to the wheelchair to take her to the Dining Room for lunch and noticed the resident's right leg was less mobile than usual, she couldn't move it like she normally had, her right knee looked larger than her left knee, the color was slightly different than the left knee, but she didn't cry out or have signs that let her know she was in pain during that transfer. Staff A stated she didn't know if the resident had arthritis or something like that, and she did not report it at the time. Staff A stated she transferred her by herself from the bed to the wheel chair for supper, the resident was making noises during the transfer as if she was in pain, she thought the right knee looked more swollen than earlier that day. When she took the resident to the Dining Room for supper, she told Staff D, Registered Nurse (RN) about the resident's swollen knee and that she thought the resident had pain in the knee. 3/12/24 at 11:44 a.m., Staff D, RN, stated she had taken care of the resident before 2/27/24, had never seen bruising and nobody reported that to her. On 2/27/24, around 5:30 p.m., a CNA brought the resident out to the Dining Room for supper and said her right leg was bigger than before and looked swollen, she did not report the resident had pain or bruising with it, the resident was seated at the supper table for supper at the time, the next shift started at 6 p.m. and she reported the issue to the oncoming nurse, Staff E, RN, during the change of shift report at 6 p.m. that day, Staff D did not assess the right leg or resident conditions reported by the CNA. 3/18/24 at 9:51 p.m., Staff E, RN, stated on 2/27/24, Staff D did report that staff reported the resident's right leg was swollen, but she did not assess it on her shift that ended at 6 a.m. the following morning. 3/13/24 at 9:11 a.m., Staff C, CNA, stated she worked the day shift (6 a.m. to 2 p.m.) on 2/28/24, she got the resident up with Staff B, CNA between 6:30 a.m. and 7:00 a.m., when they changed the resident she yelled like she was in pain. Staff C looked down and saw the resident's right leg was bruised on the front area from the knee down, and was swollen. They transferred the resident to the wheelchair, and as she took the resident to the Dining Room, she told Staff F, LPN (Licensed Practical Nurse) about the resident's bruised and swollen leg, and the resident's pain. 3/13/24 at 10:48 a , Staff F, LPN, stated on 2/28/24, around 7:00 a.m., Staff C brought the resident out for breakfast, told her and showed her the resident's right leg was swollen, and bruised, the resident was dressed in shorts, she had shoes on, the shoe on her right foot was tight from the swelling. The resident didn't say anything, but with touch or any movement she screamed and had pain. Staff F stated at the time, Staff E, RN that had worked the shift before was still in the facility, she called her over and Staff E stated she was not aware of any reports of bruising or swelling in the resident's leg. At that time of the day, management would be there shortly, she awaited their arrival and told the Assistant Director of Nursing (ADON) about the conditions when she arrived around 7:15 a.m. that morning. She was not aware of any time the resident tried to self-transfer, the resident was dependent for all care and had the paralysis on 1 side of her body. During an interview 3/14/24 at 10:23 a.m., Staff L, Radiologist physician from the radiology practice that interpreted the resident's 2/28/24 X-ray results, reviewed the resident's 2/28/24 X-ray films and stated the fractures were from an acute injury, likely from force by trauma or a fall.

Based on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to prevent development of new pressure ulcers and further failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing of existing pressure ulcers for 4 out of 5 residents reviewed for pressure ulcers (Resident #18, #24, #38, and #258). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], identified Resident #258 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had the following diagnoses: Cerebral Vascular Accident (CVA), also known as stroke, Diabetes Mellitus, general weakness, and arthritis. The MDS documented Resident #258 required extensive assistance of two staff for bed mobility and total dependence on two staff for transfers and toileting. A review of facility Admission Orders received from the Hospital Emergency Department (ED) dated 8/25/23 revealed an order for Clotrimazole-betamethasone (Lotrisone) cream to be applied to affected area twice a day. ED documentation indicated it was a home medication, order had been initiated on 9/01/2022. The Braden score assessment, used to determine risk of pressure injury development completed on 8/26/23, revealed a score of 14 indicating moderate risk for development of pressure injury. Review of Admission Nursing Assessment, dated 8/26/23, indicated a Stage II pressure injury on coccyx measuring 3 centimeters (cm) long by 3 centimeters (cm) wide. On 8/29/23, the Care Plan identified Resident #258 with the problem of the potential/actual impairment to skin integrity related to immobility, pressure sore to coccyx. The Care Plan directed the staff to: a. Perform treatment to wound per current treatment order. b. Pressure reducing cushion while up in chair. c. Pressure reducing mattress while in bed. d. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On 9/19/23 at 10:47 AM, Resident #258 reported having a bed sore on her bottom and stated the sore had worsened after an incident of sitting on a bed pan for a prolonged period and from sitting in an electric wheelchair throughout much of the day. Resident #258 reported having no cushion in her electric scooter. Her ability to shift her own weight in the scooter was limited by weakness and the inability to stand or transfer without a mechanical lift. Resident #258 reported frequent pain related to pressure sore on her bottom while sitting in the scooter, reported that lying in bed provided her relief of the pressure ulcer pain. When asked if she had received treatment for pressure injury, she reported staff had ignored her concern about the sore until recently, stated now they are doctoring it up. The Baseline Care Plan was completed and signed on 8/29/23, 4 days from date of admission (8/25/23). The care plan identified Resident #258 with skin integrity issues. The Skin Assessment, dated 8/29/23 identified Resident #258 with a Stage II pressure injury to the coccyx measuring 3 cm long and 3 cm wide, the assessment had no documentation of a description of the wound characteristics. Review of the August 2023 and September 2023 Treatment Administration Records (TAR's) revealed coccyx wound care orders: a. On 9/16/23 for calcium alginate to wound and cover with foam dressing. b. On 9/18/23 order for calcium alginate discontinued. c. On 9/19/23 order to cleanse the wound, apply Santyl ointment and cover with padded dressing one time a day, every day. There was no documentation of wound care treatment orders for 22 days between admission to facility on 8/25/23 until 9/16/23. The MDS assessment, signed 9/13/23, revealed resident required pressure reducing device for chair and pressure reducing device for bed. The Skin Assessment, dated 9/18/23, 24 days following Admission Nursing Assessment, revealed a pressure injury to the sacrum which measured 6.5 cm long, 4 cm wide and 0.1 cm deep and that the nurse obtained new orders from the Wound Doctor. The Assessment did not have documentation of wound characteristics. On 9/18/23, the Wound Doctor identified Resident #258 with a pressure ulcer to the sacrum as unstageable due to necrotic tissue which required surgical debridement. The Wound Doctor ordered an abdominal pad to be applied once daily and as needed for soilage or displacement for 30 days and Santyl Ointment to be applied topically once daily and as needed for soilage or displacement for 30 days. Observations of the resident revealed the following: a. On 9/19/23 at 10:47 AM, sitting in electric scooter in her room with the mechanical lift sling noted underneath her bottom and back and no cushion in place in scooter seat. b. On 9/19/23 at 3:14 PM, lying in bed without an air mattress with pump and no cushion in the electric scooter. Review of Resident 258 face sheet revealed resident admitted to facility on 8/25/23. On 9/20/23 at 1:00 PM, Staff A, Licensed Practical Nurse (LPN) reported she often provided wound care for Resident #258 and she had not seen a pressure ulcer on Resident #258 until 9/18/23. Staff A reported she was unaware of treatment orders upon admission, however she recalled an order for a cream for Resident #258's abdominal fold. On 9/20/23 at 1:30 PM, the Director of Nursing (DON) stated Resident #258 had a pressure ulcer present on admission. The DON could not recall what treatment was in place on admission or when the treatment was initiated. The DON reported that all skin assessments were charted in Resident Electronic Health Record (EHR). In an interview on 9/20/23 at 3:05 PM, the Wound Doctor reported on 9/16/23 an order of Calcium Alginate likely started by the facility for an observed pressure ulcer. Then on the 9/18/23 visit was the first time seeing the pressure ulcer on Resident #258 sacrum. She changed the order to Santyl ointment due to necrotic tissue. The Wound Doctor reported she would expect to see basic wound care/treatment orders in place for a Stage II pressure ulcer such as creams, padded dressing, or skin preparation, and notified the facility had her number to contact for recommendations on a treatment. The Wound Doctor also reported that she would expect the facility to inform her sooner regarding a pressure ulcer noted on admission than the first time seeing Resident #258 on 9/18/23 and thought maybe the facility was trying to treat the wound on their own at first. In an interview on 9/20/23 at 4:00 PM, the MDS/Care Plan Nurse, verified the chair cushion and pressure reducing mattress for the bed were addressed on Resident #258's Care Plan. An observation with the MDS/Care Plan Nurse of the resident's electric scooter had a cushion brought from home. The bed did not have an air mattress; however, the MDS/Care Plan nurse reported all regular facility mattresses were pressure reducing. On 9/21/23 at 1:05 PM, the DON stated that the Nurse Practitioner and Wound Doctor had discussed that Resident #258 had a pressure ulcer, but unsure of the documentation of this communication. The DON reported the wound treatment had been in place upon admission was for Clotrimazole cream. When asked if this was a usual treatment for pressure ulcers, DON replied that's what the orders from the hospital were for wound treatment. When asked how staff would know to put Clotrimazole cream on pressure injury as order is written to be applied to affected area, not indicated for application to pressure ulcer, DON stated because the ED orders said it was for wound treatment. On 9/25/23 at 9:00 AM, observed implementation of an air flow device on resident's bed. The Skin assessment completed 9/25/23, identified Resident #258 with a new left heel blackened area and orders for Skip Prep and float the heels. It did not have documentation of wound measurements or characteristics documented in assessment. A review of facility policy titled Wound Management, dated as last revised 11/15/22, informed treatments will be documented on the Treatment Administration Record (TAR) and the effectiveness of treatments will be monitored through ongoing evaluation of the Wound(s) Policy revealed that Charge Nurse will notify Physician in the absence of treatment order. 45775 2. The MDS Assessment Tool, dated 7/21/23, listed diagnosis for Resident # 18 included: Cerebrovascular accident (stroke), chronic obstructive pulmonary disease (COPD), and pressure ulcer of sacral region stage 4. The MDS listed the resident's BIMS score as 13 out of 15, indicating intact cognition. The Care Plan dated 12/08/16, revised on 5/17/23 documented, I am at risk for skin breakdown as evidenced by (AEB) resident requires assistance with mobility and is incontinent of bowels [at] all times. The Electronic Health Record (EHR) revealed a wound provider note dated 12/23/20 documenting the presence of a Stage IV pressure wound on the sacrum. A Wound Provider Note dated 9/2/21 revealed the Stage 4 pressure wound on the sacrum had resolved. A review of the weekly Skin Observation tool completed on 6/26/23 revealed the resident continues treatment for a left posterior thigh, with no new skin issues observed. A review of the weekly Wound Observation assessment completed on 6/27/23 documented an acquired trauma injury to the residents right posterior thigh. No other wounds documented. Record review revealed a Skin/Wound note dated 7/2/23 documenting the discovery of bleeding from the resident's coccyx area and an open area measuring approximately 3 centimeters (cm) deep. The note revealed there had been no documentation to follow up with wound care, communication of the wound left in the nurse's box. The note lacked documentation of provider notification. The note did indicate the resident added to the wound provider list for the following day. A review of the weekly Skin Observation tool completed on 7/4/23 revealed the resident continues treatment for the left posterior thigh, with no new skin issues observed. A review of the weekly Wound Observation assessment completed on 7/6/23 documented an acquired trauma injury to the residents right posterior thigh. No other wounds documented. The record lacked continued weekly Wound Observation assessments after 7/6/23. A Wound Provider note dated 7/3/23 revealed the presence of a Stage IV pressure wound for more than one day measuring 2.0 cm x 0.6 cm x 1.5 cm. The document described the wound having moderate serous drainage, with 10% granulation tissue, and 90% other viable tissue. During an interview on 9/19/23 at 3:34 PM, Staff B, Registered Nurse (RN) stated she recalled finding the wound in July. She stated the wound surprised her as she had not been aware of its presence. Staff B stated she did not recall what occurred after she discovered the wound. During an interview on 9/28/23 at 2:53 PM, the Director of Nursing (DON) stated after a wound is discovered she expected staff to first complete a Skin Observation assessment, then call the provider, and notify the DON or ADON if present in the building or the on-call staff after hours or on the weekend. The DON stated after the Initial Assessment is completed, she expects the wound provider to see the resident and complete an assessment. After the wound provider completes an assessment she expects staff to do Weekly Wound Assessments until the wound is healed. 25855 3. The MDS dated [DATE] identified Resident #24 as cognitively intact with a BIMS score of 15 out of 15 and had the following diagnoses: Unstageable Pressure Ulcer to the Sacral Region, Neurogenic Bladder and UTI (Urinary Tract Infection). The MDS also identified Resident #24 required extensive staff assistance with bed mobility, dressing. A review of the Nursing Admission Screening Tool dated 6/13/23 at 12:17 PM shown: a. Reason for admission from paperwork: gluteal wound. b. Under skin: large right and left gluteal decubitus ulcers, post debridement 5/25 with wound infection, osteomyelitis The tool did not have documentation of assessments/measurements of wounds. A review of an entry in the Progress Notes revealed the following entry on 6/16/2023 12:29 PM Resident has several skin issues present on admission: a. Left great toe, anterior surface - 1.0 cm x 0.5 cm x 0, granulation tissue and slough present, moderate serous drainage, no signs/symptoms of infection. b. Left great toe, distal surface - 1.0 cm x 0.5 cm x 0, granulation tissue et slough present, moderate serous drainage, no signs/symptoms of infection. c. Left lateral ankle - 2.5 cm x 1.0 cm x 0, pink tissue present in wound bed, white wound edges, small amount of serous drainage present, no odor noted. d. Left heel - 1.5 cm x 1.5 cm x 0.1 cm, red granulation tissue present with bleeding, moderate serous drainage, no odor noted. e. Right bunion has a non-blanchable red area, measuring 1.5 cm x 1.5 cm x 0. f. Right lateral ankle - 3.5 cm x 3.0 cm, moderate serous drainage present, pink granulation tissue c slough present, no odor noted. g. Right lateral foot - 3.5 cm x 3.0 cm, moderate serous drainage c pink granulation tissue et slough, no odor noted. h. Right plantar foot - 2.5 cm x 2.0 cm, thick amounts of slough present, slight odor noted. i. bilateral buttocks - wound measures over 30 cm x 8, bone present. Pink granulation tissue present, no bleeding observed. moderate serous drainage observed with no odor noted. On 7/1/23 the Care Plan identified Resident #24 with the problem of an (unstageable) pressure ulcer (gluteal region and both legs) or potential for pressure ulcer development related to the disease process of (paraplegic), history of ulcers, Immobility. The Care Plan directed staff to: a. Assess/record/monitor wound healing (daily) Measure length, width and depth where possible. b. Assess and document status of wound perimeter, wound bed and healing progress. c. Report improvements and declines to the doctor. A review of the facility Skin Observation Tools revealed the following: a. On 7/18/23 (3 weeks after identified on care plan)- no documentation of location, measurements of ulcers. Only documentation: wounds remain to ischium, L foot/ ankle, R foot/ ankle. No new skin issues b. On 8/4/23 (3 weeks after last assessment completed) no documentation of location, measurements of ulcers. Only documentation: treatments continue to ischium, right foot and left foot see weekly wound assessment for details no new skin issues to report c. On 8/28/23 (3 weeks after last assessment) documentation resident has unstageable pressure ulcers to the sacrum and right outer ankle and Stage 3 pressure ulcers to the left toe and right plantar. None of the wounds has measurements. No narrative documentation noted. d. On 9/4/23 no documentation of location, measurements of ulcers. Only documentation: continues with multiple wounds to BLE and bilateral ischium/gluteal fold, no other concerns at this time e. On 9/11/23 no documentation of location, measurements of ulcers. Only documentation: continues with current wounds at this time, no other skin issues of concern. On 9/18/23 the following wounds were identified as vascular: a. Right outer ankle: Length (L): 3.5 cm Width(W): 3.4 cm Depth (D): 0.7 cm, Stage marked as N/A. b. Right lateral foot: L:.2.0. cm W: 2.2 cm D: 0.1 cm, Stage marked as N/A. c. Left outer ankle: L: 2.3 cm W: 1.0 cm D: 0.1 cm, Stage marked as N/A. d. Pressure ulcer identified to left heel L: 0.5 cm W: 0.4 cm D: 0.1 cm, Stage marked as N/A. 9/25/23 no documentation of location, measurements of ulcers. Only documentation: No new skin issues of note at this time. On 10/2/23 the following wounds were identified as vascular: a. Right outer ankle: L: 3.3 cm W: 3.4 cm D: 0.7 cm, Stage marked as N/A. b. Right lateral foot: L: 2.0 cm W: 2.0 cm D: 0.1 cm, Stage marked as N/A. c. Left outer ankle: L: 2.0 cm W: 0.8 cm D: 0.1 cm, Stage marked as N/A. The following wounds were identified as pressure: a. Left heel: L: 0.3 cm W: 0.3 cm D: 0.1 cm, Stage marked as N/A. b. Left buttock: L: 9.0 cm W: 25 cm D: 5 cm, Stage marked as N/A. On 10/10/23 all wounds now identified as pressure and all were marked as stage N/A Right outer ankle: L: 3.1 cm W: 3.2 cm D: 0.4 cm. Right lateral foot: L: 1.8 cm W: 1.6 cm D: 0.1 cm. Left outer ankle: L: 1.8 cm W: 0.4 cm D: 0.1 cm. Left heel: L: 0.1 cm W: 0.1 cm D: 0.1 cm. Left ischium: L: 8.7 cm W: 23 cm D: 4.8 cm. Review of wound clinic progress notes a. On 7/17/23 - not seen due to non-wound related hospitalization since last visit. b. on 8/28/23 -venous wound to right lateral ankle, 2.0 cm x 3.5 cm x 0.3 cm, venous wound left lateral ankle: 4.9 cm x 1.9 cm x Not Measurable cm, Stage IV to sacrum resolved. Unstageable Deep Tissue Injury (DTI) left heel 2 x 2 x Not Measurable cm. Stage IV pressure wound to left ischium 8 cm x 28 cm x 5.5 cm. c. On 9/11/23 venous wound right lateral ankle, 3.6 cm x 3.8 cm x 0.7 cm. Venous wound left lateral ankle, 4.0 cm x 1.1 cm x 0.1 cm. Stage III pressure wound left heel 0.7 cm x 0.7 cm x 0.1 cm. Stage IV pressure wound left ischium 8 x 27.5 x 5.5 cm. d. On 9/18/23 all above wounds with adequate documentation of assessment/measurements. e. On 10/2/23 Stage IV pressure wound to left ischium 9 cm x 25 cm x 5 cm. In an interview on 9/18/23 at 7:38 AM, Resident #24 reported he had staff remove the wound vac because no one will answer the alarms. In an interview on 10/11/23 at 10:40 AM, the DON reported the resident was admitted with the Stage IV pressure ulcer to the left ischium. 4. The MDS dated [DATE] identified Resident #38 as cognitively intact with a BIMS score of 15 out of 15 and had the following diagnoses: Septicemia (clinical name for blood poisoning by bacteria), Multiple Sclerosis and Paraplegia (paralysis of legs and lower body). The MDS also identified the resident required extensive staff assistance with dressing, personal hygiene and bathing and totally dependent on staff for bed mobility, transfers and toileting. A review of the facility skin observation tools completed 6/27, 7/11, 7/17, 7/26, 7/31, 8/16, 8/22, 8/29, 9/4, 9/5, 9/11, 9/18, 9/19/2023 did not have documentation of measurements or assessment of appearance of the wound, wound bed, etc. On 6/28/23 the Care Plan identified Resident #38 with the problem of a pressure ulcer to the sacrum/ischium both, both ankles or potential for pressure ulcer development related to disease process (MS), Immobility Left lateral ankle, Right distal ischium, Right sacrum. It directed staff to: a. Follow facility policies/protocols for the prevention/treatment of skin breakdown. b. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. A review of the Wound Clinic Notes revealed only two notes dated 7/17/23 and 8/10/23. In an interview on 9/11/23 at 3:00 PM, the resident's family member reported when the wound vac isn't operating correctly, it alarms, he says that it alarmed all night long and no one would respond. In an interview on 9/13/23 at 11:29 AM, Resident #38 reported when the alarm to his wound vac goes off at night, no one comes to answer it or takes care of it and this happens daily. In an interview on 10/5/23 at 10:29 AM, Staff Y, Licensed Practical Nurse reported pressure ulcers, should the wound be assessed and measured weekly. Assessments should include the wound length, width, depth, color, drainage, pain. Staff T, LPN the Wound Nurse will document the assessment in the electronic medical record. In an interview on 10/5/23 at 11:51 AM, the DON reported the following pressure ulcers, should the wound be assessed and measured weekly and should be checked every shift. Assessments are found on a Wound Form that includes all that is required to be documented in the electronic medical record.

Based on observation, record review, resident, staff and physician office interviews, the facility failed to provide accurate assessments and implement appropriate interventions in a timely manner for 1 of 11 resident records reviewed (Resident #1), and failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1). The facility reported a census of 65 residents Findings Include: 1. The 7/25/22 Minimum Data Set (MDS) Assessment revealed Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Activity of Daily Living (ADL) Assistance problem initiated on the Nursing Care Plan 6/28/22 directed staff the resident required staff assistance for transfers, dressing, bathing, personal hygiene and toileting. The 8/16/22 Nursing Staff Schedule revealed Staff B, Registered Nurse (RN), assigned to the resident on the 6 a.m. to 6 p.m. shift and Staff C, Licensed Practical Nurse (LPN), assigned to the resident on the 6 p.m. to 6 a.m. shift that concluded 8/17/22. Nursing Progress Notes revealed the following entries: a. On 8/17/2022 at 3:14 a.m., transcribed by Staff C, LPN stated Blood Sugar (BS) level 85 at 7:30 PM. Resident had low BS of 45 earlier in shift, Insulin was held at that time. BS level 293 at 2:00 AM. Resident complained of pain from left elbow to left shoulder. Offered Tylenol and it was accepted. Will pass her complaint to First Shift Nurse. b. On 8/18/2022 at 12:24 p.m., transcribed by Staff D, RN stated resident at clinic for colonoscopy this morning. A Nurse from the clinic called to report that resident complained of elbow pain and reports there is swelling to area and recommends X-ray. Nurse Practitioner (NP) notified and obtained order for X-ray. On 8/18/2022 at 5:35 p.m., transcribed note by the Nurse Practitioner (NP) stated: SOAP NOTE Subjective: Call received stating that resident was out at an appointment, office staff reported pain to resident's left elbow. Resident stated she fell Tuesday night (8/16/22), and her arm has hurt since. Will get an X-ray to rule out anything acute. No other changes. Objective: Per staff - no changes in physical assessment other than left arm pain. Assessment: Resident with fall on Tuesday and left arm pain since. Plan: X-rays of left arm. 8/19/2022 at 8:29 a.m., a note transcribed by the Assistant Director of Nursing (ADON) stated resident alerted third shift Certified Nursing Assistant (CNA) on 8/16/22 that she had fallen earlier that evening. CNA reported to Nurse on shift and Nurse evaluated and gave Tylenol for complaint of pain which was effective and resident went to sleep. Resident had no further complaints until 8/18/22 stating in pain, left elbow area noted to be swollen, NP notified and new order received for X-ray. X-ray results received this AM with possible left ulnar fracture, NP notified and new order received to send to Hospital emergency room (ER) for evaluation and treatment. The 8/19/22 ER Visit Summary stated the resident assessed for pain in left shoulder, elbow and hip, with intermittent numbness in left arm, swelling and tenderness of left elbow and left anterior shoulder tenderness. X-ray images obtained in the ER revealed no fractures in the shoulder or elbow, a long-arm immobilization splint applied to the left arm, the resident scheduled for an appointment at an Orthopedic Physician on 8/22/22 at 8:45 a.m. for further assessment and diagnostics, and discharged from the ER with a prescription for [MEDICATION(S)]-Acetaminophen 5-325 milligrams ([MEDICATION(S)], a strong narcotic analgesic) administered oral every 4 hours as needed for pain. The 8/22/22 Orthopedic physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The provider prescribed Physical Therapy for the left upper extremity, wean out of the splint, wear a sling to the left arm for comfort, and the resident to return in 1 month. The 9/24/22 Orthopedic physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician wrote a prescription for Physical Therapy for the resident, and the resident to return in 6 to 8 weeks for a follow-up appointment. A narcotic Inventory Control Sheet revealed the resident received [MEDICATION(S)]: a. On 8/20/22 at 5:49 p.m. b. On 8/21/22 at 8:29 a.m., 4:10 p.m. c. On 8/22/22 at 1:35 a.m. and 11:12 a.m. The facility's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. All orders shall be provided by licensed practitioners. b. Orders must be recorded in the medical record by the licensed nurse. c. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. New orders will be reviewed 5 times per week by the interdisciplinary team (IDT) as part of routine clinical review. e. The resident, when practical, and/or the resident' responsible party will be notified of new orders. Staff interviews revealed: a. On 10/13/22 at 3:10 p.m., when asked to provide a copy of Physical Therapy Notes associated with the 8/22/22 Physician Order, the Director of Nursing (DON) stated the resident did not receive Physical Therapy because she wasn't Skilled (under Medicare Funding). When asked if there was an order to discontinue the Physical Therapy order, or a modified order, the DON stated he would have to check on it. b. On 10/17/22 at 2:20 p.m., Staff A, CNA, stated on the 8/16/22 evening shift (2 p.m. to 10 p.m.), around supper time he came upon the resident after she had fallen during a self-transfer from her bed to the wheel chair, she sat on the floor and leaned against the side of the bed with the side of her chest. She was awake, alert, and he left her there while he went to get the nurse and returned. Staff A could not remember who the nurse was, but thought it was Staff B, RN. c. On 10/17/22 at 5:26 p.m., Staff B, RN, stated she was not the nurse on duty when the resident fell . d. On 10/18/22 at 8:50 p.m., Staff C, LPN, reviewed her documentation from 8/16/22 and 8/17/22, and stated she remembered the resident told her that her arm/elbow hurt because she'd fallen, but she thought the resident meant she had fallen a few days prior to that. She gave the Tylenol for pain, she faxed (notified by facsimile) the NP that the resident complained of arm/elbow pain and her blood sugars were low that night. e. On 10/24/22 at 10:44 a.m., the Assistant Director of Nursing (ADON) stated Staff C notified her the resident told Staff A, CNA that she had fallen, it occurred before her shift, the resident complained of pain in her left arm, she directed Staff C to document the assessment and the ADON would complete the Incident Report. f. On 10/20/22 at 12:50 p.m., the DON could not locate any records that either the Physician or NP were notified of the resident's 8/16/22 fall and injuries until 8/18/22 when notified by Staff D, RN, and nursing staff should assess resident's for injuries whenever there is a fall, document the assessment and must notify the physician/NP of the fall and injuries if any. g. On 10/19/22 at 1:53 p.m., Staff K, Certified Occupational Therapy Assistant and Therapy Manager stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident would have benefited from therapy services at the time, it could have reduced the pain she had. They did start to provide therapy services to the resident on 10/14/22. h. On 10/24/22 at 5:02 p.m., the provider from the Orthopedic Physician's office stated applied Physical Therapy services could have improved the resident's range of motion and decreased her stiffness. i. On 10/24/22 at 11:00 a.m., the DON stated in the future, when there is a funding issue, the Administrator will make the decision in regards to funding and what is in the best interests of the resident, and the clinical decision will not be made by the Business Office. During an interview 10/13/22 at 11:25 a.m., Resident #1 stated a couple days before her colonoscopy, she hurt her left arm when the wheel chair moved and she fell , an aide and a nurse were in her room when she fell but couldn't remember their names. The resident stated her arm was swollen and sore from the injury, she had continued pain in her arm at present, rated at a 2 or 3 on a 0 to 10 pain scale, with 10 assigned to the highest pain level, and the doctor said she was supposed to have Physical Therapy, she hadn't received the therapy but wanted to have it. 2. The 9/14/22 Minimum Data Set (MDS) Assessment revealed Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An ADL Self-care deficit problem initiated 7/28/22 on the Nursing Care Plan directed staff: a. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. A Diuretic medication therapy related to [CONDITION(S)] problem (swelling by fluid accumulation in the lower extremities) on the Nursing Care Plan directed staff to: a. Administer Diuretic medications as ordered by physician. Monitor for side effects and effectiveness every shift. b. Monitor Diuretic dose. May require modification in order to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensive medications are prescribed simultaneously. c. Staff to assist resident with elevating her feet throughout each shift. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The October Treatment Administration Record when reviewed on 10/20/22 revealed staff had applied the Tubi-Grip garments every morning between 10/14/22 and 10/20/22, and removed them every evening between 10/14/22 and 10/19/22. During an observation and interview 10/20/22 at 11:05 a.m., Resident #2 stated she was very worried about the [CONDITION(S)] in her legs, the doctor looked at her legs last week and said she would order wraps that staff would apply, but staff had not done any treatments to her legs. The resident was seated in a wheel chair in her room, with gripper socks on both feet and without any compression garments on her legs, the elastic band of the gripper sock left an impression at least 1/2 inch deep at the ankle area, her lower legs swollen to at least 2 to 3 times the size they should have been for her weight, and pitting in appearance. The resident's room mate, Resident #7, also present in the room during the interview and stated she was present when the provider said she would order wraps for her legs, and staff hadn't done anything to the resident's legs since then. Observation of the resident with the DON on 10/20/22 at 12:06 p.m., revealed the resident seated in a wheel chair in the dining room, and continued to wear the gripper socks and without compression garments on her lower legs. When the DON was asked at that time what she would do about staff's documentation of implementation of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The 9/3/22 Minimum Data Set (MDS) Assessment revealed Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An ADL Self-care deficit problem on the Nursing Care Plan directed staff to provide assistance with all ADL's. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Physical and Occupational Therapy (PT/OT) to evaluate and treat the resident. The resident to be up with assist per assessment by PT. During an interview on 10/20/22 at 9:18 a.m., the resident stated when she came to the facility she could walk with a walker and staff assistance in her room until she went to the hospital in September. The resident reported she had not been out of bed or ambulated since she returned to the facility 9/14/22. Resident #6 stated she wanted to get up, out of bed, still wanted to discharge to home and worried she wasn't strong enough to ambulate. During an interview 10/24/22 at 11:00 a.m., the DON stated she thought staff must have missed the 9/14/22 PT/OT orders because they were on page 5 of the orders, and therapy staff were going to at least assess the resident. 4. The 10/8/22 Minimum Data Set (MDS) Assessment revealed Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An ADL Self-care performance problem on the Nursing Care Plan directed staff: a. Bathe or shower the resident twice weekly and as necessary. b. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation of the resident 10/20/22 at 9:01 a.m., revealed the white portion of the toe nails were at least 3/8 inch long, projected out from the tips of the toes, and the skin of the feet dry, reddened and quite frail in appearance. During an interview 10/18/22 at 11:09 a.m., the DON stated there was a Podiatrist that visited the facility every 2 or 3 months, and the facility maintains a list of residents to be seen by the Podiatrist. During an interview 10/20/22 at 12:50 p.m., when the DON was asked why the resident had not been seen by the Podiatrist, the DON responded because he wasn't on the Podiatrists list. During another interview 10/24/22 at 11:00 a.m., the DON stated the resident was added to the Podiatrists list to be seen with the next visit. 5. The 8/3/22 Minimum Data Set (MDS) Assessment revealed Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An ADL Self-care performance problem on the Nursing Care Plan directed staff: a. Bathe or shower the resident twice weekly and as necessary. b. Provide 1 staff assist for personal hygiene care. During an interview 10/17/22 at 3:20 p.m., Staff M, Registered Nurse (RN) from a hospital emergency room (ER) stated Resident #10 presented to the ER by ambulance on 9/4/22 with toe nails that were very thick, and so long they curled under beyond the tips of the toes, and the resident remained calm and cooperative with care throughout her 4 hour stay in the ER. During an interview 10/20/22 at 12:50 p.m., the DON stated the resident was probably not seen by the Podiatrist because she refused the care, but had no documentation of the resident's refusals.

Based on observation, record review, resident, resident responsible party (RP), staff, Wound Center staff and physician interviews, the facility failed to prevent the development of new pressure sores and failed to prevent worsening of existing pressure sores for 1 of 3 residents with pressure sores records reviewed (Resident #4). The facility reported a census of 48 residents. Findings include: The 8/17/20 MDS Assessment tool revealed Resident #4 had [DIAGNOSES REDACTED].(intact skin with non-blanchable redness of a localized area), 5 venous or arterial skin ulcers, and pressure reduction devices in use for the chair and bed. The resident was admitted to the facility on [DATE], transferred there from another long-term care facility. An impaired skin integrity problem related to pressure injury initiated on the Care Plan on 8/10/20 directed staff to: a. On 8/10/20 perform treatment to wound per treatment order. b. On 8/10/20 follow pressure ulcer prevention guidelines to prevent additional skin problems. c. On 8/10/20 apply pressure reduction cushion to wheel chair. d. On 8/10/20 apply alternating pressure air mattress to bed, assure inflation control is correct. A revision on 10/13/20 stated the resident refused air mattress as ordered. Wound assessments documented 8/11/20 on Weekly Wound Observation V2 forms, reflected measurements obtained at the resident's 8/6/20 Wound Clinic (WC) appointment: a. Wound #49, stasis ulcer left lower leg, 1.3 Centimeters (cm) by 2.5 cm by 0.1 cm b. Wound #50, stasis ulcer right lateral lower leg, 9.5 cm by 2.0 cm by 0.1 cm c. Wound #51, Stage 3 pressure sore left posterior heel, 1.5 cm by 1.0 cm by 0.1 cm d. Wound #54, stasis ulcer right proximal anterior lower leg, 8.9 cm by 6.0 cm by 0.1 cm e. Wound #55, Stage 3 pressure sore right posterior heel, 0.3 cm by 1.4 cm by 0.1 cm The WC Physician directed care of the resident's wounds at weekly appointments. Wound assessments at the 8/27/20 WC appointment revealed: a. #49 0.6 cm by 1.2 cm by 0.1 cm b. #50 1.5 cm by 1.2 cm by 0.1 cm c. #51 1.4 cm by 1.7 cm by 0.1 cm d. #54 4.3 cm by 0.5 cm by 0.1 cm e. #55 0 cm by 0 cm by 0 cm. healed f. #56 Newly identified pressure sore on the left lateral thigh, 3.7 cm by 2.2 cm by 0.7 cm The 9/3/20 WC appointment wound assessments revealed 3 new pressure sores and the following assessments: a. #49 3.4 cm by 1.9 cm by 0.1 cm b. #50 2.7 cm by 1.4 cm by 0.1 cm c. #51 2.2 cm by 1.3 cm by 0.2 cm d. #54 Healed e. #56, Stage 3 pressure sore of the left lateral thigh, 3.4 cm by 1.8 cm by 1.9 cm with tunneling. f. #57, Stage 1 pressure sore of the right medial buttocks, 0.4 cm by 0.4 cm by 0.1 cm g. #58, Stage 3 pressure sore of the left medial buttocks, 3.7 cm by 3.0 cm by 0.1 cm h. #59, deep tissue injury of the right lateral thigh with non-blanchable tissue. Physician order [REDACTED]. as possible. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. Wound measurements at the 9/10/20 WC appointment revealed: a. #49 0 cm by 0 cm by 0 cm healed b. #50 1.2 cm by 0.6 cm by 0.1 cm c. #51 1.6 cm by 1.6 cm by 0.2 cm d. #55 0 cm by 0 cm by 0 cm e. #56 3.3 cm by 1.6 cm by 1.6 cm, the wound tunneled f. #57 4.7 cm by 2.1 cm by 0.1 cm g. #58 5.0 cm by 4.0 cm by 0.1 cm h. #59 0 cm by 0 cm by 0 cm healed Other wound care orders transcribed at the 9/10/20 WC appointment included: a. #50 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply Polymems dressing, cover dressing with rolled gauze and secure with tape 3 times per week and as needed. b. #51 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply [MEDICATION NAME] or similar dressing, cover dressing with rolled gauze and secure with tape 3 times per week and as needed. c. #55 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply [MEDICATION NAME] or similar dressing, cover dressing with rolled gauze and secure with tape 3 times per week and as needed. d. #56 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply [MEDICATION NAME] blue lightly packed into the wound, use until wound vac is able to be placed in wound. Cover wound with [MEDICATION NAME] or similar dressing, secure dressing in place. Arrange to start negative pressure wound therapy at 125 millimeters pressure, change dressing 3 times per week. Send a black foam dressing package and wound vac canister with the resident to every WC appointment. e. #57 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply Allevyn or comparable sacral dressing, change every other day and as needed. f. #58 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply Allevyn or comparable sacral dressing, change every other day and as needed. g. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. The 9/17/20 WC physician progress notes [REDACTED]. a. #50 - 2.5 cm by 0.5 cm by 0.1 cm, adipose exposed, moderate amount of sero-sanguineous drainage, wound pain level of 5/10 (0 to 10 pain scale with 10 identified as worst pain). b. #51 - 1.5 cm by 1.0 cm by 0.2 cm, adipose exposed, moderate sero-sanguineous drainage, wound pain level 6/10. c. #55 - 0 cm by 0 cm d. #56 - 3.1 cm by 2.8 cm by 1.6 cm, adipose exposed, undermining present, moderate sero-sanguineous drainage, wound pain level 5/10. e. #57 - 1.6 cm by 1.0 cm by 0.1 cm, adipose exposed, moderate sero-sanguineous drainage, wound pain level 6/10. f. #58 - 4.8 cm by 4.0 cm by 0.1 cm, moderate amount sero-sanguineous drainage, wound pain level 7/10. WC orders transcribed at the 9/17/20 appointment directed staff: Resident needs wider wheel chair, causing pressure sores to thighs. Have resident assessed for Roho cushion. Apply a barrier cream to right thigh. Administer [MEDICATION NAME] 300 mg oral every other day for 1 week. Do not turn the wound vac off overnight as that can cause an infection, wound infection suspected due to odor of wound #56 and resident's report the wound vac was turned off. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. 9/24/20 WC physician orders [REDACTED].>a. Send a black foam dressing package and wound vac canister with the resident to every WC appointment. WC applied [MEDICATION NAME] blue to wound #56 due to the facility did not provide the required wound vac supplies. Remove the [MEDICATION NAME] blue and apply wound vac, place tube going across the resident's anterior thigh to prevent further pressure sores. b. Resident needs wider wheel chair, still causing pressure sores to thighs. c. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. The 10/1/20 WC wound assessments revealed: a. #50 - 7.5 cm by 2.0 cm by 0.1 cm, moderate sero-sanguineous drainage b. #51 - 1.0 cm by 1.2 cm by 0.2 cm, moderate sero-sanguineous drainage c. #55 - 1.0 cm by 1.2 cm by 0.1 cm, scabbed over d. #56 - 2.4 cm by 2.0 cm by 1.4 cm, tunneled, moderate sero-sanguineous drainage e. #57 - 5.0 cm by 2.5 cm by 0.1 cm, moderate sero-sanguineous drainage f. #58 - 1.0 cm by 1.5 cm by 0.1 cm, scant sero-sanguineous drainage 10/1/20 WC Physician orders [REDACTED].>a. #51 Apply alginate then [MEDICATION NAME], cover with rolled gauze and secure with tape 3 times weekly and as needed. b. #56 Send a black foam dressing package and wound vac canister with the resident to every WC appointment. WC applied [MEDICATION NAME] blue to wound #56 due to the facility did not provide the required wound vac supplies. c. Remove the [MEDICATION NAME] blue and apply wound vac, place tube going across the resident's anterior thigh to prevent further pressure sores. d. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. The September, 2020 Treatment Administration Records (TAR's) revealed staff did not administer wound care as ordered to wounds #50, #54, #55, and #56 on 9/10/20, 9/12/20, 9/15/20, 9/17/20, 9/19/20, 9/22/20, 9/26/20, and 9/29/20, and treatments to wounds #57 and #58 not administered 9/15/20, 9/19/20, and 9/29/20. The October, 2020 TAR's revealed staff did not administer wound care as ordered to wounds #50, #51, #54, #57 and #58 on 10/6/20, 10/8/20, 10/10/20 and 10/13/20. A Progress Note transcribed by the Nurse Practitioner on 10/13/20 at 5:30 p.m. described a right lower extremity wound maggot infestation, purulent discharge with associated [DIAGNOSES REDACTED], and the resident transferred to the ER in her wheel chair via facility van for evaluation. The 10/13/20 ER Progress Note described the resident treated for [REDACTED]. A 10/21/20 Hospital Progress Note described the resident treated for [REDACTED]. The last wound culture collected 8/28/20 at the WC revealed heavy growth [MEDICATION NAME] faecalis (probably skin flora), heavy growth Peptostreptococcus, and heavy growth Prevotella species. When interviewed on 10/27/20 at 9:58 a.m., the resident stated the length of time between her wound care/dressing changes seemed like it was longer than every other day and sometimes she had to ask staff to do her dressing changes or remind them. She knew there were maggots in 1 of her wounds but didn't know that happened, the facility put her in a wheel chair that wasn't wide enough, that caused pressure and how she got some of the pressure sores on her thighs, the facility got her a different wheel chair, it could still stand to be wider because if she's not seated just right it felt tight on her hips/upper legs. Observation in the resident's room on 10/19/20 at 1:28 p.m. revealed a gray and navy blue mattress on the resident's bed, a tag on the mattress read Medacure Model PX8036, Prototype ID PX8000. Observation with Staff D, the Interim Director of Nursing (DON) on 10/20/20 at 4:59 p.m. in the resident's room revealed the resident's cam boot on the floor, next to a black wheel chair cushion approximately 2 to 3 inches thick also on the floor. Staff D unzipped the cushion cover that revealed a Roho type of rubber seat inside the cover, without name on the cover. Hospital staff confirmed the resident arrived via wheel chair on 10/13/20, a black wheel chair seat foam cushion approximately 1 inch thick in the wheel chair. The resident's RP, interviewed 10/20/20 at 7:33 p.m. confirmed the resident had a wheel chair that was located at her home, she hadn't brought it to the facility. Staff interviews revealed: 10/20/20 at 12:20 p.m., Staff B, Licensed Practical Nurse (LPN) stated staff were supposed to follow physician orders [REDACTED]. When she found dressings that hadn't been changed for several days she used to take a photo of it and took it to the former DON, but nothing happened. If staff hadn't changed the dressings for several days it should be reported to the physician. 10/22/20 at 3:53 p.m. Staff C, LPN stated if a resident's dressings aren't changed as ordered, would report it to the DON. When asked why the resident's dressings had not been changed between 10/3/20 and 10/13/20, Staff C stated the resident went to a doctor appointment on 10/8/20 so missed WC appointment, normally staff changed the dressings upon the return from [MEDICAL TREATMENT] but [MEDICAL TREATMENT] sent the resident to theER on [DATE], and there was a fire at the facility on 10/10/20. 10/20/20 at 4:53 p.m., Staff E, Registered Nurse (RN), stated normally the facility did not provide wound care on days the resident was scheduled at the WC, the resident was scheduled for her weekly appointment on 10/13/20. A facility therapist saw a maggot on 1 of the resident's wounds on 10/13/20 and got the DON. The DON completed the dressing change for that wound, got orders to send the resident to the ER, so Staff E changed all the other dressings except for the wound vac, the dressings hadn't been changed since 10/3/20, the resident didn't usually refuse care but might request that staff complete it at a later time. 10/20/20 at 11:35 a.m., Staff F, RN, the facility wound nurse stated nurses should sign dressings they applied with date, time and initials, that is standard protocol. If a nurse found dressings that weren't changed as ordered they should report it to the physician and for certain the DON. If a WC physician wrote orders or made suggestions such as Roho cushion or mattress overlay, staff should read and understand that, address the orders with the DON and the resident's physician if equipment was required. 10/21/20 at 6:58 p.m., Staff K, RN stated staff should complete dressing changes and treatments as ordered, and should notify the DON if they found dressings that haven't been changed. 10/22/20 at 4:10 p.m., Staff I, RN from the resident's WC stated she was present at the resident's 9/10/20 appointment, resident was in a wheel chair that was wider than her previous appointments, but the physician said it wasn't big enough, she had a wheel chair cushion but not the Roho cushion the physician had ordered, the resident had the wound vac on but the facility hadn't sent the required supplies for the dressing change. The resident was concerned that facility staff didn't change her dressings correctly, or as often as ordered, said she had to ask staff to change them and staff would leave her up in the wheel chair too long. The WC staff didn't feel the resident received appropriate care, she had more wounds and her other wounds were worse. 10/29/20 at 8:40 a.m., Staff J, WC Physician, stated he had several concerns about the resident's wound care at the facility, sometimes the dressings removed at the WC were not as they had ordered, the resident was in a wheel chair that was too small, it was easy to see where the sides of the wheel chair under the arm rests pushed on her thighs and exactly where she developed pressure sores on her bilateral thighs, this went on for weeks. The resident developed another pressure sore from the wound vac tubing that wasn't bridged on her anterior thigh as directed, the facility didn't send the required wound vac sponges and supplies with the resident to her WC appointments as ordered and standard protocol at least 3 times, and staff were leaving her up in the wheel chair and not off-loading her pressure areas, also directed in his orders The physician was not aware the resident refused the air mattress, and staff should have notified him of that condition. 10/21/20 at 1:54 p.m., Staff N, Administrator at another facility that transferred the resident to the current facility on 8/6/20 stated the resident was discharged from their facility without durable medical equipment (DME) requirements, and her facility had not purchased a wheel chair or wheel chair seat cushion for the resident. During an interview on 10/20/20 at 4:59 p.m., Staff D stated a therapist came and got her on 10/13/20, saw a maggot that fell off the resident's lower leg and came to her. Staff D went to the room with staff M, LPN, ADON and the Nurse Practitioner. Staff D stated there were at least 20 maggots in a wound on the resident's right lateral lower leg, she flushed the wound, the nurse practitioner dressed the wound and ordered the resident's transfer to the ER. 10/21/20 at 9:07 a.m. Staff H, Physical Therapy Assistant (PTA) stated on 10/13/20 when she raised the right lower leg a maggot fell out from the dressing, the dressing was loose on the bottom, she lowered the resident's leg and reported it to Staff D immediately. During an interview on 10/20/20 at 3:46 p.m., Staff D stated the resident refused an air mattress and provided a copy of the care plan where it was documented, remembered she told the nurse practitioner about it and she said to ensure the resident was on a pressure reduction mattress. She didn't know but didn't think the WC Physician was notified about it. During an interview on 10/20/20, at 11:28 a.m., Staff D, interim DON, stated staff should follow Physician Orders, if they can't they should contact the physician for direction and new orders, it was not acceptable for staff not to complete treatments and that should be reported to the DON or administrator. Staff D reviewed the resident's September and October TAR, agreed treatments were missing, and she started audits of MAR's and TAR's a week ago. Staff D was not aware that the resident's treatments weren't done and not sure why staff hadn't reported it. During the Exit Conference on 11/3/20, facility staff present that included the Administrator, Staff D; Interim DON, the Admissions Nurse and the Infection Control Nurse could not answer why nursing staff had not changed the resident's dressings for 10 days, but have since educated staff, implemented protocols and initiated audits for documentation and treatments are administered as ordered.

Based on observation, record review, resident, staff, Wound Center staff and physician interviews, the facility failed to provide nursing care in accordance to professional standards of practice that included Care Plan development, implementation of and following physician orders for wound care and pressure sore reduction, bowel management regimen's, and resulted in a resident's treatment at a hospital emergency room (ER) and hospitalization for 1 of 9 resident records reviewed (Resident #4). The facility reported a census of 48 residents. Findings include: The 8/17/20 MDS Assessment tool revealed Resident #4 admitted to the facility on [DATE], had [DIAGNOSES REDACTED].(intact skin with non-blanchable redness of a localized area), 5 venous or arterial skin ulcers, and pressure reduction devices in use for the chair and bed. The Care Area Assessment (CAA) Summary of the MDS Assessment identified dehydration and fluid maintenance as a potential problem that required address on the resident's care plan. An impaired skin integrity problem related to pressure injury initiated on the care plan on 8/10/20 directed staff to: a. On 8/10/20 perform treatment to wound per treatment order. b. On 8/10/20 follow pressure ulcer prevention guidelines to prevent additional skin problems. c. On 8/10/20 apply pressure reduction cushion to wheel chair. d. On 8/10/20 apply alternating pressure air mattress to bed, assure inflation control is correct. A revision on 10/13/20 stated the resident refused air mattress as ordered. The resident's Care Plan did not address actual or potential dehydration or fluid maintenance problems or interventions as required. Wound assessments documented 8/11/20 on Weekly Wound Observation V2 forms, reflected measurements obtained at the resident's 8/6/20 Wound Clinic (WC) appointment: a. Wound #49, stasis ulcer left lower leg, 1.3 centimeters (cm) by 2.5 cm by 0.1 cm b. Wound #50, stasis ulcer right lateral lower leg, 9.5 cm by 2.0 cm by 0.1 cm c. Wound #51, Stage 3 pressure sore left posterior heel, 1.5 cm by 1.0 cm by 0.1 cm d. Wound #54, stasis ulcer right proximal anterior lower leg, 8.9 cm by 6.0 cm by 0.1 cm e. Wound #55, Stage 3 pressure sore right posterior heel, 0.3 cm by 1.4 cm by 0.1 cm The WC physician directed care of the resident's wounds at weekly appointments. Wound assessments at the 8/27/20 WC appointment revealed: a. #49 0.6 cm by 1.2 cm by 0.1 cm b. #50 1.5 cm by 1.2 cm by 0.1 cm c. #51 1.4 cm by 1.7 cm by 0.1 cm d. #54 4.3 cm by 0.5 cm by 0.1 cm e. #55 0 cm by 0 cm by 0 cm. healed f. #56 Newly identified pressure sore on the left lateral thigh, 3.7 cm by 2.2 cm by 0.7 cm The 9/3/20 WC appointment wound assessments revealed 3 new pressure sores and the following assessments: a. #49 3.4 cm by 1.9 cm by 0.1 cm b. #50 2.7 cm by 1.4 cm by 0.1 cm c. #51 2.2 cm by 1.3 cm by 0.2 cm d. #54 Healed e. #56, Stage 3 pressure sore of the left lateral thigh, 3.4 cm by 1.8 cm by 1.9 cm with tunneling. f. #57, Stage 1 pressure sore of the right medial buttocks, 0.4 cm by 0.4 cm by 0.1 cm g. #58, Stage 3 pressure sore of the left medial buttocks, 3.7 cm by 3.0 cm by 0.1 cm h. #59, deep tissue injury of the right lateral thigh with non-blanchable tissue. Physician orders transcribed at the 9/3/20 WC appointment directed staff to evaluate the resident's wheel chair and room chair for size due to pressure sores on resident thighs, have resident assessed for Roho cushion (a pressure relief wheel chair cushion), resident to be out of wheel chair for pressure relief as much as possible. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. Wound measurements at the 9/10/20 WC appointment revealed: a. #49 0 cm by 0 cm by 0 cm healed b. #50 1.2 cm by 0.6 cm by 0.1 cm c. #51 1.6 cm by 1.6 cm by 0.2 cm d. #55 0 cm by 0 cm by 0 cm e. #56 3.3 cm by 1.6 cm by 1.6 cm, the wound tunneled f. #57 4.7 cm by 2.1 cm by 0.1 cm g. #58 5.0 cm by 4.0 cm by 0.1 cm h. #59 0 cm by 0 cm by 0 cm healed Other wound care orders transcribed at the 9/10/20 WC appointment included: a. #50 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply Polymems dressing, cover dressing with rolled gauze and secure with tape 3 times per week and as needed. b. #51 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply [MEDICATION NAME] or similar dressing, cover dressing with rolled gauze and secure with tape 3 times per week and as needed. c. #55 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply [MEDICATION NAME] or similar dressing, cover dressing with rolled gauze and secure with tape 3 times per week and as needed. d. #56 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply [MEDICATION NAME] blue lightly packed into the wound, use until wound vac is able to be placed in wound. Cover wound with [MEDICATION NAME] or similar dressing, secure dressing in place. Arrange to start negative pressure wound therapy at 125 millimeters pressure, change dressing 3 times per week. Send a black foam dressing package and wound vac canister with the resident to every WC appointment. e. #57 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply Allevyn or comparable sacral dressing, change every other day and as needed. f. #58 Cleanse wound and periwound with non-cytotoxic agent such as normal saline, apply Allevyn or comparable sacral dressing, change every other day and as needed. g. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. WC orders transcribed at the 9/17/20 appointment directed staff: a. Resident needs wider wheel chair, causing pressure sores to thighs. b. Have resident assessed for Roho cushion. c. Apply a barrier cream to right thigh. d. Administer [MEDICATION NAME] 300 mg oral every other day for 1 week. e. Do not turn the wound vac off overnight as that can cause an infection, wound infection suspected due to odor of wound #56 and resident's report the wound vac was turned off. f. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. 9/24/20 WC physician orders directed staff: a. Send a black foam dressing package and wound vac canister with the resident to every WC appointment. WC applied [MEDICATION NAME] blue to wound #56 due to the facility did not provide the required wound vac supplies. Remove the [MEDICATION NAME] blue and apply wound vac, place tube going across the resident's anterior thigh to prevent further pressure sores. b. Resident needs wider wheel chair, still causing pressure sores to thighs. c. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. 10/1/20 WC physician orders directed staff: a. #51 Apply alginate then [MEDICATION NAME], cover with rolled gauze and secure with tape 3 times weekly and as needed. b. #56 Send a black foam dressing package and wound vac canister with the resident to every WC appointment. WC applied [MEDICATION NAME] blue to wound #56 due to the facility did not provide the required wound vac supplies. Remove the [MEDICATION NAME] blue and apply wound vac, place tube going across the resident's anterior thigh to prevent further pressure sores. c. Use wheel chair cushion and mattress overlay or specialty bed or pressure relief mattress. The September, 2020 Treatment Administration Records (TAR's) revealed staff did not administer wound care as ordered to wounds #50, #54, #55, and #56 on 9/10/20, 9/12/20, 9/15/20, 9/17/20, 9/19/20, 9/22/20, 9/26/20, and 9/29/20, and treatments to wounds #57 and #58 not administered 9/15/20, 9/19/20, and 9/29/20. The October, 2020 TAR's revealed staff did not administer wound care as ordered to wounds #50, #51, #54, #57 and #58 on 10/6/20, 10/8/20, 10/10/20 and 10/13/20. Medication orders transcribed 8/6/20 included the following bowel medications: [REDACTED] a. [MEDICATION NAME] 10 milligrams (mg) administered rectal every 24 hours as needed for constipation. b. [MEDICATION NAME] Sodium 100 mg administered oral daily. c. Polyethylene [MEDICATION NAME] 3350 powder 17 Grams administered oral daily. d. Senna 8.6 mg administered oral every other day. The resident's October elimination records, reviewed 10/20/20 revealed no documentation of a bowel movement between 10/1/20 and 10/12/20 on paper records, and no recorded bowel movement between 10/13/20 and 10/19/20 on electronic records initiated on 10/12/20. The October, 2020 Medication Administration Record [REDACTED]. A Hospital ER Progress Note dated 10/9/20 revealed the resident transferred to the ER from her [MEDICAL TREATMENT] appointment due to abdominal pain and the resident reported no bowel movements for 6 or 7 days, the physician removed a large fecal impaction. A Progress Note transcribed by the Nurse Practitioner on 10/13/20 at 5:30 p.m. described a right lower extremity wound maggot infestation and purulent discharge with associated [DIAGNOSES REDACTED], and the resident transferred to the ER for evaluation. When interviewed on 10/27/20 at 9:58 a.m., the resident stated the length of time between her wound care/dressing changes seemed like it was longer than every other day and sometimes she had to ask staff to do her dressing changes or remind them. She knew there were maggots in 1 of her wounds but didn't know that happened, the facility put her in a wheel chair that wasn't wide enough, that caused pressure and how she got some of the pressure sores on her thighs, the facility got her a different wheel chair, it could still stand to be wider because if she's not seated just right it felt tight on her hips/upper legs. Staff interviews revealed: 10/20/20 at 12:20 p.m., Staff B, Licensed Practical Nurse (LPN) stated staff were supposed to follow physician orders for dressing changes, if staff can't complete the dressing change it is passed on to the next shift, dressings should be dated and initialed. When she found dressings that hadn't been changed for several days she used to take a photo of it and took it to the former Director of Nursing (DON), but nothing happened. If staff hadn't changed the dressings for several days it should be reported to the physician. 10/22/20 at 3:53 p.m. Staff C, LPN stated if a resident's dressings aren't changed as ordered, would report it to the DON. When asked why the resident's dressings had not been changed between 10/3/20 and 10/13/20, Staff C stated the resident went to a doctor appointment on 10/8/20 so missed WC appointment, normally staff changed the dressings upon the return from [MEDICAL TREATMENT] but [MEDICAL TREATMENT] sent the resident to theER on [DATE], and there was a fire at the facility on 10/10/20. Nurses were supposed to ask the certified nursing assistants (CNA's) about resident's bowel patterns daily. 10/20/20 at 4:53 p.m., Staff E, Registered Nurse (RN), stated normally the resident's dressings were changed at the WC during her weekly appointment there. The resident was scheduled for the WC on 10/13/20, a therapist saw a maggot on 1 of the resident's wounds and got the DON. The DON completed the dressing change for that wound, got orders to send the resident to the ER, so Staff E changed all the other dressings except for the wound vac, the dressings hadn't been changed since 10/3/20, the resident didn't usually refuse care but might request that staff complete it at a later time. 10/20/20 at 11:35 a.m., Staff F, RN, the facility Wound Nurse stated nurses should sign dressings they applied with date, time and initials, that is standard protocol. If a nurse finds dressings that aren't changed as ordered they should report it to the physician and for certain the DON. If a WC physician wrote orders or made suggestions such as Roho cushion or mattress overlay, staff should read and understand that, address the orders with the DON and the resident's physician if equipment was required. 10/21/20 at 6:58 p.m., Staff K, RN stated staff should complete dressing changes and treatments as ordered, and should notify the DON if they found dressings that haven't been changed. Nurses are responsible for monitoring resident's bowel status, the certified nursing assistants (CNA's) document the resident's bowel movements, the records are accessible to the nurse and a place for it on the TAR. 10/22/20 at 4:10 p.m., Staff I, RN from the resident's WC stated she was present at the resident's 9/10/20 appointment, resident was in a wheel chair that was wider than her previous appointments, but the physician said it wasn't big enough, she had a wheel chair cushion but not the Roho cushion the physician had ordered, the resident had the wound vac on but the facility hadn't sent the required supplies for the dressing change. The resident was concerned that facility staff didn't change her dressings correctly, or as often as ordered, said she had to ask staff to change them and staff would leave her up in the wheel chair too long. The WC staff didn't feel the resident received appropriate care, she had more wounds and her other wounds were worse. 10/29/20 at 8:40 a.m., Staff J, WC Physician, stated he had several concerns about the resident's wound care at the facility, sometimes the dressings removed at the WC were not as they had ordered, the resident was in a wheel chair that was too small, it was easy to see where the sides of the wheel chair under the arm rests pushed on her thighs and exactly where she developed pressure sores on her bilateral thighs, this went on for weeks. The resident developed another pressure sore from the wound vac tubing that wasn't bridged on her anterior thigh as directed, the facility didn't send the required wound vac sponges and supplies with the resident to her WC appointments as ordered and standard protocol at least 3 times, and staff were leaving her up in the wheel chair and not off-loading her pressure areas, also directed in his orders The physician was not aware the resident refused the air mattress, and staff should have notified him of that condition. During an interview on 10/20/20, at 11:28 a.m., Staff D, Interim DON, stated staff should follow physician orders, if they can't they should contact the physician for direction and new orders, it was not acceptable for staff not to complete treatments and that should be reported to the DON or administrator. Staff D reviewed the resident's September and October TAR, agreed treatments were missing, and she started audits of MAR's and TAR's a week ago. Staff D was not aware that the resident's treatments weren't done and not sure why staff hadn't reported it. During an interview on 10/20/20 at 2:48 p.m., Staff D stated the nurse is responsible for monitoring resident bowel function, they should check the ADL book (activities of daily living), and since 10/12/20 the information is documented in the electronic record. There were some standing orders for bowel protocols, and the nurse should call the physician for orders when needed. Staff D reviewed the resident's October bowel records and could not identify when the resident had a bowel movement in October, knew [MEDICAL TREATMENT] had sent the resident to the ER [DATE] because she needed an enema, and could not identify any action that she had taken as the interim DON to address the issue with the staff. During an interview on 10/20/20 at 3:46 p.m., Staff D stated the resident refused an air mattress and provided a copy of the Care Plan where it was documented, remembered she told the nurse practitioner about it and she said to ensure the resident was on a pressure reduction mattress. She didn't know but didn't think the WC Physician was notified about it. During the Exit Conference on 11/3/20, facility staff present that included the Administrator, Staff D; Interim DON, the Admissions Nurse and the Infection Control Nurse could not answer why nursing staff had not changed the resident's dressings for 10 days, but have since educated staff, implemented protocols and initiated audits for documentation and treatments are administered as ordered.

Based on record review, and staff, physician, laboratory staff and the resident's responsible party interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for 1 of 6 resident records reviewed (Resident #6). Record review revealed the facility failed to ensure Resident #6 received care and treatment in a timely manner. The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had [DIAGNOSES REDACTED]. Resident #6 scored 13 out of 15 points possible on the Brief Interview of Mental Status (BIMS) cognitive assessment and without symptoms of [MEDICAL CONDITION]. The assessment identified Resident #6 required extensive assistance of one staff member for transfers to and from bed and chair, bathing, dressing, toileting and personal hygiene. Resident #6 had a urinary catheter in place and the resident continent of bowel. On 11/10/17, a urologist physician ordered [MEDICATION NAME], an antibiotic medication, 250 milligrams (mg) administered oral daily as a [MEDICATION NAME] treatment to prevent urinary tract infections (UTI's); and the continued use of the urinary catheter, changed monthly. On 11/17/17, the resident's regular physician ordered a complete medical profile laboratory (lab) test performed on 12/21/17. On 12/5/17, the resident's regular physician ordered the following supplements, administered as UTI [MEDICATION NAME]: Cranberry tablets, 450 mg, administered oral twice daily. UTI Stat liquid, 30 milliliters (ml), administered oral daily. Additionally, push oral fluids, 240 ml (8 ounces) 3 times daily with medication administration. On 12/14/17, the resident's regular physician ordered the urinary catheter discontinued, and straight catheterization (catheter inserted to drain the bladder and then removed) every 8 hours as needed if unable to urinate. On 12/18/17, the physician ordered urinalysis with culture and sensitivity (C and S) report (a urine test that determines a UTI and the appropriate antibiotic treatment if present). The 12/18/17 urinalysis with C and S report revealed: Faxed to facility (information sent via facsimile) on 12/19/17 at 7:50 a.m. WBC (white blood cell) Esterase 100 (high value, normal range 0 to 25 WBC per deciliter). Urobilinogen 8 (high value, normal range less than 1 mg per deciliter). WBC 11 to 30 (high value, normal range 0 to 3), all positive indications of a UTI. Faxed to facility on 12/19/17 at 11:51 a.m. Preliminary urine culture and colony count reported a culture pending (positive sign of a UTI). Faxed to facility on 12/22/17 at 9:50 a.m. Final urinalysis C and S report stated greater than 100,000 colony forming units (CFU) per ml of [MEDICATION NAME] resistant [MEDICATION NAME] faecium (VRE, a super bug infection resistant to [MEDICATION NAME], a very strong antibiotic), and greater than 100,000 CFU of Acinetobacter BaumannII/Calcoaceticus Complex. The report listed antibiotics effective against both organisms. A complete blood cell (CBC) blood test performed on 12/22/17 at 5:20 a.m., faxed to the facility on [DATE] at 9:45 a.m., revealed 68.3 [DIAGNOSES REDACTED]ls (high value and indicative of acute infection, normal range 43.0 to 65.0). Facility documents revealed: Faxed physician the urinalysis report, the physician responded that C and S needed and returned to the facility via fax on 12/19/17 at 3:06 p.m. Faxed physician the final C and S report, the physician responded results of kidney function tests were needed and returned to the facility via fax on 12/22/17 at 10:59 a.m. Nurse's Notes revealed the following entries: On 12/18/17 at 4:48 p.m. - Responsible party (RP) concerned about the resident's increased confusion, stated this is what she does when she gets septic. On 12/18/17 at 6:10 p.m. - Straight catheter, 490 ml of dark amber foul smelling urine obtained, urine specimen obtained. On 12/18/17 at 6:45 p.m. - Lab picked up the urine specimen. On 12/20/17 at 4:09 p.m. - ate poorly at breakfast, did not eat lunch. On The sequential next entry on 12/24/17 at 1:27 a.m. - Afebrile and remains on contact isolation for VRE in urine. Encouraged to increase fluids. On 12/25/17 at 10:10 a.m., transcribed by Staff A, registered nurse (RN) - Decline in status this a.m., non-responsive to verbal and tactile stimulus. Oxygen saturation 83 percent (normal 95 to 100 percent) pulse 122 beats per minute (normal range 60 to 80 beats per minute), temperature 98.8 degrees oral (normal 98.6 degrees), physician notified, order to send to the hospital emergency room (ER). A hospital discharge summary, dated 1/20/18, revealed the resident brought to the ER from the nursing home on 12/25/17 with altered mental status, lethargic and urine culture with VRE. The resident diagnosed with [REDACTED]. Interviews revealed: On 2/1/18 at 3:25 p.m., the resident's responsible party stated he/she was very concerned about the resident's condition, she had a history of [REDACTED]. The responsible party stated the resident did not have lab work done until 12/22/17 or 12/23/17; he/she was certain he/she had spoken with Staff F, licensed practical nurse (LPN), about the concerns. The responsible party stated he/she didn't think staff responded to his/her concerns until it was too late, the resident was in a coma when she arrived at the hospital. On 2/1/18 at 3:40 p.m., staff at Metropolitan, the processing laboratory, stated the 12/18/17 urinalysis with C and S reports were faxed to the facility as follows: 12/19/17 at 7:50 a.m. - the urinalysis micro report. 12/19/17 at 11:51 a.m. - the culture preliminary report. 12/20/17 at 1:35 p.m. - the final culture report 12/22/17 at 9:50 a.m. - the final report with sensitivities listed. Additionally, the laboratory notified Staff A, RN, at the facility, of the VRE result by phone on 12/22/17 at 9:48 a.m. On 2/6/18 at 11:13 a.m., the office manager at the resident's physician's office stated they had no other documentation of any correspondence from the facility about the 12/18/17 urinalysis with C and S report, the physician had not received any contact from the facility via her cell phone, and the physician expected staff to contact her if they had not heard a response from a fax within a reasonable time or after office hours for abnormal test values such as this. On 2/5/18 at 5:05 p.m., Staff A, RN, assigned to the resident on 12/22/17 from 6 a.m. to 6 p.m., had no recollection of communication with the physician's office about the urinalysis test. On 2/5/18 at 11:03 a.m., Staff B, RN, assigned to the resident on 12/22/17 from 6 p.m. to 6 a.m. on 12/23/17, had no recollection of the resident in isolation, VRE in urine, or any pending orders from the physician related to the urinalysis with C and S. On 2/5/18 at 1:18 p.m., Staff C, certified nursing assistant (CNA), assigned to the resident's hall from 6 a.m. to 2 p.m. the week before 12/25/17, stated she did not remember the resident being in isolation, she was normally alert but a little confused right before she went to the hospital. On 2/5/18 at 1:21 p.m., Staff D, CNA, assigned to the resident's hall from 6 a.m. to 2 p.m. the week before 12/25/17, stated she did not remember the resident being in isolation, and the resident was alert. On 2/6/18 at 12:25 p.m., Staff E, RN, stated nursing staff complete a 24 hour sheet daily that contained information communicated between nurses at change of shifts, with pertinent information about each resident, the sheets are then placed in a wall hanger and collected by the assistant director of nursing. On 2/6/18 at 1:50 p.m., Staff F, the facility's corporate nurse, stated she could not locate the 12/22/17 and 12/23/17 24 hour sheets requested by the surveyor, the facility did not have a policy for physician notification of resident conditions, couldn't find the and expected the nursing staff to notify the physician of the abnormal lab values and obtained orders for treatment.

Based on observation, record review, staff interviews and review of policy and procedures, the facility failed to provide interventions for residents with pressure sores by failing to reposition Residents #4 and #5 for more than 2 hours, failing to provide a treatment ordered for Resident #5 and failed to prevent the development of heel pressure sores to both feet of Resident #8. The facility reported a census of 59 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Ulcer: inability to see the wound bed. Resident #8 had a Minimum Data Set (MDS) assessment with a reference date of 11/01/17. The MDS identified the resident had [DIAGNOSES REDACTED]. Additionally, the MDS noted to have short and long term memory problems and moderately impaired with decision making skills. The MDS indicated Resident #8 required extensive assistance of 1 staff member with most activities of daily living (ADL) skills. Review of the Skin Condition section of the MDS identified the resident did not have any unhealed pressure ulcers at the time of the assessment. Review of the Care Plan identified a potential problem with impaired skin integrity and/or development of pressure related ulcer(s) and/or breakdown with a date of initiation as 8/09/16. The interventions directed the nursing staff to refer to weekly skin check sheet/TAR (Treatment Administration Record) for a treatment plan for actual impaired skin integrity problems. Revision of the care plan on 4/26/17 directed the staff to observe skin for any type of skin breakdown. The interventions indicated a pressure reducing mattress and cushion was placed on the bed and chair. On 10/20/17 the Care Plan identified a problem with self- care deficit related to a right [MEDICAL CONDITION] from a fall and repair. The interventions directed staff that the resident required 2 staff persons with mobility and to turn and reposition. The intervention indicated the resident had an abductor pillow (to prevent crossing of legs due to hip repair) and to keep the resident's hips straight. On 10/25/17, the resident identified with Suspected Deep Tissue Injury to both heels and nursing staff were directed to float heels when in bed. On 11/20/17 the Care Plan was revised for the resident to wear PRAFO boots (boots worn to suspend heels and reduce pressure). Review of the Nurse's Progress Notes for Resident #8 shown on 10/12/17 at 3:17 p.m., the resident found lying on the floor between the resident's bed and his/her roommate's bed. Orders were received to have a portable x-ray of the right hip/pelvis area as the resident favored that area with an assessment. At 7:45 p.m., the facility received confirmation of a right [MEDICAL CONDITION]. Orders then received to send the resident to the ER for evaluation and treatment. Resident returned to the facility on [DATE]. Continued review of the Progress Notes noted no documentation of skin issues for the resident or of any prevention interventions of floating the resident's heels. A Progress Note on 10/25/17 at 11:52 a.m. by the Wound Nurse identified the resident's skin assessed and noted to have Suspected Deep Tissue Injury (SDTI) to each heel. The right heel measured 3.5 centimeters (cm) x 4.5 cm and the left heel measures 5 cm x 0.5 cm. The registered dietician was notified and awaiting recommendations at this time. Review of the Skin Observation Tool dated 10/18/17 upon readmission after repair of the right [MEDICAL CONDITION] indicated the only skin issue to be the surgical incision on the right hip. On 10/22/17 a Skin Observation Tool showed a right thigh scratch and no other skin issues. On 10/23/17 no issues noted documented on the Skin Observation Tool form. On 10/25/17 an Initial Wound Assessment completed for a pressure wound noted to the left heel measuring 2 cm x (by) 0.5 cm and the right heel measured 3.5 cm x 4.5 cm, with both staged as a Suspected Deep Tissue Injury. The assessment documented the wounds acquired after admission to the facility. Under the Clinical Unavoidability section, the resident received two or more treatments or demonstrated signs/symptoms that increased the likelihood of the development of an unavoidable wound. Treatments consisted of bed pressure reduction/redistribution mattress, positioning/splinting device, and wound treatment/application of dressing. On 10/31/17, a form titled Weekly Wound Observation form was completed for both the left and right heels. The forms identified an acquired date for both wounds on 10/25/17. The identified special equipment/preventative measures documented were pressure relief mattress and float heels, with a current treatment plan of skin prep daily. Both heels were identified with 100% necrotic tissue present with the left heel measuring 1 cm x 2 cm and the right heel measuring 3 cm x 4 cm. On 11/07/17 a Weekly Wound Observation form completed for both the left and right heels. The forms showed an acquired date for both wounds on 10/25/17. The identified special equipment/preventative measures documented remained pressure relief mattress and float heels, with a current treatment plan of skin prep daily. Both heels identified with 100% necrotic tissue present with the left heel measuring 5 cm x 5 cm and the right heel measuring 4.8 cm x 5.3 cm. Both heel areas documented under the visible tissue section that the overall impression to be worsening. The resident documented often noted to be refusing the abductor pillow as well as float heels. On 11/14/17 a Weekly Wound Observation form completed for both the left and right heels. The forms identified an acquired date for both wounds on 10/25/17. The identified special equipment/preventative measures documented remained pressure relief mattress and float heels, with a current treatment plan of skin prep daily. Both heels identified with 100% necrotic tissue present with the left heel measuring 4 cm x 4.5 cm and the right heel measuring 4.6 cm x 4 cm. Both heel areas documented under the visible tissue section that the overall impression to be worsening. The resident documented often noted to be refusing the abductor pillow as well as float heels. Review of the Order Summary Report for Resident #8 noted the following current orders: Float heels while in bed every day and night shift for skin prevention with a start date of 10/25/17. Right heel skin prep daily every day shift to promote healing with a start date of 10/26/17. Left heel skin prep twice a day every day and night shift for wound healing dated 11/18/17 (changed from initial treatment of [REDACTED]. PRAFO Boots on at all times, may remove for skin checks and bathing, every day and night shift for prevention (start date of 11/18/17). Review of the doctor orders identified the left heel to have a treatment from 11/13/17 to 11/18/17 and to cleanse the heel area with normal saline or wound wash, apply [MEDICATION NAME] to the wound bed, cover with [MEDICATION NAME], wrap with gauze daily, and as needed for wound healing every day shift. During the survey, observation on 11/20/17 at 10:30 a.m. noted the resident in bed asleep lying to her right side with bare feet, no socks or PRAFO boots on and no pillow to float the heels. This remained that way in bed until approximately 1:30 p.m. (3 hours) after Staff K and Staff L, Certified Nurse Aides completed cares for the resident and put slipper socks and the PRAFO boots on the resident and floated his/her heels with a pillow. While in the resident's room during cares, noted an undated sign posted on the resident's armoire that directed the nursing staff the patient to have hip abductor pillow at all times while lying in bed. Heels to be floated off mattress. Any questions- contact Therapy/Nursing. On 11/21/17 at 7:06 a.m., observation noted Resident #8 out in the hallway propelling self in the wheelchair with slipper socks on, but no PRAFO boots on feet. At 8:06 a.m. the resident observed with PRAFO boots on feet. Resident laid down in bed per Staff M and Staff N, both CNA's at 8:24 a.m. and noted the resident to have the PRAFO boots on, but no pillow utilized to float the resident's heels. At 9:57 a.m., the resident remained in bed lying on her right side with the left leg dangling off the bed and the right leg on the bed with no pillow at the end of the bed to float the heels. On 11/22/17 at 7:10 a.m., observation identified the resident up in her wheelchair, dressed and sitting in a line waiting to go to the dining room. The resident noted to be awake, feet on foot pedals with slipper socks on feet but no PRAFO Boots on. At 7:14 a.m. observation identified the PRAFO Boots on the room floor in the corner next to the resident's armoire. At 7:18 a.m., the resident now in the dining room at a table in her wheelchair with no PRAFO boots on. At 9:00 a.m., observation identified the resident in bed asleep with bilateral PRAFO Boots on. Later at 10:40 a.m., the resident remained in bed with PRAFO Boots on and at 12:45 p.m. now in the dining room in her wheelchair with feet on the foot pedals, slipper socks on and no PRAFO Boots on feet. On 11/21/17 at 10:22 a.m., the Wound Nurse was interviewed and stated yes, the resident's heels were not noted till 10/25/17, a week after readmitted from the hospital. The staff are trying to float heels now, was refusing the abductor pillow and not always complying with floating heels. The order for the PRAFO boots was made 11/18/17 and no wound clinic referral due to non-compliance. On 11/27/17 at 3:10 p.m., the Wound Nurse stated she could not prove nor known if Resident #8's heels were floated when readmitted to the facility from the hospital after her right [MEDICAL CONDITION] repaired and prior to when the areas to the heels noted on 10/25/17. The Wound Nurse reported the heels to be floated now after the areas noted to the bilateral heels and orders received for that. During the interview, the Wound Nurse went to the resident's room to review the sign posted on the resident's armoire about the hip abductor pillow and floating heels. The Wound Nurse reported she did not create the sign and does not know who did. The Assistant Director of Nursing (ADON) was asked if aware of the sign and denied knowledge or creating the sign and that maybe the therapy staff did. On 11/28/17 at 7:55 a.m., the Consultant Nurse reported she could not defend what happened with Resident #8's heels and the development of the pressure sores a week after readmitted from the hospital. The heels should have been floated and other preventative measures taken right away, not sure when the resident was placed on the air mattress either. The PRAFO Boots were not ordered till 11/18/17 a month after admission. The Consultant Nurse stated the facility is working on better education for the nursing staff. During an interview on 11/28/17 at 8:45 a.m. the Director of Therapy presented the lap top computer utilized to create the sign posted on Resident #8's armoire directing the nursing staff about the abductor pillow usage and floating heels for the resident. The Director showed that sign not created till 11/6/17 as logged in the computer when completed. The sign was created 9 days after the areas to the heels noted. Review of the policy and procedures titled Skin Management Guidelines Practice Guidelines (revision 7/2017) explained the purpose of the policy is to identify at risk residents for potential breakdown or ulcerations, to prevent breakdown of tissue or ulcerations, and to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations. The policy directed the appropriate preventive measures will be implemented on all residents identified at risk and the interventions documented on the Care Plan. This may include: Floating areas of concern such as heels when appropriate and use elbow or heel protectors when appropriate. 2. Resident #5 had a MDS quarterly assessment with a reference date of 10/6/17. The MDS had documentation of the following Diagnoses: [REDACTED]. It also identified the resident with a brief interview for mental status score of 15 out of 15. A score of 15 represented no cognitive problems. The MDS identified the resident required extensive staff assistance with most activities of daily living and had 1 Stage IV pressure ulcer. The Care Plan, with the target date of 1/2/18, identified the resident with actual impaired skin integrity and directed staff to provide treatment as ordered and turn and reposition every 2 hours and as needed. The November 2017 TAR identified an order with a start date of 10/27/17 to pack the wound twice a day with Kerlix dressing and Vashe with doses circled to indicate the treatment had not been given on November 8, 9, 10, 11, 12, 16, 17, and 18. The back of the TAR had the following handwritten: 11/4, 11/10, 11/11, 11/12 - NS (normal saline) used, 11/9/17 treatment did not get completed on morning shift, 11/11/17 out of Vashe (cleanser) - ordered from pharmacy, used Dakin's. 11/13/17, 11/14/17 No Vashe but used Dakin's 11/17, 11/18, 11/19, 11/20, 11/2 No Vashe and used NS (normal saline). Orders from the Wound Clinic dated 10/26/17 identified an order to pack wound twice a day with Kerlix and Vashe. A review of the Nurse's Notes indicated: On 11/10/17 at 11:57 p.m. client dressing changed per orders. On 11/13/17 at 9:30 a.m. spoke with pharmacist regarding Vashe and reordered at this time. They have one bottle in stock and will overnight it today. A review of the wound assessments identified on 4/6/17 (on admission) the resident had the Stage IV pressure ulcer to the left buttock which measured 4 centimeters (cm) in length, 4 cm in width and 3.5 cm deep. On 10/4/17, length 4 cm, width 8.5 cm and depth 4 cm and 4 cm tunnel at 12:00 o'clock and 4.5 cm tunnel at 9:00 o'clock. A review of the wound nurse's weekly wound tracking identified: On 11/1/17 length 8.2 cm, width 4 cm, depth 4 cm On 11/8/17 length 4 cm, width 8.5 cm, depth 4 cm On 11/15/17 length 3.6 cm, width 7 cm, depth 4 cm. An observation of wound care on 11/21/17 identified the following: On 8:02 a.m., Staff B, RN removed a Kerlix dressing from the treatment cart and reported the VA still has not sent the Vashe solution yet, will get a verbal order for normal saline from the doctor today. Staff B proceeded to remove scissors from her pants pocket and cut the Kerlix and placed the scissors back in her pocket without disinfecting. At 8:11 a.m., Staff B turned the resident to lie on his right side, handed the resident a [MEDICATION NAME] suction tip, the resident had used the tip to suction mucus from his/her mouth, Staff B placed the [MEDICATION NAME] suction tip on top of the suction machine and did not change gloves prior to cleansing the wound with normal saline soaked Kerlix. She then proceeded to remove Kerlix from the resident's night stand, removed scissors from her pocket and cut the Kerlix, left the scissors on top of the over bed table without a barrier. At 8:13 a.m. Staff B changed gloves, packed the wound with Kerlix soaked in normal saline, removed gloves and placed the scissors back in her pants pocket without disinfecting. Observations of the resident revealed the resident laid on his back in bed and not repositioned at the following times on 11/22/17: 5:05 a.m., 5:42 a.m., 6:05 a.m., 6:30 a.m., and 7:08 a.m. Interviews with staff revealed the following: On 11/21/17 at 8:02 a.m., Staff B, RN reported the VA had not sent the Vashe solution yet and verified the order was written 10/27/17 and the documentation on the back of the current TAR showed the treatment had not been completed with the first date 11/9/17. The staff used Dakin's solution because the Vashe smells like Dakin's. She also verified the documentation on the back of the TAR had documentation out of Vashe - ordered from pharmacy - used Dakin's. Staff B also checked the treatment cart and reported We still don't have the Vashe, I called the doctor and got an order for [REDACTED].>On 11/22/17 at 6:32 a.m., the wound nurse for the facility reported she would expect staff to turn/reposition at least every 2 hours and more frequently if needed. If they have areas to their heels, float the heels with pillows, skin prep in place. We should try to get an order for [REDACTED]. The wound seemed to have increased in size. When the resident went to the UIHC burn and Wound Care Center, they changed the order to the Vashe twice daily. The VA is supposed to provide his medications. The floor nurses should ensure that the residents have all the medications that have been ordered. If the medication is not there the next day, they should follow up. We have Pharmerica that contracts with the local Walgreens and they usually do 2 runs a day. There should have been no reason for the resident not to have the Vashe for almost 3 weeks. After the cap for the spray bottle for wound cleanser fell on the floor, she would have expected the nurse to sanitize the cap before putting it back on the bottle. She also reported she would expect the nurse to change gloves wash hands and don new gloves before changing dressing to each wound. During an interview on 11/22/17 at 9:10 a.m., Staff Q, CNA reported the resident should be repositioned every 2 hours and that he is compliant with being repositioned. In an interview on 11/22/17 at 8:35 a.m., Staff R, CNA reported residents with pressure sores should be repositioned every 2 hours and that Resident #4 and #5 to be pretty compliant with being repositioned. During an interview on 11/22/17 at 9:43 a.m., Staff S, CNA reported residents with pressure sores should be repositioned every 2 hours and Resident #5 had been compliant with being repositioned. Upon request of any physician orders [REDACTED]. 3. Resident #4 had a MDS assessment with a reference date of 10/23/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident to be cognitively impaired with a brief for mental interview status score of 9 out of 15. A score of 9 identified the resident as moderately cognitively impaired for decision making skills. The MDS indicated the resident required extensive staff assistance with most activities of daily living and had 2 Stage III pressure ulcers. The care plan with the target date of 2/2/18 identified the resident with pressure ulcers to the left buttock, right groin, right heel and ankle, left foot and heel and left and right ischial areas. It also directed the staff to: Turn and reposition the resident frequently when in bed and in the wheelchair Perform treatment to wounds per current treatment order Follow pressure ulcer prevention guidelines to prevent addition skin problems to promote healing and prevent complications. Observations of the resident revealed the resident laid on his/her back without being repositioned on 11/21/17 at the following times: 6:00 a.m., 6:45 a.m., 7:55 a.m., 8:27 a.m., 8:30 a.m., 9:00 a.m., 9:30 a.m., 10:00 a.m., 10:28 a.m., 11:09 a.m., 11:37 a.m. 11/22/17 while the resident laid on his/her back with the Prevalon boot lying beside the resident's right foot resting directly on the mattress without being floated at 5:05 a.m., 5:42 a.m., 6:07 a.m., 6:30 a.m., 7:00 a.m. and 7:30 a.m. An observation of changing the wafer to the [MEDICAL CONDITION] bag and wound cares to the pressure ulcers on 11/21/17 revealed the following: 11:40 a.m. Staff B, RN did not place a barrier underneath the dressing supplies, reported the resident had been in isolation for an infection to an open area to the right groin. 11:42 a.m. Staff B removed scissors from her pants pocket, cut a hole in the wafer for the [MEDICAL CONDITION], dropped the scissors on the floor, did not disinfect the scissors before cutting 5 different strips of antifoam tape. 11:47 a.m. Staff B used the scissors to cut the wafer and placed the scissors on top of the over bed table. 11:52 a.m. after changing the [MEDICAL CONDITION] bag, Staff B changed gloves, removed the Prevalon boot from the resident's left foot. A moderate amount of serosanguinous drainage had been observed on the fitted sheet under the left foot. Staff B then used scissors to cut the old dressing off the left foot, removed the dressing, did not change gloves before cleansing the wound to the top of the foot or before applying [MEDICATION NAME] to the open area. She also did not change gloves before cleansing the open area to the heel. 11:59 a.m. Staff B placed dressings on the over bed table without a barrier, changed gloves, did not disinfect the scissors before cutting the new [MEDICATION NAME] dressing. 12:03 p.m. Staff B placed a section of chux (which had been placed under the left heel while irrigated) into the inside of the Prevalon boot and did not change gloves prior to obtaining new 4x4 gauze dressings out of the nightstand and before applying dressings to the wound. 12:10 p.m. Staff B changed gloves and removed the dressing to the left gluteal fold which had a small amount of serous drainage on the chux underneath the resident, removed the dressing to the wound and did not change gloves prior to cleansing the wound with wound spray. Staff B dropped the cap to the wound spray on the floor and recapped the spray bottle immediately afterward. A review of the skin observation tool dated 11/16/17 had documentation of the following pressure ulcers and measurements: Left heel - length 7.0 centimeters (cm) width 7.0 cm depth 0.2 cm unstageable Top of left foot - length 6.0 cm width 4.0 cm depth 0.1 cm Stage II Right ischial - length 2.0 cm width 1.4 cm depth 0.1 cm Stage II Left ischial - length 4.3 cm width 2.0 cm depth 1.0 cm Stage III A review of the initial wound assessments had documentation of the following dated 11/16/17: Right heel - length 2.5 cm width 2.0 no depth documented Right buttock - length 0.4 cm width 0.5 cm depth 0.2 Stage II Right groin - length 6.0 cm width 2.0 cm depth 0.4 cm Left dorsal foot - length 0.7 cm width 1.2 cm depth - none documented Left heel - length 6.0 cm width 7.5 cm depth 0.4 cm Stage III Left buttock - length 3.5 cm width 2.0 cm depth 2.0 cm Stage III During an interview on 11/21/17 at 11:09 a.m., the resident's spouse stated when visiting the resident daily from 10:00 a.m. to 2:00 p.m., the staff do not reposition the resident and this is concerning as the resident has open areas to the buttocks and heels. In an interview on 11/22/17 at 6:32 a.m., the wound nurse stated when a nurse does a dressing change, she would expect the nurse to clean the scissors with alcohol before and after each dressing and put the scissors in a plastic bag before placing it back in the pocket. She also reported she would expect the nurse to use a clean chux (disposable sheet) to line the Prevalon boot with, not the one she used to place under the heel when irrigating the wound. During an interview on 11/22/17 at 9:10 a.m., Staff Q, CNA stated the resident should be repositioned every 2 hours and should have the boots to his feet on at all times.

Based on record review, observations and interviews, the facility failed to prevent the development of pressure ulcers and failed to promote healing of the pressure ulcers for 3 of 4 residents reviewed with pressure ulcers (Residents #2, #5, #6). Resident #2 had a cast applied for a fractured ankle on 6/5/17. The orthopedist wanted the resident seen in 3 weeks and no appointment had been made and the family notified the facility and the orthopedist saw the resident 10 weeks after the cast applications which identified 2 avoidable pressure sores (top of foot and heel). Upon admission, the resident had pressure ulcers behind the right knee. The open areas were not addressed. The facility reported a census of 60 residents. Findings include: 1. According to the Admission Record dated 8/23/17, Resident #2 had an admitted into the facility on [DATE]. The record identified the resident had [DIAGNOSES REDACTED]. Resident #2 had a MDS (Minimum Data) assessment with a reference date of 6/20/17 revealed Resident #2 had no cognitive impairments. Resident #2 had total dependence of staff for bed mobility, dressing, toilet use and personal hygiene. The MDS identified the resident to be at risk for the development of pressure ulcers and had 2 Stage II pressure ulcers. The MDS identified a Stage II as the following: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured blister. The MDS identified the following Stages of pressure ulcers: A Stage I is an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: Skin temperature, Tissue consistency, Sensation, and or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. A Stage II is described as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured blister. A Stage III is described as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining or tunneling. A Stage IV is described as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The Care Plan directed the staff to assess circulation, motion, sensation and temperature every shift until cast removed, provide pain medication as ordered, hospice care, inspect feet daily for open areas, sores, blisters, [MEDICAL CONDITION] and redness, apply alternating air mattress to bed and ensure inflation control is correct, unable to assist with positioning in bed, staff to assist with turning and positioning, weekly head to toe assessment by licensed nurse, review skin risk via Braden scale, clinical observation/assessment, avoid friction and shearing when repositioning, use two staff for repositioning, use lift sheet, bed should be flat as possible while lifting and monitor skin with all cares and report changes to nurse. The orthopedic visit note dated 6/5/17 indicated Resident #2 had a mildly displaced bimalleolar (ankle) fracture and a cast applied to the right lower extremity. The note revealed a plan to follow up in 2-4 weeks. The admission orders [REDACTED]. The Orthopedic visit note dated 8/15/17 revealed Resident #2 had a visit 10 weeks post displaced bimalleolar right ankle fracture. The note had documentation that at the last visit, the nurse from the skilled nursing facility that Resident #2 stays, did not stop at the front desk and make a follow up appointment. The distal fibular and medial malleolus fracture healed. The cast was removed and Resident #2 had wounds on the right foot from the cast. The note indicated the physician assistant (PA) documented he would need to keep a close eye on the wounds and placed a non-stick dressing on the wounds before applying the boot. The PA ordered [MEDICATION NAME] (antibiotic) and the resident should follow up in 10-14 days with the physician (orthopedist). The Hospice Clinical Notes dated 8/15/17 indicated the resident's responsible party called and reported he/she called the orthopedic clinic and the clinic reported Resident #2 should have been seen three weeks ago for a follow up. The responsible party made an appointment. The Hospice staff talked to the facility nurse on Friday, the computer was down and the facility nurse could check when the appointment was scheduled. The Progress Notes dated 8/15/17 at 2:22 p.m. revealed the staff received a new order from the orthopedic clinic for [MEDICATION NAME] 500 milligrams by mouth every six hours for 14 days. The Progress Noted dated 8/18/17 at 7:12 p.m. revealed Resident #2 had the cast removed from the right foot on 8/15/17. Resident #2 had two necrotic areas from the cast. An oral antibiotic ordered. However, no treatment ordered. The nurse notified Hospice to look at the wound. The Initial Wound assessment dated [DATE] identified the right heel had an unstageable area that measured 4.0 centimeters (cm) (length) by 3.0 cm (width). The Initial Wound assessment dated [DATE] revealed the top of the right foot had an unstageable area that measured 9.0 cm (length) by 4.8 cm (width). The physician's orders [REDACTED]. The Advanced Registered Nurse Practitioner (ARNP) visit note dated 8/20/17 at 3:33 p.m. identified Resident #2 had a medical device associated pressure injury. The right dorsal foot ulcer measured 8.0 centimeters (cm) by 5.4 cm. The note indicated the right heel ulcer measured 3.9 cm by 4.3 cm. and unable to stage both areas due to the amount of eschar (dead tissue that is generally black and hard) obscuring the wound bed. The nurse practitioner changed the treatment to cleanse both wounds with normal saline, pat dry, paint with [MEDICATION NAME], allow to air dry, apply Telpha, secure with Kerlix and tape every day and as needed. Observation on 8/24/17 at 4:50 p.m. identified a dressing to Resident #2's right foot dated 8/23 and the initials CO. Observation on 8/25/17 at 5:52 a.m. identified a dressing to Resident #2's right foot dated 8/23 and the initials CO. Observation on 8/25/17 at 9:35 a.m. identified Staff B changed the dressing to Resident #2's right foot. Resident #2 reported the dressing was not changed on 8/24/17. Observation on 8/27/17 at 4:56 p.m. identified a dressing to Resident #2's right foot dated 8/27 at 1:15 p.m. Resident #2 reported the treatment as not completed on 8/26/17. Review of the August 2017 Treatment Administration Record for Resident #2's right heel and top of the right foot revealed omissions on 8/24/17 and 8/26/17. A phone interview on 8/27/17 at 6:10 p.m. Staff C (Assistant Director of Nurses) reported she worked as a charge nurse on West Hall on 6/26/17, the Director of Nurses worked North Hall and an Agency Nurse worked East. Staff C reported the Agency Nurse had Resident #2's treatment. An interview on 8/24/17 at 10:02 a.m. Staff B reported he/she noticed Resident #2 had the right foot wrapped in Kerlix after Resident #2 returned from the orthopedic clinic on 8/15/17. Staff B asked Staff D (Agency Nurse) if Resident #2 returned with treatment orders. Staff D reported Resident #2 had orders. Staff B reported he/she worked the floor on 8/18/17 and removed a dressing from the right foot and noted the two necrotic areas. Staff B reported she noted there was not an order for [REDACTED]. An interview on 9/1/17 at 9:44 a.m. Staff D (Agency Nurse) reported she did not recall Resident #2 returning from the orthopedic appointment. Staff D reported she worked 8/16 and completed Resident #2's calf treatment. Staff D noticed Resident #2's right foot had two eschar areas. Staff D checked the treatment record and noticed there was not a treatment to the areas. Staff D told the Assistant Director of Nurses that there was not a treatment ordered. Staff D reported the main reason treatments are not getting done is due to a lack of nursing staff. Staff D stated she reports to the next shift any treatments that he/she didn't get done. Staff D reported at times the next shift cannot get the treatments done either. An interview on 8/31/17 at 2:41 p.m. Staff A (Hospice Nurse) reported he/she went to the orthopedic appointment with Resident #2 on 6/5/17. Staff A reported she arranged emergency placement for Resident #2 as he/she could not return home. Staff A reported Resident #2 had family at the appointment. Staff A was not aware of a follow up appointment for Resident #2. Staff A reported the family had Resident #2's paperwork from the appointment. An interview on 8/31/17 at 2:11 p.m. Staff C (Charge Nurse) reported she completed the admission paperwork for Resident #2. Staff C did not recall Hospice staff assisting Resident #2 with the admission process. Staff C did not recall if Resident #2 needed to follow up with the orthopedic clinic. An interview on 8/31/17 at 11:33 a.m. Resident #2 reported he asked the staff 5 to 6 times when he needed to go back to the orthopedic clinic. Resident #2 reported his heel started to hurt 5 to 6 weeks after the cast was put on. Resident #2 reported he told the staff that his heel hurt. Resident #2 reported the heel hurt worse than the ankle. Resident #2 described the pain as a stabbing pain. An interview on 9/1/17 at 1:35 p.m. Resident #2's responsible party reported she asked the staff when Resident #2 had a follow up appointment and the staff did not seem to know. The responsible party called the orthopedic clinic on 8/14/17. The responsible party explained the cast was on 10 weeks and it was way too long. An appointment was set up for the next day. The responsible party reported she was at the orthopedic appointment on 6/5/17 and did to receive any paperwork from the clinic with a follow up appointment time. An interview on 9/8/17 at 10:48 a.m. the ARNP reported she saw Resident #2's wounds and then the facility had a wound management company look at the wounds. The ARNP reported the nursing staff did not always get the treatments completed as ordered. The ARNP reported she looked at Resident #2's wounds. The ARNP reported the dressing as several days old according to the date on the dressing. An interview on 9/6/17 at 4:55 p.m. the Orthopedic Specialist reported he treated Resident #2 on 6/5/17. The Specialist reported Resident #2's extensive medical history placed the resident at high risk. That being the case, the specialist planned to follow up in 2 to 4 weeks. The Specialist reported at the 2 to 4 week point he/she removes the cast and inspects the skin, obtains an x-ray and then decides the treatment plan. The Specialist reported wounds can develop after one week. The Specialist reported if wounds are identified the treatment can be changed to an immobilizing device, internal fixation, apply a cast with a window, add additional padding to the cast or consult cardiology for a work up. The Specialist reported Resident #2 should have been seen three times in the 10 weeks. The Specialist reported that had Resident #3 been seen at the 2 to 4 week point he/she could have intervened faster. The Specialist reported the wounds are extensive and Resident #2 has an 80% chance of amputation. Pressure Areas on the posterior right knee (behind knee). The Care Plan identified Resident #2 was admitted to the facility with a wound to the right leg. The Plan of Care directed the staff to provide treatments as ordered and complete a weekly assessment. The Admit/Readmit Screener dated 6/5/17 revealed Resident #2 had the following areas on the back of the right knee: a) A Stage II blister that measured 4.0 centimeters (length) by 4.0 centimeters (width). b) A Stage II pressure area that measured 2.0 centimeters (length) by 2.0 centimeters (width). The Progress Notes dated 6/5/17 at 4:30 p.m. revealed Resident #2 admitted with hospice. Resident #2 had a right lower extremity casted from the knee down. Resident #5 had a pedal pulse and exposed toes appeared cyanotic. The hospice staff reported Resident #2 had 2 pressure ulcers covered with an island dressing. The Hospice admission orders [REDACTED]. An interview on 8/31/17 at 2:41 p.m. Staff A (Hospice Nurse) reported he/she went to the orthopedic appointment with Resident #2 on 6/5/17. Staff A reported she arranged emergency placement for Resident #2 as he/she could not return home. Staff A reported Resident #2 had family at the appointment. Staff A reported he/she went to the facility and prepared the admission orders [REDACTED]. Staff A reported after Resident #2 transferred to bed he/she completed an assessment and noted Resident #2 had an area on the calf and an area on the thigh. Staff A reported she either wrote a telephone order or gave the nurse a verbal order for Duoderm (a thin [MEDICATION NAME] dressing). The Order Summary Report dated 8/30/17 revealed the following orders to the right lower extremity: a) On 6/8/17, two orders to cleanse the right dorsal knee and with normal saline or wound wash, apply Hydrogel to the wound bed and cover with a dressing daily. b) On 6/9/17, two orders to apply Duoderm to the right lower extremity and change every three days and as needed. c) On 6/13/17, an order to apply Santyl Ointment ([MEDICATION NAME] medication) 250 unit/gram to the right lower leg. d) On 6/15/17, two orders to cleanse the right posterior leg with foam/wound cleaner, apply a thick layer of Santyl ointment to the eschar wound bed and wrap with Kerlix. Review of the Treatment Administration Record for June 2017 revealed the staff first completed the treatment as ordered to the two areas on 6/17/17. Review of the Treatment Administration Record for July 2017 revealed omission in Resident #2's treatment on 7/4, 7/7, 7/8, 7/14, 7/19, 7/20, 7/21 and 7/24. Review of the Treatment Administration Record for August 2017 revealed omissions in Resident #2's treatment on 8/2, 8/5, and 8/6. During an interview on 8/31/17 at 2:55 p.m. the Director of Nurses (DON) reported the Treatment Record for Resident #2 is very confusing. The DON reported the staff did not sign the treatment out as completed from 6/5/17 to 6/16/17. The DON planned to in-service the staff on entering orders in the computer and selecting a treatment time. Resident #2's Weekly Wound Assessment sheets for right knee -posterior (back of knee) 1) revealed the following: a) On 6/5/17, the area measured 4.0 centimeters (cm) length by 4.0 cm (width). b) On 6/8/17, the area measured 0.4 (length) cm by 4.7 cm (width). c) On 6/14/17, the area measured 2.4 cm (length) by 4.7 cm (width). d) On 6/21/17, the area measured 4.2 cm (length) by 4.7 cm (width). e) On 6/13/17, the area measured 4.2. cm (length) by 4.7 cm (width). Resident #2's Weekly Wound Assessment sheets for the right knee posterior blister (Area 2) revealed the following: a) On 6/5/17, the area measured 2.0 centimeters (length) by 2.0 centimeters (width). b) On 6/8/17, the area measured 0.7 cm (length) by 1.0 cm (width). c) On 6/14/17, the area measured 1.7 cm (length) by 1.5 cm (width). d) On 6/21/17, the area measured 1.5 cm (length) by 2.3 cm (width). e) On 6/28/17, the area measured 0.5 cm (length) by 1.2 cm (width). The Progress Note dated 8/25/17 at 11:18 a.m. revealed the wound below Resident #2's right knee healed. The staff notified the physician and received a new order. The Order Summary Report dated 8/31/17 revealed an order to apply [MEDICATION NAME] to legs and feet bilaterally once a day for dry skin and observe right upper leg to ensure are does not open again. An interview on 8/25/17 at 12:54 p.m. the Director of Nursing (DON) reported the facility did not currently have a wound nurse. The DON reported there is a lapse in weekly assessments. However, the DON was uncertain how long the assessments have not been done. The DON reported she could not locate any assessments for Resident #2 for July and August for the right calf wounds. 2. According to the Admission Record dated 8/30/17 Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment with a reference date of 7/21/17 revealed Resident #5 had no cognitive impairments. The MDS identified Resident #5 required extensive assistance of one staff person with bed mobility, dressing and personal hygiene. The MDS identified the resident at risk for the development of pressure sores and had 2 Stage III pressure sores 2 Staff IV pressure sores. The pressure ulcers were present upon admission or reentry to the facility. The MDS describes a description of the following wounds: Stage III pressure ulcer as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling or undermining of the wound. Stage IV pressure ulcer is full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often included undermining and tunneling. The Care Plan directed the staff to utilize an alternating air mattress to the bed, culture wounds as needed, encourage good nutrition to promote healing, pressure reducing cushion to wheelchair, Prevalon boots to bilateral lower extremities, nutritional supplement to help healing, trapeze to bed to assist mobility, treatment as ordered, turn and reposition frequently when in bed and wheelchair and wound clinic appointments when scheduled (every three weeks). Review of the Weekly Skin Assessment sheets identified the last facility assessment completed on 7/20/17 revealed the following: a) The Stage III wound to the left greater trochanter (hip bone) measured 1.0 centimeters (cm) (length) by 2.5 cm (width) by 3.4 cm (depth). b) The Stage III wound to the right greater trochanter measured 3.8 cm (length) by 2.5 cm (width) by 7.0 cm (depth). c) The Surgical Incision to the right gluteal fold measured 7.3 cm (length) by 5.4 cm (width) by 0.4 cm (depth). The Wound Clinic Multi Wound Chart details dated 8/24/17 identified the following: a) The Stage IV Pressure Injury wound to the left trochanter measured 0.2 cm (length) by 0.4 cm (width) by 2.0 cm (depth). b) The Stage IV Pressure Injury wound to the right trochanter measured 0.5 cm (length) by 1.0 cm (width) 1.3 cm (depth). c) The Stage III Pressure Injury wound to the left proximal posterior thigh measured 3.5 cm (length) by 5.5 cm (width) by 1.6 cm (depth). The Treatment Administration Record sheet for July 2017 revealed an order to cleanse the left trochanter with normal saline or wound cleanser, pack with gauze soaked with normal saline and cover with an abdominal pad twice a day until healed. The sheet revealed omissions in the treatment one time on 7/2, 7/4, 7/7, 7/8, 7/10, 7/22, 7/23, 7/24 and 7/29. The Treatment Administration Record sheet for August 2017 revealed omissions in the left trochanter treatment once a day on 8/1, 8/3, 8/7, 8/15, 8/20, 8/21 and 8/23. The Treatment Administration Record sheet for July 2017 revealed an order to cleanse the right trochanter with normal saline, pack with gauze soaked with normal saline and cover with an abdominal pad twice a day until healed. The sheet revealed omissions in the treatment one time on 7/4, 7/7, 7/8, 7/10, 7/22, 7/23, 7/24 and 7/29. The Wound Clinic notes dated 7/13/17 revealed the wound clinic ordered to change the treatment to cleanse with normal saline, apply 0.125% Dakin's soaked gauze tucked into wound bed and cover with a secure dressing and MUST BE CHANGED TWICE DAILY!!!! The Treatment Record revealed the treatment first completed on 8/4/17. The Treatment Administration Record sheet for August 2017 revealed omissions in the right trochanter treatment twice a day on 8/1, 8/2 and 8/3, 8/5, 8/8, 8/13, 8/14, 8/19, 8/20 and 8/21 and once a day on 8/7, 8 /10, 8/11, 8/12, 8/15, 8/16, 8/17, 1/18 and 8/22. The Treatment Administration Record sheet for July 2017 revealed an order to cleanse the left ischial wound with normal saline, pack with gauze soaked in normal saline and cover with an abdominal pad twice a day. The sheet revealed omissions once a day on 7/2, 7/4, 7/7, 7/8, 7/10, 7/22, 7/23, 7/24 and 7/29. The Treatment Administration Record for August 2017 revealed omissions in the left ischial wound treatment once a day on 8/3, 8/7, 8/13. 8/15, 8/20, 8/21 and 8/23. An interview on 8/25/17 at 2:01 p.m. Resident #5 reported the staff rarely measure the wounds. Resident #5 reported the wound clinic measures the wounds every three weeks. An interview on 8/25/17 at 9:15 a.m. Resident #5 reported he goes to the Wound Clinic every three weeks. Resident #5 told the Wound Clinic the treatments were not getting done as ordered. The physician wrote an order to complete the treatments twice a day. Resident #5 reported its better but the treatments are still not getting done every day. An interview on 8/30/17 at 1:19 p.m. the Wound Clinic registered nurse reported Resident #5's wounds all looked stable. The registered nurse reported a plan for flap surgery on Resident #5's left and right greater trochanter wounds as soon as clearance is obtained. The registered nurse reported Resident #5 reported to the Wound Clinic that the facility was not completing the treatments to his wounds as ordered. The Wound Clinic physician wrote an order to complete the treatments twice a day with no exceptions. On 9/5/17 at 9:06 a.m. the Assistant Director of Nurses (ADON) was interviewed and stated there was a lapse in weekly wound assessments. The Assistant Director of Nurses reported assessments completed on 7/20/17. The Assistant Director of Nurses reported Resident #5 had assessments in progress dated 8/16/17. However, the 8/16/17 assessments were not completed. The ADON reported she is starting weekly assessments tomorrow and will be in charge of completing the assessments weekly. On 9/5/17 at 10:17 a.m. the ADON verified the right trochanter treatment ordered on [DATE] was not completed until 8/4/17. 3. Resident #6 had a MDS assessment with a reference date of 8/4/17. The MDS indicated Resident #6 had [DIAGNOSES REDACTED]. The MDS indicated Resident #6 had no cognitive impairments and required extensive assistance of one staff member for mobility, dressing, toilet use and personal hygiene. The Care Plan directed the staff to provide Wound Care Clinic services, administer medications and treatments as ordered, alternating air mattress, assess/record/monitor wound healing weekly, measure length, width depth, document status of wound perimeter, wound bed and healing progress, report improvements and declines to physician, educate resident/family/caregivers on causes of skin breakdown, including transfer/positioning requirements importance of taking care during ambulation and mobility good nutrition and frequent positioning, encourage to lay down after meals, prefers to sit in electric wheelchair most of the day, encourage to stop smoking to promote wound healing, extra protein at breakfast, follow facility policies/protocols for prevention/treatment of [REDACTED]. The Treatment Administration Record sheet for July 2017 revealed an order to cleanse the sacral wound with 0.125% Dakin's soaked gauze, apply z-guard to periwound, apply silver alginate to wound bed, cover with abdominal pad and secure with tape daily. The July 2017 Treatment Record sheet revealed omissions in the treatment on 7/4, 7/7, 7/8, 7/10, 7/14, 7/18, 7/21 and 7/23. The August 2017 Treatment Record sheet revealed omissions in the treatment on 8/5, 8/14, 8/15, 8/19 and 8/21. The Treatment Administration Record sheet for July 2017 revealed an order to cleanse the left ischial wound with 0.125% Dakin's soaked gauze, apply z-guard to periwound, apply silver alginate to wound bed, cover with abdominal pad and secure with tape every day and as needed. The July 2017 Treatment Administration Record sheet revealed omissions in the treatment on 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/14, 7/18, 7/20, 7/21, 7/22, 7/23, 7/25, 7/26, 7/27 and 7/28. The August 2017 Treatment Administration Record sheet revealed omission in the treatment on 8/1, 8/5, 8/6, 8/8, 8/11, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/19, 8/20 and 8/21. The Wound Clinic Physician order [REDACTED]. The orders directed to use silver alginate and an abdominal pad secure with tape until the wound vac received. The Treatment Administration Record sheet for August 2017 revealed the staff administered the wound vac on 8/29/17. On 8/30/17 at 1:41 p.m. the Wound Clinic registered nurse was interviewed and reported Resident #6 currently at the Wound Clinic. The registered nurse reported the facility did not properly apply the wound vac to the left ischial. The registered nurse reported there was not enough sponge in the wound and the disc caused pressure and expanded the wound. The registered nurse reported the clinic planned to change the wound vac three times a week. The Wound Assessment Details (Wound Clinic Note) dated 8/30/17 indicated the clinic assessed the Stage IV left ischial wound. The wound measured 3.4 cm (length) by 2.5 cm (width) by 2.1 cm (depth). The Multi Wound Chart Details (Wound Clinic Note) dated 8/23/17 revealed the left ischial wound measured 2.2 cm (length) by 1.4 cm (width) by 2.1 cm depth. On 8/25/17 at 9:30 a.m. Resident #6 was interviewed and reported the nurses complete the treatment about four days a week. Resident #6 reported it to be sporadic. On 9/4/17 at 1:40 p.m. the ADON was interviewed reported the facility had a lapse in the weekly wound assessments for Resident #6. The ADON reported the last weekly assessment completed on the sacral wound was 8/10/17 and the last assessment completed on the ischial wound was 8/17/17. The ADON planned to take over the weekly assessments. The ADON reported the DON assisted her to place the wound vac on Resident #6's ischial wound. The ADON reported they both have experience with [DEVICE]. The ADON reported the vac must have shifted after it was placed on Resident #6. The Skin Management Guidelines Overview revised 7/2017 revealed residents who are at risk or with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The Skin Management Guidelines Practice Guidelines revised on 7/2017 revealed residents admitted with skin impairments will have physician's orders [REDACTED]. Lower extremity Ulcers will be monitored closely during treatment to evaluate appropriateness of treatment regime. Note: At the time of the complaint investigation, the complaint was coded at a J immediate and serious jeopardy. By September 1, 2017, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the D level. The Director of Nursing and Assistant Director of Nurse audited all residents with treatments. The Administrator hired a daily treatment nurse (licensed practical nurse) that started on 9/2/17 and 2 registered nurses. The staffing agency nurses were informed of residents needing treatments and instruction. As of the 9/13/17 exit conference, the facility continued to need to: · Continue to ensure wounds are assessed and treatments performed per the physician's orders [REDACTED]. · Continue to ensure adequate staffing is available to perform treatments. · Continue to monitor the facility Skin Management Practice Guidelines so residents admitted with skin impairments, have physician's orders [REDACTED].

Based on record review, observations and resident and staff interviews, the facility failed to provide sufficient nursing staff to provide nursing care to residents. The facility reported a census of 60 residents and staff and residents reported there was inadequate staff to perform treatments and respond to the activated call lights in a timely manner (within 15 minutes). Findings include: 1. According to the Minimum Data Set (MDS) assessment with a reference date of 6/20/17, Resident #2 had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #2 had no cognitive impairments. Resident #2 required total staff assistance with bed mobility, dressing, toilet use and personal hygiene. Observation on 8/23/17 at 11:26 a.m. revealed Resident #2 lying in bed with the call light activated. Resident #2 reported he/she had the call light on for 5 to 10 minutes. Resident #2 reported he had a bowel movement and needed changed. Resident #2 had a clock on the wall and reported he/she timed the response at times. Resident #2 reported it can take the staff up to 30 to 45 minutes to respond to the call light. Resident #2 reported sitting in his/her feces for an hour. At 11:44 a.m., Staff P answered the light. Resident #2 told Staff P he needed changed. Staff P left the call light on and left the room to find another staff to help provide cares. At 11:47 a.m., Staff P and Staff Q returned to the room to assist Resident #2. 2. According to the MDS assessment dated [DATE] Resident #1 had a [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #1 had moderately impaired decision making. Resident #1 required total staff assistance with bed mobility, transfers, toilet use and personal hygiene. Observation on 8/23/17 at 3:45 p.m. revealed Resident #1 lying in bed with call light activated. Resident #2 yelling out momma. At 3:50 p.m., call light still activated. Resident #1 yelling out momma. At 3:57 p.m., Resident #1 with a hoarse voice asking for a drink of water; at 4:00 p.m., the call light still activated. Resident #1 yelling out momma and water. At 4:03 p.m., Staff R responded to Resident #1. Staff R raised the head of the bed and assisted Resident #1 with a drink of water. 3. Observation on 8/25/17 at 6:30 a.m. revealed Staff S (Agency Nurse) assigned to North Hall, Staff T (Registered Nurse) assigned to West Hall and Staff U (Medication Aide) assigned to East Hall. Staff A reported he/she had North Hall. Staff S reported he/she was only assigned to North Hall and did not have insulin or treatments on East Hall. Staff U (Medication Aide) reported he/she could not do the treatments on East Hall. Staff T reported he/she had West Hall and the treatments and insulin for room [ROOM NUMBER] - 8 on East Hall. An interview on 8/24/17 at 12:40 p.m. Staff E reported the facility does not have enough nurses. Staff E reported they are able to get some agency nurses. However, they cannot get the treatments completed with two nurses and a medication aide. When they have two nurses they have to take a hall and split another hall. Staff E reported the facility at one time staffed 3 nurses. 4. An interview on 8/24/17 at 9:54 a.m. Staff B reported the facility had a limited amount of nurses. Staff B reported the facility had 3 charge nurses on the facility payroll. Staff B reported the Director of Nursing, Assistant Director of Nursing and the MDS Coordinator covered recent shifts. Staff B reported the Assistant Director of Nursing worked 7:00 a.m. to 11:45 p.m. as a charge nurse and had to call agency and beg for them to send someone to relieve her. Staff B reported it's not always possible to get the treatments completed as ordered with limited nurses. An interview on 8/25/17 at 6:06 a.m. Staff V (certified nursing assistant/certified medical assistant) reported the facility schedules one aide on each hall at times. Staff V reported the staff cannot get to the call lights in a timely manner and baths do not get completed. Staff V reported the residents complain that their treatments do not get done and they have their call light on for 20 to 30 minutes. The residents complain that they had to sit in their urine and feces because the staff do not respond. Staff V reported a very good nurse walked out because she had two halls and a medication aide on the other hall. The nurse couldn't do it anymore. An interview on 8/25/17 at 6:16 a.m. Staff W (certified nursing assistant) reported with the current staffing the staff cannot answer the call lights in a timely manner. Staff W reported the residents complain the call lights do not get answered for 20 to 30 minutes. Staff W reported working doubles and had 127 hours the last pay period. Staff W reported it is impossible to provide adequate care with the lack of staff. An interview on 8/29/17 at 1:40 p.m. Staff J (Registered Nurse) reported the facility decided to quit using medication aides. Staff J was scheduled with an agency nurse. Staff J pulled a medication aide off the floor to pass medications as two nurses could not do all the medications, treatments, insulin injections and charting. Staff J reported it is not physically possible to get everything done with the lack of nurses. Staff J reported the residents complain about treatments not getting completed. Staff J told the Director of Nursing that the treatments were not getting completed. On 8/29/17 the Director of Nursing (DON) reported she had to work as a charge nurse over the weekend with an Agency Nurse and the Assistant Director of Nursing. The DON reported she worked a 12 hour shift and had to pass treatments on to the next shift because she could not get them completed. The DON reported a plan to assign the treatments to the Assistant Director of Nurses (ADON) and herself this week and the weekend to ensure they are completed. The DON reported the facility planned to sign 13 week contracts with traveling nurses to ensure nursing coverage. On 9/1/17 at 12:07 p.m. the Administrator was interviewed and stated he just learned the Director of Nursing and Assistant Director of Nurses had leave through 9/4/17. The Administrator reported he planned to take over the scheduling for the nurses and stay in town through the holiday weekend to ensure nursing coverage. The Administrator reported the facility had a licensed nurse from a sister facility arriving 9/2/17 to do all the treatments over the weekend. The Administrator had a Director of Nursing from a sister facility was arriving 9/2/17 to provide Registered Nurse coverage. The Written Statement dated 8/29/17 revealed the Administrator noted the facility did not have a call light policy. However, the facility expected the staff to answer the call lights within the 15 minute State of Iowa regulation. During an interview with a group of residents on 8/24/17 at 11:00 a.m., 1 of 4 residents voiced treatments are not done as ordered by the doctor. The resident stated if the order is for the treatment twice a day, then it is only done once. One of the 4 residents stated it usually takes staff 20 to 60 minutes to respond to a call light when he has to have a bowel movement or lay down in bed.

The following information relates to investigation of complaint # . Based on record review and staff interviews, the facility failed to properly assess, implement interventions and provide adequate supervise to ensure against hazards to self (Resident #1). The sample consisted of 6 residents and the facility reported a census of 72 residents. Findings include: 1. According to the Care Plan dated 8/15/13, Resident #1 had [DIAGNOSES REDACTED]. The annual Minimum Data Set Assessment (MDS) with a reference date of 4/10/14, identified Resident #1 had moderately impaired decision making skills, disorganized thinking and delusions. Resident #1 had highly impaired vision while in adequate light. Resident #1 required supervision of one staff with transfers, dressing and personal hygiene. Resident #1 required a walker for mobility. The Care Plan, initiated on 8/15/13, directed the staff to take Resident #1 outdoor for walks, small groups, 1:1 as needed, give a snack, reminisce and do crafts in room for diversion. The Elopement Risk assessment dated [DATE] revealed a question if Resident #1 had the physical ability to leave the building by himself/herself marked "yes". The facility marked Resident #1 cognitively impaired "no". The assessment sheet directed the staff if both questions marked "yes" and any other; consider a prevention plan for elopement. The facility marked Resident #1 had a history of [REDACTED].#1 did not have a history of wandering or elopement. The Nurse's Notes dated 6/13/13 at 2:00 p.m. revealed Resident #1 exited the facility at 9:15 a.m. to go for a walk around the building per usual routine. The nurse checked Resident #1 at 9:20 a.m. and noted Resident #1 walking on the sidewalk around the building. At 10:00 a.m., an aide checked on Resident #1 and Resident #1 was not outside the building. Resident #1 walked to McDonalds (Restaurant) without notifying the staff. At 10:20 a.m., Resident #1 returned to the facility. The Social Services Progress Notes dated 6/19/13 revealed Resident #1 went for a walk yesterday and someone picked him/her up. The Corporate staff directed (staff) not to place a Wanderguard (bracelet device) on Resident #1 as it's a restraint. Resident #1 reported he/she did it to get the police involved and promised not to do it again. The Nurse ' s Notes dated 4/29/14 at 10:45 a.m. revealed the police called and reported Resident #1 was sighted in a nearby neighborhood and on foot with a walker. Resident #1 left the facility without notifying the staff. The police returned Resident #1 to the facility. The note reflected the resident refused to get out of the vehicle and stating " I ' m not going back in there " . Nobody takes care of me! They don ' t feed me, and they ' re trying to dope me up " ! The police officer and nurse escorted the resident into the building. The police Incident Report dated 4/29/14 at 9:47 a.m. revealed an individual in the community called the police and reported Resident #1 " run away " from the facility. The police called the facility. The facility informed the police that Resident #1 had dementia. The police returned Resident #1 to the facility. An interview on 5/1/14 at 3:41 p.m. the Director of Nursing (DON) reported she did an assessment on Resident #1 after the police returned him/her to the facility. The DON reported at that time Resident #1 had no cognitive impairment. The DON reported Resident #1 had delusions. Resident #1 reported he/she left the property to find someone to help him/her. The DON provided education to Resident #1 on signing in and out when leaving the facility. Resident #1 also voiced concerns to the DON about the hip pain he/she had and felt like he/she was not being listened to about it. Resident #1 asked to see the physician regarding the hip pain. The DON reported Resident #1 still had the privilege to leave the facility when he/she desired. On 5/1/14 at 3:13 p.m. the Administrator was interviewed and reported Resident #1 did not tell the staff prior to leaving the facility. The Administrator stated the facility did not have knowledge Resident #1 left the property. The Administrator stated was aware the police returned Resident #1 to the facility. The Administrator reported he/she did not report the incident to the department as Resident #1 was alert and oriented and able to go outdoors for walks independently. On 5/5/14 at 1:41 p.m. Staff D (MDS Coordinator) was interviewed and reported she did not do a care plan for Resident #1 to be outside independently. Staff D stated she did not feel comfortable with Resident #1 going outside independently due to Resident #1's glaucoma, delusions, paranoia and a past incident of leaving the facility. On 5/6/14 at 10:05 a.m. the Director of Nursing (DON) was interviewed and verified the 4/10/14 Care Plan did not direct the staff to allow Resident #1 outside independently. The DON reported Resident #1 was going outside independently about every other day. As far as the DON knew, Resident #1 told the nurse prior to going outdoors. On 5/2/14, the facility implemented 15 minute checks, meditation room and social worker visits 1-2 times a week. The DON reported Resident #1 can still go outside independently if he/she signs out and tells the nurse. The DON reported the Corporate staff directed the facility not to place a Wanderguard device on Resident #1 because Resident #1 had no cognitive impairments. The DON stated an incident report was not completed for the incident on 4/29/14. On 5/6/14 at 1:45 p.m. Staff E (Licensed Practical Nurse) was interviewed and reported there was a disagreement after the incident in June of 2013. Staff E stated some of the staff thought Resident #1 needed supervision outside of the facility and others did not agree. Staff E reported she did not feel it was safe for Resident #1 to go outside unsupervised. The Elopement Policy adopted 7/22/13 identified the definition of an elopement is a situation where a resident with impaired decision making ability, who is oblivious to his/her own safety and therefore at risk for injury outside the confines of the facility, has left the facility without the knowledge of the staff. The policy directed the staff to assess each resident admitted /readmitted to the facility for the potential for elopement using the Elopement Assessment Tool, implement immediate interventions such as personal security device or divisional activities and the facility will maintain a system to identify residents at risk that is readily accessible to the facility staff. The policy directed the staff after an elopement to complete a physical evaluation of the resident, notify the physician, notify the family/responsible party complete an incident report; implement interventions to promote safety and the Administrator will report the occurrence to the appropriate state agencies per regulations. On 5/6/14 at 4:56 p.m. the Director of Nursing was interviewed and stated a long term plan was to place a Wanderguard device on Resident #1 immediately, place a picture of Resident #1 in the elopement binder, monitor Resident #1's psychosocial needs, social worker to meet with Resident #1 twice a week and activities to schedule walks outdoors. On 5/8/14 at 12:05 p.m. the Director of Nursing was interviewed and stated the facility looked at all residents in the facility that had cognitive impairments and had independent mobility. The DON planned to check the elopement assessments for accuracy. The DON identified 8 residents who needed Wanderguard devices placed. The DON stated she planned to update the care plans to reflect the changes. Note: At the time of the complaint investigation, the complaint was coded at a "J" immediate and serious jeopardy. By 5/7/14, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. Staff implemented a Wanderguard device on to Resident #1. The Wanderguard checks would be documented on the TAR (Treatment Administration Record). The checks would be performed on the weekends by the nurses. During the week, the Restorative Aide (RA) would check the Wanderguards. The resident's Facesheet and picture was placed in the facilty elopement binder. The resident would receive emotional health with the social worker 2 times per week. Activity staff would go out with residents on scheduled times or upon resident's request. As of the 5/19/14 exit conference, the facility needed to: . Finish inservicing the nurses and restorative aide regarding the checking of the Wanderguards and documenting the checks on the Treatment Administration Record. . Monitor to ensure Resident #1's emotional needs are being met through social service. . Monitor the activity staff to ensure the resident goes outside with the activity staff. . Monitor the staff to ensure the elopement binder is being utilized in order to ensure the staff are aware of residents at risk for eloping.

The following information relates to investigation of complaint # and # . Based on observation, record review and staff interviews, the facility failed to provide the appropriate assistance with transfers according to the plan of care in order to prevent accidents for 3 of 6 sampled. (Resident #2, #17 and #18). The facility reported a census of 71 residents. Findings include: 1. Resident #18 had an MDS with a reference date of 1/4/14 and reflected the resident required extensive assistance of two staff with bed mobility and transfers. The Care Plan, updated on 12/2/13 directed the staff to provide 2:1 assistance with Sara (sit to stand) lift for transfers. The Care Card dated 12/23/14 directed the staff to provide 2:1 assistance with a Sara (sit to stand) lift for transfers. The Incident Report dated 3/19/14 at 7:35 p.m. reflected Resident #18 had a laceration to the left lower extremity with a copious amount of blood present. The facility had the resident transferred to the emergency room . The Non-Pressure Skin Condition Report dated 3/19/14 reflected Resident #18 had 31 stitches and an open area measuring 3.0 by 3.0 centimeters to an unidentified area. The Witness Statement form dated 3/20/14 revealed Staff I asked Resident #18 what had happened. Resident #18 reported she/he hit leg on the bed when the staff assisted him/her her to bed. Staff H reported he/she transferred Resident #18 to bed by him/herself. On 3/26/14 at 11:05 a.m. Staff H (Certified Nursing Assistant) was interviewed and stated she transferred Resident #18 from the wheelchair to the bed with a gait belt. Staff H looked down and noticed blood dripping. Staff H lifted Resident #18's gown and noticed the left leg bleeding. Staff H wrapped the area with a towel and summoned the nurse. Staff H reported Resident #18 was impatient so Staff H decided to transfer him/her without another staff. Staff H reported Staff D was in the room helping the roommate at the time of the incident. An interview on 3/26/14 at 3:26 p.m. the Assistant Director of Nurses (ADON) reported after the recent improper transfers, the facility planned to reformat the Care Cards that hang in the resident's rooms. The ADON stated some of the staff do not understand how to read the cards. The ADON reported the facility planned to simplify the form. 2. Resident #17 had a Minimum Data Set assessment with a reference date of 1/16/14 which reflected the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident had a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 identified a severe cognitive impairment. The MDS reflected Resident #17 required extensive assistance of two staff persons with bed mobility and transfers. The Care Plan, with an initiated date of 2/18/14 for a problem for self- care deficit, directed the staff to provide extensive assistance of two staff persons with transfers and ambulation, use a gait belt, walker and difficulty lately with ambulation and using a wheelchair. The Resident Care Card dated 11/22/13 directed the staff to provide 2:1 assistance with a gait belt and walker for transfers. The Incident Report sheet dated 3/21/14 at 7:15 a.m. revealed Staff C lowered Resident #17 to the ground during a transfer. The sheet revealed Resident #17's knees buckled. An interview on 3/26/14 at 12:56 p.m. Staff C reported Staff K transferred Resident #17 into the shower chair. Staff C pushed Resident #17 to the shower room and provided a shower. Staff C had Resident #17 hold the sides of the shower chair to stand up. When Resident #17 stood up his/her knees gave out and Staff C lowered Resident #17 to the floor. Staff C was told by other staff that Resident #17 required assist of one. Staff C reported he/she never looked at Resident #17's care card. 3. The Minimum Data Set assessment, with a reference date of 1/30/14, identified Resident #2 as cognitively impaired and dependent upon 2 staff persons to transfer. The resident did not ambulate in the resident ' s room or corridor and used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The Care Plan dated 6/7/13 identified the resident had a problem with activities of daily living and at risk for falls manifested by dependence on staff for assistance with activities of daily living. The intervention directed staff to transfer the resident per Hoyer lift (total mechanical lift) with the assistance of two staff persons. The staff Resident Care Card dated 10/10/13 directed the staff to provide 2:1 (2 to 1) assistance with a Hoyer (total mechanical lift). The Care Card identified the resident at high risk for falls and non-ambulatory. Observation on 3/18/14 at 1:45 p.m. revealed Staff C and J (Certified Nursing Assistants) transfer Resident #2 with the Hoyer lift from the wheelchair to the bed. Observation on 3/24/14 at 4:50 p.m. revealed Resident #2 sitting in the wheelchair and Staff A (Certified Nursing Assistant) stripping (removal of linens) the bed. Staff A reported he/she transferred Resident #2 with a gait belt from the bed to the wheelchair. Staff A reported the staff transfer Resident #2 based on his/her mood. On 3/24/14 at 5:00 p.m. the Director of Nurses (DON) was interviewed and stated Resident #2's Care Plan directs the staff to use the total mechanical lift and two staff for all transfers. The DON spoke to Staff A who reported when Resident #2 had a good day they completed the transfer with one staff. The DON stated an expectation of staff is to follow the Care Card hanging in the room.

Based on observation, record review, and staff and resident interviews, the facility failed to provide adequate supervision to prevent accidents (Resident #5) and failed to protect residents from hazards to themselves and others. A construction project was in progress within the facility and the facility failed to protect residents from power equipment left unattended, doors left open and alarms not activated, oxygen tanks not stored securely and a therapy hydrocollator left unattended in an unlocked room. The facility reported a census of 71 residents. The facility identified 39 cognitively impaired and independently mobile resident. Five of the 71 residents wore wanderguard bracelets. Findings Include: 1. Observation on 8/27/13 at 8:20 a.m. revealed the boiler room door, adjacent to the resident's dining room, not latched and unlocked. An exit door to the outside, once in the boiler room, was propped open. The new therapy room was unalarmed. The Administrator and Maintenance Supervisor reported the boiler room door is to be locked at all times. Observation on 8/28/13 at 8:45 a.m. revealed the boiler room door unlocked. Staff V (sat at a dining room table) reported a construction worker walked out of the boiler room 15 minutes ago. An exit door (off the boiler room) had a door propped open. The back exit door of the facility (off the new Therapy Room) was propped open and unalarmed. Observation during the Environmental Tour on 8/28/13 from 8:30 a.m. to 9:11 a.m. revealed the south dining room door unalarmed. The first door through the south hall (new door) was propped open. When walking through the new door it was observed residents could leave the facility via the new laundry room. The exit door alarm was shut off during the day due to the construction. The Administrator reported a plan to put a lock on the new south hall door to eliminate access to the laundry room exit door. On 8/27/13 at 9:50 a.m. the Maintenance Director was observed to place a lock on the new south hall door. The Maintenance Director reported a plan to put another lock on another door to the laundry room which provided access to the outside exit door (since it was not alarmed). The Maintenance Director planned to provide a key to the construction workers. Observation on 8/27/13 at 12:13 p.m. revealed both interior laundry room doors had locks on them. This eliminated access to the unalarmed laundry room exit. On 8/27/13 at 4:26 p.m. revealed the new laundry room interior door unlocked, making the unalarmed laundry exit door accessible. On 8/27/13 at 4:51 p.m. the Administrator reported the facility had difficulty with the construction workers understanding to lock the door. The Administrator planned to talk to the Project Manager. The Administrator reported both interior laundry room doors would be locked and both exit doors activated when the construction crew finished for the day. Observation on 8/27/13 at 8:00 p.m. revealed the laundry exit door unalarmed and propped open with a rock. The interior laundry room door was open. The surveyor walked through the interior laundry room door and opened the south dining room door. The open south hall women's bathroom light switch had 3 exposed and 3 capped wires in the light switch, a blow torch sitting on the floor, a drill and a handsaw. The open south hall men's restroom had 7 exposed wires in the ceiling, tile tools, an extension cord and capped wires in light switch. On 8/27/13 at 8:41 p.m. the Administrator reported he/she gave Staff AA instructions to make sure the exit doors were locked and alarmed and to lock the garage. The Administrator reported the construction crew leaves for the day at 7:00 p.m. The Administrator told the construction supervisor to pick up their tools and lock up. The Administrator called the Project Manager to the facility to secure the area. On 8/27/13 at 9:20 p.m. the Project Manager was interviewed and informed the crew to secure anything hazardous. The Project Manager was unaware the South Dining Room door did not lock. At 8:25 p.m. on 8/28/2013 observation revealed the laundry room exit door locked. The south hall dining room door had a key pad alarm in place which sounded when the door opened. The south hall men and women bathrooms were locked. On 8/28/13 at 8:40 p.m. the laundry exit door did not sound when opened. Staff AA reported the dryer room door kept sounding so she shut off the alarm at the panel. Staff AA figured the laundry staff opened the door. The Director of Nursing opened the south dining room door and set off the alarm and informed the staff the south dining room door and laundry exit door were different sounding alarms. On 8/28/13 at 9:00 p.m. the Director of Nursing reported the staff didn't know which door the dryer room door was on the alarm panel. The staff shut off the dryer door alarm immediately because it ' s so loud. The Director of Nursing instructed Staff AA how to set the south dining room door. The Director of Nursing planned to in-service staff about the door alarms before leaving for the night. Observation on 8/26/13 at 12:17 p.m. revealed the facility had extensive remodel in progress. The construction crew had a large blue tarp across a sizeable opening in the wall across from the front entrance of the facility. The tarp secured with duct tape at the top allowed the construction staff to freely access the new therapy room behind the tarp. A couch and two chairs sat in front of the tarp. Across from the tarp the facility had a lounge for the resident. The residents passed the tarp area on the way to and from the dining room. Observation behind the tarped area in the unattended therapy room revealed the following. a. 4 power tools b. a table saw c. a skill saw d .a Sawzall e. wood glue f. hand saw g. 2 gallons of white paint h. 3 saws plugged into the wall i. 4- 5 gallon buckets of sheet rock joint compound j. a large hole in the floor exposing sewer pipes k. an exit door to the outside open and unalarmed On 8/26/13 at 12:27 p.m. the Administrator was interviewed and informed of the hazards. The Administrator stated the facility had no reported incidents with resident's accessing the area. At 1:11 p.m., the Administrator reported a plan to have a staff person monitor the area until a temporary wall could be built. Observation on 8/26/13 at 4:45 p.m. revealed a tarp secured with screws to a 2 foot by 4 foot boards. The tarped area measured 12.5 feet as a temporary wall. On 8/27/13 at 8:17 p.m. observation revealed the therapy room exit door did not sound when opened. The tarp covering the 12.5 foot open area in the wall was pulled back. The surveyor gained access to the new Therapy Room from the lounge area through the pulled back tarp. Observation behind the tarp identified 7 holes in the ceiling with exposed wires. The heating unit along the floor had exposed coils. A table saw was plugged into a wall electrical socket. On 8/26/13 at 12:35 p.m. the new reception desk (under construction) had an unlocked swinging half door. Behind the door on the unfinished wall contained two outlets with exposed wires. The area unattended by staff had two cordless power drills sitting on the floor. No staff were present. Observation on 8/27/13 at 8:23 p.m. revealed the new reception desk had an unlocked door. The wall behind the reception area contained an outlet with 4 exposed wires. Behind the desk, the floor contained an electric saw, a nail gun and a sander plugged into an electrical socket. Note: At the time of the survey, the investigation was coded as a " K " , immediate jeopardy to the residents health and safety. By August 28, 2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " D " level. The Administrator had placed a plastic barrier wall to divide the construction area and the lobby. The Administrator implemented a safety check sheet which is to be used by the Maintenance Supervisor. The Maintenance Supervisor will lock the doors, activate the alarm system, lock the garage door and ensure tools are secured before the construction workers leave. The reception desk swinging door now has a lock mechanism and is added to the safety checklist for power tools not left at the reception desk area. An audible alarm was installed on the south dining room door to ensure resident safety. All staff were in-serviced for awareness of possible safety hazards that may exist when having a construction crew in the facility. New lock mechanisms were installed to the washing machine room, bathroom doors and laundry room door. As of the 9/12/2013 exit conference, the facility continued to need to : ? Continue to In-service staff of possible safety hazards existing when having a construction crew in the facility, ? Continue to monitor the implementation of the safety check sheet to ensure the alarm system is activated, doors locked and tools secured after the construction crew leave the building. ? Continue to monitor the reception desk for effectiveness of the lock mechanism and power tools are no longer left at the desk. ? Continue to monitor the south dining room door to ensure the alarm has activated and audible. 2. Resident #5 had an MDS (Minimum Data Set) assessment with a reference date of 8/9/13, which identified the resident with the following Diagnoses: [REDACTED]. The MDS also identified the resident required extensive assistance in all activities of daily living, could not walk, had impairment to both legs, used a wheelchair for mobility and had a history of [REDACTED]. The care plan dated as last reviewed 8/23/13 identified the resident to be at risk for falls and directed staff to implement the following interventions: On 8/2/13- keep personal items and frequently used items within reach, transfer and ambulate using gait belt and walker with assist of one On 8/10/13 -chair and bed alarm On 8/21/13- medication review and extenders on wheelchair brakes On 8/23/13- place on walk to dine program when able to A review of the incident reports revealed the resident fell on : 8/10/13 at 10:30 a.m. while the resident tried to self-propel across the hall to another resident ' s room and attempted to toilet and fell to the floor. The report documented an implemented intervention to prevent further falls was to put a bed and chair alarm in place. 8/21/13 at 7:05 p.m. while the resident tried to unlock the wheelchair, stood and lost his/her balance. The form did not have documentation of whether or not the bed or chair alarms (which should have been implemented after the last fall) had malfunctioned. The report documented an implemented intervention to prevent further falls was to complete a medication review and apply brake extenders. 8/23/13 at 7:45 a.m. while the resident walked out to the hallway and fell to the floor. The report indicated no alarms had sounded. A review of the radiology reports from the emergency room visit on 8/23/13 revealed on the left shoulder an acute chronic left humeral neck (shoulder) fracture and on the left elbow a laceration which extended to the olecranon process (the elbow). A review of the fall risk evaluations revealed scores of 13 on 8/10/13 and 21 on 8/21/13. Scores of 10 or more identified the resident at high risk for falls. On 8/29/13 at 8:20 a.m. the DON was interviewed and reported on 8/23/13 the staff could not locate the resident's chair pad alarm and placed a personal alarm on the resident. There were extra pad alarms stored in the restorative nurse's office which the staff had access to during the day when the resident fell . She also reported the nurse was responsible for completing the incident report and could not explain why there was no documentation regarding the bed or chair alarms on the incident report. 3. On 8/26/13 from 4:46 p.m. to 5:28 p.m. observation revealed an unsecured oxygen cylinder leaning against the metal cylinder holder located in the medication room. The Director of Nursing picked up the cylinder and secured it in the metal holder. 4. Observation on 8/29/13 of the West hall therapy department identified a hydrocollator stored on a counter surface. The room also had the following items available for anyone and fully accessible to all that entered the room revealed: 7:47 a.m. - doors to the department open, no staff in the room, the hydrocollator plugged in and hot to touch the outside surface. 7:53 a.m. - doors remained open, no staff present. 7:59 a.m. - no staff in the therapy department, doors remained open, water inside the hydrocollator was 1 inch from the top and revealed a temperature of 164.1 degrees Fahrenheit. 8:07 a.m. - doors remained open, no therapy staff in the room, Staff B, housekeeping supervisor, was in the hall outside the therapy door and stated that he/she had not seen any therapy staff in the building yet and had opened the room to perform housekeeping duties. 8:16 a.m. - doors remained open, no staff in the room. 8:21 a.m. - staff in the room and stated they had arrived a few minutes ago. Based on observation, record review, and staff and resident interviews, the facility failed to provide adequate supervision to prevent accidents (Resident #5) and failed to protect residents from hazards to themselves and others. A construction project was in progress within the facility and the facility failed to protect residents from power equipment left unattended, doors left open and alarms not activated, oxygen tanks not stored securely and a therapy hydrocollator left unattended in an unlocked room. The facility reported a census of 71 residents. The facility identified 39 cognitively impaired and independently mobile resident. Five of the 71 residents wore wanderguard bracelets. Findings Include: 1. Observation on 8/27/13 at 8:20 a.m. revealed the boiler room door, adjacent to the resident's dining room, not latched and unlocked. An exit door to the outside, once in the boiler room, was propped open. The new therapy room was unalarmed. The Administrator and Maintenance Supervisor reported the boiler room door is to be locked at all times. Observation on 8/28/13 at 8:45 a.m. revealed the boiler room door unlocked. Staff V (sat at a dining room table) reported a construction worker walked out of the boiler room 15 minutes ago. An exit door (off the boiler room) had a door propped open. The back exit door of the facility (off the new Therapy Room) was propped open and unalarmed. Observation during the Environmental Tour on 8/28/13 from 8:30 a.m. to 9:11 a.m. revealed the south dining room door unalarmed. The first door through the south hall (new door) was propped open. When walking through the new door it was observed residents could leave the facility via the new laundry room. The exit door alarm was shut off during the day due to the construction. The Administrator reported a plan to put a lock on the new south hall door to eliminate access to the laundry room exit door. On 8/27/13 at 9:50 a.m. the Maintenance Director was observed to place a lock on the new south hall door. The Maintenance Director reported a plan to put another lock on another door to the laundry room which provided access to the outside exit door (since it was not alarmed). The Maintenance Director planned to provide a key to the construction workers. Observation on 8/27/13 at 12:13 p.m. revealed both interior laundry room doors had locks on them. This eliminated access to the unalarmed laundry room exit. On 8/27/13 at 4:26 p.m. revealed the new laundry room interior door unlocked, making the unalarmed laundry exit door accessible. On 8/27/13 at 4:51 p.m. the Administrator reported the facility had difficulty with the construction workers understanding to lock the door. The Administrator planned to talk to the Project Manager. The Administrator reported both interior laundry room doors would be locked and both exit doors activated when the construction crew finished for the day. Observation on 8/27/13 at 8:00 p.m. revealed the laundry exit door unalarmed and propped open with a rock. The interior laundry room door was open. The surveyor walked through the interior laundry room door and opened the south dining room door. The open south hall women's bathroom light switch had 3 exposed and 3 capped wires in the light switch, a blow torch sitting on the floor, a drill and a handsaw. The open south hall men's restroom had 7 exposed wires in the ceiling, tile tools, an extension cord and capped wires in light switch. On 8/27/13 at 8:41 p.m. the Administrator reported he/she gave Staff AA instructions to make sure the exit doors were locked and alarmed and to lock the garage. The Administrator reported the construction crew leaves for the day at 7:00 p.m. The Administrator told the construction supervisor to pick up their tools and lock up. The Administrator called the Project Manager to the facility to secure the area. On 8/27/13 at 9:20 p.m. the Project Manager was interviewed and informed the crew to secure anything hazardous. The Project Manager was unaware the South Dining Room door did not lock. At 8:25 p.m. on 8/28/2013 observation revealed the laundry room exit door locked. The south hall dining room door had a key pad alarm in place which sounded when the door opened. The south hall men and women bathrooms were locked. On 8/28/13 at 8:40 p.m. the laundry exit door did not sound when opened. Staff AA reported the dryer room door kept sounding so she shut off the alarm at the panel. Staff AA figured the laundry staff opened the door. The Director of Nursing opened the south dining room door and set off the alarm and informed the staff the south dining room door and laundry exit door were different sounding alarms. On 8/28/13 at 9:00 p.m. the Director of Nursing reported the staff didn't know which door the dryer room door was on the alarm panel. The staff shut off the dryer door alarm immediately because it ' s so loud. The Director of Nursing instructed Staff AA how to set the south dining room door. The Director of Nursing planned to in-service staff about the door alarms before leaving for the night. Observation on 8/26/13 at 12:17 p.m. revealed the facility had extensive remodel in progress. The construction crew had a large blue tarp across a sizeable opening in the wall across from the front entrance of the facility. The tarp secured with duct tape at the top allowed the construction staff to freely access the new therapy room behind the tarp. A couch and two chairs sat in front of the tarp. Across from the tarp the facility had a lounge for the resident. The residents passed the tarp area on the way to and from the dining room. Observation behind the tarped area in the unattended therapy room revealed the following. a. 4 power tools b. a table saw c. a skill saw d .a Sawzall e. wood glue f. hand saw g. 2 gallons of white paint h. 3 saws plugged into the wall i. 4- 5 gallon buckets of sheet rock joint compound j. a large hole in the floor exposing sewer pipes k. an exit door to the outside open and unalarmed On 8/26/13 at 12:27 p.m. the Administrator was interviewed and informed of the hazards. The Administrator stated the facility had no reported incidents with resident's accessing the area. At 1:11 p.m., the Administrator reported a plan to have a staff person monitor the area until a temporary wall could be built. Observation on 8/26/13 at 4:45 p.m. revealed a tarp secured with screws to a 2 foot by 4 foot boards. The tarped area measured 12.5 feet as a temporary wall. On 8/27/13 at 8:17 p.m. observation revealed the therapy room exit door did not sound when opened. The tarp covering the 12.5 foot open area in the wall was pulled back. The surveyor gained access to the new Therapy Room from the lounge area through the pulled back tarp. Observation behind the tarp identified 7 holes in the ceiling with exposed wires. The heating unit along the floor had exposed coils. A table saw was plugged into a wall electrical socket. On 8/26/13 at 12:35 p.m. the new reception desk (under construction) had an unlocked swinging half door. Behind the door on the unfinished wall contained two outlets with exposed wires. The area unattended by staff had two cordless power drills sitting on the floor. No staff were present. Observation on 8/27/13 at 8:23 p.m. revealed the new reception desk had an unlocked door. The wall behind the reception area contained an outlet with 4 exposed wires. Behind the desk, the floor contained an electric saw, a nail gun and a sander plugged into an electrical socket. Note: At the time of the survey, the investigation was coded as a " K " , immediate jeopardy to the residents health and safety. By August 28, 2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " D " level. The Administrator had placed a plastic barrier wall to divide the construction area and the lobby. The Administrator implemented a safety check sheet which is to be used by the Maintenance Supervisor. The Maintenance Supervisor will lock the doors, activate the alarm system, lock the garage door and ensure tools are secured before the construction workers leave. The reception desk swinging door now has a lock mechanism and is added to the safety checklist for power tools not left at the reception desk area. An audible alarm was installed on the south dining room door to ensure resident safety. All staff were in-serviced for awareness of possible safety hazards that may exist when having a construction crew in the facility. New lock mechanisms were installed to the washing machine room, bathroom doors and laundry room door. As of the 9/12/2013 exit conference, the facility continued to need to : ? Continue to In-service staff of possible safety hazards existing when having a construction crew in the facility, ? Continue to monitor the implementation of the safety check sheet to ensure the alarm system is activated, doors locked and tools secured after the construction crew leave the building. ? Continue to monitor the reception desk for effectiveness of the lock mechanism and power tools are no longer left at the desk. ? Continue to monitor the south dining room door to ensure the alarm has activated and audible. 2. Resident #5 had an MDS (Minimum Data Set) assessment with a reference date of 8/9/13, which identified the resident with the following Diagnoses: [REDACTED]. The MDS also identified the resident required extensive assistance in all activities of daily living, could not walk, had impairment to both legs, used a wheelchair for mobility and had a history of [REDACTED]. The care plan dated as last reviewed 8/23/13 identified the resident to be at risk for falls and directed staff to implement the following interventions: On 8/2/13- keep personal items and frequently used items within reach, transfer and ambulate using gait belt and walker with assist of one On 8/10/13 -chair and bed alarm On 8/21/13- medication review and extenders on wheelchair brakes On 8/23/13- place on walk to dine program when able to A review of the incident reports revealed the resident fell on : 8/10/13 at 10:30 a.m. while the resident tried to self-propel across the hall to another resident ' s room and attempted to toilet and fell to the floor. The report documented an implemented intervention to prevent further falls was to put a bed and chair alarm in place. 8/21/13 at 7:05 p.m. while the resident tried to unlock the wheelchair, stood and lost his/her balance. The form did not have documentation of whether or not the bed or chair alarms (which should have been implemented after the last fall) had malfunctioned. The report documented an implemented intervention to prevent further falls was to complete a medication review and apply brake extenders. 8/23/13 at 7:45 a.m. while the resident walked out to the hallway and fell to the floor. The report indicated no alarms had sounded. A review of the radiology reports from the emergency room visit on 8/23/13 revealed on the left shoulder an acute chronic left humeral neck (shoulder) fracture and on the left elbow a laceration which extended to the olecranon process (the elbow). A review of the fall risk evaluations revealed scores of 13 on 8/10/13 and 21 on 8/21/13. Scores of 10 or more identified the resident at high risk for falls. On 8/29/13 at 8:20 a.m. the DON was interviewed and reported on 8/23/13 the staff could not locate the resident's chair pad alarm and placed a personal alarm on the resident. There were extra pad alarms stored in the restorative nurse's office which the staff had access to during the day when the resident fell . She also reported the nurse was responsible for completing the incident report and could not explain why there was no documentation regarding the bed or chair alarms on the incident report. 3. On 8/26/13 from 4:46 p.m. to 5:28 p.m. observation revealed an unsecured oxygen cylinder leaning against the metal cylinder holder located in the medication room. The Director of Nursing picked up the cylinder and secured it in the metal holder. 4. Observation on 8/29/13 of the West hall therapy department identified a hydrocollator stored on a counter surface. The room also had the following items available for anyone and fully accessible to all that entered the room revealed: 7:47 a.m. - doors to the department open, no staff in the room, the hydrocollator plugged in and hot to touch the outside surface. 7:53 a.m. - doors remained open, no staff present. 7:59 a.m. - no staff in the therapy department, doors remained open, water inside the hydrocollator was 1 inch from the top and revealed a temperature of 164.1 degrees Fahrenheit. 8:07 a.m. - doors remained open, no therapy staff in the room, Staff B, housekeeping supervisor, was in the hall outside the therapy door and stated that he/she had not seen any therapy staff in the building yet and had opened the room to perform housekeeping duties. 8:16 a.m. - doors remained open, no staff in the room. 8:21 a.m. - staff in the room and stated they had arrived a few minutes ago. During an interview on 8/26/13 at 1:35 p.m., the therapy manager stated that residents were to be supervised at all times when in the therapy room because of the hazards associated with the hydrocollator. During an interview on 8/29/13 at 10:30 a.m., the manager was not aware that Staff B had opened the therapy department at or prior to 7:47 a.m., that all therapy staff had a key to the room. The manager stated there is a key stored in the handrail,right outside the door for staff to access the room when therapists are not there. Based on observation, record review, and staff and resident interviews, the facility failed to provide adequate supervision to prevent accidents (Resident #5) and failed to protect residents from hazards to themselves and others. A construction project was in progress within the facility and the facility failed to protect residents from power equipment left unattended, doors left open and alarms not activated, oxygen tanks not stored securely and a therapy hydrocollator left unattended in an unlocked room. The facility reported a census of 71 residents. The facility identified 39 cognitively impaired and independently mobile resident. Five of the 71 residents wore wanderguard bracelets. Findings Include: 1. Observation on 8/27/13 at 8:20 a.m. revealed the boiler room door, adjacent to the resident's dining room, not latched and unlocked. An exit door to the outside, once in the boiler room, was propped open. The new therapy room was unalarmed. The Administrator and Maintenance Supervisor reported the boiler room door is to be locked at all times. Observation on 8/28/13 at 8:45 a.m. revealed the boiler room door unlocked. Staff V (sat at a dining room table) reported a construction worker walked out of the boiler room 15 minutes ago. An exit door (off the boiler room) had a door propped open. The back exit door of the facility (off the new Therapy Room) was propped open and unalarmed. Observation during the Environmental Tour on 8/28/13 from 8:30 a.m. to 9:11 a.m. revealed the south dining room door unalarmed. The first door through the south hall (new door) was propped open. When walking through the new door it was observed residents could leave the facility via the new laundry room. The exit door alarm was shut off during the day due to the construction. The Administrator reported a plan to put a lock on the new south hall door to eliminate access to the laundry room exit door. On 8/27/13 at 9:50 a.m. the Maintenance Director was observed to place a lock on the new south hall door. The Maintenance Director reported a plan to put another lock on another door to the laundry room which provided access to the outside exit door (since it was not alarmed). The Maintenance Director planned to provide a key to the construction workers. Observation on 8/27/13 at 12:13 p.m. revealed both interior laundry room doors had locks on them. This eliminated access to the unalarmed laundry room exit. On 8/27/13 at 4:26 p.m. revealed the new laundry room interior door unlocked, making the unalarmed laundry exit door accessible. On 8/27/13 at 4:51 p.m. the Administrator reported the facility had difficulty with the construction workers understanding to lock the door. The Administrator planned to talk to the Project Manager. The Administrator reported both interior laundry room doors would be locked and both exit doors activated when the construction crew finished for the day. Observation on 8/27/13 at 8:00 p.m. revealed the laundry exit door unalarmed and propped open with a rock. The interior laundry room door was open. The surveyor walked through the interior laundry room door and opened the south dining room door. The open south hall women's bathroom light switch had 3 exposed and 3 capped wires in the light switch, a blow torch sitting on the floor, a drill and a handsaw. The open south hall men's restroom had 7 exposed wires in the ceiling, tile tools, an extension cord and capped wires in light switch. On 8/27/13 at 8:41 p.m. the Administrator reported he/she gave Staff AA instructions to make sure the exit doors were locked and alarmed and to lock the garage. The Administrator reported the construction crew leaves for the day at 7:00 p.m. The Administrator told the construction supervisor to pick up their tools and lock up. The Administrator called the Project Manager to the facility to secure the area. On 8/27/13 at 9:20 p.m. the Project Manager was interviewed and informed the crew to secure anything hazardous. The Project Manager was unaware the South Dining Room door did not lock. At 8:25 p.m. on 8/28/2013 observation revealed the laundry room exit door locked. The south hall dining room door had a key pad alarm in place which sounded when the door opened. The south hall men and women bathrooms were locked. On 8/28/13 at 8:40 p.m. the laundry exit door did not sound when opened. Staff AA reported the dryer room door kept sounding so she shut off the alarm at the panel. Staff AA figured the laundry staff opened the door. The Director of Nursing opened the south dining room door and set off the alarm and informed the staff the south dining room door and laundry exit door were different sounding alarms. On 8/28/13 at 9:00 p.m. the Director of Nursing reported the staff didn't know which door the dryer room door was on the alarm panel. The staff shut off the dryer door alarm immediately because it ' s so loud. The Director of Nursing instructed Staff AA how to set the south dining room door. The Director of Nursing planned to in-service staff about the door alarms before leaving for the night. Observation on 8/26/13 at 12:17 p.m. revealed the facility had extensive remodel in progress. The construction crew had a large blue tarp across a sizeable opening in the wall across from the front entrance of the facility. The tarp secured with duct tape at the t

Based on observation, record review, resident and staff interviews, the facility failed to provide privacy during incontinence care and wound care for 1 of 5 residents (Resident #1) and failed to treat 1 of 13 residents (Resident #10) reviewed in the standard sample, with dignity and respect. The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 8/9/13, identified Resident #1 with the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively impaired, required staff assistance with all activities of daily living, always incontinent of bladder and bowel. The care plan dated as last reviewed on 5/22/13 identified the resident with the problem of functional urinary incontinence directed staff to provide incontinence care after each incontinent episode and apply moisture barrier to skin. During an observation of incontinence care on 8/27/13 at 1:38 p.m. neither Staff O, LPN or Staff C, CNA pulled the privacy curtain completely around the resident's bed, only the curtain between the beds. The resident's roommate and roommate's spouse were also in the room. At 2:11 p.m., the resident laid on the right side with gluteal folds exposed as he/she had been incontinent of stool when the roommate's son walked in to the room and able to see Resident #1 exposed before the DON asked the son to return later and before Staff C covered the resident with a sheet. At 2:18 p.m., the privacy curtains still had not been pulled around the foot of the bed which left the resident exposed during incontinence care when the roommate's son, the roommate's spouse and the housekeeping supervisor entered the room. Staff O pulled the privacy curtain around the bed and requested all to return later. During an observation of wound care on 8/28/13 at 12:32 p.m., Staff O, LPN and Staff II, CNA entered the room without pulling the privacy curtain completely around the bed leaving the entire side of the bed facing the door to the room exposed. At 12:54 p.m., a staff member knocked on the door and before receiving a response pushed the resident's roommate in a wheelchair into the room. Staff O closed the door immediately with her foot. In an interview on 8/28/13 at 8:20 a.m., the Director of Nursing reported she expected staff to pull the privacy curtain around the bed, close any curtains or blinds to the windows and keep the resident covered at all times as possible while providing care. 2. Resident #10 had a MDS assessment with a reference date of 7/19/2013 which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident required extensive assistance for most activities of daily living and totally dependent on staff for transfers and toileting. During an interview on 8/27/13 at 7:08, the resident requested to speak to the surveyor and reported "I had spinal cord surgery and I need to be repositioned every two hours. Last night Staff S, CNA, repositioned me at 11:00 p.m., I was awake at 1:00 a.m. and Staff S never came in to reposition me, she didn't come in at 3:00 a.m. so I pushed my call light and she didn't come in until 3:20 a.m. When I asked her to get some help to turn me, she yelled "they're all busy" When she works with me, she's very rude, she's rough and I have talked to the DON about it." During an interview on 8/27/13 at 7:38 a.m., the resident reported "Staff S, CNA, is rough, not polite and she makes me feel bad and when she's here, my hair stands up when I know she's taking care of me, I worry." The resident continued to state Staff S talks to her/him and the tone is always as though she is made at him/her. The resident stated she/he has to get up to the commode to have a bowel movement and have had accidents in bed waiting for help. The resident voiced that this make her/him feel bad. In an interview on 8/29/13 at 8:30 a.m., the DON reported she spoke to the resident and the resident's spouse who reported Staff S would pull the resident up too quickly and too rough. The DON stated she spoke to Staff HH (Staff S's sister) and asked if Staff HH could speak to Staff S for her. The DON stated she felt Staff S did not have enough training with how to care for Resident #10. On 8/28/13 at 6:12 p.m., the resident's spouse was interviewed and stated staff handled the resident rough. The spouse stated the resident had pain in his/her back from surgeries and he/she had repeated requests for staff to handle the resident with gentle care were ignored. The spouse stated staff knew the resident needed repositioned at least every 2 hours during the night and the staff would not provide the care. The resident used his/her call light to summon assistance and would call the nurse's station with his/her cell phone when staff didn't respond to the call light. The spouse stated they had made the Administrator and the Director of Nursing aware of their concerns on repeated occasions and nothing had changed.

Based on observation, record review and staff interviews, the facility failed to prevent the development and promote the healing of pressure ulcers (Resident #5, Resident #1) for 3 residents reviewed with pressure ulcers and failed to provide appropriate care for a resident at high risk for the development of pressure ulcers (#6). The facility reported a census of 71 residents and 4 residents with pressure ulcers. Findings include: The following descriptions reflect the stages of pressure ulcers: Stage 1-Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Stage 2-Partial thickness loss of dermis, presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open ruptured blister. Stage 3-Full thickness tissue loss. Subcutaneous fat may be visable but bone, tendon or muscle is not exposed. Stage 4-Full thickness tissue loss with exposed bone, tendon or muscle. 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 8/9/2013. The assessment identified Resident #1 with the following Diagnoses: [REDACTED]. The MDS reflected the resident to be cognitively impaired, required staff assistance with all activities of daily living, always incontinent of bladder and bowel and had one stage 3 pressure ulcer and one unstageable ulcer. The MDS reflected the resident had a weight gain since the last assessment and weighed 117 pounds. The resident received fluids and calories via a tube feeding. The Admission Care Plan dated 5/2/2013 identified an admission [DIAGNOSES REDACTED]. The Care Plan did not provide interventions for pressure sores/skin care, such as turn every 2 hours, preventive measures, etc. The Care Plan dated as last reviewed on 5/22/13 identified the resident had a stage 3 ulcer to the right ankle and an unstageable ulcer to the left heel without documentation of the date of onset. It directed the staff to report any new areas of skin breakdown, notify the physician of any skin issues and perform treatments as ordered, hospice to complete wound cares, float heels with pillows when in bed with heel protectors on at all times and pressure reduction mattress. Observations of the resident revealed the resident wore foam boots, however, the heels had not been floated when observed on 8/26/13 at 4:08 p.m. and at 5:15 p.m. lying on back in bed. On 8/27/13 at 8:45 a.m. before Staff O, LPN began wound care and on 8/27/13 at 8:52 a.m. after Staff O completed wound care, and both heels were placed directly on the pillow. The care card above the head of the bed directed staff to have heels floated with pillows when in bed and heel protectors must be on at all times per hospice. On 8/27/13 at 9:20 a.m. Staff C, Licensed Practical Nurse (LPN) administered medications and the tube feeding while Staff O, LPN observed. The resident ' s heels remained not floated from the bed/pillow during the procedure and after leaving the room. On 8/27/13 at 9:53 a.m. the resident continued to lie in bed without heels floated. On 8/28/13 at 7:40 a.m. the resident had been moved to a different room without a care card posted anywhere in the room. The resident ' s bilateral heels rested directly on a pillow and supine in bed (lying on back). On 8/28/13 at 9:00 a.m., the resident lay supine in bed and both heels rested directly on the top of a pillow and not floated. On 8/28/13 at 12:35 p.m. the resident laid on right side in bed and both heels rested directly on top of a pillow and not floated. Observations of the wound on the resident's left heel revealed the following: On 8/27/13 at 1:56 p.m. Staff O, LPN, was observed to remove the dressing. The wound began dripping moderate amounts of sanguineous (bloody) drainage and the wound bed appeared beefy red without any other discolorations noted. On 8/28/13 at 12:44 p.m. Staff O removed the dressing. The wound appeared beefy red, however, now appeared to have a portion of a tendon exposed and now with a thin line of necrotic (dead tissue) tissue lining the wound from the 10 o'clock to 12:00 o'clock position A review of the nursing admission assessment dated [DATE] identified the resident with an open area to the left calf without measurements, a blood like blister to the left heel and a stage 2 area to the right heel. The hospice transfer form dated 5/2/13 identified only one open area to the left calf. The admission physician orders dated 5/2/13 revealed orders to change the right medial ankle dressing as needed and apply [MEDICATION NAME] (dressing) to the left heel for protection. The Braden scales completed revealed the resident was identified at high risk for developing pressures sores with a score of 14 (a score of greater than 12 indicated the resident at high risk) on May 2, 9, 16 and 23, 2013. A review of the Nurse's Notes revealed the following entries: On 5/2/13 at 6:30 p.m. [MEDICATION NAME] (adhesive patch to promote moisture for healing) to the left heel is protective only, as with [MEDICATION NAME] (dressing) to the right medial ankle which is covering a reddened area and for padding and protection. On 6/5/13 at 1:00 p.m. Hospice notified of moderate amounts of red/brown drainage to the right ankle and left heel. The Hospice nurse redressed wounds as per the new order. A review of the Hospice skin assessments revealed the following entries: On 5/1/13 -open areas to both shins and both calves only, On 5/15/13- left heel with 5.5 cm (centimeter) by 5 cm boggy dark purple area, skin intact. The right ankle with a 2.0 cm by 2.0 cm open area. No documentation of the initial measurements and assessments of wounds identified to the left heel and the right ankle as identified in the Nurse's Notes on 6/5/13. On 6/11/13 the right ankle was described as a bright red area which measured 3 cm long and 2 cm wide and the left heel with an open area which measured 5 cm long by 5 cm wide with a necrotic area in the center (no measurement of the necrotic area). On 6/24/13 the right ankle with an open area which measured 3 cm by 3.25 cm and the left heel now measured 6.0 cm by 4.5 cm and the center of the wound with eschar (dead tissue) which measured 2.0 cm by 2.5 cm. On 7/9/13 no documentation or measurements or assessments of wounds as both were covered with dressings. The notes did not include documentation of reassessment and measurement of the above wounds from 5/30/13 through 6/11/13 (12 days) and from 6/12/13 through 6/24/13 (12 days) From 7/16/13 through 8/20/13 measurements and assessments were completed weekly on the Hospice skin assessments and facility wound/skin healing records. A review of the facility wound/skin healing records revealed the following: No documentation of the date of onset, notification of the physician, family, or dietitian. Initial assessment on the form dated 7/18/13 (wounds initially identified on 6/5/13). The only measurements and assessments documented on the form had been dated as completed on 8/8/13 with the right ankle at 3.5 cm long by 3.0 cm wide and 0.2 cm deep and the left heel at 5.0 cm long and 6.0 cm wide and covered with eschar and the remaining entries were documented as "see hospice measurements" A review of the August 2013 treatment administration record revealed orders dated 6/6/13 to cleanse wounds to the left heel, left calf and right ankle with McKesson dermal (skin) wound cleanser, fill with alginate dressing and cover with [MEDICATION NAME] dressing twice weekly and as needed. A record review of the dietitian progress notes revealed the following: On 5/2/13 admission weight 123 pounds, nothing by mouth, received tube feeding of Fibersource HN 1.2 calories, 300 milliliters (ml) four times daily with 60 ml of water. On 5/23/13- skin is intact, enteral support meets needs On 7/16/13 -currently with stage 3 pressure areas to the right ankle and left heel and stage 2 area to the right inner leg. Current weight is 104 (pounds). On 8/8/13- current weight is 117 (pounds) and question if possible error with June weight. Continues with pressure areas. Increased the tube feeding to 250 milliliter five times daily. In an interview on 8/28/13 at 8:22 a.m., Staff O, LPN, wound nurse, reported she had not been informed of the resident's wounds when admitted in May 2013. She discovered the wounds when she returned from medical leave of absence on a hospice skin sheet dated 7/2/13 and when she asked the nurse about the wounds, she had been informed the resident had them on admission (5/2/2013). She also reported when new orders are received for wounds, the nurses were to report to her when she comes to the facility on ce a week via a skin sheet with measurements which Staff O then reviewed along with the TAR and new orders. The wound to the left heel had pink granulating tissue with a small area of slough in the middle of the wound and blisters around the side which were not there on 8/27/13. The resident ' s heels should have been offloaded with pillows to float the heels. In an interview on 8/29/13 at 8:20 a.m., the Director of Nursing (DON) reported during the observation of the wound care completed 8/28/13 that a spot on the left heel appeared to be a tendon, however, it was difficult to visualize as the room was poorly lit. She also reported when the wound nurse had taken a leave of absence, the hospice nurses completed the wound care twice a week. 2. Resident #5 had an admission MDS assessment with a reference date of 8/9/2013. The MDS dated [DATE] identified Resident #5 with the following Diagnoses: [REDACTED]. It also identified the resident required extensive assistance in all activities of daily living, could not walk, had impairment to both legs and was at risk for developing pressure ulcers. The Care Plan dated 8/15/13 identified the resident with the problem of a stage 2 pressure ulcer to the left heel and directed staff to: a. Assess the pressure ulcer for location, stage, size (length, width and depth), presence/absence of granulation tissue and epithelization and condition of the surrounding skin weekly. b. Turn and reposition every 2hours c. Pressure reduction mattress d. Treat according to the physician orders e. Notify family and doctor of any changes A review of the discharge summary from the hospital dated 8/2/13 identified the resident's skin to be intact without [MEDICAL CONDITION]. The admission skin condition report dated 8/2/13 had documentation of pressure ulcers identified on the buttock and left great toe, however, also had documentation that the above areas were identified as only reddened areas on the diagram of the body. A review of the facsimile request to the physician dated 8/12/13 informed the physician of a wound to the left heel which measured 3.0 centimeters (cm) by 2.0 cm and a request for an order for [REDACTED]. A review of the August 2013 TAR (Treatment Administration Record) revealed no orders for the triple antibiotic ointment and dressings, however, orders dated 8/15/13 directed staff to cleanse the left heel with wound cleanser before the application of hydrogel and Kerlix (gauze) dressings daily. The non-pressure skin condition report dated 8/12/13 identified a wound to the left heel which measured 3.0 cm long, 2.0 cm wide and less than 0.1 cm deep, that the physician and family were notified on 8/12/13 and no documentation of the Dietitian being notified. The wound/skin healing record which identified the resident with a wound to the left heel, however, did not have documentation of the type of wound, the date of onset, the original stage or notification of the dietitian. The date of 8/15/13 had been documented with the first assessment on the form. A review of a lab report dated 8/16/13 revealed the resident had a [MEDICATION NAME] level (a test to detect protein-calorie [MEDICAL CONDITION] which can affect the body's ability to heal wounds) of 9.1 milligrams per deciliter (mg/dL) and the normal range should have been between 20 to 40 mg/dL. A review of the dietary progress notes revealed: on 8/8/13 the resident's skin had no pressure related areas, but may have been at an increased risk related to meal intakes and mobility issues and on 8/21/13 identified the resident developed a pressure area to the heel, however, did not include documentation of the date the dietitian had been notified of the wound. In an interview on 8/29/13 at 8:22 a.m., Staff O, LPN, Wound Nurse reported the resident ' s wound developed at the facility which had not been documented on admission. Staff O stated she was unsure of the cause but assumed it had been from not being repositioned or not offloading the heels. Staff O reported the interventions included placing foam boots on the resident's feet at all times with the exception of when physical therapy worked with the resident. In an interview on 8/29/13 at 4:19 p.m., Staff DD, LPN, reported the notification process after the wound had been identified did not include notification of the Dietitian and foam boots should have been placed on both feet at all times except when working with physical therapy. The following observations revealed the resident did not have the foam boots on to both feet on: On 8/26/13 at: 12:12 p.m. while sitting in the wheelchair in the main dining room wearing only bedroom slippers on both feet 2:15 p.m. while sitting in the wheelchair at the nurse's station with only gripper socks on both feet 3:12 p.m. while self-propelling in the wheelchair with only gripper socks on both feet 4:47 p.m. while sitting in the wheelchair at the nurse's station with only gripper socks on both feet 8:13 p.m. while asleep in in bed without heels floated On 8/27/13 at: 6:03 a.m. while asleep in low bed with the foam boot on to the left foot only and the right heel bare resting directly on the mattress and foam boot on the floor beside the bed 6:20 a.m. while asleep in bed with right heel still bare, not floated and boot on the floor beside the bed 6:57 a.m. position unchanged, when asked which heel the resident had a wound on, the wound nurse entered the resident's room to check and did not place the boot to the right foot before she left the room. 8:00 a.m. position unchanged with boot still on the floor beside the bed On 8/29/13 at 6:00 a.m. while asleep in bed with the left heel resting directly on the mattress as the left knee was drawn up. Both heels were not floated and both foam boots were on the floor beside the bed. An observation on 8/27/13 at 9:57 a.m. revealed the care card in the resident's room did not direct staff when to apply the foam boots. On 8/29/2013 at 8:20 a.m., the DON was asked to describe what staff were expected to do once a wound had been discovered. The DON reported the following expectations: a. Identify and measure the wound in the nurse ' s notes. b. Notify the physician, family, the Wound Nurse and the DON. The DON would notify the dietitian c. Initiate any new orders or new interventions d. The wound nurse would assess upon her next scheduled day (usually at the facility once a week) which would include looking at the care plan, current treatment and the Wound Nurse or floor nurse would notify the physician to request any changes and family would be notified of new orders e. The Wound Nurse would then monitor the wound on a weekly basis f. The floor nurses would be expected to notify the Wound Nurse of any changes by leaving a note. A review of the facility policy dated April 2004 titled: non-pressure related wounds and skin conditions revealed the staff directions to carry out the following procedure: a. Perform a complete assessment of the wound b. Alert the physician to the formation of the wound, assessment of the wound and possible order for treatment. The physician will assist the nursing staff in determining the nature of the wound, i.e. vascular venous pressure. Notify family/responsible party to the formation of a new wound. c. Complete all sections of the weekly skin form and use the non-pressure sore skin problem report as needed. d. Following completion on the skin forms, the information will be communicated to the DON or his/her designee and dietary supervisor for on-going management. e. The charge nurse will make an entry in the progress notes regarding the progression of the wound. f. The charge nurse or treatment nurse will notify the attending physician of lack of progress, deterioration or signs and symptoms of inflammation. g. In addition to documenting in the progress report, the treatment nurse or licensed nurse will document the treatment as ordered on the treatment sheets. 3. Resident #6 had a MDS assessment following a significant change in condition with a reference date of 7/27/13 which identified the resident had diabetes, arthritis and hypertension (high blood pressure). The resident required extensive assistance of 2 or more staff members for repositioning, transfers to and from bed and chair. The resident had an indwelling urinary catheter and always experienced bowel incontinence. The resident was identified to be at risk for the development of pressure sores and did not have pressure ulcers. The Care Area Assessment on the MDS tool indicated the resident at risk for skin breakdown associated to incontinence, with interventions that included pressure relief mattress on bed and cushion in wheel chair. The resident's record did not reveal a completed skin assessment or a standardized tool used to identify the risk of skin breakdown. Observation of personal care with Staff O (Wound Nurse), and Staff P, CNA, on 8/27/13 between 7:15 a.m. and 8:47 a.m. revealed an incontinent brief on the resident. Staff removed the brief that revealed the resident's skin on his/her bilateral buttocks extremely reddened. The areas measured approximately 4 centimeters (cm) wide and 10 to 12 cm long, with an open area observed on the left buttocks that measured approximately 1 cm wide, 1 and 1/2 to 2 cm long, and depth of 1 to 2 millimeters, with pink wound bed and red surrounding tissue. Staff P stated the resident did not have an open area on the previous week; Staff O was not aware that the resident had a wound and stated he/she would follow-up as needed. The Assistant Director of Nursing (ADON), that also observed the care, brought the resident's barrier cream to the room, dispensed the cream in Staff P's hand and he/she applied it to the resident's buttocks as Staff O held the resident in position on his/her side. During an interview on 8/29/13 at 8:40 a.m., Staff O stated that she had not documented Resident #6's wound assessment performed on 8/27/13 and she faxed (sent a facsimile) to the physician with a request for barrier cream with zinc to treat the resident's wound. On 8/29/13 at 9:20 a.m., Resident #6's Physician ' s Orders were reviewed with Staff O. Staff O stated she wasn ' t aware the resident already had an order for [REDACTED].

Based on record review and resident interview, the facility failed to display respect when caring for Resident #9. Resident #9 activated the call light system and waited 2 ? hours before staff responded and assisted the resident. 1. Resident #9 had an MDS (Minimum Data Set) assessment with a referenced date of 10/21/2011. The MDS reflected the resident had a BIMS (Brief Interview Mental Status) with a scope of 14. A scope of 13-15 indicated residents without cognition problems and cognitively intact. The MDS indicated the resident required routine toileting and had experienced a fall in the past. The MDS identified Resident #9 as continent of both bowel and bladder function. On 11/02/11 at 4:32 p.m., Resident #9 was interviewed and stated had been toileted throughout the day and hardly ever had an accident. Resident #9 stated that on 11/1/2011 at 11:00 a.m. she/ he activated the call light because she/he needed to use the toilet to have a bowel movement. The staff did not come until 1:30 p.m. As a result of the call light not being answered for 2 ? hours, Resident #9 had to go ahead and have the bowel movement. Resident #9 stated just could not wait any longer. Resident #9 stated she/he could remember the time because of the clock on the wall just above the television.

Based on observation, record review and staff interviews, the facility failed to regularly and adequately assess pressure ulcers which resulted in delayed healing and increase in size and pain. (Resident #3 #10). Concerns were noted for 2 of 10 residents reviewed. The facility reported a census of 74 residents. 1. The Admission Sheet indicated Resident #3 entered the facility on 01/28/1983 with [DIAGNOSES REDACTED]. The nurse ' s notes indicated the following: On 07/20/11 at 8:00 a.m. Resident #3 remained hospitalized for [REDACTED]. On 07/21/11 at 5:00 p.m. Resident #3 returned to the facility from the hospital. The facility Admission Nursing Assessment form dated 07/21/11 at 4:00 p.m. described bruising on the left hand from IV (intravenous) and bilateral upper/inner thighs with open blisters with yellow exudate. On 07/23/11 at 5:30 p.m. the nursing assistant called the nurse to the room due to a sore on the resident ' s foot. The area measured 7.0 cm by 6.0 centimeter (cm) stage III pressure ulcer on the resident ' s left foot. The nurse noted it as difficult to adequately assess due to left side [MEDICAL CONDITION] and contractures. The resident complained of pain, grimacing and crying. On 7/23/2011 at 6:25 p.m. the staff received physician orders [REDACTED]. The physician gave approval to apply TAO (triple antibiotic ointment), cover with [MEDICATION NAME] and Kling wrap until further assessment on Monday. The nurse documented the following ongoing assessments on the Wound/Skin Healing Record are as follows: On 07/26/11- Stage III, 4 cm by 5 cm, no depth; no exudate, no odor, slough wound bed; bright red surrounding color; rolled edges. On 07/not legible date- Stage II, 6 cm by 3 cm, 0.1 depth; small amount of serous exudate; wound bed [MEDICATION NAME] tissue; normal surrounding skin color, normal skin edges. On 7/28/2011 the APNP (Advanced Practice Nurse Prescribers) saw the resident ' s wounds. The left heel measured 6 cm by 3 cm by 0.1 cm. The heel had yellowish black material within the wound bed. The assessment determined the wound to be Stage III with no overt signs of an active infection. The APNP discontinued the [MEDICATION NAME] treatment and began Santyl twice a day with a dry gauze dressing. A soft boot was ordered to off load pressure and Vitamin C was added to the current regimen. The APNP saw the resident on 8/4/2011 and determined the left plantar foot had a Stage III pressure with healing somewhat stalled. A new pressure ulcer had been identified on the left hip. The APNP identified the new area as a Stage II pressure ulcer. The APNP recommended off loading boot to the left heel and to keep the heels off of the bed to prevent any deterioration of the ulcers and use Santyl to all wounds twice daily under Vaseline gauze, followed by a dry gauze dressing. A culture was obtained from the left heel and thigh areas to determine the level of bacteria present. The APNP identified the wounds appeared infected. The APNP saw the resident on 8/11/2011 and the dictated report identified the left heel pressure ulcer as Stage III and showing poor progress. The APNP identified the thigh areas to be secondary to thermal injury and improving. The resident indicated the resident began Hospice on 8/10/2011. The culture collected last week had been advertently missed by the nursing staff and had not been sent. On 08/18/11, Stage III, 4.2 by 4.2 cm; 0.3 depth; small amount of serosanguineous exudate; wound bed [MEDICATION NAME] tissue with normal skin color and normal surrounding tissue. The dietary and physician notified. The APNP saw the resident on 8/18/2011 for a follow up review. The APNP identified the left heel continued to show poor progress and a Stage III. The APNP ordered the Santyl to be continued to help facilitate the removal of the necrotic tissue. On 08/23/11 Stage III 4 by 4 cm, 0.3 depth; moderate amount of serosanguineous exudate; wound bed pink/beefy red; normal skin color and normal surrounding tissue. On 08/30/11 Stage III 4.5 by 4, 0.3 depth; moderate amount of serosanguineous exudate, wound bed beefy red, pink surrounding skin and normal surrounding tissue; no odor. The record revealed the pressure ulcers and thighs had not been assessed again until 9/21/2011 (3 weeks). Two assessments completed in September with the left heel. On 09/21/11 Stage IV (deeper) 2 1/2 cm by 1 1/2; no depth documented but Stage IV; large amount of purulent drainage; foul smelling; wound bed black/brown (eschar) surrounding skin color white/gray pallor; wound edges rolled. On 09/27/11 Stage IV, 4 cm by 5 (enlarged), no depth documented; large amount of purulent exudate; foul smelling; wound bed black/brown (eschar) surrounding skin color black/brown; surrounding tissue hardness/induration. Additional information documented included Resident #3 now experienced pain related to the wound and the following non-verbals demonstrated: grimacing, moaning, irritability and anger. Three assessments completed in October: for the left heel. On 10/04/11 Unstageable, 4 by 5; no depth documented; large/copious amounts of purulent exudate; foul smelling; wound bed black/brown (eschar) surrounding skin white/gray, surrounding tissue hardness/induration. On 10/11/11 unstageable, 4 by 5; no depth documented; copious amounts purulent exudate; foul smelling; wound bed slough and black/brown eschar; surrounding skin white/gray; surrounding tissue hardness/induration. On 10/18/11 the left heel identified as unstageable and 4 cm by 5 cm no depth documented; copious amounts of purulent drainage; foul smelling; wound bed brown/black eschar; surrounding skin white/gray; surrounding tissue hardness/induration. November assessment: On 11/01/11 no stage identified on left heel measured 4 cm by 5; no depth documented; no exudate documented, slight odor; small amount of exudate; wound bed- slough; surrounding skin color, dark red/purple; surrounding tissue, rolled edges. Do to the lack of continued and weekly assessments, the wound continued to increase in size and stage which resulted in delayed healing, further infection and pain. 2. According to documentation in the care plan dated 09/06/11, staff identified Resident #10 as being at risk for skin breakdown related to decreased mobility, incontinence and [MEDICAL CONDITION]. An entry in the nurse's notes dated 10/18/11 at 10:35 a.m. indicated staff noted during cares, two openings on Resident #10's left buttock. One wound measured 01. cm and the other pinpoint. The notation indicated Resident #10's physician was notified. Review of the medical record for Resident #10 also indicated staff completed a skin sheet dated 10/18/11 which indicated a stage 2 pressure ulcer 0.1 cm. Staff documented no further assessment of the area. Another entry in the nurse's notes dated 10/26/11 indicated staff noted with cares, Resident #10 had an open area on his/her left buttock," approximately 2 cm by 2 cm", "left in bed and repositioned every 1- 3 hours". Staff also completed a facility "non-pressure ulcer skin condition" report dated 10/26/11 which identified a 2 by 2 cm open area on Resident #10's right buttock. Staff did not document any further assessment of the area. Documentation in the nurse's notes dated 10/26/11 (no time given) indicated staff noted Resident #10 with an open area, approximately 2 cm by 2 cm on his/her right buttocks. The notation added that Resident #10 "left in bed and repositioned every 1 to 3 hours.

Based on observation, record review, and staff and family interview, the facility failed to implement interventions and provide adequate supervision designed to prevent accidents for 1 of 8 residents reviewed who fell out of bed and sustained a left cheek laceration which required suturing at the hospital (Resident #8). The facility reported a census of 73 residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment tool dated 5/20/11, Resident #8 had [DIAGNOSES REDACTED]. According to the MDS, Resident #8 had short and long-term memory problems and moderately impaired decision making capabilities. The assessment indicated the resident as non-ambulatory, required extensive assistance of 2 staff for bed mobility and transfers, extensive assistance of 1 staff for dressing and personal hygiene, and relied totally on staff for toilet use and bathing. The resident's care plan, dated 5/25/11 identified the resident as at risk for falls and directed the nursing staff to ensure the resident had a low bed and a bed alarm, and padded half rails times 2. The facility's records indicated Resident #8 had fallen on: 5/28/11- no injuries sustained. 6/1/11- required 6 sutures to left cheek after falling out of bed. 7/3/11- no injuries sustained. The nurses' notes revealed a certified nursing assistant (C.N.A.) called a nurse to the resident's room on 6/1/11 at 11:40 p.m. Staff discovered the resident sitting on the floor next to the bed with a 2 centimeter (cm) x 0.3 cm laceration to his/her left cheek. Staff notified the physician and family member of the resident's fall. Staff received orders to transfer the resident to the local hospital for evaluation and treatment. According to the note, an ambulance transferred the resident to the hospital at 12:15 a.m. on 6/2/11. The resident returned to the facility at 3:30 a.m. on 6/2/11 per the family member with no new orders, however, the resident had received 6 sutures that closed the left cheek laceration. According to the nurses' notes, the facility monitored the resident's neurological status through the night and the resident had no further negative outcomes from the fall on 6/1/11. According to a written statement by the administrator dated July 22, 2011, the resident now had a low bed (that could not be raised) with a lip mattress and a permanent 1/2 rail placed on the bed for positioning. The statement also revealed that the bed controls should be out of the resident's reach. Review of the facility incident report completed on 6/1/11 per Staff H, Licensed Practical Nurse (LPN) revealed that Resident #8 had bedrails ordered but that they were not in the proper position at the time of the fall. During an interview on 7/21/11 at 4:35 p.m., Resident #8's family member reported receiving a phone call at about 11:45 p.m. on 6/1/11 from Staff H to report the resident had fallen out of bed and needed care to the left cheek. The family member he/she went to the facility and found the resident lying on the floor, with his/her face bleeding and blood on his/her hands. The family member reported that the side rails were in a vertical position, instead of the proper horizontal position, and that the blue foam pads were not on the side rails, but lying on the floor nearby. The family member indicated he/she had mentioned to Staff H that the side rails were not in place and staff stated the 2nd shift CNAs had failed to affix the blue protective pads and properly position the side rails on the bed. The family member noted the resident's bed appeared in a higher than normal position when he/she entered the resident's room. The family member reported the resident's alarm had been in place and sounding which had alerted the staff. The family member stated staff had informed him/her that they weren't sure when the resident actually fell as they had been attending to a resident in another hall. During an interview on 7/21/11 at 5:50 p.m., Staff I, CNA, reported having worked the 2:00 p.m. to 10:00 p.m. shift on the east hall on 6/1/11. Staff I indicated he/she had completed the usual rounds at 9:00 p.m. or 9:15 p.m., had checked on Resident #8 and his/her roommate, and left the facility at 10:00 p.m.. Staff I revealed that when he/she last saw Resident #8, he/she laid in bed on his/her back, off to one side of the bed, with the 1/2 side rails in position. Staff I indicated he/she didn't recall the side rail pads as in place at the time, but wasn't 100% sure of that as he/she didn't usually care for the resident. Staff I remembered the controls to the bed were within the resident's reach on the 1/2 side rail, and that the bed was in the lowest position, about 12-18 inches off the floor. During an interview on 7/22/11 at 7:05 a.m., Staff J, CNA, reported working the 3rd shift a night in early June when he/she heard a bed alarm going off. Staff J had just come back into the general area at approximately 10:30 p.m. or 11:00 p.m.. Staff J tracked the sounding alarm to Resident #8's room. Staff J found the resident lying on his/her back on the floor and left side of the resident's face was bloody. Staff J immediately went into the hallway and hollered for help. Staff H, LPN, and Staff L, an orienting LPN, came to the room, asked what happened, and assessed the resident. Staff J recalled the resident's bed as in a high, but not really high position. The head of the bed was elevated, and the 2 1/2 side rails were not in the proper position. The blue pads were not on the side rails. Staff J noted the bed control had been hanging down on the side of the bed. Staff J reported being the first staff member to enter the room once the resident's alarm sounded. During an interview at 7/22/11 at 9:30 a.m., Staff H, LPN, reported worked the 3rd shift on 6/1/11. He/she recalled that around 11:30 p.m., he/she heard Staff J call for a nurse to come to Resident #8's room. Staff H noted the resident lying on his/her back on the floor and the bed was up against the north wall. The bed was not completely lowered to the floor. At the time of the fall, the resident's bed was positioned about 2-2 1/2 feet off the floor, both side rails were in the upright position (the bed rails hyper-extended towards the head of the bed, not in the proper position) with no pads on the rails. One pad was placed in the geri-chair and the other pad rested against the dresser. Staff H assessed the resident as having a laceration to the left cheek, and multiple bruising from the shoulder down the left side. After notifying the physician and family member of the resident's fall and condition, Staff H stayed with the resident and applied pressure to the resident's left cheek and assured the resident his/her family member was on his/her way. During an interview on 7/22/11 at 11:58 a.m., Staff K, CNA, reported working 4:00 p.m. to 8:00 p.m. on 6/1/11. Staff K reported that after giving the resident a bed bath, he/she lowered the bed to the lowest position, repositioned all padding to the side rails, gave the resident the call light, and ensured the side rails were in the down position and in place prior to leaving the facility. During an interview on 7/22/11 at 2:50 p.m., Staff M, Registered Nurse (RN), stated he/she was the 2nd shift nurse on the east hall on 6/1/11. Staff M recalled being in the resident's room at approximately 9:30 p.m. administering 10:00 p.m. medications. Staff M recalled the bed height at about knee level, and he/she stood 5 foot 1 inch. Staff M remembered the side rails in place so the resident could use them for assistance and that the blue rail cushions were in place. During an interview on 7/22/11 at 4:00 p. m., Staff L, LPN, reported working the 3rd shift on 6/1/11 and orienting with Staff H. Both Staff L and Staff H ran down the east hall to respond to a call for help from Staff J who was in Resident #8's room. Staff L recalled seeing the resident sitting on the floor near the bed and bleeding from the left cheekbone. Staff L noted the bed to be in a high position. Staff L, who stands approximately 5 foot 3 inches, indicated the top surface of the bed hit him/her waist high. Staff L indicated the resident's bed should always be in a low position; the bed wasn't in its highest position, but it was higher than it should have been. Staff L noted the side rails as not in the proper position and the blue side rail pads not attached to the rails. Staff L reported assessing the resident while Staff H called the doctor and the family member.