Every finding on record at Bishop Drumm Retirement Center

Based on clinical record review, resident interviews, staff interviews and policy review, the facility failed to provide adequate staffing to meet the needs of the residents in a timely manner when call lights were activated for 6 of 35 residents reviewed (Residents #8, #28, #39, #42, #52 and #99). The facility reported a census of 124 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] indicated that Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The Care Plan initiated 4/27/26 indicated that Resident #42 required assistance of one staff and a front wheeled walker to transfer and needed assistance with toileting. In an interview on 8/10/26 at 11:49 AM Resident #42 stated she was left in the bathroom for an hour about 2 weeks ago. In an interview on 8/13/26 at 10:45 AM Staff E, CMA stated he sometimes works the floor as well as passing medications. Sometimes they don't have enough staff due to call ins. The facility had a lot of call ins. In an interview on 8/13/26 at 11:10 AM Staff F, CNA stated that they do not have enough staff on weekends usually, due to call ins. Feels the schedule definitely has enough staff but it is hard to predict call ins. 2. The MDS assessment dated [DATE] documented Resident #52 had a BIMS score of 15, indicating intact cognition. Resident #52 had diagnoses to include osteoporosis, cerebral palsy, and anxiety. The MDS indicated the resident used a motorized wheelchair and was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Review of Resident #52 EMR revealed a Progress Note on 1/10/26 at 3:03 PM the resident had complained to the nurse regarding lack of staff and her call light not being answered promptly. During an interview on 8/10/26 at 3:06 PM Resident #52 stated she had voiced her concerns to staff regarding the long time it took to answer her call light and had asked for better call light response, but stated she felt no action had been taken. Resident #52 stated this morning, 8/10/26 she had put her call light on at 7:30 AM and it took staff 45 minutes to answer her call light at 8:15 a.m. She stated that she has put her call light on and the staff have come into her room stating they will be in shortly while turning it off and it takes them quite a while to return. She stated during the night shift it takes up to an hour to an hour and a half for her call light to be answered. She stated she had expressed the concern she had with the night shift staff and the response was We are working on it but that there had been no improvement. 3. The MDS assessment dated [DATE] documented Resident #99 had a BIMS score of 14, indicating intact cognition. Resident #99 had diagnoses to include amyotrophic lateral sclerosis [a progressive nervous system disease that destroys nerve cells in the brain and spinal cord, leading to the loss of muscle control and eventual paralysis], weakness, and dysphagia [difficulty swallowing]. The MDS indicated the resident used a wheelchair and a walker and was dependent on staff for eating, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. During an interview on 8/10/26 at 2:04 PM Resident #99 stated that during the night, his call light took quite a while to get answered. He stated it had taken an hour and a half for the staff to respond to his call light. When asked how often that had happened, he stated pretty much every night. Resident #99 stated he had let the staff know of his concern with answering the call light at night and stated the response he received was that they were going to work on it. During an interview on 8/13/26 at 12:52 PM, Staff P, CNA, stated that staffing was a sorrowful story as she worked on the facility's northeast nursing unit which had thirty residents and at times only 2 CNA staff on the day shift to care for those 30 residents. She stated she worked from 7 AM to 3 PM and that they were supposed to be staffed with 3 CNA staff for that shift. When asked how often the nursing unit had only 2 CNAs on the day shift, she stated every weekend and sometimes on the weekday. She stated when the nursing unit has 3 CNA staff, they are able to get more of the residents to the dining room for breakfast. When only 2 CNA staff are working not every resident was able to be gotten up for breakfast and they served more room trays. She stated there should be more CNA staff and that the northeast unit has no shower aide, so with 2 CNAs for the day shift, the resident showers had not been completed. During an interview on 8/13/26 at 1:01 PM with Staff O, RN, stated she typically worked on the northeast nursing unit and ideally there should be 3 CNAs on the day shift. She stated that at times they had to work with only 2 CNAs and that it happened a lot on the weekends. She stated it happened due to staff calling off for their scheduled shift. She stated the facility struggles with staffing on the weekends 4. The MDS assessment dated [DATE] documented Resident #8 had a BIMS score of 14, indicating intact cognition. Resident #8 had diagnoses to include stroke, Chronic Obstructive Pulmonary Disease(COPD) and hemiplegia (the total or severe loss of movement on one side of the body) affecting left nondominant side. The MDS indicated the resident used a wheelchair and was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. During an interview 8/10/26 at 3:13 PM, Resident #8 stated she has to wait for 30 minutes routinely for a call light response. She stated she has timed them, she stated it can be at any time of the day. She advised at times she has had a wet brief while waiting. 5. The MDS assessment dated [DATE] documented Resident #28 had a BIMS score of 14, indicating intact cognition. Resident #28 had diagnoses to include Diabetes Mellitus, stroke, lung disease, unsteadiness on feet and muscle weakness. The MDS indicated the resident used a walker and a wheelchair, and required substantial/maximal assistance from staff for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. The resident required partial/moderate assistance from staff for upper body dressing, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. During an interview 8/10/26 at 2:30 PM, Resident #28 stated she can wait 30 minutes up to an hour for a call light response. She stated it is not as often that she has to wait for an hour, but waiting 30 minutes happens more often. She has to use her call light for many of her care needs, such as toileting and a brief change. She stated she has sat in a wet brief for 30 minutes. Resident #28 stated waiting for a 30 minute, up to an hour call light response from staff can happen at any time of the day, and has occurred often. 6. The MDS assessment dated [DATE] documented Resident #39 had a BIMS score of 15, indicating intact cognition. Resident #39 had diagnoses to include anemia, coronary artery disease, Diabetes Mellitus, and lung disease. The MDS indicated the resident used a walked and a wheelchair, and required substantial/maximal assistance from staff for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying and lying to sitting on side of bed. The resident required partial/moderate assistance from staff for upper body dressing and to walk 10 feet, 50 feet and 150 feet. During an interview 8/10/26 at 11:35 AM, Resident #39 stated at least once a week he will wait up to an hour for a call light response. He will push his call light for staff to change his brief and assist him with getting into bed at night. He stated he required assistance with changing his brief throughout the day, and can wait for an hour for staff assistance, especially when staff are busy, which is in the morning, and at meal times. Resident #39 stated he has lain in bed with a wet brief for up to an hour. During an interview 8/13/26 at 11:25 AM, Staff L, CNA, stated she works in each hallway of the building, today she is working on the [NAME] unit. She stated staffing has fluctuated over the years, but currently they do not have enough staff hired, especially to cover the weekends. On the [NAME] side they need 6 CNA's during the day to meet resident needs. Recently management took a CNA off the floor and had them be a shower aide, so this leaves 5 CNA's on the floor and one doing showers. This at times does not feel like enough to meet the resident's needs. On the weekends, they can get down to just 3 CNA's for all of the [NAME] side when she has worked, which has 60 residents on average. On the weekends, they cannot answer all call lights within 15 minutes and residents are waiting 30 minutes or a little longer for a call light response, especially during busy times. Staff L stated longer call light response times take place on the weekends more than during the week. During an interview 8/13/26 at 11:35 AM, Staff M, CNA, stated she normally works on the [NAME] unit. She stated the facility has had struggles with staffing and having enough staff hired to meet the resident's needs. She stated on the [NAME] side they need 6 CNA's to be fully staffed and they do not always have 6 CNA's. Management changed it recently where one of the 6 CNAs is now a shower aide, so there are 5 CNA's on the floor. She stated on the weekends it is worse, they can get down to just 3 CNA's on the [NAME] side, this happens often. They cannot meet resident's needs as well with just 3 CNA's for over 60 residents. Residents wait routinely on the weekends 30 minutes for a call light response. She stated this is not how they want things to go with the residents, they want to answer call lights within 15 minutes. She stated CNA's try so hard to answer call lights in 15 minutes, but they cannot answer all of them within 15 minutes when they get down to just 3 CNA's. She stated residents have waited longer than 30 minutes for a call light response, especially during busy times. During an interview 8/13/26 at 11:45 AM, Staff N, CNA, she normally works on the [NAME] unit. She stated staffing has been an issue at the facility and they currently do not have enough staff hired to meet the resident's needs on the weekends. During the week, staffing is not as much of an issue. On the weekends, they can get down to 3 CNA's on the [NAME] side and when this happens they cannot answer all call lights within 15 minutes. Resident have waited 30 minutes or longer for a call light response. A review of the Resident Council Minutes dated June 2026 documented an issue of call light response time with a status update of slight improvement, still a problem on the night shift, this was under the old business review section. Documentation under the new business section included a current situation/concern of call light response time, night time is a problem. The outcome indicated not resolved, action needed. A review of the Resident Council Minutes dated July 2026 documented a current situation/concern of weekend slow call light response time. A review of the Resident Council Minutes dated August 2026 documented an issue of slow call lights on weekends with a status update of improving. During an interview 8/13/26 at 1:46 PM, the Administrator stated for the [NAME] unit, which typically has around 60 residents, to be fully staffed for CNA's they need 6 CNA's on the 7-3 shift (5 CNA's on rooms and 1 CNA for showers). For the 3pm to 11 pm shift they need 5 CNA's (the shower aide works a 7 am to 7 pm shift) and for the 11 pm to 7 am shift they need 4 CNA's. For the Central unit, which typically has around 30 residents, they need 3 CNA's for the 7 am to 3 pm shift, 3 CNA's for the 3 pm to 11 pm shift and 2 CNA's for the 11 pm to 7 am shift. The Northwest unit is the same as the Central unit. They Administrator stated they try to have 1 CNA for 10 residents. They also have 2 CMA's for the [NAME] unit and 1 CMA for the Central and Northwest unit. The CMA's can help with resident care needs and the expectation is that they help with call lights and have the nurse pass medications if they are short staffed with CNA's or if it is a busy time. They do have call ins or have staff who do not show up for work. They try to fill the spot. The Administrator acknowledged call light response times have been brought up as a concern in the last 3 resident council meetings by residents voicing a concern about call light response times. They are performing audits of call lights on different units and shifts. The Administrator feels there has been improvement, but acknowledged there are still some residents who state they wait longer than 15 minutes for a call light response. He stated there has been an improvement since Spring. They have received fewer call light complaints through grievances and the guardian angel problem. The Administrator stated an expectation call lights are answered within 15 minutes. Review of the facility provided staffing schedule, beginning on Sunday the 12th of July, 2026 through Saturday the 8th of August, revealed the following: a. Sunday 7/12/26: On the [NAME] unit, 1 CMA for the 6:30 am to 3:00 PM shift, 4 CNA's for the 7:00 am to 3:00 PM shift with no restorative/shower aide scheduled for the day. 4 CNA's scheduled for the 3:00 PM to 11:00 PM shift. b. Wednesday 7/15/26: On the [NAME] unit, 4 CNA's scheduled for the 3:00 PM to the 11:00 PM shift. c. Sunday 7/19/26: On the [NAME] unit, 5 CNA's scheduled for the 7:00 AM to 3:00 PM shift, with no restorative/shower aide scheduled for the day. 3 CNA's for the 3:00 PM to the 11:00 PM shift. d. On the [NAME] unit, 2 CNA's scheduled on the 11:00 PM to 7:00 AM shift on 7/13/26, 7/19/26, 7/20/26, 7/23/26, 7/25/26 and 8/5/26. e. Sunday 7/26/26: On the [NAME] unit, 4 CNA's scheduled for the 7:00 am to 3:00 PM shift with no restorative/shower aide scheduled for the day. f. Monday 7/27/26 and Tuesday 7/28/26: on the [NAME] unit, 4 CNA's scheduled for the 7:00 am to 3:00 PM shift. g. Thursday 7/30/26: On the [NAME] unit, 5 CNA's scheduled for the 7:00 am to 3:00 PM shift with no restorative/shower aide scheduled for the day and 3 CNA's scheduled for the 3:00 PM to 11:00 PM shift. i. Saturday 8/1/26: On the [NAME] unit, 4 CNA's scheduled for the 3:00 PM to 11:00 PM shift. j. Friday 8/7/26: On the [NAME] unit, 4 CNA's scheduled for the 7:00 AM to 3:00 PM shift. Review of the facility policy Call Lights: Accessibility and Timely Response, revised 12/1/25, documented all staff members who see or hear an activated call light are responsible for responding. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on clinical record review, family and staff interviews, and policy review, the facility failed to provide timely notification to the son (Durable Power-of-Attorney - DPOA) for 1 of 3 residents (#2) who repeatedly refused critical medication. The facility reported a census of 119 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of diabetes mellitus, liver cirrhosis, irregular heartbeat, and heart failure. It indicated she required maximal assistance with toileting, lower body dressing, and footwear, moderate assistance with bathing, supervision with upper body dressing and all forms of mobility except bed repositioning, and was independent with all other Activities of Daily Living (ADLs) and bed repositioning.The Electronic Health Record (EHR) included a physician's order dated 5/15/26 for 45 milliliters (mL) of lactulose oral solution by mouth every six (6) hours.The Care Plan dated 8/10/25 included liver cirrhosis and directed staff to give medications as ordered and to monitor/document effectiveness and side effects. It also included a medication focus and directed staff to keep her family informed of her condition.A Nurse's Note Progress Note dated 5/17/26 at 11:53 AM revealed the resident stated to the nurse that she didn't want the lactulose anymore due to the diarrhea and nausea. It also indicated the son was in the facility and stated his mother would be ok once her mental status improved and instructed staff to continue to give it to her.The Medication Administration Record (MAR) revealed the resident refused the lactulose on the following dates and times:5/17/26 - 6:00 PM5/18/26 - 00:00 AM, 6:00 AM5/19/26 - 00:00 AM, 6:00 AM, and no documentation at 6:00 PM5/20/26 - 00:00 AM, 12:00 PM5/21/26 - 00:00 AM, 6:00 PM5/22/26 - 00:00 AM, 6:00 AM, 12:00 PM, 6:00 PM5/23/26 - 00:00 AM, 6:00 AM, 6:00 PM5/24/26 - 00:00 AM, 6:00 AMA Alert Note dated 5/17/26 documented no bowel movement for 3 days. resident returned from hospital on 5/15/26. Resident reports having bowel movements.A Nurse's Note Progress Note dated 5/19/26 at 5:54 AM revealed the resident refused both the midnight and 6:00 AM doses of lactulose despite nursing encouragement. The Progress Note did not include documentation the son was notified of the aforementioned refused doses.A Nurse's Note Progress Note dated 5/20/26 at 1:29 PM revealed the resident's son was present at the resident's bedside but did not include notification the resident refused the prior eight (8) doses of lactulose.A Nurse's Note Progress Note dated 5/20/26 at 3:30 PM indicated the son was present during lunchtime and attempted to wake his mother. The Progress Note did not include documentation the resident's son was notified his mother refused the prior eight (8) doses of lactulose.A MDS Note Progress Note dated 5/22/26 at 2:47 PM revealed the resident's son (DPOA) visited frequently but did not include documentation the son was notified his mother refused the prior 13 doses of lactulose.A Nurse's Note Progress Note dated 5/22/26 at 4:55 PM revealed the resident was ordered a new antianxiety medication and indicated the son was made aware of it. The Progress Note did not include documentation the son was notified the resident refused the prior 13 doses of lactulose.On 6/08/26 at 12:29 PM, the resident's son stated the facility did not notify him that Resident #2 was repeatedly refusing the medication. He stated he had always been able to convince her to take it in the past and felt he would've been able to again had he been notified.Four (4) Progress Notes dated 5/22/26 at 8:19 PM, 5/23/26 at 1:58 AM, 5/24/26 at 1:06 PM, and 5/24/26 at 3:47 PM included new medication orders and revealed the son was notified of each order but did not include documentation he was notified of the previously refused lactulose doses.On 6/09/26 at 9:31 AM, Staff O, Licensed Practical Nurse (LPN) stated if a resident refused a significant medication, a progress note should be documented and the provider and family member should be notified as long as the POA was invoked.On 6/08/26 at 10:00 AM, Staff P, Registered Nurse (RN) stated if a resident refused a significant medication, a progress note should be documented and the family member and the provider, or hospice if the resident received hospice services, should be notified as long as the POA was invoked.On 6/10/26 at 1:59 PM, the Director of Nursing (DON) stated staff should've notified the DPOA after two (2) consecutive medication refusals.A policy titled Notification of Changes revised 4/29/26 indicated the facility must inform the resident, consult with the resident's physician and / or notify the resident's family member or legal representative when there is a change requiring such notification. It defines circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status and may include clinical complications. It also included circumstances that require a need to alter treatment.On 6/15/26 at 5:04 PM, the Administrator provided a Progress Notes report which included a Late Entry Progress Note documented sometime after 6/09/26 at 12:27 PM with a 5/17/26 effective date and timed for three (3) hours prior to the first lactulose refusal dated 5/17/26 at 6:00 PM that led to the deficiency.

Based on clinical record review, staff interview, and policy review, the facility failed to provide post-fall assessments and interventions for 2 of 3 residents (#2, #5). The facility reported a census of 119.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of diabetes mellitus, liver cirrhosis, irregular heartbeat, and heart failure. It indicated she required maximal assistance with toileting, lower body dressing, and footwear, moderate assistance with bathing, supervision with upper body dressing and all forms of mobility except bed repositioning, and was independent with all other Activities of Daily Living (ADLs) and bed repositioning.An Interdisciplinary Note Progress Note dated 8/29/25 at 11:52 AM revealed Resident #2 was found on the floor in her room on 8/22/25 at 4:30 PM. The Progress Note also referenced neurological checks.The Neurological assessment dated [DATE] revealed the last two (2) 4-hour neurological checks and the first 12-hour neurological check were not completed.A Nurse's Note Progress Note dated 2/07/26 at 11:11 AM revealed Resident #2 was observed sitting on the floor in her bedroom and told the nurse she fell walking to her recliner. It also indicated neurological checks were initiated.The Neurological assessment dated [DATE] revealed the last 4-hour neurological check and the two (2) 12-hour neurological checks were not completed.The Care Plan revised 8/25/25 did not include a neurological check focus or interventions.2. Resident #5's MDS assessment dated [DATE] identified a BIMS score of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, low blood pressure upon standing, a stroke, and non-Alzheimer's dementia. It indicated she was independent with walking 10 feet, required setup assistance with eating, oral hygiene, bed mobility, sit-to-lying, lying-to-sitting, sit-to-stand, chair-to-chair and toilet transfers, supervision with dressing, footwear, personal hygiene, and ambulating 50-feet or greater, and moderate assistance with toileting, shower transfers, and showering.A Nurse's Note Progress Note dated 2/08/26 at 12:17 PM revealed Resident #5 was found on the floor by staff. It indicated neurological checks were initiated.The Neurological assessment dated [DATE] revealed the fourth 4-hour neurological check was not completed.The Care Plan revised 4/15/26 did not include a neurological check focus or interventions.On 6/10/26 at 6:32 AM, Staff N, Registered Nurse (RN) stated neurological checks should be done every (1) hour x 4, every 4 hours x 5, and every 12 hours x 2 if a resident had an unwitnessed fall. She also stated there were no reasons neurological checks should not be completed unless the resident was sent to the hospital.On 6/10/26 at 7:34 AM, Staff O, Licensed Practical Nurse (LPN) stated neurological checks should be done every (1) hour x 4, every 4 hours x 5, and every 12 hours x 2 if a resident had an unwitnessed fall. She also stated neurological checks should resume if the resident is not admitted to the hospital.On 6/10/26 at 7:51 AM, Staff H, RN stated neurological checks should be done every (1) hour x 4, every 4 hours x 5, and every 12 hours x 2 if a resident had an unwitnessed fall. She also stated the neurological checks should be completed in their entirety unless the resident left the building.On 6/10/26 at 1:59 PM, the Director of Nursing (DON) stated neurological checks should be completed as indicated in the form directives.The facility did not have a policy specific for assessments & interventions directly related to nursing care.

Based on photographs, family and staff interviews, and policy review, the facility failed to provide adequate nursing supervision by not preventing a Certified Nurse Aide (CNA) from sleeping while on-duty. The facility reported a census of 119 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of diabetes mellitus, liver cirrhosis, irregular heartbeat, and heart failure. It indicated she required maximal assistance with toileting, lower body dressing, and footwear, moderate assistance with bathing, supervision with upper body dressing and all forms of mobility except bed repositioning, and was independent with all other Activities of Daily Living (ADLs) and bed repositioning.The Care Plan dated 8/10/25 included liver cirrhosis and directed staff to give medications as ordered and to monitor/document effectiveness and side effects. It also included a medication focus and directed staff to keep her family informed of her condition.On 6/08/26 at 12:29 PM, the resident's DPOA stated he was at the resident's bedside on 5/23/26 and activated the call light to get staff assistance for the resident. He stated after about an hour, he walked to the nurses' station at 11:49 PM and discovered the CNA asleep at the nurses' station. He also stated he did not want to touch the CNA because he didn't want her to misperceive his intentions so he called out to her several times but received no response. He stated she remained asleep for approximately 30 minutes before other staff arrived and woke her up.On 6/10/26 at 10:25 AM, the Director of Nursing (DON) stated the staff member was terminated for sleeping on duty.On 6/10/26 at 1:59 PM, the DON stated staff should not have slept at the nurses' station. She also stated that if the staff member was taking a break, she should've notified the nursing supervisor that she was going to take her break in the breakroom.On 6/10/26 at 8:54 AM, the Associate Executive Director revealed the facility did not have a policy specific to nursing supervision as it was part of the RN and LPN job descriptions.

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 119 residents. Findings included:On 6/10/26 at 6:03 AM, a medication cart was discovered unlocked with staff operating from another medication cart at the end of a resident hall but not in direct line-of-sight. The medication cart contained hydralazine (a potent blood pressure medication) and ondansetron (a nausea medication that can cause heart rhythm problems). There were no residents present.At 6:04 AM, Staff N, Registered Nurse (RN) approached the medication cart and stated she thought she locked it.On 6/10/26 at 1:16 PM, Staff I, Licensed Practical Nurse (LPN) stated medication carts should be locked when staff walk away. She also stated there is no situation that justifies leaving the medication cart unlocked and unattended.On 6/10/26 at 1:28 PM, Staff O, LPN stated the medication cart should be locked when staff leaves it unattended. She stated the only scenarios that would justify not locking the medication cart is If in an emergency situation such as a resident fall or screaming for help or an actual fire.On 6/10/26 at 1:59 PM, the Director of Nursing (DON) stated staff should lock the medication cart before they walk away.A policy titled Security of Medication Cart revised 1/03/22 revealed the nurse must secure the medication care during the medication pass to prevent unauthorized entry.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access by leaving 6 residents' information unsecured and visible when staff left a report sheet face-up on the medication cart when the staff walked away. The facility reported a census of 119 residents. Findings include: On 6/10/26 at 6:20 AM, a report sheet was observed on a medication cart with 6 residents' code statuses and functional abilities unsecured and visible. Staff N, RN stated she normally covers it but there were no residents in the hall and a resident called emergently, so she responded quickly. Her medication cart and laptop were noted to be locked and she stated she was able to lock those but not able to turn the report sheet over before responding to the resident. She stated she accepted responsibility for the report sheet being left exposed.On 6/10/26 at 1:16 PM, Staff I, LPN stated staff should put paper with someone's name or personal information on it in their pocket or position it so no one can see it.On 6/10/26 at 1:59 PM, the Director of Nursing (DON) stated resident information should be secured.A policy titled Confidentiality of Information and Personal Privacy revised 1/03/22 indicated the facility will safeguard the personal privacy and confidentiality of al resident personal and medical records.

Based on observations, staff interview, and policy review the facility failed to use infection prevention standards when staff failed to cover clean linen when transported in a resident hall and failed to don appropriate Personal Protective Equipment (PPE) when providing personal care for a resident on Enhance Barrier Precautions (EBP) (#8). The facility reported a census of 119 residents. Findings include:On 6/10/26 at 6:03 AM, Staff K, Certified Nurse Aide (CNA) transported an uncovered cart with linen down a resident hall.On 6/10/26 at 1:21 PM, Staff J, CNA stated clean linen being delivered to resident rooms should be in a bag.On 6/10/26 at 1:33 PM, Staff L, CNA stated staff should place clean linens in a bag when delivering them to multiple resident's rooms. 2. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of diabetes mellitus, a stroke, chronic obstructive pulmonary disease (COPD), and left-sided paralysis. It revealed the resident required setup assistance with eating and oral hygiene, moderate assistance with upper body dressing and bed repositioning, maximal assistance with personal hygiene, and was dependent for all other Activities of Daily Living (ADLs) and mobility.The Care Plan revised 11/11/25 included a break in skin integrity (wound) and indicated the resident required Enhanced Barrier Precautions with close contact cares related to presence of skin disruption.On 6/10/26 at 7:45 AM, Staff G, Certified Nurse Aide (CNA) entered Resident #8's room without putting on PPE.At 8:09 AM, Resident #8 and Staff G exited Resident #8's room. Staff G stated she dressed, toileted, groomed, and changed Resident #8's underwear with maximal assistance.At 8:16 AM, Staff H, Registered Nurse (RN) carried the trash out of the resident's bathroom. She confirmed she could not find a used PPE gown in the trash. At 8:28 AM, Staff G she was not sure if she used one but was unable to locate one in the resident's room. She stated night shift staff emptied the trash so whatever was in the trash, was what she put in it. She was unable to locate a used PPE gown in the resident's trash can.On 6/10/26 at 1:16 PM, Staff I, Licensed Practical Nurse (LPN) stated staff should wear the PPE including the gown when providing direct resident care for residents on EBP precautions.On 6/10/26 at 1:21 PM, Staff J, CNA stated staff should wear the PPE gown if the resident is on EBP and dressing, toileting, or cleaning is to occur.On 6/10/26 at 1:28 PM, Staff K, LPN stated staff should wear PPE when toileting, dressing, or cleaning a resident on EBP.The EBP sign on the resident's door titled Enhanced Barrier Precautions indicated:PROVIDERS AND STAFF MUST ALSO:Wear gloves and a gown for the following High-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use:central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressing3. On 6/10/26 at 6:03AM Staff pushed an uncovered linen cart down the central hallway.On 6/10/26 at 1:59 PM, the Director of Nursing (DON) stated staff should've covered the linen cart when transporting linen in the hall and staff should've worn PPE if resident contact was anticipated.A policy titled Handling Clean Linen revised 3/02/23 indicated clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport and unloading, such as: placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that can be secured to the cart.A policy titled Enhanced Barrier Precautions revised 9/16/25 identified Enhanced Barrier Precautions (EBP) as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. It defined high-contact resident care activities to include:DressingBathingTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline cathetersWound care: any skin opening requiring a dressing

Based on direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to maintain adequate staffing levels resulting in excessively long call-light times reported by residents, reports of staff members sleeping on the job, the North East Dining room being closed due to low staffing, and the Director of Nursing (DON) working the floor as a charge nurse when prohibited. The facility reported a census of 124. Findings include: The Minimum data sets (MDS) for the following residents documented their Brief Interview for Mental Status Scores (BIMS) scores, which indicated levels of cognition. Resident #1's MDS reported her BIMS score as 10, indicating moderate impairment. Resident #2's MDS reported her BIMS score as 00, indicating the test could not be completed. Resident #3's MDS reported her BIMS score as 15, indicating fully intact cognition. Resident #4's MDS reported her BIMS score as 15, indicating fully intact cognition. Resident #7's MDS reported her BIMS score as 15, indicating fully intact cognition. Resident #8's MDS reported her BIMS score as 12, indicating moderate impairment. Resident #9's MDS reported her BIMS score as 15, indicating fully intact cognition. Resident #10's MDS reported her BIMS score as 15, indicating fully intact cognition. A continuous direct observation on 02/09/2026 from 07:45 PM until 09:03 PM recorded the following. At 07:50 PM room [ROOM NUMBER]'s call light was turned on. At 08:01 PM room [ROOM NUMBER]'s call light was answered with staff responding for seconds before leaving the room. At 08:08 PM room [ROOM NUMBER]'s call light was turned on. At 08:17 PM room [ROOM NUMBER]'s call light was answered ,with staff again responding for seconds before leaving the room. At 08:26 PM room [ROOM NUMBER]'s call light was turned on. At 08:30 PM room [ROOM NUMBER]'s call light was answered, with staff again responding for seconds before leaving the room. At 08:42 PM room [ROOM NUMBER]'s call light was turned on. At 08:43 PM room [ROOM NUMBER]'s call light was answered, with staff responding for approximately one second before leaving the room. In an interview on 02/09/2026 at 08:54 PM with Resident #10, who resided in room [ROOM NUMBER], she was asked directly if the staff members had addressed her call light request. She stated they had not, she was waiting and had been turning on her call light for approximately one hour without them answering her questions or telling her why she could not get help. She stated she was waiting to see if they would be able to do a bath or bed bath as she had not been given one tonight despite her requesting one. She reported staff members entering her room just to turn her call light off without a word. She expressed frustration. Review of staffing files dated from 01/10/2026 through 02/09/2026, revealed the Director of Nursing (DON) worked the floor on two occasions, on 01/11/2026 and 01/21/2026. The DON is prohibited from serving as a charge nurse when the average daily census exceeds 60 residents. Review of the Resident Council Minutes from 10/01/2026 through 02/04/2026 identified issues related to staff members not providing showers/baths as scheduled, not providing fresh water, staff members being on their cell phones while on the job, and long call light times as repeated issues during the lookback period. In an interview with Resident #1 on 02/09/2026 at 01:08 PM she stated call light times are terrible in the facility, frequently over 30 minutes, and she identified nights as the worst period of time to get help. In an interview on 02/10/2026 at 11:30 AM with Resident #4, she stated call light times have been long, and identified the weekends and nights as periods when call light times were the worst. When asked how long call lights can take she stated they can take over an hour recently. In an interview on 02/10/2026 at 11:36 AM with Resident #2, she reported she can expect to wait over an hour for call lights, and also identified the nights and weekends as the worst, she stated this was a frequent every day occurrence. In an interview on 02/10/2026 at 02:34 PM with Resident #3 and Resident #7, who wished to speak to me together, they stated they have directly seen staff members sleeping on the job. Resident #7 reported seeing staff members sleeping as recently as the past weekend. She provided the exact time and location the Staff member was alleged to be sleeping. Resident #3 and Resident #7 both stated call light times and bad, and agreed call light times during the nights and weekends can take hours, with Resident #7 noting it took three hours for them to assist her in changing a soiled incontinence brief this past weekend. Resident #7 stated she had brought this up to the administration a number of times, both privately and through the Resident Council. Resident #3 agreed she had also brought it up a number of times to facility management. Both residents wished the surveyor to know they do not feel the facility has an adequate number of staff, and report the issues with call lights is almost daily. In an interview on 02/10/2026 at 03:39 PM with Resident #9, she stated the staffing in the facility is the biggest issue in the facility. She stated this past weekend, the weekend identified as 02/07/2026 and 02/08/2026, she waited an hour and a half for assistance changing a soiled incontinence brief. She stated they also closed the North East Dining hall due to lack of staff and forced all residents to eat in their rooms. She stated she is very vocal about this significant issue, and has reported it to a number of management staff but feels nothing has been done to improve the situation. She expressed frustration over having to wait an hour and a half or assistance in being changed after having soiled herself, and stated it made her feel terrible. In an interview on 02/10/2026 at 03:47 PM with Resident #8, she stated call lights are terrible in the facility, and identified nights and weekends as the hardest time to get help. She stated it took over two hours this past weekend, identified as 02/07-02/08, to get help getting off of the toilet. She stated they also closed the NE dining all this weekend and forced all residents to eat in their rooms. She reported catching a staff member sleeping this weekend, and identified the same location and time as another resident did. In an interview on 02/11/2026 at 11:40 AM with Staff S, Certified Nurse Aide (CNA), she stated the facility does not have enough staff to get her job done, and stated it was taking sometimes hours to get residents the assistance they requested. In an interview on 02/11/2026 at 02:00 PM with Staff N, she stated the facility doesn't have adequate staffing and she has personally seen staff members sleeping on the job about a month ago. She stated she had brought this up to the DON. In an interview on 02/12/2026 at 08:36 AM with Staff M, Registered Nurse (RN), she stated the overnight and early morning shifts struggle for staff members. She feels sometimes she has enough to do her job, but if someone calls in there might not be any relief and people call in frequently. She stated the weekends are the worst for staffing. She stated she had not seen fellow staff members sleeping, but stated she was aware of at least one staff member who had gotten in trouble for sleeping on the job. She stated the facility does not fire people if they are caught sleeping on the job. In an interview on 02/12/2026 at 09:12 AM with Staff P, RN, she stated she had not seen or heard of other staff members sleeping on the job. She stated she does know of staff members who go on break and sleep at the nurses station, but noted they had a meeting where they were told they should not do this. She stated her job can be hard due to call ins, and feels that it happens at least a few times a week when they are working short staffed. She also stated the DON had been working the floor in an attempt to cover open shifts when there was no one else available. In an interview on 02/12/2026 at 11:58 AM with Staff L, CNA, she stated she has personally seen staff members sleeping on the job before and noted she reported it to the DON. She stated her job can be hard with call ins, which can be frequent, but noted the DON had been working the floor to try and cover open shifts before she went on leave. In an interview on 02/12/2026 at 12:07 PM with Staff T, CNA, she stated she does not like picking up shifts on nights or weekends because they are always short handed and it makes the job too hard. She stated she knows the DON has been working the floor to try and cover open shifts, usually on at night or on the weekends. She stated that while she has not directly seen staff members sleeping while on the floor, she knows it does happen at night and on the weekends, and reiterated it is why she doesn't like picking up those shifts. She stated she believes this is happening because staff members are working frequent back-to-back shifts in an attempt to cover open shifts. In an interview on 02/12/2026 at 03:16 PM with Staff U, Occupational Therapist Registered and Licensed (OTR/L), she stated that while she has not seen staff members sleeping on the job, residents have told her they have caught staff members sleeping on the job. She stated the last a resident had approached her about this issue was a week or two ago, and she encouraged the resident to report this to the DON and Long Term Care Ombudsman (LTCO). In an interview on 02/12/2026 at 03:40 PM with Staff V, Maintenance Director, he stated that while he had not directly seen staff members sleeping on the job residents had reported night shift staff sleeping on the job. He encouraged them to report this to the DON. In an interview on 02/12/2026 at 04:36 PM with Staff D, RN, she stated that while she has not directly seen staff members sleeping on the job she has had reports from residents about staff members sleeping on the job. She also noted she has seen staff members at the nursing station with their eyes closed who appeared to startle when a noise was made, but she was unsure if they were asleep. In an interview on 02/12/2026 at 04:43 PM with Staff W, RN, he stated that while he has not seen staff members sleeping on the job, he does work short handed once or twice a week on his shift. He notes it makes his job harder and slows call lights. He stated weekends are the worst for being short handed. In an interview on 02/11/2026 at 02:59 PM with the Assistant Director of Nursing (ADON), she stated staff members were prohibited from sleeping while on the job, and noted it was her expectation for call lights to be answered within 15 minutes. Review of a facility policy titled Rules of Conduct identifies Sleeping or giving the appearance of sleeping on the job during working hours as Unsatisfactory Behaviors/Terminations in the code of conduct rules. There was no policy available for the Director of Nursing working the floor.

Based on clinical record review, resident and staff interview, and facility policy review, the facility failed to prevent the Director of Nursing (DON) from serving as a charge nurse when a facilities daily average census exceeds 60 residents. The facility reported a census of 124. Findings Include: In an interview on 02/12/2026 at 09:12 AM with Staff P, Registered Nurse (RN), she stated the facility is under staffed and the DON has been working nights and overnight shifts to help cover staffing. She confirmed the DON was serving in her role as a charge nurse. In an interview on 02/12/2026 at 9:36 AM with Staff Q, RN, she confirmed the DON has been working as a charge nurse alongside the Assistant Executive Director and other nursing leadership to cover staffing shortfalls in the facility. She stated the DON is currently on maternity leave but she knew the DON was working the floor of the facility the week she left for maternity leave. In an interview on 02/12/2026 at 11:39 AM with Staff R, Certified Nurse Aide (CNA), she confirmed the DON has been working the floor as a nurse leading up to her maternity leave due to staffing shortages. In an interview on 02/12/2026 at 11:58 AM with Staff L, CNA, she confirmed what other staff members had stated, the DON was working the floor as nurse leadership to cover staffing shortages. She stated it last happened in January. Review of the last 30 days of staffing logs documented the DON worked as a floor nurse on 01/11/2026 and 01/21/2026. In an interview on 02/12/2026 at 12:16 PM with the Assistant Executive Director, she confirmed the DON had been serving as a charge nurse on the floor and stated she was aware it was prohibited. She clarified that she was new to the role and was not aware it had been an issue until it was brought up over the course of the survey. A policy was unavailable for review.

Based on review of The State Survey Agency website found at https://dia-hfd.iowa.gov/, staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. This resulted in the facility receiving an Insufficient Nursing Staff deficiency for the fifth time in a two-year period. The facility reported a census of 124 residents.Findings Include:Review of the State Agency's public website https://dia-hfd.iowa.gov/ contained the following certification actions during the following surveys: Ending on 09/17/2025 resulted in a deficiency cited related to staffing. Ending on 07/21/2025 resulted in a deficiency cited related to staffing. Ending on 04/03/2025 resulted in a deficiency cited related to staffing. Ending on 06/27/2024 resulted in a deficiency cited related to staffing. Review of the Quality Assurance and Performance Improvement (QAPI) Plan provided by the facility, with a creation date of 02/26/2025, identifies how the QAPI team will identify issues, and specifically identifies staff retention as a QAPI improvement focus. In an interview on 2/18/26 at 10:14 AM with the Executive Direct and Assistant Executive Director, they stated the QAPI plan did not currently have a Performance Improvement Plan (PIP) related to staffing.

Based on observations, staff interview, and policy review the facility failed to use infection prevention standards to secure a resident's indwelling catheter tubing (#4), failed to maintain equipment in a manner to prevent cross-contamination, and failed to don appropriate Personal Protective Equipment (PPE) when providing wound care for a resident on Enhance Barrier Precautions (EBP) (#12). The facility reported a census of 124 residents. Findings include: On 2/16/26 at 9:47 AM, Resident #4's indwelling catheter drainage bag was observed hanging on a wall hook with the tubing lying across the top of her trashcan.Resident #4's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of chronic kidney disease, neurogenic bladder (bladder dysfunction caused by nerve damage), and paraplegia. It revealed the resident required maximal assistance with eating, oral and personal hygiene, upper body dressing, and bed mobility and was dependent for all other Activities of Daily Living (ADLs) and other mobility. It also revealed the resident had an indwelling catheter in the 7-day look-back period.The Care Plan 1/13/26 directed staff to check the tubing for kinks as needed and keep the bag lower than the resident's bladder.A Nurse's Note progress note dated 2/14/26 at 11:17 PM indicated the resident had bilateral stent (tube used to keep the tubes leading from the kidney to the bladder open) exchange on 2/13/26.On 2/17/26 at 8:33 AM, Resident #4's indwelling catheter drainage bag was observed again hanging on a wall hook with the tubing lying across the top of her trashcan.On 2/17/26 at 8:51 AM, Staff F, Certified Nurse Aide (CNA) stated it is not ok to use a resident's trashcan to keep the indwelling catheter tubing off the floor.On 2/17/26 at 9:03 AM, Staff G, Certified Medication Aide (CMA) stated it is ok to use a resident's trashcan to keep the indwelling catheter tubing off the floor.On 2/17/26 at 9:06 AM, Staff H, CNA stated it is not ok to use a resident's trashcan to keep the indwelling catheter tubing off the floor. 2. On 2/17/26 at 8:40 AM, Staff I, Housekeeper (Hskg) was observed using a housekeeping cart with silver duct tape lining both sides of the top rolling door and the back access door. The tape was not completely affixed to the cart and had multiple areas where the adhesive was exposed and able to harbor bacteria.On 2/17/26 at 8:43 AM, Staff I stated the cart was new but broke about a month prior.On 2/17/26 at 2:15 PM, Staff J, Environmental Services Director (Evs Dir) stated housekeeping staff report repair needs to him and equipment is replaced when it is damaged. He admitted he was aware of the cart with tape but was not aware it was used for repair purposes. 3. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 06 out of 15 which indicated severely impaired cognition. It included diagnoses of chronic kidney disease, non-Alzheimer's dementia, heart failure, diabetes mellitus, and a right foot chronic ulcer. It revealed the resident required setup assistance with eating and oral hygiene, maximal assistance with upper body dressing and personal hygiene, and was dependent for all other ADLs and mobility. It also revealed the resident had diabetic and surgical wounds in the 7-day look-back period.A physician's order dated 6/06/24 indicated enhanced barrier precautions: PPE required for high resident contact care activities. indication: wounds, indwelling medical devices, infection, and/or MDRO (multidrug resistant organism) status.The Care Plan dated 6/20/24 indicated the resident had actual skin impairment and required enhanced barrier precautions (EBP) with close contact cares related to presence of wounds.On 2/17/26 at 10:19 AM, Staff K, (in-home nurse) entered Resident #12's room, removed the resident's right foot dressings, and took pictures of it. He was not wearing PPE. Staff L, CNA notified asked Staff I, who was in the resident's room entrance, to tell Staff K to put on a PPE gown. Staff K declined. Staff K was also observed holding Resident #12's cup with the same gloved hands so she could have a something to drink. On 2/17/26 at 10:26 AM, Staff K confirmed he removed Resident #12's right foot wound to obtain pictures for the resident's medical record. He stated he received Infection Prevention education and noticed the resident was on EBP. He also stated he was not familiar with EBP but admitted he did not refer to the EBP sign that was posted at the resident's door. He stated he refused to wear a PPE gown when Staff I asked because he was already finished in the resident's room.The EBP sign on the resident's door titled Enhanced Barrier Precautions indicated:PROVIDERS AND STAFF MUST ALSO:Wear gloves and a gown for the following High-Contact Resident Care Activities. DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use:central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressingOn 2/17/26 at 10:35 AM, Staff M stated she asked Staff L to have Staff K put on a PPE gown because the resident was on EBP which required a gown and gloves because the resident had invasive devices and a wound that required a dressing.On 2/17/26 at 3:17 PM, the Infection Preventionist (IP) stated it was absolutely not ok to use a trashcan to support any component of an indwelling catheter. She also stated duct tape is absolutely not ok to be used on equipment, especially direct resident care equipment. She further stated support and contract staff are expected to comply with EBP precautions.A policy titled Infection Prevention and Control Program effective 10/07/25 indicated the facility has established and maintains an infection prevention and control program designed toprovide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.A policy titled Enhanced Barrier Precautions effective 9/18/25 indicated an order for enhanced barrier precautions will be obtained for residents with any of the following:Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.)

Based on direct observation, clinical record review, resident and staff interview the facility failed to provide dignified grooming for residents who requested it in 1 of 15 residents surveyed (Resident #2). The facility reported a census of 124. Findings include: The quarterly Minimum Data Set (MDS) for resident #2, dated 11/27/2025, documented the following relevant diagnoses: Coronary artery disease, Diabetes Mellitus (diabetes), anxiety disorder, depression, unspecified fracture of left hip, generalized muscle weakness. The MDS also documented that the resident required assistance with personal cares, and specified the resident required substantial or maximal assistance with personal hygiene. The Care Plan for Resident #2, last revised on 02/13/2026, documented the resident requires assistance with personal cares and discussed the resident's preference for her hair to remain long, brushed daily, and that she requested to be shaved daily. This was initiated in the care plan on 02/22/2025. In a direct observation of Resident #2 on 02/10/2026 at 11:36 AM Resident #2 was noted to have a long, substantial beard and had matted unwashed hair. On 02/10/2026 at 11:36 AM Resident #2 reported she had requested that staff members to help her shave every time they come to offer her a shower. She admitted she prefers bed baths, but the staff members tell her they cannot shave her because she is diabetic and she had to be shaved by a barber or nurse because of her diabetic status. The resident reported this had increased her feelings of depression, because she was not getting help caring for herself when she asks for it. A review of the Kardex entry for personal hygiene between the dates of 01/13/2026 and 02/11/2026 failed to document a single refusal for showers or personal cares. The Kardex included documentation that bathing had occurred on every single day during the look back period and documented the resident required extensive assistance with personal hygiene tasks on more than half of all the opportunities for personal hygiene. A review of the Kardex entry for bathing between the dates of 01/13/2026 and 02/11/2026 failed to document a single resident refused bathing opportunity. On 02/11/2026 at 02:00 PM with Staff N, facility barber reported she was told by other residents in the facility that staff members have refused to trim their beards or cut facial hair. She believed CNAs and shower aides could cut hair at a residents request but did not believe this is getting regularly done due to staffing shortages. On 02/12/2026 at 08:36 AM Staff M, Registered Nurse (RN), reportedly confirmed Resident #2 had been asking to ger her facial hair removed for several days, but she worked nights, and was unable to help with the request. She was unsure if a certified nurses aide (CNA) could cut the facial hair of a resident with diabetes. In an interview on 02/12/2026 at 09:46 AM with Staff O, CNA, she stated she was familiar with Resident #2 and confirmed she preferred to be clean shaven. She stated the resident moved to a hall and she no longer worked directly with her but at her request kept her shaved. She did not believe Resident #2 had ever refused to be shaved while she was directly working with her, but noted refusals would be noted in the Kardex or Pocket Plan of Care in the electronic health record (EHR). In an interview on 02/11/2026 at 02:59 PM with the Assistant Director of Nursing (ADON), she confirmed shaving is provided by the facility for residents who request to be shaved and confirmed it was her expectation that staff members provide this service when requested by residents. Review of a facility provided document titled Shaving the Resident, with a last approved date of 05/22/2025, notes proper procedure for shaving a resident includes documenting any refusals with nurse supervisor and documenting it in the resident's medical record.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide timely physician and family notification for 1 of 1 resident (#8) who experienced a change in condition or treatment. The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility.The Care Plan dated 6/18/25 directed staff to involve her family with decisions and medical updates.On 2/16/26 a continuous observation starting at 11:48 AM contained the following; Staff A, Licensed Practical Nurse (LPN) attempted to wake Resident #8 while seated in her wheelchair at the dining room table. Resident #8 was lethargic and Staff A had to grab or tap Resident #8's left arm multiple times to get Resident #8 to respond. Staff A transported Resident #8 in her wheelchair to an area in the hall that provided more sunlight. Staff A asked Staff B, Certified Medication Aide (CMA) to get Resident #8's vital signs. Staff B informed Staff A that Resident #8's temperature was 100.4 degrees Fahrenheit ( F). Staff A instructed Staff B to give Resident #8 Tylenol. Staff B attempted to give Resident #8 two (2) Tylenol tablets but the resident pulled her head back both times and said no! Staff A instructed Staff C, Certified Nurse Aide (CNA), to transport Resident #8 back to her room.At 12:19 PM, Staff A went to the nurses' station, got her purse, stopped to assist another resident in her room, then left the unit for lunch. She returned to the unit from lunch at 1:25 PM.A Nurse's Note progress note dated 2/16/26 at 12:05 PM documented the res <resident> is semi responsive, responds to touch and voice otherwise not. has temp of 100.4 refuses to take Tylenol.The following multiple interviews conducted on 2/16/2026 revealed;At 1:51 PM, Staff D, Registered Nurse (RN) stated a temperature of 100.4 F is significant and added if a resident, who is typically responsive, has to be touched or spoken to loudly to elicit a response, and has a temperature of 100.4 F, it is a change in condition and the provider should be notified. She stated the provider notification should be documented on the electronic change in condition form and in the nursing progress notes.At 2:01 PM, Staff E, LPN stated 100.4 F is a significant temperature. She also confirmed if a resident, who is typically responsive, has to be touched or spoken to loudly to get a response, and has a temperature of 100.4 F, it is a change in condition and the provider should be notified. She also stated the provider communication would be documented in the progress notes.At 2:30 PM, Staff A confirmed Resident #8's event constituted a change-of-condition and stated the change-of-condition form should've been completed at that time. She also admitted she contacted the resident's brother and the provider after she returned to the unit from lunch. She further stated she was not aware of a facility policy specifying a family or provider notification timeframe.An eINTERACT Change in Condition Evaluation dated 2/16/26 at 2:53 PM indicated Staff A documented a family and provider notification at 1:00 PM.On 2/17/26 at 2:30 PM, the Assistant Director of Nursing (ADON) stated anytime there is a change in condition or vital signs outside of parameters, staff should escalate it through an eINTERACT Change in Condition and notify the provider. She also stated the staff member should not have gone to lunch without communicating it to another nurse prior.A policy titled Notification of Changes effective 7/25/25 indicated the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. It identified circumstances requiring notification include a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide assessment and interventions for 1 of 1 resident (#8) who experienced an elevated temperature and a change in mental condition. The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility.The Care Plan revised 1/20/26 indicated the resident had memory problems but did not include staff directives for a mental change in condition.On 2/16/26 a continuous observation which started at 11:48 AM revealed the following, Staff A, Licensed Practical Nurse (LPN) attempted to wake Resident #8 while seated in her wheelchair at the dining room table. Resident #8 was lethargic and Staff A had to grab or tap Resident #8's left arm multiple times to get Resident #8 to respond. Staff A transported Resident #8 in her wheelchair to an area in the hall that provided more sunlight. Staff A asked Staff B, Certified Medication Aide (CMA) to get Resident #8's vital signs. Staff B informed Staff A that Resident #8's temperature was 100.4 degrees Fahrenheit ( F). Staff A instructed Staff B to give Resident #8 Tylenol. Staff B attempted to give Resident #8 two (2) Tylenol tablets but the resident pulled her head back both times and said no! Staff A instructed Staff C, Certified Nurse Aide (CNA), to transport Resident #8 back to her room.At 12:19 PM, Staff A went to the nurses' station, got her purse, stopped to assist another resident in her room, then left the unit for lunch. She returned to the unit from lunch at 1:25 PM.A Nurse's Note progress note dated 2/16/26 at 12:05 PM documented the res <resident> is semi responsive, responds to touch and voice otherwise not. has temp of 100.4 refuses to take Tylenol.Interviews conducted on 2/16/26 revealed the following;a. At 1:51 PM, Staff D, Registered Nurse (RN) stated a temperature of 100.4 F is significant and added if the resident refused Tylenol, she would take the resident's temperature at least hourly. She also stated she would notify the provider and document it in the nurse's progress notes.b. At 2:01 PM, Staff E, LPN stated 100.4 F is a significant temperature. She also confirmed if a resident, who is typically responsive, has to be touched or spoken to loudly to get a response, and has a temperature of 100.4 F, it is a change in condition and the provider should be contacted. She also stated the provider communication would be documented in the progress notes.c. At 2:30 PM, Staff A confirmed Resident #8's event constituted a change-of-condition. She admitted she did not contact the provider until she returned from lunch at 1:25 PM. She stated her assessments were documented in the Electronic Health Record (EHR) on a Change in Condition form and the nurse's progress notes.An eINTERACT Change in Condition Evaluation dated 2/16/26 at 2:53 PM indicated Staff A documented Resident #8's assessment but did not include any interventions.The Progress Notes did not include any follow-up assessments or interventions for Resident #8's change in condition.On 2/17/26 at 2:30 PM, the Assistant Director of Nursing (ADON) stated anytime there is a change in condition or vital signs outside of parameters, staff should escalate it through an eINTERACT Change in Condition and notify the provider. She also stated the staff member should not have gone to lunch without communicating it to another nurse prior.The facility did not have a policy that directly addressed assessment and interventions of standard nursing practice.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to apply foot pedals to a resident's wheelchair during transport for 1 of 1 resident (#8). The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility. It also indicated the resident used a wheelchair and walker in the 7-day look-back period.The Care Plan revised 1/20/26 did not indicate the resident was non-compliant with foot pedal use on her wheelchair.On 2/16/26 at 11:48 AM, Staff A, Licensed Practical Nurse (LPN) attempted to wake Resident #8 while seated in her wheelchair at the dining room table. Resident #8 was lethargic and Staff A had to grab or tap Resident #8's left arm multiple times to get Resident #8 to respond. Staff A transported Resident #8 in her wheelchair without accompanying foot pedals to an area in the hall that provided more sunlight.At 1:51 PM, Staff D, Registered Nurse (RN) stated it is never ok to transport a resident in a wheelchair without foot pedals.At 2:01 PM, Staff E, LPN stated it is never ok to transport a resident in a wheelchair without foot pedals and added the resident's feet must be on the foot pedals during transport.At 2:30 PM, Staff A confirmed staff should ensure foot pedals are applied to a resident's wheelchair during transport and admitted she should've had Resident #8's foot pedals on her wheelchair when she transported her from the dining room.On 2/17/26 at 2:30 PM, the Assistant Director of Nursing (ADON) stated staff should always have foot pedals on a wheelchair during transport unless the resident is propelling themselves.The facility did not have a policy that included staff directives for transporting residents in wheelchairs.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to correctly administer insulin by failing to prime a newly attached insulin pen needle before administering it for 1 of 3 residents (#14) and verifying documented open date for 2 of 3 residents (#14, #15), and attempted to administer a medication without an order for 1 of 3 residents (#8). The facility reported a census of 124 residents.Findings include:Resident #15's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of chronic kidney disease and diabetes mellitus. It indicated she required setup assistance with eating, moderate assistance with oral hygiene, was dependent with transfer mobility, and required maximal assistance with all other Activities of Daily Living (ADLs) and mobility. It also indicated she received insulin injections 7 days within the 7-day look-back period.The Electronic Health Record (EHR) included a Clinical Physician's Order dated [DATE] for fast-acting insulin with a FlexPen three (3) times per day with meals.The Care Plan revised [DATE] directed staff to administer diabetes medication as ordered by doctor.A continuous medication observation on [DATE] at 11:23 AM revealed Staff A, Licensed Practical Nurse (LPN) prepared an insulin FlexPen to administer Resident #15's insulin. She removed the insulin pen from the medication cart, placed a needle on the tip of the FlexPen, swabbed the resident's left, lower abdomen, placed the needle tip against the abdomen, and injected the insulin. She did not prime the needle to remove the air and ensure the resident received the full dose of insulin.At 11:31 AM, Staff A stated the insulin pen was good for 30 days after the date opened and confirmed there was no date opened documented date on the FlexPen. She also stated she forgot to prime the pen and should not have used the insulin pen since the date opened was not documented. She admitted she did not notice the date opened label was blank prior to administering the insulin. 2. Resident #14's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of chronic kidney disease, diabetes mellitus, heart failure, and morbid obesity. It indicated she was independent with eating, required setup assistance with oral hygiene, and maximal assistance with all other Activities of Daily Living (ADLs) and mobility. It also indicated she received insulin injections 7 days within the 7-day look-back period.The EHR included a physician's order dated [DATE] for fast-acting insulin, with a FlexPen three (3) times per day with meals.A continuous medication observation on [DATE] at 11:40 AM revealed Staff A prepared an insulin FlexPen to administer Resident #14's insulin. She removed the insulin pen from the medication cart, placed a needle on the tip of the FlexPen, primed the needle with 2 units of insulin from the FlexPen, swabbed the resident's right, lower abdomen, placed the needle tip against the abdomen, and injected the insulin.At 11:43 AM, Staff A stated she did not know when the insulin pen was opened because it wasn't dated. She admitted she did not check the date opened label before administering the insulin. 3. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility.The Care Plan revised [DATE] included a chronic pain focus area and directed staff to administer pain medication as ordered. Monitor for pain on scale 0-10. Notify MD if medication and non-medication intervention ineffective. The EHR included a Clinical Physician's Order dated [DATE] for Acetaminophen 650 mg every six (6) hours as needed for mild pain. The order was noted to be on hold status. It did not include directives for a fever.On [DATE] at 11:48 AM, Staff A attempted to wake Resident #8 while seated in her wheelchair at the dining room table. Resident #8 was lethargic and Staff A had to grab or tap Resident #8's left arm multiple times to get Resident #8 to respond. Staff A transported Resident #8 in her wheelchair to an area in the hall that provided more sunlight. Staff A asked Staff B, Certified Medication Aide (CMA) to get Resident #8's vital signs. Staff B informed Staff A that Resident #8's temperature was 100.4 degrees Fahrenheit ( F). Staff A instructed Staff B to give Resident #8 acetaminophen. Staff B attempted to give Resident #8 two (2) acetaminophen tablets but the resident pulled her head back both times and said no! Staff B stopped trying to administer the medication.On [DATE] at 1:51 PM, Staff C, Registered Nurse (RN) stated the date opened should be checked prior to administering insulin and should not be used if no date opened is documented. She also stated if she had an order for acetaminophen for a resident's pain, she would use it for a resident's fever also.At 2:01 PM, Staff E, LPN, stated the date opened should be checked prior to using insulin. She also stated staff should discard the insulin if the date opened is not documented and get a new one. She further stated she would contact the provider for an order to use the acetaminophen for the resident's fever if the original order did not include provider's approval.At 2:30 PM, Staff A stated it was not ok to use a medication for a reason not included on the physician's order. She admitted she did not know the acetaminophen order did not include use for a fever.On [DATE] at 2:30 PM, the Director of Nursing (DON) stated all medications opened should have a date on it and staff should be checking for a date prior to use. She also stated staff should correctly assemble the insulin pen and prime the needle before administering insulin. She further stated staff should've made sure there was an order for acetaminophen for a fever.A policy titled Medication Administration effective [DATE] indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It also directed staff to identify the expiration date and to notify the nurse manager if the medication was expired.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide an accurate health record for a change in condition for 1 of 1 resident (#8). The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility. The Care Plan dated 6/18/25 directed staff to involve her family with decisions and medical updates. On 2/16/26 a continuous observation starting at 11:48 AM revealed the following, Staff A, Licensed Practical Nurse (LPN) attempted to wake Resident #8 while seated in her wheelchair at the dining room table. Resident #8 was lethargic and Staff A had to grab or tap Resident #8's left arm multiple times to get Resident #8 to respond. Staff A transported Resident #8 in her wheelchair to an area in the hall that provided more sunlight. Staff A asked Staff B, Certified Medication Aide (CMA) to get Resident #8's vital signs. Staff B informed Staff A that Resident #8's temperature was 100.4 degrees Fahrenheit ( F). Staff A instructed Staff B to give Resident #8 Tylenol. Staff B attempted to give Resident #8 two (2) Tylenol tablets but the resident pulled her head back both times and said no! Staff A instructed Staff C, Certified Nurse Aide (CNA), to transport Resident #8 back to her room. At 12:19 PM, Staff A went to the nurses' station, got her purse, stopped to assist another resident in her room, then left the unit for lunch. She returned to the unit from lunch at 1:25 PM.A Nurse's Note progress note dated 2/16/26 at 12:05 PM documented the res <resident> is semi responsive, responds to touch and voice otherwise not. has temp of 100.4 refuses to take Tylenol.On 2/16/26 at 2:30 PM, Staff A confirmed Resident #8's event constituted a change-of-condition and stated the change-of-condition form should've been completed at that time. She attested she did not perform any work-related duties while she was at lunch and admitted she contacted the resident's brother and the provider after she returned to the unit. An eINTERACT Change in Condition Evaluation dated 2/16/26 at 2:53 PM indicated Staff A documented a family and provider notification at 1:00 PM, during the time she was at lunch.On 2/17/26 at 2:30 PM, the Assistant Director of Nursing (ADON) stated staff should not be backdating and should accurately record events to reflect the time it occurred.A policy titled Documentation in Medical Record effective 1/27/26 indicated each resident's medical record shall contain an accurate representation of the actual experiences of theresident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on clinical record reviews, hospital clinical record review, hospital images, staff interviews and policy review the facility failed to identify a resident with a pressure ulcer/injury and to assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of an unstageable pressure ulcer/injury for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 114 residents.Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound.Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Clinical Census sheet for Resident#10 documented April 18, 2025 as the residents original admit date to the facility.Resident #10's Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #10 required substantial/maximal assistance with rolling left and right in bed and was dependent on staff with sitting up or lying in bed and with all transfers. Resident #10's MDS included diagnoses of anemia, diabetes mellitus, traumatic brain injury, malnutrition and respiratory failure. The MDS documented Resident #10 was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcer/injuries. The MDS documented Resident #10 had one unstageable pressure ulcer present. The MDS documented the following skin and ulcer/injury and treatments: pressure reducing device for chair/bed, nutrition/hydration to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing and application of ointments/medications.The Care Plan with a target date of 10/14/25 revealed Resident #10 was at risk for skin breakdown due to impaired mobility, impaired cognition, incontinence and taking high risk medications. In addition the care plan identified Resident #10 had a break in skin integrity but did not address an unstageable pressure ulcer/injury to the left heel. The care plan directed the following interventions:- Staff to educate resident and/or family regarding skin problem and treatment-Staff to provide treatment as ordered.-Staff to complete weekly skin checks.-Pressure reducing mattress.-Staff to clean and dry Resident #10's skin after each incontinent episode. The Care Plan lacked any interventions related to repositioning, turning or keeping Resident #10's heels floated or elevated off of a surface to reduce the risk for pressure ulcers and promote healing. The Braden Scale for Predicting Pressure Sore Risk documented the following scores:6/3/25- 8- Very High Risk7/2/25- 8- Very High [NAME] Progress Note dated 6/27/25 at 5:28 PM revealed Resident #10 was not at his baseline and the on call Physician gave an order to transfer Resident #10 to the ER (emergency room) for an evaluation. A Progress Note dated 6/28/25 revealed Resident #10 was admitted to the critical care unit for sepsis (life threatening complication of an infection).Resident #10's discharge assessment, return anticipated MDS dated [DATE] documented Resident #10 did not have any unhealed pressure ulcer/injuries.A Hospital Image dated 6/27/25 at 10:36 PM revealed a wound to the left heel approximately the size of a two 50 cent pieces (half dollars). The wound bed was 100% black eschar (dead tissue) with wound edges dry and peeling. The heel was pink and boggy in appearance. The bottom of the left foot was dry and cracked. A Progress Note dated 7/2/25 documented Resident #10 returned to the facility. The note revealed Resident #10 returned to the facility with a dry eschar to the left heel. The progress note lacked documentation regarding wound measurements, staging, wound characteristics of the wound bed and peri wound. The assessment lacked any documentation regarding a wound treatment or intervention to assist with wound healing and reduce pressure to the left heel. A Progress Note titled N Adv Skin Check dated 7/2/25 lacked documentation regarding the pressure ulcer/injury to the left heel. A Progress Note titled N ADV Clinical admission dated 7/2/25 lacked documentation regarding the pressure ulcer/injury to the left heel.A Progress Note dated 7/9/25 revealed Resident #10 was admitted to the hospital. Resident #10's discharge assessment, return anticipated MDS dated [DATE] documented Resident #10 did not have any unhealed pressure ulcer/injuries.A Hospital Image scanned on 7/11/25 at 12:33 PM revealed a wound to the left heel that was approximately the size of a 50 cent piece. The wound bed was 100% black eschar with wound edges dry. The heel was red and boggy in appearance. The bottom of the left foot was dry and cracked. A Progress Note dated 7/16/25 documented Resident #10 returned to the facility from the hospital. A Progress Note title N Adv-Skin Check dated 7/16/25 lacked a skin assessment for the left heel. A Progress Note titled N ADV Clinical admission dated 7/16/25 lacked a skin assessment for the left heel. A Progress Note dated 7/18/25 revealed Resident #10 was sent to the emergency room (ER) and hospitalized . Resident #10's discharge assessment, return anticipated MDS dated [DATE] documented Resident #10 did not have any unhealed pressure ulcer/injuries.A Hospital Image scanned on 7/22/25 at 12:33 9:01 AM revealed a wound to the left heel approximately the size of a 50 cent piece. The wound bed was 100% black eschar with wound edges dry and peeling. The heel was pink and boggy in appearance. A Progress Noted titled N ADV Clinical admission dated 7/28/25 documented Resident #10 returned to the facility and had an unstageable pressure ulcer/injury to the left heel that measured 2 cm (centimeters)(length) x 3 cm (width). The assessment lacked any documentation regarding a wound treatment or intervention to assist with wound healing and reduce pressure to the left heel. The July 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of a wound treatment or new skin intervention for the left heel pressure wound/injury until 7/31/25. The July 2025 TAR directed the following treatments with a start date of 7/31/25:1. Cleanse left heel with normal saline and apply betadine and cover with bordered gauze every evening shift.2. Apply heel protector boots every shift for protection.Review of Progress Notes titled N Adv-Skin Check for the following dates 7/30/25, 8/10/25, 8/19/25, 8/30/25 revealed the skin assessments for the unstageable pressure ulcer/injury to the left heel were incomplete and lacked documentation regarding wound measurements, wound characteristics of the wound bed and the peri wound. The assessments lacked documentation on the treatment/condition of the pressure ulcer/injury and whether the wound was improving or not. A Progress Note dated 8/14/25 revealed Resident #10 was sent to the ER and hospitalized . A Hospital WOC (Wound, Ostomy, Continence) Nurse Consult dated 8/18/25 documented an unstageable pressure ulcer/injury to the left heel that measured 3 cm (length) x 4 cm (width) with dry, necrotic eschar/sloughing with calloused margins. A Hospital Discharge summary dated [DATE] documented a stage 3 pressure ulcer/injury of the left heel and the following wound care orders:1. Left heel: Cleanse with normal saline and gauze. Cover wound bed with betadine moistened gauze then cover with ABD (abdominal) pad. Secure loosely with kerlix and ace wrap. Perform wound care daily and as needed for saturation dressing. 2. Turn every 2 hours with TAPs system (turn and position system) and wedges3. Float both heels on pillows daily. Review of the July, August and September 20205 MAR and TAR lack any documentation regarding repositioning or turning. A Skin and Wound Evaluation dated 9/2/25 documented the left heel unstageable pressure ulcer measured 2.5 cm (length) x 2.3 cm (width) with 100% eschar and light serous drainage (clear, watery fluid). The assessment documented the heel was boggy and with unstable eschar. The note section of the assessment documented treatment order received to add opticell (gelling fiber wound dressing) to promote autolytic debridement (body's own enzymes to remove dead tissue) of the unstable eschar. On 9/11/25 at 9:05 AM, the Director of Nursing (DON) acknowledged Resident #10 had a pressure ulcer/injury to the left heel that was documented by the facility nurse on 7/2/25. The DON verified the left heel ulcer/eschar was omitted from the admission skin assessment on 7/16/25. The DON reported the facility did not receive any orders from the hospital related to the left heel wound on readmission on 7/2, 7/16 and 7/28.On 9/15/25 at 11:45 AM, the DON reported she did not have any further information regarding Resident #10 wound assessments. She said what was in the medical record was what the facility had. The DON said she expected wound measurements and characteristics to be included in the medical record documentation. She said the nurses are to measure the wounds with approximate measurements. She said the wound nurse would complete the official measurements when consulted. She said the wound nurse used an IPAD to assist with obtaining wound measurements and surface volume of the wound. She said once the wound nurse was consulted, the wound nurse would complete measurements weekly. She said Resident #10 was frequently in and out of the hospital and each time the wound nurse planned to see him he was in the hospital. She said Resident #10 was a very wiggly man and would move around in bed. When asked about turning and repositioning, the DON said the care plan addressed bed mobility and everything else related to repositioning/turning was a standard of practice. She said when Resident #10 first came to the facility in April he was dependent on staff for bed mobility but since then he had woken up some and has been having more movement. She said due to his frequent movement and medical diagnoses causing shearing and friction it was difficult to obtain proper pressure relief. On 9/16/25 at 9:00 AM, the DON reported Resident #10 had a cracked left heel on admission in April. She reported she was not aware of any pressure ulcers to Resident #10's left heel prior to hospitalization on 6/27/25. When asked if she would expect treatments and interventions to be in place for the left heel, the DON said she knew Resident #10 had heel lift boots for a while but was not sure when the boots were put in place. She reported the facility skin protocol did not address treatment for eschar. She said the nursing staff could implement treatments according to the skin protocol otherwise they would have to obtain an order from the Physician. On 9/16/25 at 11:23 PM, the Nurse Practitioner (NP) reported she was not sure that she had evaluated Resident #10 left heel pressure ulcer/injury and could not comment if the area was avoidable or unavoidable. The NP said she did not see the wound during rounds on 9/4/25. She reported Resident #10 had started moving around more and therapy was working on getting him up. A facility policy titled Turning and Repositioning dated 9/11/25 directed staff to implement turning and repositioning as part of a systemic approach to pressure injury prevention and management. The policy explanation and compliance guidelines documented all residents at risk of, or with existing pressure ulcer will be turned and repositioned unless contraindicated due to medical condition. The frequency of turning and repositioning to be documented in the resident's care plan and be determined by the resident's tissue tolerance, level of activity/mobility, skin condition, overall medical condition, treatment goals, type of pressure redistribution support surface, comfort level and resident preferences. The policy further directed staff to ensure that heels are floated off the surface of the bed with pillows or devices designed to do so. If using a heel protector, the heel must still be floated. A facility policy titled Pressure Injury Prevention and Management revised 9/11/25 documented the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The policy further documented the facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce, or remove the underlying risk factors; monitoring the impact of interventions, and modifying the interventions as appropriate. In addition the policy documented licensed nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any new identified pressure injury. The finding of the skin assessment would be documented in the medical record. After completing a thorough assessment/evaluation, the interdisciplinary team should develop a care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies and have an effective quality assurance program in place to assist in the provision of quality of care for residents and attain substantial complaining with Federal regulation and State rule. The facility reported a census of 114 residents. Findings include: Review of the Department of Inspections Appeals and Licensing (DIAL) website under the facility's visit history revealed the facility had the following concerns identified at the current revisit and complaint survey, that were also cited at past surveys in the last two and half years. a. F686- Pressure Sores b. F658- Services to Meet Professional Standardsc. F725- Sufficient Nursing Staffingd. F880- Infection ControlThe following surveys revealed repeated deficiencies from 6/29/23 to current survey:7/21/25- Recertification, Complaint, Incident Survey: F725, F8804/3/25- Complaint, Incident: F7259/19/24- Recertification, complaint, Incident: F8808/18/24- Complaint revisit: F6866/27/24- Complaint: F686, F7255/3/24- Complaint: F6582/27/24- Complaint, Incident: F658, F686, F88010/9/23- Complaint, Incident, Recertification revisit, Complaint Revisit, Incident Revisit: F725, F8806/29/23- Recertification, Complaint, Incident: F725, F880A Quality Assurance and Performance Improvement Plan (QAPI) dated 2/26/25 documented the facility used a systematic approach to determine when in-depth analysis was needed to fully understand identified problems, causes of the problems, and implications of a change. The policy further documented that to prevent future events and promote sustained improvement the facility would develop actions to address the identified root cause and/or contributing factors of an issue/event that would affect change at the systems level. To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, the facility would choose indicators/measures that tie directly to the new action and conduct ongoing periodic measurement and review to ensure that the new action has been adopted and was performed consistently.In an interview on 9/17/25 at 1:45 PM, the surveyor asked the Administrator what the facility had done to improve and address the repeat deficiencies from the current survey and prior surveys. The Administrator acknowledged the repeated deficiencies and stated that the facility had put in place quite a few things to improve and address the deficiencies. He said the facility had implemented new wound assessments/tracking and had hired a wound nurse. The Administrator reported he thought the facility had a good process in place for pressure wounds until the current survey identified concerns. He said the facility was tracking infection control in a different way so trends could be identified easier. He said the facility was conducting routine audits and reviewing resident infections. The Administrator reported the facility was working with an outside quality of care coalition on a monthly basis to share information, resources and review quality of care outcomes. He said the facility had been tracking call lights and had made some changes on how the staff were scheduled and supported. He said he felt call lights had improved. The Administrator reported the concerns identified through the survey process would be reviewed and discussed through QAPI.

Based on clinical record review and staff interviews, the facility failed to notify the family/emergency contact when a resident had a significant change of condition for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 114 residents.Findings include: Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #10 was dependent on staff for eating . Resident #10's MDS included diagnoses of anemia, diabetes mellitus, traumatic brain injury, malnutrition and respiratory failure. The MDS documented Resident #10 had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The MDS identified Resident #10 had a feeding tube and received 51% or more of the total calories through the feeding tube daily. A Progress Note dated 6/5/25 titled Dietary Note revealed Resident #10 had a weight loss of 8.8 pounds (5%) in one week. The note documented the dietician recommended switching tube feeding to prevent further weight loss. Review of the clinical record lacked documentation Resident #10's family/emergency contact was notified regarding the weight loss and recommendations from the dietician. A Progress Note dated 8/11/25 titled Dietary Note revealed Resident #10 triggered for weight loss. The note documented Resident #10 had a 11.9 pound weight loss (7.3%) in one month and 21.4 pound weight loss (12.4 %) in 3 months. A Progress Note dated 8/14/25 titled Dietary Note revealed the dietician recommended to increase the tube feeding rate to help prevent further weight loss. Review of the clinical record lacked documentation Resident #10's family/emergency contact was notified regarding the weight loss and recommendations from the dietician. On 9/16/25 at 9:00 AM, the Director of Nursing (DON) verified she could not locate family notification for the weight loss in the medical record. She said she would expect family notification to be documented in the clinical record. She said she had multiple conversations with the family and did not document the conversations. A facility policy titled Notification of Changes revised 3/5/25 documented the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician and notifies the resident's representative when there was a change requiring notification. The policy documented circumstances requiring notification include significant change in the resident's physical condition or a circumstance that required a need to alter treatment.

Based on record review, observations, and family and staff interviews, the facility failed to carry out therapy recommendations and provide restorative exercises for 1of 4 residents reviewed for rehabilitation services and/or limited range of motion (Resident #10). The facility reported a census of 107 residents. Findings include:The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of dementia, mild intellectual disability, and failure to thrive. The MDS documented the resident required set-up assistance for eating, partial to maximum assistance for bed mobility, and had dependence on staff for transfers and toileting. The MDS indicated the resident's upper and lower extremity range of motion (ROM) not impaired. The resident required partial to moderate assistance to wheel a wheelchair 50 and 150 feet. Physical Therapy (PT) last completed on 12/15/23 and Occupational Therapy (OT) last completed 11/3/23. The MDS recorded a Restorative Nursing Program (RNP) completed zero (0) days during the seven day look-back period. The Quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating cognition severely impaired. The MDS documented the resident required substantial to maximum assistance for eating and bed mobility, and had dependence on staff for transfers and toileting. The MDS also indicated the resident had impaired ROM to the lower extremity on one side of the body. The MDS recorded the resident had no PT or OT services, and recorded a RNP Active Range of Motion (AROM) and transfers occurred 6 of the 7 days during the lookback period. The Significant Change MDS assessment dated [DATE] revealed the resident had impaired short-term and long-term memory. The resident required substantial to maximum assistance for eating, and had dependence on staff for bed mobility and transfers. The MDS documented the resident had impaired range of motion to the upper and lower extremities bilaterally. A RNP for AROM was recorded 5 of 7 days during the look-back period. The MDS revealed the resident on hospice. The Care Plan revised 3/13/24 revealed Resident #10 had an ADL (activities of daily living) performance deficit related to dementia, an intellectual disability, and limited mobility. The care plan directed staff to use a Hoyer (mechanical lift) and two staff for assistance with transfers, and provide set up assistance for eating. Hospice initiated on 4/28/25. Care plan revised on 5/2/25 revealed the resident had pain related to decreased mobility, osteoarthritis, and bilateral hand contractures. The Physician's Encounter Note documented in the Progress Notes on 4/9/25 and e-signed 4/13/2025 at 2:15 PM revealed Resident #10 seen for an acute visit due to muscle tightness and contractures in her bilateral hands, primarily affecting the fingers and wrists, with the left wrist being more affected than the right. Nursing staff expressed concerns that these contractures are compromising her hand hygiene. During the previous visit, new orders were given for occupational therapy to address the hand contractures. The possibility of prescribing a muscle relaxer was considered, but it was noted that the patient is already on several centrally acting medications, and adding a muscle relaxer could increase the risk of sedation or worsening cognitive status.A Nurse Practitioner (NP) Encounter Note e-signed on 6/2/25 at 1:44 PM revealed resident had significant bilateral hand contractures and the hands had a tight clenched fist/ grip. Resident given Dilaudid (opioid analgesic) for pain. Progress Notes revealed the following: a. On 4/1/2025 at 3:35 PM, resident keeps her hands in a fist like hold. Her hands appear to be in pain when staff released her hands to examine the skin underneath. The skin appears to have cuts to where her nails dug into her skin and the skin appeared to have a foul odor present. Hands cleansed with soap and water and a gauze roll was placed between her nails and her skin. Resident had contractures previously to the ankles and OT and PT were used to establish positioning and release the contractures. The Care Plan was reviewed and updated to include Occupational Therapy to release contractures.b. On 4/14/2025 at 8:38 PM, resident's ongoing contractures and muscle tension discussed with NP. An order received for Baclofen (muscle relaxer) 5 mg twice a day.c. On 4/29/2025 at 3:30 PM, hospice NP saw resident and noted the resident had contractures and redness and pain to her right palm. Orders received for an antifungal treatment daily to her right palm for 14 days.d. On 5/13/25 at 2:08 PM, the IDT team met to review the skin wound that happened due to the resident's contractures to her bilateral hands. Resident's contractures were so severe that it caused broken skin to the right palm. Pain present when manipulated the hand and it was difficult to release the hands to reduce the pressure to the area. Baclofen muscle relaxer medication adjustments made to increase to 10 mg three times a day. As the contractures have been progressing, resident has been pulling back and has not been talking to team members. A wound care nurse specialist started to see the resident and treatment orders received. e. On 5/14/2025 at 8:21 AM, new splints applied to contracted hands. Splints will be applied in the AM and removed in the PM. The Treatment Administration Records (TAR) dated 5/1/25 to 6/30/25 revealed left and right splint on in the AM and off if the PM for contractures and reduced mobility had a start date 5/14/25 and discontinued on 6/16/25. The TAR also revealed OT carrots to bilateral hands during the day and removed at night for the right and left hand contractures started on 5/6/25. The Documentation Survey Report revealed the following Nursing Rehab tasks: Task: AROM: participate in activity of choice as tolerated--fold towels, match socks, sort papers 3-5 times per week2/1-2/28/25 documented 15x's3/1-3/31/25 documented 13x's5/1 - 5/31/25 documented 15 x's6/1 - 6/30/25 - documented 11x's. 7/1 - 7/15/25 - documented 9 x's Task: NURSING REHAB: Transfers/ROM: NuStep (sitting bicycle) x10 minutes, resistance as tolerated 3-5 times per week1/1-1/31/25 documented 6 x's2/1-2/28/25 documented 3x's3/1-3/31/25 documented 3x's4/1 - 4/30/25 - documented 5 x's 5/1 - 5/31/25 documented 5x's. 6/1 - 6/30/25 documented 2x's7/1 - 7/15/25 - documented 0 x's The Clinical Physician's Orders revealed the following: a. OT evaluation and treatment for hand contractures started on 4/1/25. b. OT carrots to bilateral hands during the day and take out at night related to contractures to the right and left hands started on 5/6/25. c. Apply left and right hand splint in the AM and off in the PM for contractures related to reduced mobility had a start date 5/14/25 and a discontinued date 6/16/25 due to resident unable to have splints applied. The Occupational Therapy (OT) Discharge summary dated [DATE] revealed OT recommended Resident #10 have assistance of one for transfers, and a RNP for bilateral upper extremities and bilateral lower extremities AROM. RNP recommended in order to maximize the resident's quality of life in her current living environment. An OT Evaluation and Plan of Treatment with a start of care date 4/1/25 revealed Resident #10 had diagnoses of bilateral hands stiffness and a contracture to her right hand. Staff H, OT, documented the resident presented with a severe decline and bilateral hand and ankle contractures as well as limited hip and knee extension, limited shoulder and elbow ROM. Functional limitations present due to contracture resulting in limitations in participation in tasks, feeding self, dressing, grasping and gathering. OT needed to evaluate and address positioning, bilateral upper and lower extremity ROM, and ADL performance. The resident had bilateral hand pain due to contractures. OT recommended the resident wear a carrot finger orthosis. An order for a muscle relaxer was pending. The resident had therapy services that ended 12/25/24. Prior treatment outcome included the resident discharged to the LTC facility and required assistance of one for transfers and ADL's, and used a wheelchair for mobility. The OT Treatment Encounter Notes revealed the following: a. On 4/1/25, Resident #10 had hand/ankle contractures. Waiting for an order for a muscle relaxer. Therapy needs to address the resident's pain. Pain exhibited by resident's clenched fists, clenched jaw, facial grimacing and protective barriers to the area of pain. OT performed an in depth hand washing and drying of bilateral hand/digits due to severe contractures and foul odor. The resident's finger nails were clipped due to current skin breakdown and indentation on the left palmar aspect of her hand. Bilateral carrot orthoses applied. b. On 4/2/25, hand carrot orthotics placed in the resident's hands. OT recommended to keep the carrots in her hand until bedtime, and provide proper hand hygiene cares. c. On 4/8/25, the resident became tearful with ROM provided to left index finger and thumb digits. Hand hygiene provided and carrot placed in left upper extremity and a built-up foam roll placed in right upper extremity. d. On 4/11/25, OT found the resident had a carrot donned in the right hand. The left carrot was lying in her lap. Resident had increased tearfulness with bilateral wrist and digit ROM. e. On 4/14/25, OT discussed with the DON about a prior meeting regarding getting a muscle relaxer for the resident and she needed to relay the message to the Nurse Practitioner. f. On 4/15/25, nursing staff indicated the resident started on baclofen today (4/15/25). g. On 4/16/25, nursing reported a discussion about hospice if the resident's muscle tension does not improve. The OT Discharge Summary signed by Staff H on 4/21/25 revealed the resident had dependence for ADL's including eating, hygiene, dressing and transfers. Resident #10's Self Care Function Score (Score 0-12, with 12 being the highest function) was 0, indicating the lowest functional level. Skilled treatment interventions focused on education and training the resident and caregivers in positioning maneuvers, pressure relieving techniques and splinting/orthotic use in order to decrease pain and promote optimal positioning in the wheelchair. OT recommended continued placement of bilateral carrots for hand contractures to decrease skin breakdown and improve hygiene cares. At the time of discharge, the resident tolerated the carrots for 4 hours. Observations revealed the following: a. On 07/15/25 at 10:34 AM, Resident #10 sat in a high back wheelchair and had contractures to both hands. No carrots observed in the hands. b. On 07/16/25 at 7:52 AM, resident lying in bed. The resident had contractures to bilateral hands and the right foot turned inward. Staff B, CNA, and Staff C, CNA, used a mechanical lift and transferred the resident from the bed to the wheelchair. c. On 7/17/25 at 9:00 AM, Resident #10 sat in wheelchair across from the nurse's station. The resident had arms bent and her fingers were curled inward toward palms of her hands (contracted). The right foot also turned inward and was deformed. No carrots observed in the hands. In an interview on 7/16/25 at 10:20 AM, the Director of Nursing (DON) reported the facility no longer had paper charts. The nurse entered orders in the computer and noted the order whenever an order was received. The order went into the bin for another nurse to double check the order, then the orders got checked by the unit manager. Medical Records went to each unit and picked up the medical records / documents that needed to be scanned by 5 PM each day. Medical Records scanned the documents into the residents' records typically within 24-72 hours. In an interview 7/17/25 at 9:05 AM, Staff D, Certified Medication Aide (CMA), reported he had worked at the facility for one year. Resident #10 had hand contractures since he had worked at the facility. The staff gave the resident carrots to hold in her hands to keep her hands more open. They don't document when the carrots were donned or doffed. In an interview 7/17/25 at 9:10 AM, Staff F, Registered Nurse (RN), reported she had worked at the facility for two years. Resident #10 had contractures that developed about 3-4 months ago. Staff found it hard to open her hand so therapy saw her. Staff F reported the resident was suppose to use the carrots during the day and remove the carrots at HS (bedtime). In an interview 7/17/25 9:25 AM, Staff B, Certified Nursing Assistant (CNA), reported she had worked at the facility for a year but she had also worked at the facility previously. She was familiar with Resident #10, Staff B reported Resident #10 had the deformity in her hands and feet for at least a year but requested the surveyor to ask the nurse about the resident's contractures. In an interview 7/17/25 1:30 PM, Staff H, OT, reported she had worked at the facility since 2017. Therapy made recommendations such as a restorative exercise program when a resident's therapy services ended. Sometimes they had repeat residents that required therapy services such as when a resident had a decline or had multiple falls. Therapy also screened residents at various times to determine transfer status or other ADL's. Staff H reported she was the one who found Resident #10's hand contracture. One day a few months ago, she was working with the resident's roommate and happened to notice Resident #10's hands were clenched in a fist. She opened Resident #10's fingers and saw wounds inside her hands. At that time, she requested orders for therapy services for Resident #10. Resident #10 was noted to be very tense and her fingers were curled up. OT evaluated the resident and used carrots to help open the hand up and prevent wounds from developing. No hand splints could be placed or used because the resident's hand/fingers were so tight. Carrots were recommended by OT and there was an order for use of the carrots. Resident #10 discharged from therapy services and went on hospice. Staff H reported she was unsure why Resident #10 didn't have carrots in place currently but thought maybe hospice had discontinued them. In an interview 7/21/25 at 8:15 AM, Staff M, Restorative Nursing Assistant, (RNA) reported she received a restorative program sheet for any resident who needed restorative exercise activity. She did restorative activities whenever she gave a resident a shower. Staff M reported she recently started in the RNA role but Staff L, RNA, had been doing restorative longer. In an interview 7/21/25 8:25 AM, Staff L, RNA reported she had worked as the restorative aide since 9/2024. Therapy gave her a program for the residents on a restorative program. If she noted a decline in the resident, she let therapy know. Restorative performed to maintain what level of function the resident had. Restorative exercises done Monday through Saturday in the dining room in a group setting as well. Staff L reported when she first took care of Resident #10, the resident had a transfer program to help with transfers and to do ROM. Resident #10 was very stiff. She worked with the resident in the beginning, but then she went to therapy services. Staff L reported the resident's arm was very tight when she did ROM exercises with her. She tried to put a brace on her arm but it didn't help. She had cones to put in her hands. Staff L reported when she tried to do ROM exercised with the resident it felt like she was fighting and she did not want to break her bones so she was careful on what she did with her. One day she went in to wash the resident's hands and noticed a break in the skin on the palm of her hand. She let the nurse know about it. Staff L reported she tried to work with the resident three times a week for restorative activities. Staff L reported she had 60 residents in her restorative program. The facility only had two restorative aides for the building (1 restorative aide on [NAME] and 1 on NE). Staff L reported she had been pulled to work on floor as a CNA or CMA when they needed her. Staff L shared that when restorative not done with the resident consistently because she had a day off or got pulled to work another area, she found it harder to work with the resident on ROM. No back-up restorative aide scheduled on RNA days off or when the RNA covered the floor as CNA or CMA. A Restorative Nursing Program policy revised 10/20/22 revealed the facility provided maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. RNP refers to nursing interventions that promoted the resident's ability to adapt and adjust to living as independently and safely as possible. All residents will receive maintenance nursing services as needed by CNA's including assisting residents with the use of assistive devices and assistance with ROM exercises. Passive ROM exercises performed for residents who lack AROM ability.

Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to perform post dialysis assessment and failed to assess for side effects of missed medication doses for Resident #2 on 3/22/25. Resident #2 later transferred to the hospital on 3/22/25 for abnormal vital signs, lethargy, and hypothermia. Resident#2 was 1 of 3 residents reviewed for assessment and intervention. The facility additionally failed to document a post fall assessment, greater than 24 hours, following a fall on 4/02/25 (Resident #9) for a witnessed fall without injury. Resident#9 was 1 of 3 residents reviewed for falls. The facility reported a census of 119 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had been admitted to the facility on [DATE], and had an unplanned discharge to an acute care hospital on 3/22/25 with return to facility anticipated. The MDS identified the following active diagnosis: Diabetes Mellitus, malnutrition, fracture of left lower leg, End Stage Renal Disease (ESRD), acute respiratory failure with hypoxia (low oxygen saturation), chronic diastolic heart failure, and anemia in Chronic Kidney Disease. Resident #2 required antidepressant, opioid, and antiplatelet medications. The Care Plan, initiated 3/15/25, revealed a focused area for hemodialysis three times per week. Interventions instructed staff to assess for thrill and bruit at fistula (dialysis access site), complete dialysis treatments as ordered, obtain dry weights from dialysis center, observe for bleeding at dialysis access site, and provide therapeutic diet as ordered. The Care Plan identified Resident #2 at risk for weight fluctuations related to current health status with intervention to encourage fluids with meals and between meals. The Treatment Medication Record (TAR), dated March 2025, revealed an order for Hemodialysis in the morning every Tuesday, Thursday, and Saturday with transportation at 9:45 AM, initiated on 3/15/25. The TAR instructed staff to check Resident #2 ' s weight and vitals signs on days of hemodialysis appointments. Documentation on 3/22/25 included one entry of weight and vital signs. The Medication Administration Record (MAR), revealed an order, initiated 3/13/25, for nursing to monitor thrill and bruit to dialysis access site every shift daily. A negative result (thrill/bruit not felt at access site) recorded on 3/15/25 and 3/19/25. Review of Resident #2's Electronic Health Records lacked documentation of reassessment or physician notification related to negative results. The MAR revealed an order, initiated 3/13/25, for fluid restriction every shift and lacked the amount of fluid allocated per day. Review of Resident #2's Electronic Health Records lacked physician notification for fluid restriction order clarification. The Resident's Care Plan also lacked direction for staff for how to follow fluid restriction. The Medication Administration Record (MAR), dated March 2025, revealed a number 3 had been coded for each of the following morning medications to be given on 3/22/25, The code 3 indicated, medications not administered due to Resident #2 away from home. 1. Amlodipine Besylate 10 milligrams (mg), with instructions to give one tablet one time a day, scheduled at 9:00 AM, related to hypertensive emergency. 2. B Complex Vitamins Oral Tablet, with instructions to give one tablet in the morning, scheduled at 7:00 AM, related to muscle weakness and other specified abnormal findings of blood chemistry. 3. Escitalopram Oxalate 10 mg, with instructions to give one tablet one time a day, scheduled at 9:00 AM, related to nicotine dependence, cigarettes. 4. Lisinopril Oral Tablet 40 mg, with instructions to give one tablet, one time a day, scheduled at 9:00 AM, related to hypertensive emergency. 5. Rosuvastatin Calcium 40 mg, with instructions to give one tablet one time a day, scheduled at 9:00 AM, related to arteriosclerotic heart disease. 6. Aspirin Low Dose Chewable 81 mg, with instruction to give one tablet twice a day, scheduled at 9:00 AM and 6:00 PM, related to fracture of left lower leg. 7. Dulera Inhalation Aerosol 200-5 micrograms per actuation (mcg/ACT), with instructions to inhale 2 puffs twice daily, scheduled at 9:00 AM and 6:00 PM, related to acute respiratory failure with hypoxia. 8. Metoprolol Tartrate Oral Tablet 50 mg, with instructions to give one tablet twice daily, scheduled at 9:00 AM and 6:00 PM, related to hypertensive emergency. 9. Senna-S Oral Tablet 8.6-50 mg, with instructions to give one tablet twice daily, scheduled at 9:00 AM and 6:00 PM, related to fracture of left lower leg. 10. Renvela (Sevelamer Carbonate) 800 mg, with instructions to give 4 tablets three times daily, scheduled at 8:00 AM, 2:00 PM, and 7:00 PM, related to End Stage Rental Disease. The MAR revealed Resident #2 additionally had an order for Insulin Aspart Injection Solution 100 units per milliliter, with instructions to inject insulin subcutaneously following sliding scale protocol with meals related to Type 2 Diabetes Mellitus with Chronic Kidney Disease. The start date for this order was documented as 3/20/25. For blood sugars between 0-199, no insulin given. For blood sugars between 200-249, give 2 units of insulin. For blood sugars between 250-299, give 4 units of insulin. For blood sugars between 300-349, give 6 units of insulin. For blood sugars between 350-399, give 8 units of insulin. For blood sugars greater than 400, physician to be called. The 3/22/25 12:00 PM blood sugar check and sliding scale insulin administration coded as 3 for Resident #2 away from home. Review of Resident #2's Electronic Health Records lacked physician notification of missed medication doses on 3/22/25 or follow up assessments of Resident #2 for potential side effects related to missed medication doses. Review of Resident #2's list of assessments revealed a Skilled Assessment, completed 3/22/25 at 1:44 PM, that lacked Resident #2's post dialysis weight, vitals, or an assessment of fistula access site. Review of Resident #2's Nursing Progress Notes, revealed an entry on 3/22/25 at 3:16 PM, Note informed that Resident #2 was in the Sunshine Room and family came in to visit, Family took Resident #2 to his room and requested assistance to transfer Resident #2 to bed. The Note informed that Resident #2 had been very lethargic and hypothermic, cold to touch and not at baseline. Blood sugar was noted to be 272, heart rate 130 beats per minute, blood pressure 98/58, temperature 97.6 degrees Fahrenheit, 16 respirations per minute, and oxygen saturation at 70% (normal being greater than 90%). Supplemental oxygen initiated at 5 liters per minute which increased oxygen saturation to 88%. Note revealed physician was notified of Resident #2 change in status and orders received to send Resident #2 to the emergency room via ambulance. On 4/02/25 at 11:00 AM, the Director of Nursing (DON) reported the expectation of nursing staff to check the weight and vital signs of residents who required dialysis before and after the procedure. DON reported that Resident #2's weights and vitals should be reflected in his medical record and informed that the facility would normally send a paper with residents to dialysis and stated sometimes the dialysis center didn't send the paper back. DON confirmed that nursing staff did not call the dialysis center if paper had not been sent back, but would do an assessment of resident upon return to facility. DON stated it was probably an oversight not to put post dialysis assessment on the MAR and informed that it was a standard of practice to do post dialysis assessments. The DON identified a Skilled Assessment had been documented at 1:44 PM, confirmed this assessment lacked the check of vital signs, weight, or check of dialysis access site. When queried about Resident #2's allocated amount of fluid per day related to fluid restriction order, DON revealed this order had been part of a general order set for dialysis patients and no amount had been put in because there had been no specific recommendation received. On 4/02/25 at 2:45 PM, Staff G, Licensed Practical Nurse (LPN), confirmed working the morning of 3/22/25 with Resident #2, and reported being unaware of Resident #2's dialysis appointment until a driver showed up to transport Resident #2. Staff G revealed Resident #2 returned to the facility close to 2:00 PM and Staff G requested driver to put Resident #2 at a table in the Sunshine Room. Staff G stated that the MAR did not have orders for post dialysis vitals and revealed they had forgotten to do vitals on Resident #2 when he got back to the facility. On 4/03/25 at 10:58 AM, the DON confirmed that a number 3 coded on the Medication Administration Record (MAR) indicated that the medication had not been administered due to Resident #2 away from home. The facility policy, titled Hemodialysis, dated 3/28/25, revealed the following compliance guidelines listed: 1. The facility will coordinate and collaborate with the dialysis facility to assure that documentation requirements are met to assure that treatments are provided as ordered by nephrologist, attending practitioner, and dialysis team; and there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 2. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility. Physician/treatment orders, laboratory values, and vital signs. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. Dialysis treatment provided and resident ' s response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site. Changes and/or decline in conditions unrelated to dialysis. 3. The nurse will monitor and document the status of the resident ' s access site upon return from the dialysis treatment to observe for bleeding or other complications. 4. The facility will communicate with the dialysis facility, attending physician, and/or nephrologist any medication administration or withholding of certain medications prior to the dialysis treatment and document such orders. 5. The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility, and/or nephrologist. The facility policy titled, Medication Administration, dated 12/30/24, instructed staff to administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. 2. The Minimum Data Set (MDS), dated [DATE], for Resident#9 documented a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Resident #9 had impairment to bilateral lower extremities, required substantial to maximal amount of staff assistance with bed mobility and dependence upon staff for transfers. Resident #9 unable to ambulate at time of MDS assessment. Resident #9 had no falls since previous MDS assessment. Diagnoses included urinary tract infection, urinary retention, Diabetes Mellitus, and malnutrition. The MDS documented that the Resident had lower extremity impairment to both sides, and required substantial/maximal assistance with dressing the lower body. The Care Plan, initiated 1/02/25, revealed Resident #9 at risk for falls and injury related to deconditioning, gait/balance problems, pain, repeated falls in the community, right patellar fracture, and right lower extremity cellulitis. Interventions instructed staff to ensure call light is within reach, appropriate footwear is on, floor is free of clutter, and non-skid strips in front of bed and recliner. The Care Plan revealed Resident #9 had an actual fall due to weakness and impaired balance, staff instructed to continue interventions on the at risk plan and to determine/address causative factors of the fall. On 4/02/25 at 8:15 AM observation of Resident #9 on the floor in his room with Staff H, Infection Prevention Nurse, and 3 other direct care staff present in the room. Resident #9 lying flat on his back, feet pointed towards the bathroom and head/upper body visible through the doorway from the hallway. Review of Resident #9's Nursing Progress Notes for 4/02/25 lacked documentation of fall incident or post fall assessment. Review of Resident #9's Assessment List lacked assessments completed on 4/02/25. Review of Resident #9's Weights and Vital Signs list lacked entry of vital signs documented on 4/02/25. On 4/03/25 at 9:00 AM, Staff I, Registered Nursing (RN), confirmed working on 4/02/25 morning shift on Resident #9's unit. Staff I confirmed Resident #9 fell due to weakness with staff present in his room, who assisted him to the floor. On 4/03/25 at 8:45 AM, Staff H, Infection Prevention Nurse, confirmed being present in Resident #9's room to assist with getting him up from the floor. Staff H reported she had checked Resident #9's vitals, pain, and orientation. Staff H denied documentation of fall assessment and stated she had reported Resident #9's fall assessment to Staff J, Registered Nurse (RN), who had been charge nurse for Resident #9 on 4/02/25. On 4/03/25 at 9:38 AM, Staff J, Registered Nurse (RN) confirmed working as charge nurse for Resident #9 on 4/02/25 at the time of his fall. Staff J denied documentation of fall or post fall assessment in Resident #9's medical record, but stated the fall had been documented into the facility's risk management system. Staff J reported she had been notified by Director of Nursing (DON) of missed documentation related to Resident #9's fall on 4/02/25 and would be coming into the facility to complete a late entry of the incident. Review of a Nursing Progress Note, with effective date of 4/03/25 at 9:56 AM, documented by Staff J, revealed a late entry of nurse being alerted by nursing assistant that Resident #9 was on the floor in front of the toilet. Note indicated Resident #9's vital signs were within normal limits, denied pain, and had not hit head. Note informed that the family had been notified and no other concerns were noted. On 4/03/25 at 10:58 AM, the Director of Nursing (DON) revealed expectation of Staff J to document Resident #9's fall on 4/02/25 with vital signs and fall assessment in the medical record and confirmed this had not been documented until 4/03/25 in Resident #9's medical record. The DON explained the that facility's risk management system documentation could only be viewed by the Facility Executive Director, Director of Nursing, and Assistant Director of Nursing. The facility policy titled, Incident and Accidents, dated 4/03/25, revealed the nurse would enter the incident/accident information into the appropriate form or system within 24 hours of occurrence and would document all pertinent information. The policy revealed the expectation of documentation to include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow up interventions. The facility policy titled, Documentation in Medical Record, dated 4/03/25, revealed the expectation that documentation be completed at the time of service, but not later than the shift in which the assessment, observation, or care service occurred. The policy revealed when documentation occurs after the fact, outside of acceptable time limits, the entry must be clearly indicated as a late entry.

Based on record review, observation, policy review, resident interview and staff interview the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed (Resident #3 and #7) requiring mechanical equipment device transfers. The facility reported a census of 117 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. MDS documented Resident #7 was dependent on staff for upper body/lower body dressing, application of footwear and completion of personal hygiene. MDS also documented Resident #7 was dependent on staff for position changes from lying to sitting, sitting to standing, and chair to bed. Review of Resident #7's Care Plan documented Resident #7 required 1 staff to assist him with all transfers using a platform walker with start date of 1/2/25. On 4/2/25 at 8:06 AM Resident #7 stated he was having a terrible morning. An observation on 4/2/25 at 8:07 AM revealed Staff A, Certified Medication Assistant (CMA) and Staff D, Certified Nurses Assistant (CNA) complete a transfer with gait belt on Resident #7. Staff D applied anti slip socks on Resident #7. Staff D was on the left side of Resident #7 with Staff A on the right side. Staff D applied a gait belt to Resident #7. Staff A lifted Resident #7 by the waist of his pants and under his shoulder and Staff D lifted with the gait belt and under Resident #7's shoulder. Resident #7 was transferred to the wheelchair this way. On 4/2/25 at 12:52 PM the DON stated she would expect that a gait belt would have been applied during transfers with Resident #7. Stated can always go up with assistance and she would have preferred the staff to use the gait belt and not his pants for transfer and would like to have the staff have a conversation with Resident #7 about the use of the walker for transfers. 2. The MDS for Resident #3 dated 2/1/24 documented a BIMS of 13 which indicated intact cognitive function. The MDS documented diagnosis of hemiplegia or hemiparesis, non-Alzheimer's dementia, cancer, anemia, and orthostatic hypotension. The MDS reflected a total dependence on staff for transfers and most of the activities of daily living. In an interview with the family on 4/2/25 at 10:30 am, it was confirmed Resident #3 sustained an injury during a transfer due to staff using an incorrect mechanical lift and only 1 person instead of 2 person lift as required. The family member stated the resident was transferred using a sit-to-stand mechanical lift instead of a mechanical full body lift. A Verbal Communication Order from the Nurse Practitioner dated 3/22/25 at 2:16 pm documented the following order; Ace wrap to the lump on top of the right hand as tolerated by the resident until seen by the provider on Monday. A Follow Up Note (Orders for Resident) by the provider dated 3/24/25 documented Raised area soft, surrounding bruising healing, continue to monitor. An Electronic Health Record review documented an Interdisciplinary Note on 3/20/25 at 11:46 am a bruise occurred on 3/14/25 at 4:20 pm. The note documented a conclusion of the incident was due to a Certified Nurse Assistant (CNA) assisted Resident #3 and told her to hold onto the bars of the mechanical lift (sit to stand) during the transfer. Resident #3 was to be transferred using a mechanical full body lift and not the mechanical lift (sit to stand). Resident #3 was prescribed Plavix and Aspirin for a blood thinner and it increased risk for bruising. Resident#3 stated she did have slight discomfort with movement. Orders received to increase pain medications, X-ray, and ice to the hand as tolerated. The note further documented the facility, reported the incident and findings to the family members and provided education to the team members. In an interview with the Director of Nursing (DON) on 4/3/25 at 11:05 am, she confirmed Resident #3 was transferred improperly by CNA using a mechanical lift (sit to stand) instead of a mechanical full body lift. The DON stated Resident #3 did not have a good core strength and the physical therapy department was working with the resident to improve mobility and used a mechanical lift (sit to stand) during therapy sessions but was not successful and CNA's were not given instructions to use a mechanical lift (sit to stand) for transfers, only a mechanical full body lift. The DON stated the staff member was removed from providing hands-on assistance to Resident #3 per family's request and was disciplined. A review of Staff E, Certified Nursing Assistant (CNA) personnel file revealed a Corrective Action Report signed by Staff E on 3/24/25 with the details of violation: you did not follow the plan of care when transferring a resident. You must always review the plan of care for each resident and then follow it. The plan of improvement was 1:1 coaching by a nurse. An observation on 4/3/25 at 11:50 am of a mechanical lift (sit to stand), revealed a severely damaged foam padding on the handles, exposing sharp metal edges on the right side where hands were to be placed during use. In an interview with the Administrator and the DON on 4/3/25 at 11:50 am they both visualized and confirmed the mechanical lift (sit to stand) stand-mechanical lift had a compromised integrity and removed it from the floor to replace the foam piece. A review of the facility policy titled Safe Resident Handling/Transfers revised 4/3/2025 documented directives to staff as follows; It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The document also revealed Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 3 residents (Resident #69) reviewed for nutrition. This failure resulted in harm due to Resident #69 experiencing a weight loss of 10.4% in an approximate 3 month period. The facility reported a census of 120 residents. Findings Include: The Quarterly Minimum Data Set (MDS) of Resident #69, dated 8/15/24 identified a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS identified a PHQ-9 (Patient Health Questionnaire) score of 13, indicating moderate depression. The MDS documented diagnoses that included: anemia (low red blood cell count), renal (kidney) insufficiency), diabetes, dementia, and depression. The MDS documented a height of 65 inches and weight of 139 pounds. The MDS identified a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, not on a physician-prescribed weight-loss regimen. The Care Plan of Resident #69 identified a Focus Area of Nutrition, dated 6/17/21. An intervention was added 8/13/24 to receive 8 oz of Glucerna (a meal replacement supplement for diabetics) with each meal to promote weight maintenance and prevent further weight loss. No further interventions for weight loss were documented in the Care Plan. The Weight Summary section of the Electronic Health Record (EHR) documented Resident #69 weighed 147.9 pounds on 6/1/24. The Weight Summary documented a weight of 132.5 pounds on 9/9/24, 10.41% weight loss in 15 weeks time. Resident #69 was next weighed one week later, with a documented weight of 131.1 pounds, an additional 1% loss in one week. The following weights were recorded: 6/01/24 147.9 pounds 7/11/24 149.3 pounds 7/23/24 134.0 pounds 7/29/24 136.7 pounds 8/12/24 145.8 pounds 8/26/24 133.9 pounds 9/01/24 134.6 pounds 9/09/24 132.5 pounds 9/16/24 131.1 pounds The Active Orders section of the EHR, reviewed on 9/19/24 at 8:09 am, revealed an order dated 8/2/24 which read Dietitian to eval and offer nutritional supplements. No supplements were ordered except Glucerna three times a day. The Medication Administration Record (MAR) identified a start date of 8/12/24 for the Glucerna Order. The MAR failed to identify any further nutritional supplements. On 9/18/24 at 9:56 am, Resident #69 was observed lying in bed sleeping soundly. A breakfast tray was at her bedside, still covered. Her full breakfast remained on the tray, untouched. The Schedule of Mealtimes documented provided by the facility noted breakfast times to be between 7:30 am and 9:00 am. On 9/18/24 at 9:58 am, Staff M, Certified Nurse Aide (CNA) stated Resident #69 was sleeping when her breakfast tray was brought in but that she would feed her at this time. Staff M stated Resident #69's tray had not been sitting there for very long. She said her tray was delivered separately because she likes to sleep late and the food should still be warm. At 9:59 am, Resident #69 was sitting up in bed and feeding herself breakfast. On 9/18/24 at 12:23 pm, room trays arrived for Resident #69's hall. When all trays were passed, it was observed Resident #69's tray was included on the same cart as all resident's. Her meal was not separated from other residents. On 9/18/24 at 12:27 pm, the Registered Dietitian (RD) stated the resident is of Bosnian descent and prefers Bosnian food. She stated the Dietary Manager is also Bosnian and is able to assist in translating for interviews to determine what foods the Resident prefers. She stated Resident #69 has some depression and has stated her desire is to return to Bosnia. The RD stated the facility does use fortified foods in the facility (foods with extra butter, brown sugar, etc. to add extra calories to food for residents who experience weight loss). She stated she was not aware if fortified foods had ever been tried for Resident #69. She confirmed no current supplements were in place except Glucerna. She added the facility holds a weekly meeting to discuss resident weights and watch nutrition trends. She was aware the resident weighed somewhere in the 130 pound area and confirmed this to be a significant weight loss with no interventions except Glucerna. On 9/18/24 at 3:05 pm, the Director of Nursing (DON) stated Resident #69 has been facing other health challenges besides just weight loss. She stated she has had a decrease in physical ability and an overall health decline. She stated she is no longer walking to the bathroom or getting up and sitting in her chair. She said she was aware of no interventions put in place except Glucerna. She stated she would look into some cultural and personal interventions that could be done in the weekly weight meeting. On 9/19/24 at 9:05 room trays were delivered to the hallway where Resident #69's room was on. On 9/19/24 at 9:11 am, the breakfast tray for Resident #69 was delivered to her room. Resident #69's tray was not separated from other residents' trays. On 9/19/24 at 9:19 am, Resident #69 was observed sleeping soundly in bed with her breakfast tray still sitting on her table covered. On 9/19/24 at 9:24 am, the Dietary Supervisor stated Resident #69 had been expressing desires to return to Bosnia over the past year. She stated this is not a possibility for Resident #69's family to accommodate her wishes. She stated Resident #69 likes to sleep late in the mornings. She said Resident #69's tray is sent to the floor the same time as all of the other residents. It is not kept separate. She stated that she had given Magic Cup (a fortified high calorie ice cream) to Resident #69 in the past but she did not like it. She stated it was added to her tray card to try again the previous day. She added super mashed potatoes (fortified food) to her list the prior day as well. She stated the resident has always liked oatmeal and has coffee creamer in her room that she has always added to her oatmeal herself but super oatmeal with extra brown sugar was also added the prior day. She confirmed the additional interventions were put in place on 9/18/24. No mention of special foods, or Bosnian food were specified in the interview. The Encounter Note dated 8/1/24 revealed the Nurse Practitioner was aware of the weight loss and noted for the Dietitian to evaluate and offer nutritional supplements and for the facility to obtain weekly weights. The Progress Notes revealed no Dietary Note was placed with additional supplements until 9/19/24. The facility policy Nutritional Management, revision date 11/28/22 documented: Point 4 - Care Plan Implementation: a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet ii. Altered-consistency food/liquids after underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy) iii. Weight-related interventions iv. Environmental interventions v. Disease-specific interventions vi. Physical assistance or provision of assistive devices vii. Interventions to address food-drug interactions or medication side effects c. Real food will be offered first before adding supplements. The facility policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017 documented: Monitoring 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting). 2. When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident/patient's responses, goals, wishes, prognosis, and complications. 3. The physician and staff will collaborate to address any ethical issues related to weight and nutrition (for example, possible use of artificial nutrition and hydration) related to severe or prolonged impairment of nutritional status and weight loss. a. Such recommendations should be consistent with resident/patient treatment wishes; for example, as expressed through an advance directive. b. The physician and staff should ordinarily not recommend or order a feeding tube until seeking to identify causes and trying other alternatives or identifying them as legitimately not feasible. c. The physician and staff will document the medical and ethical rationale for recommending, not recommending, or discontinuing tube feedings, consistent with the clinical situation and applicable laws and regulations about the withholding or withdrawing of artificial nutrition and hydration.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to prevent the development of a pressure ulcer for 1 of 3 (Resident #1) residents reviewed. The resident was admitted with one Stage IV pressure ulcer, having comorbidities which made her susceptible to further impaired skin integrity. The facility failed to provide recommended every 2 hour repositioning, and failed to do all ordered skin treatments. This failure resulted in Immediate Jeopardy to the health and safety of the resident when she developed a second stage IV pressure ulcer, which required multiple antibiotics and medical intervention during a hospital. The facility reported a census of 119 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/17/24 at 4:05 pm. The IJ began on June 9, 2024. Facility staff removed the Immediate Jeopardy on 8/18/24 through the following actions: -Skin assessments conducted on all residents with active wounds, and reviewed and revised treatments orders as necessary -Braden scale assessments (an assessment to predict pressure ulcer risk) conducted on all residents -Policies regarding Pressure Injury Prevention and Turn/Repositioning reviewed and updated as needed -Education provided to all nursing staff of policies and procedures related to skin/wound care, turning and repositioning -Audits put in place to be completed 5 days a week to ensure accurate and complete documentation of skin related treatments -Audits put in place to be completed on 3 residents per week for observation of treatments, preventative skin care and weekly skin assessments -A QAPI (Quality Assurance Performance Improvement) action plan was initiated The scope lowered from J to D at the time of the survey after ensuring the facility implemented the education, audits and their policy and procedures. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Minimum Data Set (MDS) dated [DATE] of Resident #1 identified a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS revealed the resident to be dependent on rolling side to side and chair/bed-to-chair transfers. The MDS coded the presence of an indwelling catheter. The MDS reflected the resident always incontinent of bowel. The MDS documented diagnoses that included: Diabetes Mellitus, paraplegia and spinal stenosis. The MDS revealed the resident had one Stage IV pressure ulcer, which had been present upon admission to the facility. The MDS additionally revealed the resident to have Moisture Associated Skin Damage. The MDS documented that resident admitted to the facility as 9/15/2023. The Comprehensive Care Plan of Resident #1, initiated 9/20/23, identified a Focus Area of Skin Breakdown, dated 9/26/23. The Care Plan directed staff to encourage the resident to turn side to side when in bed to decrease pressure, dated 9/26/23. The Care Plan failed to direct staff of a turning/repositioning schedule. The Care Plan failed to document that the Skin Breakdown Focus Area had been updated since 2023. The Focus Area ADL (Activities of Daily Living) self-care performance deficit, dated 9/26/23 directed the resident required 2 staff members to reposition and turn in bed, dated 9/26/23. The Care Plan failed to document the resident to be non-compliant with repositioning. The Nurse's Note dated 6/9/24 at 12:15 p.m. revealed multiple abrasions were noted on the resident's tailbone with small amounts of bleeding. An order was received for topical wound care. The Encounter note dated 6/10/24 at midnight by the house Nurse Practitioner documented the resident to have a wound on her buttocks and stated the resident was seen by and cared for by a wound care provider once a week. She documented the resident does not turn in bed without staff assistance. The resident complained of increased pain from a wound on her buttocks. The Nurse's Note dated 6/10/24 at 2:58 p.m. documented ensure (a protein drink) ordered with meals for wound healing due to the resident refusing liquacel (a high protein supplement). A Skin/Wound Note dated 6/11/24 at 6:13 p.m. documented an open area to the sacrum with a small amount of serosanguinous (a mixture of blood and serum [the liquid part of blood]) drainage noted. It stated the surrounding skin to have blanchable erythema. The Wound Evaluation and Management Summary dated 6/11/24 documented the initial evaluation of a non-pressure wound to the sacrum. The Wound Advanced Registered Nurse Practitioner (ARNP) ordered alginate calcium with a gauze bordered dressing for 30 days. (Alginate is used for wounds with exudate). The Treatment Administration Record (TAR) for June of 2024 revealed the above order was implemented as ordered, documented as being done June 12th through June 16th, 2024. It was discontinued on June 17th, 2024. The Order Audit Report documented the order was discontinued on 6/17/24 by Staff A, Registered Nurse (RN) at 3:47 am. The reason was documented as New Order Received. The Progress Notes failed to document any new orders received on 6/16/24 or 6/17/24. The TAR failed to document any treatment being completed on the sacrum between June 16th and June 21st when a new order was received. The TAR for June of 2024 showed the calcium alginate order with gauze was re-started on 6/21/24 and documented as completed through 6/25/24. On 6/25/24 a new order was given to apply alginate calcium and Santyl (an ointment used to remove damaged tissue from chronic pressure ulcers or burns) and to continue the use of the bordered dressing. There were no wound treatments for the sacral wound documented as being completed 6/17/24 - 6/20/24 or on 6/26/24. The Skin & Wound Evaluation dated 6/18/24 documented the resident to have a new unstageable pressure ulcer, 1 week old, house acquired, which was described as 100% of the wound being filled with eschar (dead tissue which forms over wounds). Per the definition of pressure injuries, eschar is not present until the injury reaches at least a Stage 3 Pressure Injury. The Wound Evaluation and Management Summary dated 6/18/24 documented the sacrum wound to be 4 x 3 x 0.1 cm, listed as moisture associated skin damage and repeated the orders from the prior week of alginate calcium and a gauze island bordered dressing daily. The Wound Evaluation and Management Summary dated 6/25/24 documented the sacrum wound to be 7 x 3 x 0.1 cm. The wound progress was documented as exacerbated due to the patient not offloading as she should and not telling the aides when she is wet. An order was placed to continue the same treatment, but to add Santyl as part of the treatment. (Santyl is an ointment used to remove damaged tissue from chronic skin ulcers, or debriding of a wound). The Wound ARNP did not see the resident again after 6/25/24 until 7/16/24. The Skin and Wound Evaluation dated 7/2/24 documented the sacral wound as being Moisture Associated Skin Damage, house acquired, with measurements documented 9 x 7 x 0.2 cm. The Evaluation documented the wound was 10% filled with granulation and 90% filled with eschar. Additional documentation included a moderate amount of serous exudate, and attached wound edges. The Evaluation documented Provider recommended off-loading the wound and letting staff know when soiled, nursing staff educated on making sure resident's briefs are changed frequently throughout the day. On 8/15/24 at 3:32 pm, the Wound ARNP stated when she saw the wound on 6/25/24 the wound was not a pressure injury. She stated it may have worsened after she saw it prior to admitting to the hospital. She stated the resident can assist in repositioning but is unable to turn herself in bed without staff assistance. The Point of Care charting portion of the resident's record, where the Certified Nurse Aides (CNA) document cares, revealed the section of Rolling left and Right was to be documented 3 times a day (once a shift), every day, for the month of June. The documentation was left blank 17 times during the month of June. The Point of Care charting revealed the section of Skin: Turn and Reposition at least every 2 hours was also left blank 17 times during the month of June. On 8/15/24 at 4:12 pm, the Director of Nursing (DON) stated the CNAs only chart in Point of Care. She stated there is nowhere else the turning is documented to show it is being done. She also stated the resident does not comply with repositioning all of the time. On 8/15/24 at 4:30 pm, Staff B, Registered Nurse (RN), acting in house wound nurse, stated he was not familiar with the wound prior to the resident's hospitalization . He stated he only saw it after she returned from the hospital. He stated based on the description in the Skin and Wound assessment, the wound did not sound like it was Moisture Associated Skin Damage. He stated at times MASD can break down further and lead to pressure ulcers. The Encounter Note dated 7/5/24 by the facility ARNP documented an acute visit was made due to labs showing an elevated white blood cell count (an indication of infection) and a urinalysis which indicated a need for a culture to be done. The WBC count was 20.9 (normal range 4.5 - 11). The resident's blood pressure was slightly low and heart rate was 99. The note documented a concern of sepsis (a serious condition in which the body responds improperly to an infection). The ARNP recommended the resident be sent to the Emergency Department for further evaluation. The records from the acute care hospital documented upon arrival to the Emergency Department, the resident had a WBC count of 23.4 and a C-reactive protein of 27.2 (an indication of inflammation in the body). The Patient Active Problem list identified: - Pressure ulcer of the left ischium, Stage 4 - Pressure injury of sacral region, Stage 4 - Incomplete paraplegia - Diabetes Mellitus, type 2 - Degenerative arthritis of the spine - Lumbosacral spondylosis without myelopathy - Acquired kyphosis - Status post cervical spinal fusion - Lumbar radiculopathy- Lumbar spinal stenosis (all comorbidities which could put the resident at a higher risk of impaired skin integrity). The Computed Tomography (CT) scan dated 7/5/24 documented the pressure ulcers and chronic osteomyelitis of the coccyx (a long-term bone infection which can develop, be treated and return). The CT also showed subcutaneous emphysema (development of air under the skin which may indicate deeper pathological issues). The History and Physical documented a prior history of multiple decubitus ulcers, with admission diagnoses of sepsis secondary to cellulitis and chronic osteomyelitis associated with a large decubitus ulcer. The resident was referred to plastic surgery for wound debridement and was treated with multiple antibiotics. The note stated the resident also had rhinovirus (the common cold) and a UTI which was noted to be another possible source of infection. The resident was discharged from the hospital on 7/15/24, listed in stable condition with wound care orders in place for ischium and sacrum pressure ulcers to be done twice daily. The Wound ARNP visited the resident on 7/16/24 and wrote orders to initiate a wound vac for the pressure ulcers (a vacuum-assisted device used for closure of a wound). On 7/22/24 the Director of Nursing (DON) documented a Nurse's Note that stated the orders that were received on 7/16/24 were being initiated on this date (7/22/24). The note documented the wound practitioner and the spouse of the resident were informed of the late initiation of orders. On 8/17/24 at 10:09 am, Staff C, Licensed Practical Nurse (LPN) stated she had worked with Resident #1 often since beginning employment greater than 6 months ago. She stated the sacral wound was open and she would have considered it a pressure injury, not Moisture Associated Skin Damage. On 8/17/24 at 10:55 am, the Wound ARNP verified wound #1 in her weekly wound charting is referring to the resident's initial pressure ulcer that was present on admission. This pressure ulcer is on her left ischium (the curved bone forming the base of each half of the pelvis). Her notes document this wound as being on her coccyx (tail bone). She stated she considers the buttocks, the coccyx and the ischium to all be basically the same spot. The resident's skin was observed on 8/17/24 at 11:40 am. The wound vac was in place and running as ordered, with the sponges covering two wounds on the left ischium and on the sacral area. On 8/17/24 at 1:22 pm, the DON stated the Wound ARNP comes every Tuesday. She stated the in house wound nurse had been working overnight shifts covering the floor, so Staff B, RN had been acting as the in house wound nurse to assist. She stated each week when the Wound ARNP comes she (the DON) prefers to discuss all of the wounds with the in house wound nurse. She stated it had been very busy and there had not been a discussion of the wound orders from 7/16/22. She said on 7/22/24, she asked to have a conversation with Staff B about the wounds and at that time he informed her he had not implemented any of the orders received that on 7/16/24. He stated he had been busy all week and had not had a chance to place the order in the Electronic Health Records of the residents. She stated there were orders for 4 residents. She stated she immediately contacted the wound vac supplier and it was delivered the following day. On 8/18/24 at 8:25 am, Resident #1 stated she is supposed to be supported by a pillow on one side of her body, and then the pillow is supposed to be switched to the other side of her body every couple of hours. She stated that sometimes it happens on time and sometimes it takes a long time to get somebody. She stated she thinks part of the reason it takes a long time is the staff thinks it takes two people to reposition her but she feels if the staff know how to do it, it can be done with one person. She stated at that moment, she was lying on her back with no pillows under her. She stated she was not sure how long it had been since anyone had been in to reposition her. She said occasionally she has a staff member who will stick to the schedule and let her know exactly when they will be back to reposition again, but she considers it rare when staff follow through. On 8/18/24 at 8:37 am, Staff C, LPN stated Resident #1 prefers to be on her back during meals. But with encouragement she will reposition. She stated she has never had the resident refuse to reposition during times she has cared for her. On 8/18/24 at 8:41 am, Staff D, CNA stated the resident occasionally says no when she is asked about repositioning. On 8/18/24 at 8:46 am, Staff E, CNA stated at times when she offers to reposition Resident #1, the resident will tell her she is ok for now. She stated she can ring her call light when she wants repositioned. She stated if the resident refuses repositioning, it should be charted in Point of Care as refused. On 8/18/24 at 9:05 am, Staff F, Certified Medication Aide (CMA) stated Resident #1 is to be turned side to side only. He stated Resident #1 has never refused repositioning when he has worked with her. On 8/18/24 at 9:09 am, Staff G, RN, stated she works all over the building but is familiar with Resident #1. She stated to turn the resident and prop a pillow, it can be done with one staff member but she generally also needs to be boosted up in bed which requires 2 staff members. She stated the resident is fully alert and oriented and she has never refused cares for her. She stated the resident will ring her call light and also request to be turned at times. The undated facility policy Turning and Repositioning documented It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. The Policy Explanation and Compliance Guidelines documented: Repositioning will be documented in the resident's plan of care, and will be determined by the resident assessment which may include Braden Scale for predicting Pressure Sore Risk and/or like assessment as determined by the facility. The facility policy Pressure Injury Prevention and Management, review date 10/22/22 documented This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Point 2: The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Point 4d. -Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. -i. Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous diabetic, moisture or incontinence related skin damage. -ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics.

Based on record review, staff interviews, and policy review the facility failed to provide the care, interventions, and services to prevent the development of a pressure sore for 2 of 6 residents sampled as at risk for pressure ulcer development, (Resident #1 and #2). The facility reported a census of 116. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The admission MDS assessment dated [DATE] revealed Resident #1 admitted to the facility on [DATE] and had diagnoses of septicemia, MRSA (methicillin resistant staphylococcus aureus) (a bacterial infection), multi-drug resistant organism, and dementia. The MDS documented the resident had a risk for pressure ulcer development but had no pressure ulcers or skin issues during the assessment period. The MDS indicated the resident took an antibiotic during the 7-day look-back period. The MDS documented the resident required substantial to maximum assistance of staff for bed mobility and transfers, and had incontinence. The care area assessment triggered a category for pressure ulcer. The Care Plan initiated on 5/28/24 revealed the resident at risk for skin breakdown due to impaired mobility, incontinence, and high-risk medication use. The resident also required assistance with activities of daily living such as transfers and bed mobility. A focus area added to the Care Plan on 6/14/24 revealed the resident had an actual skin breakdown and classified the left and right heels had an unstageable deep tissue injury, and the right buttock had a skin tear. The Care Plan initiated 5/28/24 directed staff to: o Reposition and turn the resident in bed. o Provide assistance of one for transfers. o Administer medications and treatments as ordered. o Ensure a pressure reducing cushion in the chair, and a pressure relieving mattress on the bed. o Consult a wound care specialist as needed initiated 6/12/2024. o Assess the wound for signs or symptoms of infection such as redness, drainage, and odor initiated on 6/12/2024. o Administer antibiotics as ordered for bilateral heel wounds initiated on 6/14/2024. A CHI Admission assessment dated [DATE] indicated the resident's skin integrity intact. A CHI Skin One Time Observation Tool assessment dated [DATE] revealed the resident had intact skin (no abnormalities). The Braden Scale (used for predicting pressure sore risk) dated 5/17/24 documented the resident had a risk for pressure sore development. A Skin and Wound evaluation dated 6/11/24 revealed the resident had a new skin tear measuring 1.9 centimeters (cm) x 1.7 cm. The assessment lacked documentation of the wound location. The Medication Administration Record (MAR) dated 6/1/24 to 6/30/24 revealed the following orders: a. Bactrim (antibiotic) by mouth (PO) two times a day (BID) for 10 days for bilateral heel wounds started on 6/12/24. b. Portable 2-3 view x-ray of bilateral heels to rule out osteomyelitis ordered on 6/12/24 due to acute wounds to heels. c. Labs ordered on 6/13/24 due to resident's signs and symptoms of infection. The Treatment Administration Record (TAR) revealed the following: a. Reposition the resident per facility protocol and off-load wound every shift started on 6/12/24 at 7:00 AM. b. Prevalon boots to bilateral lower extremities at all times as the resident tolerated every shift started on 6/12/24 at 3:00 PM. c. Cleanse bilateral heels and apply betadine-soaked gauze pads, ABD (a large dressing) pad, kerlix, and tape in place daily for wound management started on 6/13/24 at 7:00 AM. d. Apply Triad paste to open wound on right buttock and cover with optifoam dressing daily started on 6/13/24 at 7:00 AM. e. Air mattress setting at 350. Check air mattress for correct setting and ensure it functioned properly each shift started on 6/13/24 and 3:00 PM. The Progress Notes revealed the following: a. On 5/17/2024 at 11:49 PM, resident admitted to the facility at 3:00 PM. Resident alert and oriented to time, person and place. Skin intact. Vital signs: blood pressure (BP) 135/76, temperature (T) 98.0, pulse (P) 75, respirations (R) 18. b. On 5/21/2024 at 10:16 PM, skin color normal. Skin intact with no abnormalities. c. On 6/11/2024 at 6:44 AM, a 2 cm x 2 cm skin abrasion noted on the resident's coccyx during cares. Triple antibiotic and ABD dressing applied. Resident repositioned to the lateral side to relieve pressure from coccyx. Resident did not seem to have pain during cares. d. On 6/12/2024 at 8:29 AM, the resident's skin assessed and a treatment performed to his peri-rectal area. Resident had the following new skin areas: 1). A 5.0 cm x 4.8 cm dark purple area with a white center on the left heel. 2). A 4.5 cm x 2.4 cm dark purple area on the right heel. Skin intact but not blanchable to either site. The resident denied pain. Heel protector boots placed and an air mattress ordered. At 10:34 AM, physician (Dr) at facility. New orders for wound care consult regarding heel wounds, bactrim ordered BID for 10 days for wound management, and x-ray of bilateral heels ordered to rule out osteomyelitis. At 3:20 PM, x-rays of bilateral heels obtained. Results pending. At 5:54 PM, an alternating air mattress delivered and set up on the bed. At 7:29 PM, x-ray results showed no acute fracture or dislocation or bony destruction to suggest acute osteomyelitis to bilateral heels. e. On 6/14/2024 at 3:26 PM, per hospital report, resident admitted for septic shock and respiratory failure. Resident currently intubated. A Physician's Encounter note dated 6/12/2024 at 12:00 AM, documented on 6/12/24 at 7:21 PM, revealed a follow-up on the resident's declining functional status and bilateral heel wounds on 6/12/24. Nursing staff noticed what appeared to be deep tissue injuries to the bilateral heels. The resident reported his feet are not painful. A family member reported she noticed some discoloration on his feet, particularly on the right foot. The physician documented the heel wounds as fairly extensive pressure-induced deep tissue damage with purulence in the center. X-rays of the bilateral heels ordered to evaluate for possible osteomyelitis. Started on Bactrim BID for 10 days due to concerns about potential infection in the heels. Wound care consulted. Nursing staff shall ensure proper offloading and pressure relief for the affected areas. An Origami Risk (incident) Report for Resident #1 revealed on 6/13/2024 at 10:00 AM, a skin assessment revealed the resident had the following new areas: 1. A 5.0 cm x 4.8 cm dark purple area with a white center on the left heel. 2. A 4.5 cm x 2.4 cm dark purple are on the right heel. Skin intact but not blanchable to either site, and surrounding skin pink/blanchable. The resident denied any pain or discomfort when areas palpated. Heel protector boots put in place. Director of Nursing (DON) notified and an air mattress ordered 6/13/24. A physician expected to visit the facility on 6/14/24 to assess the areas for appropriate dressings and further orders. The Braden scale indicated the resident at a high risk for pressure ulcers. A reviewer follow-up determined the areas as a deep tissue injury (DTI). A Stop, Think, Act, Review (S.T.A.R.) universal skill could have been used to prevent this incident from occurring. Immediate actions included: Wound areas measured and treatment initiated. Heel boots on at all times. Alternating air mattress ordered for the bed. A Provider's Encounter note dated 6/13/2024 at 12:00 AM that was signed on 6/14/24 at 3:07 PM revealed the provider saw the resident on 6/13/24 but the resident had a decline in status, fever, and hypoxia. Order to send resident to the Emergency Department (ED) for evaluation. An E-interact Change in Condition form dated 6/14/24 revealed the resident had a sudden change in level of consciousness and unresponsive, and required more assistance with ADL's started on 6/14/24. Vital signs included B/P 68 / 50, P 155, R 24, T 101.9, pulse oximetry (PO) 73%. Physician and resident representative notified. Resident sent to the ED. An E-interact Transfer form dated 6/14/24 at 4:00 PM revealed the resident sent to the ED due to abnormal vital signs (low b/p, elevated temperature and elevated pulse), pain in right heel, and pressure ulcers to his heels. The ED Provider note dated 6/14/24 at 12:22 PM revealed the resident presented to the ED with a B/P 58/42, T 99.0, P 172, R 30, PO 95 %. The resident had wounds present with ulcers on his bilateral heels. The provider's clinical impression/diagnoses included: septic shock (a life-threatening condition due to an infection causing low blood pressure and organ damage) and acute respiratory failure with hypoxia (lack of oxygen to the tissues). In an interview on 6/25/24 at 9:30 AM, Staff D, Registered Nurse (RN) reported she used an app on the IPAD for tracking wounds. A dot placed by the wound, and when she took a picture of the wound, the program calculated the wound measurements. Staff D stated since they had been unable to find the dots, the wound provider measured the resident's wounds. In an interview on 6/25/24 at 11:45 AM, Staff E, Certified Nursing Assistant (CNA), stated she looked at the resident's Care Plan in the Plan of Care (POC) to know what cares or things needed done for the residents. Staff E reported she placed a sheet under the resident in bed for lifting if a resident had a risk for pressure sores. The resident may also use an air mattress. She checked on the resident every 2 hours to see if they needed anything. Staff E reported she documented in POC whenever she transferred or did something with the resident. In an interview on 6/25/24 at 12:00 PM, Staff F, CNA, reported she got updates from the nurse and other staff on what she needed to do for the residents. A booklet at the nurse's station had information about new admissions such as how a resident transferred, if the resident had incontinence, and things like that. She didn't know who updated the book. Staff F stated the electronic POC not as reliable because the information not updated as often. Staff F reported a resident needed repositioned if a resident at risk for pressure ulcer. She rolled the resident onto their side as tolerated, then shifted the resident onto the opposite side the next time she checked on the resident. Boots placed on the resident's feet if the resident had a sore on their feet or heel. In an interview on 6/25/24 at 1:55 PM, Staff C, Licensed Practical Nurse (LPN), reported skin assessments performed by the nurses weekly on each resident and documented on the MAR. A Braden Scale assessment done when a resident admitted to determine their level of risk for pressure ulcers. Staff C also reported a total body assessment completed and documented in the EHR. At the bottom of the form, staff documented 0 if no new skin issues, or indicated the number of new skin issues found. Staff C reported if a resident is at risk for pressure ulcer and had incontinence, she started house barrier cream, and let the DON know if the resident needed an alternating air mattress. If the resident at risk or had breakdown, then heel boots applied or heels floated on a pillow. Staff C stated if a resident had a wound, she documented in the Nurse's Note, notified the family and Dr., and filled out an incident report. Staff C stated she helped follow up on pressure ulcers/wounds whenever Staff D was off. Staff C stated a little dot placed by the wound, a picture taken, and the program calculated the measurements of the wound. Since they haven't been able to find the little white dots, a manual measurement done instead using a paper measuring tool. She communicated in report to the CNA's any new skin areas, and interventions or what they needed to do for the resident. Staff C reported only one nurse with 3 CNA's on Central (skilled unit) Hall. The residents' acuity levels were higher and there were a number of treatments to do. Several residents needed a hoyer lift for transfers and some residents needed help with eating. Staff not getting residents up because they don't have time and they don't have enough help, and the residents don't get repositioned like they should. She confirmed she had noticed residents with a lot of skin issues. Staff C stated staff had to choose if they were going to change someone or do something else. Staff C reported she was the one who found the wounds on Resident #1's heels when she went to do a treatment on his bottom. When she rolled him over to do the treatment, she noticed the wounds on his heels. One wound was the full size of his heel, and had swelling and a fluid-filled blister. The fluid did not appear clear, it was black. If she took a pin and popped it open, the skin under it would be necrotic. The resident didn't have an air mattress on the bed and he had no heel boots on the day she found wounds on his heels. She let the DON know and the air mattress was delivered the same day. She called the Dr and started treatment on his heels. In an interview on 6/25/24 at 2:30 PM, Staff G, RN, reported staffing could be better. One nurse for 30 residents is a lot. Staff get pulled to work in other areas when other units are short staffed. Staff not able to get residents up or provide the assistance they needed. In an interview on 6/25/24 at 3:10 PM, the wound Dr. reported the interventions put into place depended on the resident and if a resident at risk for pressure ulcers. If a resident had a Stage 2 pressure ulcer on the feet/heels then heel boots should be placed. In an interview on 6/26/24 at 9:15 AM, Staff H, RN, reported a head to toe skin assessment for certain residents assigned each day to the day and evening shift nurses. Skin assessments documented in the EHR under the full body assessment. She documented any skin concerns or wounds on the skin & wound assessment. Boots applied if a resident had a risk for pressure sores or a history of pressure ulcer on the heels. An air mattress placed on the bed and resident frequently repositioned if the resident had a wound/skin area on the sacral area. Staff H reported things don't get done when they are short-staffed. There are delays, residents don't get positioned timely and not changed as frequently, and then pressure ulcers developed. Staff D reported they do the best they can, but only have 2 nurses or 1 nurse and 1 CMA for 60 residents. In an interview on 6/26/24 at 3:20 PM, Staff J, RN, reported the nurses made recommendation on positioning devices if a resident at risk for pressure ulcer. He called the DON whenever a skin concern/area found. He got permission to use boots, and he may get an air mattress depending upon if the resident had a wound or risk for skin breakdown. He would also elevate legs on pillows to float heels if a resident not able to position themselves in bed. Staff J reported Resident #1 required staff to check on him. He didn't remember to use the call light. Staff checked on him every 2 hours on the night shift. They elevated his extremities on a pillow because he was in bed most of the time. In an interview on 6/27/24 at 2:15 PM, the surveyor asked the Administrator what the facility had done to improve and address the repeat deficiencies from the most recertification survey and prior surveys included pressure ulcer development. The Administrator responded he had been the Administrator at this facility since 3/2024, and he couldn't speak for prior Administration. They continued to do audits and staff education monthly since he started in 3/2024. He implemented a PIP (Performance Improvement Plan) on 4/2024, and put in some action plans in the past month. They made a targeted effort and are strategically working with staff to be successful to learn what needed to be done. The Administrator stated he is not a nurse but thought a lot of skin concerns were related to moisture, some residents refuse to eat or drink, and the resident's skin integrity already compromised from their hospital stay. A facility's policy for Pressure Injury Prevention and Management implemented 10/24/22 revealed the facility is committed to the prevention of avoidable pressure injuries and provision of treatments and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Evidence-based interventions for prevention implemented for all residents assessed at risk for pressure injury or who had a pressure injury present. Basic, routine care interventions included: pressure redistribution such as repositioning, protecting or offloading heels, exposure to moisture minimized, skin kept clean, and nutrition maintained. Interventions documented on the care plan and also communicated to all relevant staff. 2 The admission MDS assessment dated [DATE] revealed Resident #2 had diagnoses of stroke, hemiplegia (paralysis on one side), diabetes, malnutrition, and adult failure to thrive. The MDS documented the resident had a risk for developing a pressure ulcer but had no pressure ulcers or skin issues. The resident had incontinence, required substantial to maximum assistance for bed mobility, and had dependence on staff for transfers. The MDS assessment 4/23/24 revealed the resident had a Stage 4 pressure ulcer to the sacral region. The MDS documented the resident had incontinence, required substantial to maximum assistance for bed mobility, and had dependence on staff for transfers. The MDS assessment dated [DATE] revealed the resident discharged to the hospital and a return to the facility anticipated. A Baseline Care Plan dated 1/18/24 revealed the resident had no skin alterations. The Care Plan initiated on 1/29/24 revealed the resident had a risk for skin breakdown due to left hemiplegia, diabetes, immobility, incontinence, and malnutrition. The resident required assistance of two staff for transfers and to reposition and turn in bed. The Care Plan directives included the following: o Administer treatments as ordered and monitor for effectiveness. o Use a pressure reducing cushion in the chair and a pressure reducing mattress on the bed. A Care Plan revision on 3/29/24 included a low air loss mattress. The Care Plan revised on 4/18/24 revealed the resident had an actual skin breakdown and blistering on her lower back. The staff directives included: o Consult a wound care specialist as needed. o Monitor for wound healing and notify the physician if no improvement. A Care Plan focus area initiated 4/26/24 revealed the resident had a Stage IV pressure ulcer to the sacrum. The staff directives included to encourage the resident to reposition frequently (Initiated 4/26/24). A CHI Admission assessment dated [DATE] indicated the resident's skin intact. A CHI Skin One Time Observation Tool assessment dated [DATE] revealed the resident had intact skin (no abnormalities). The One Time Skin Observation Took assessment dated [DATE] documented a new skin concern, indicating a medium fluid-filled intact blister to Resident #2's upper mid-vertebrae. The Braden Scale dated 1/18/24 documented the resident had a moderate risk for pressure sore development. The Braden assessment dated [DATE] revealed the resident had a high risk for pressure ulcer development. The Skin and Wound assessments revealed the following: On the left ischial tuberosity: 2/6/24 MASD 1.9 cm x 0.9 cm 2/13/24 MASD 0.4 cm x 0.4 cm 2/20/24 MASD 1.4 cm x 0.6 cm; Treatment: Triad paste 2/27/24 MASD 1.1 cm x 0.9 cm 3/5/24 MASD 0.4 cm x 0.4 cm 3/12/24 MASD 1.3 cm x 1.1 cm 3/19/24 MASD 1.6 cm x 1.2 cm 3/26/24 MASD 1.4 cm x 0.7 cm 4/2/24 MASD 1.7 cm x 1.0 cm 4/9/24 Stage 3 pressure area (in-house acquired) measured 5.7 cm x 3.2 cm 4/16/24 Stage 3 pressure area 6.7 cm x 3.5 cm 4/23/24 Stage 4 pressure ulcer 3.9 cm x 2.8 cm. Wound deteriorated. Wound specialist notified. 4/30/24 3.9 cm x 3.1 cm x 0.3 cm 5/7/24 3.6 cm x 2.4 cm On the left lower back: 4/16/24 A blister on the left lower back measured 0.3 cm x 0.1 cm The Treatment Administration Record (TAR) dated 3/1/24 to 4/30/24 revealed the following: a. Apply Triad paste to left buttock BID until wound healed started on 2/5/24 at 6:45 PM and discontinued on 3/31/24. b. Apply Triad paste to bilateral buttocks for BID started on 3/31/24 at 8:00 PM c. Check air mattress each shift to ensure air mattress plugged in, functioning properly and at the correct setting for skin protection started on 3/28/24 at 11:00 PM. d. Apply skin prep to fluid filled blister on left side of back (mid rib cage) started on 3/20/24, and discontinued on 3/29/24 at 4:56 PM. e. Apply bacitracin to site, cover with protective dressing daily and PRN for compromised skin area started on 3/30/24 at 7:00 AM and discontinued on 4/13/24. f. Apply calcium alginate to buttocks wound bed and a foam dressing to the sacral area daily started on 4/14/24 at 7:00 AM and discontinued on 4/24/24. g. Apply santyl and calcium alginate to the wound bed, then apply a sacral foam dressing daily started on 4/25/24 at 7:00 AM and discontinued on 5/7/24. An Origami Risk (incident) Report for Resident #2 dated 3/19/24 at 2:00 PM revealed a medium size intact fluid-filled blister noted to the back (posterior rib cage). No signs or symptoms of infection observed. Treatment orders obtained and education provided to the resident about frequent re-positioning. No incident report provided by the facility for the left ischial tuberosity skin concern. A Notice of Resident Transfer form dated 5/8/24 revealed the resident transferred to the hospital for evaluation of a wound and abnormal labs. Review of the Progress Notes revealed the following: a. 1/18/24 at 10:49 PM, resident admitted to facility. Skin intact. b. 2/25/24 at 11:55 PM, Skin assessment completed and no new skin issue noted. c. 3/29/24 at 5:00 PM, an open skin area on the left side of resident's back just below the armpit. The blister on the left side of her at the mid rib cage now open. Dr. notified. New orders received for bacitracin and protective dressing daily and PRN until resolved. d. 4/13/24 at 9:36 PM, wound bed and size of wound on bottom had deteriorated. Wound bed reddish/yellow in color and had clear drainage. Area tender when touched. New orders received to cleanse bilateral buttocks, apply calcium alginate to wound bed, and apply a sacral foam dressing daily until the area healed. e. 5/7/24 at 5:04 PM, open area on back measured 3 cm x 2 cm. Triple antibiotic ointment applied and area covered with a gauze. f. 5/8/24 at 7:15 PM, Dr assessed resident at approximately 12:30 PM. Resident unresponsive to questions but responded to pain. Face is cold and clammy but extremities warm. Dr assessed wound to sacrum. No signs of infection or odor noted. No drainage observed when removed the packing. T: 100.6, B/P: 42/39, P 119, unable to obtain pulse ox reading. Resident sent to the ED. g. 5/9/24 at 10:47 PM, hospital nurse reported the resident passed away at 6:52 PM. In an interview on 6/25/24 at 1:55 PM, Staff C, LPN, confirmed Resident #2 did not have a wound when she came to the facility. Staff C reported the resident had started to decline prior to going to the hospital. She was bed ridden, used a hoyer for transfers, and staff had to help feed her. It was the resident's preference to stay in bed because it hurt her to get up. She started to get skin breakdown on her bottom. She offered to send the resident to the hospital but a family member didn't want her to go to the hospital at that time. In an interview on 6/26/24 at 9:15 AM, Staff H, RN, reported Resident #2 used a hoyer and required assistance of staff for transfers and bed mobility. The resident developed a pressure sore while at the facility. A treatment was started. The wound Dr saw her. Staff H reported when they are short-staffed things don't get done. There are delays in residents not getting positioned timely and they don't get changed as frequently. Staff H confirmed residents then developed pressure ulcers. Staff D reported they do the best they can, but only have 2 nurses or 1 nurse and 1 CMA (certified medication aide) for 60 residents. In an interview on 6/26/24 at 3:20 PM, Staff J, RN, reported Resident #2 was bedbound and needed assistance with everything. She had weakness on one side, and she liked to [NAME] on one side. She complained of pain whenever they positioned her onto her left side. They checked and changed the resident. She had a wound on her bottom and had treatments provided to the area.

Based on observations, clinical record review, staff interviews, provider interviews and facility policy review the facility failed to provide skin assessments per policy and provide treatments per physician's orders to prevent the development and worsening of a facility acquired pressure ulcer which required the physician to complete a debridement of a Stage IV pressure ulcer to the coccyx for 1 of 3 residents (Resident #11) reviewed for pressure ulcers. There was an immediate need for the facility to take steps to ensure residents were protected from risk of development or worsening of wounds. The facility reported a census of 110 residents. On February 22, 2024 at 3:05 PM, the State Survey Agency informed the facility of the staff's failure to assess and provide treatments per physician's orders created an Immediate Jeopardy situation resulting in the development of a Stage IV pressure ulcer as discovered on February 14, 2024. The facility staff removed the immediacy on February 23, 2024 at 1:37 PM when the staff implemented the following Corrective Actions: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 16 [DATE]) a) The Director of Nursing (DON) and designee(s) conducted skin assessments on all residents. Concerns were not identified. b) An audit was conducted to ensure all treatments, supplies, and equipment were readily available for ordered wound treatments by Nursing Supervisors and designee(s). c) A medical records review was completed on all residents by Nursing Supervisors and designee(s) to ensure weekly skin assessments were completed and treatment recommendations/orders were in place. The facility took the following actions to prevent an adverse outcome from reoccurring: (Completion Date: 22 [DATE]) a) The facility policies on Skin Assessment and Pressure Injury Prevention and Management were reviewed and revised as needed. b) An audit of all pressure relieving devices and support surfaces was conducted by the Nursing Supervisor(s) to ensure proper use. c) The DON or designee provided education to all licensed nurses on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures. This included ensuring residents had necessary support surfaces and pressure relieving devices. d) The DON or designee educated all nurse aides on preventative skin care. e) The DON or designee conducted treatment record and nursing documentation audits 5 days a week to ensure accurate and complete documentation of skin related treatments and preventative measures. f)The DON or designee will continue to monitor/audit 3 residents each week for the following: 1)Observation of treatments 2)Preventative skin care 3)Weekly skin assessments g) A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education, their policy and procedures. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3, or stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The admission Minimum Data Set (MDS) assessment tool with a reference date of 12/11/23 documented Resident #11 had a Brief Interview of Mental Status (BIMS) score of 9. A BIMS score of 9 suggested she had mild cognitive impairment. An admitted was documented at 12/7/2023. Resident #11 did not exhibit rejection of care during the 7-day review period. The MDS indicated Resident #11 was at risk for the development of pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. Resident #11 had moisture associated skin damage (MASD), had a pressure reducing device for her chair and bed, was not on a turning/repositioning program, did not utilize nutrition or hydration interventions to manage skin problems and had ointments/medication other than to her feet. The MDS documented her weight in pounds was 327 and was 64 inches tall. The following diagnoses were listed: stroke, cancer, diabetes mellitus, hemiplegia, seizure disorder, anxiety, morbid obesity, and body mass index (BMI) 50.0-59.9. The discharge-return anticipated MDS assessment tool with a reference date of 2/16/24 documented Resident #11 had severely impaired cognitive skills for daily decision making. She did not exhibit rejection of care during the 7-day review period. She was dependent on staff for toileting hygiene, showering, dressing, chair/bed to chair transfer. The MDS documented she had an unhealed stage 4 pressure ulcer/injury that was not present upon admission. The active diagnoses portion of the Electronic Health Record (EHR) of Resident #11 documented diagnoses of: hemiplegia (paralysis of one side of the body) affecting left dominant side, muscle weakness, reduced mobility, need for assistance with personal care, seizures, malignant neoplasm of endometrium, anxiety disorder, atrial fibrillation, lymphedema, morbid obesity, obstructive sleep apnea, BMI 50-59.9, spinal stenosis, type 2 diabetes mellitus, vitamin D deficiency, cerebral infarction due to thrombosis of right cerebellar artery. The Baseline Care Plan for Resident #11 dated 12/7/2023 documented the following skin integrity issues: slight redness to groin, abdominal folds, and groin. Her bilateral lower extremities and feet dry and scaly. The Comprehensive Care Plan of Resident #11 initiated 12/13/2023, identified a Focus Area of an Activities of Daily Living (ADL) self care performances deficit related to hemiplegia, impaired balance, limited range of motion and stroke. The Care Plan indicated she required two staff members to reposition and turn in bed. Staff directed to use a mechanical lift for transferring and two staff members. She is totally dependent on staff for bathing and toileting. A second Focus Area documented she is at risk for skin breakdown due to diabetes, immobility, and incontinence. Staff directed to administer treatments as ordered and monitor for effectiveness. Staff also encouraged to follow facility protocols for prevention/treatment of skin breakdown. The care plan documented she had a pressure reducing cushion in her chair and mattress on her bed. A Focus Area with an initiated date of 2/18/24 documented she had a stage IV pressure ulcer to her coccyx. Staff directed to measure length, width, and depth where possible. Assess and document the status of wound perimeter, wound bed and healing progress and report improvements and declines to the physician. Staff to consult the wound specialist as ordered and his physician will see her in the facility. Staff to encourage frequent repositioning. Resident #11 will require supplemental protein, amino acids vitamins, minerals as ordered to promote wound healing. While completing dressing changes staff to monitor the wound for signs and symptoms of infection/worsening (redness, increased pain/tenderness/drainage, edema, warmth). Resident #11 had a low air loss mattress placed. The following Braden scales for predicting pressure sore risk completed as following: -On 12/7/23 at 7:37 PM documented a score of 13, indicating Resident #11 was at moderate risk for developing pressure sores -On 2/14/24 at 10:00 PM documented a score of 13, indicating resident #11 was at moderate risk for developing pressure sores -On 2/15/24 at 1:01 PM documented a score of 10, indicating Resident #11 was at high risk for developing pressure sores The Admission assessment dated [DATE] at 5:21 PM documented slight redness to abdominal folds, bottom and groin with treatment in place. Bilateral lower extremities and feet dry and scaly. The admission Skin One Time Observation Tool dated 12/7/23 at 7:39 PM documented the following impaired skin areas: slight redness to her groin, abdominal folds and bottom; bilateral lower extremities and feet dry and scaly. The total body skin assessments completed on 12/22/23, 12/29/23, 1/5/24, 1/9/24, 1/12/24, 1/19/24, 1/26/24, and 2/2/24 documented 0 when asked to enter the # of new wounds. The plan of care response history review completed on 1/29/24, 2/4/24, 2/5/24, 2/6/24, 2/7/24, 2/8/24, 2/11/24, 2/12/24, 2/13/24, and 2/15/24 instructed staff to complete skin observations and notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Staff documented yes when asked if an observation of resident's skin completed. The Skin and Wound Evaluation dated 2/15/24 at 9:21 AM documented it was still in progress. The evaluation documented Resident #11 had a new Stage III: full-thickness skin loss, pressure ulcer on her intergluteal cleft (butt crack) that was acquired in-house with the following measurements 43.9 centimeters (cm) x 10.2 cm x 6.9 cm. The depth, undermining, and tunneling were not applicable. Review of Resident #11 orders revealed the following order with a start date of 12/7/23 and end date of 2/15/23: cleanse resident's buttocks with soap and water, apply a layer of Z-guard paste every shift for skin integrity. The paste is to be applied during the day, evening and night shifts. Review of the December 2023 Treatment Administration Record (TAR) revealed the order not signed out as being completed on: a. 12/10/23 day shift b. 12/13/23 night shift c. 12/15/23 day and evening shifts d. 12/16/23 evening shift e. 12/17/23 day shift f. 12/20/23 day shift g. 12/21/23 day shift h. 12/22/23 day shift i. 12/26/23 day, evening and night shifts j. 12/27/23 night shift k. 12/28/23 day shift l. 12/29/23 evening shift m. 12/30/23 evening and night shifts Review of the January 2024 TAR revealed the order not signed out as being completed on: a. 1/2/24 evening shift b. 1/3/24 day shift c. 1/4/24 day and evening shifts d. 1/5/24 day and evening shifts e. 1/9/24 day and evening shifts f. 1/12/24 day shift g. 1/13/24 evening shifts h. 1/15/24 day shift i. 1/16/24 evening shift j. 1/18/24 evening shift k. 1/19/24 evening shift l. 1/20/24 day shift m. 1/22/24 day shift n. 1/23/24 day shift o. 1/26/24 evening shift Review of the February 2024 TAR revealed the order not signed out as being completed on: a. 2/14/24 night shift The Occupational Therapy (OT) Discharge Summary with a date of service of 12/8/23-1/4/24 documented an Assessment and Summary of Skilled Services: trialed multiple interventions to promote out of bed activity. Resident able to tolerate an average of 15 minutes of sitting in her wheelchair before requesting to go back to bed. Trialed sitting unsupported, averaging about 5 minutes of sitting with minimum to moderate assistance. Resident dependent with peri cares and toileting due to inability to tolerate out of bed activity. Discharge Recommendations and Status: recommend 15-20 minutes of sitting in wheelchair with the use of the mechanical lift to transfer. The Physical Therapy (PT) Discharge Summary with a date of service of 12/8/23-1/4/24 documented a Discharge Recommendations and Status: resident requires assistance for all ADL's and is dependent on staff for all functional mobility to prevent skin breakdown. The Progress Notes documented the following: a) On 2/14/24 at 10:00 PM the charge nurse called asking this nurse to come to Resident #11's hall right away. The charge nurse for unit stated that she had a skin issue she would like for this nurse to look at. They entered the resident's room and two Certified Nursing Assistants (CNAs) were present providing peri cares to resident. Resident turned on her left side. Charge nurse stated that she would like for this nurse to see resident's bottom. This nurse assessed peri-rectal area. Resident had a pressure area the size of a baseball with undetermined depth/tunneling to coccyx site. Edges are irregular and macerated. Wound bed with dark red, black tissue present. Serosanguinous (bloody drainage) drainage noted to site with other areas of excoriation surrounding wound. Current treatment regimen that has been in place to site since admission is Z-guard ointment to site. Z-guard treatment discontinued as it was no longer effective for deteriorated site. Treatment initiated as follows to coccyx: (1) cleanse site; (2) apply skin prep to intact skin surrounding site; (3) pack wound with saline soaked gauze; (4) cover with protective dressing every shift and as needed (PRN). Order written to have wound assessed/followed by the physician who will be in house tomorrow. Resident not on an air mattress and will need one due to the wound. Staff educated that resident is to be turned and repositioned frequently off-loading off of bottom as much as possible and is also to be checked and changed frequently. Resident incontinent of urine and consideration may need to be suggested for a Foley catheter placement for wound management. Note left for Accredidated Registered Nurse Practitioner (ARNP) regarding area who will be in house on rounds tomorrow. Attempted to notify emergency contact with no answer. Message left requesting returned call to facility. Will continue to monitor for any change in status. b) E-signed by ARNP on 2/15/24 at 3:22 PM notified by nursing this morning of newly discovered wound to resident's coccyx. On assessment she has a decubitus ulcer, stage 3 to intergluteal cleft. Gauze packing present with gauze covering dressing. Wound with mild serosanguinous drainage. Second open more superficial wound to about 4:00. Peri wound with redness to deep purple discoloration. Wound is painful to resident with dressing change. Orders left in facility for dressing changes. Resident is incontinent of urine, order given for Foley catheter for wound care. Consult placed for physician for wound care. She is planning to see resident tomorrow morning. Date wound was identified 2/15/24 on her coccyx, stage 3, measured at 10.17 cm x 6.94cm, 3.08cm x 1.76cm with moderate amount of serosanguinous drainage, no odor. Orders left in facility for: wet to dry dressing pack with gauze soaked in Dakins (clean infected wounds) solution. Cover with boarder Mepilex (absorbent foam dressing). Change BID. Skin prep to peri wound. Insert Foley catheter for wound care, liquicel (liquid protein) twice a day (BID), consult dietician for nutritional support for wound healing, consult Doctor of Osteopathic medicine (DO) for continuing wound care, complete blood count (CBC) with differential, sedimentation rate (look for inflammation in body), basic metabolic panel (BMP) today, air mattress, and frequent repositioning of patient. c) On 2/16/24 11:07 AM resident seen by DO today for an assessment of her coccyx wound, wound debrided during today's visit. Wound measured 14cm x 13cm x 3.5cm, moderate serosanguinous drainage noted, noted redness to surrounding skin area, resident tolerated procedure well, no complaints of pain, treatment orders in place, family updated and plan of care ongoing. An Initial Wound Evaluation and Management Summary dated 2/16/24 documented by DO. The following was documented: resident present with a wound on her coccyx. At the request of the referring provider a thorough wound care assessment and evaluation performed today. Focused wound exam (site 1): stage 4 pressure wound that measured 14 cm x 13 x 3.5cm with a surface area of 182cm. There was moderate serosanguinous drainage with 70% thick adherent devitalized necrotic tissue, 20% slough and 10% other viable tissue (muscle, bone). Site 1 Surgical Excisional Debridement Procedure: to remove necrotic tissue. The wound cleansed with normal saline and anesthesia achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups used to surgically excise 36.4cm of devitalized tissue and necrotic periosteum and bone along with slough and biofilm were removed at a depth of 4 cm and healthy bleeding tissue observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 90 percent to 70 percent. Hemostasis achieved and a clean dressing applied. Observation on 2/21/24 at 2:45 PM revealed resident had an air mattress on her bed. There was a pair of Prevalon boots in her chair, a black wedge, two chair cushions and a U-shaped chair cushion in her room. Only two pillows noticed in her room, rested on her bed. On 2/22/24 at 1:45 PM resident remained at the hospital. On 2/21/24 at 4:12 PM Staff K Registered Nurse (RN) called. The number stated the party was unavailable, please try again later and the call ended. On 2/21/24 at 4:18 PM Staff M LPN stated total body skin assessments are usually completed in the morning or evenings and when there is a new skin area of concern. They do have a wound physician that will come in and assess and complete the treatments if the wounds are chronic or in bad shape. When asked how she completes the skin assessment she stated she usually goes in while they are getting their shower to check everything. She will also let staff know so she can do a skin check during cares, then they will come get her. She did take care of Resident #11 and when she did care for her she spent most of her days in bed. When staff would get her up in her wheelchair she instantly wanted to go to bed. Staff M added the resident was incontinent of urine and bowel. Since she met her she could tell her cognition had decreased due to her brain tumor. At the beginning of her time at the facility, Resident #11 was more active with movement but now she does not move at all. When asked how Resident #11 would reposition, Staff M stated she would do little movements but would not roll over on to her side for offloading, staff would do that. When asked if she noticed her offloading she stated she's not sure because she was a bigger lady and would flatten the pillows or anything they put under her to offload. She does not remember seeing positioning wedges or body pillows of any kind in her room. When asked if Resident #11 had skin issues, Staff M stated just on her buttocks, they were putting triad cream on it for a little while. Then they started to discontinue a lot of the treatments because it was too expensive so they either changed to no treatment or to A&D ointment, creams like that. Her bottom had a pinkish tint to it but did not know how long ago it started. Staff M stated she had a regular mattress and that did not make sense to her since she was a bigger woman. The last few times they repositioned her, staff went to pull the sheets from under her and they found a big wound on her buttock that required cleansing and packing. She indicated this was found on the morning of February 15th. She believed staff had known about it for a day or two before that. Staff M was asked if she felt the facility did everything they could to prevent this wound from developing she stated she was unsure but felt they could have done more. When asked what she would have done differently she stated for a woman her size she would get overlooked. Staff would not want to do cares on the bigger residents because they were harder to do. Plus, when they run short on the overnight shifts it's harder for staff to do cares like they would like to do. Once the wound was discovered they inserted a Foley catheter, repositioned her more and an air mattress was put in place. On 2/21/24 at 4:34 PM Staff B Licensed Practical Nurse (LPN) stated the Director of Nursing (DON) makes a list on paper of what skin assessments she wants checked, then leaves it at the nurse's station for the nurses to complete. When asked how those assessments are completed she stated the nurse goes in and checks the skin, then will go to the computer and chart in the Electronic Health Record (EHR) this includes any new areas. She likes to do them while the residents are in bed before they get dressed. Staff B stated she was recently educated to look at every skin area, separate the buttocks and lift folds to see if there are any wounds. When asked why this education was provided she stated they recently had a large woman that had a wound but all she knew she had was an area where they were putting cream on it. She admitted before she was not separating the skin to look for wounds, she would just turn the resident side to side, not open up the buttocks to see if there were wounds. She never saw the wound that was developed but was told it was between her buttocks and since she was obese you would have to separate the butt cheeks. Other staff members told they would have to lift the excess skin to see the wound. Staff B stated nobody noticed that wound, not even the DON when she went in to her room, no one noticed it because she was a bigger lady. Staff B stated when she would work on Resident #11's hall, she was always in bed, was not up in her wheelchair but when they tried to get her up she would cry to go back to bed. She could not recall what kind of bed the resident had and indicated she was not sure if the CNAs were turning her or not. Staff B stated Resident #11 was incontinent of urine and bowel. When asked if the resident was ever in bed offloading, she acknowledged when she would go in to do the cream treatment she never saw pillows under her. When asked if she felt the facility could have done more to prevent the pressure ulcer from developing she stated she felt bad that no one noticed it. She felt there was too much to do with what staff they had on the floor working. She felt staff are over worked and under staffed. She added Resident #11 was on the skilled unit and they need more staff on that unit. She felt if they been staffed well, this would not have been an issue but everyone is rushed there. On 2/21/24 at 4:59 PM Staff C LPN stated skin assessments are completed dependent on what resident the DON tells nurses that need an assessment completed. When asked how they are completed she stated she will go to their rooms to complete the skin assessment while they are in bed. When asked to talk about Resident #11 she stated she liked to spend most of her time in bed, and did not recall if she got out of bed. When the resident was first admitted she was working with therapy and got her up maybe one time. She would get up to shower maybe twice. Staff C was asked if staff assisted Resident #11 with repositioning and she stated the resident could not do that herself, staff would have to do it but was unsure how they repositioned her. When asked what she meant she stated that floor is busy but when she would go in there she would see her on her side, not sure for how long those. When staff are busy they can't pay attention to everything. Staff C unsure what kind of bed the resident had because she was always in it. She recalled Resident #11 had superficial areas on her bilateral buttocks that they were applying creams to. Staff C added only nurses could apply those creams and would be signed out on the TAR every shift. When asked if Resident #11 had any open wound, she stated they were not open just superficial, and two areas. She did not see anything else, she couldn't see anything else. When asked what she meant by that she stated unless you were looking for something or aware of it, you would need to separate her butt cheeks. She indicated Resident #11 was a big lady and when she would lie down the skin lays over itself making it hard to see anything. To see anything, you have to move the area, lift the buttocks with two hands to see the superficial areas. On 2/21/24 at 6:19 PM Staff L Certified Medication Aide (CMA) stated she never assisted with any personal cares and was unsure what kind of bed she had. When asked if she noticed Resident #11 being repositioned she stated she had not noticed her being repositioned on her sides. She had witnessed some CNAs telling nurses that Resident #11's bottom needed attention but that was it. On 2/22/24 at 8:14 AM Staff F CNA stated Resident #11 would get out of bed with therapy and with staff. Once she was up she would not want to stay up long because she complained of back pain. She had a regular mattress, no air mattress but did get an air mattress after they found the wound. Resident #11 required staff assistance for positioning because of her left sided weakness. Staff F stated when she would go in to Resident #11's room she would put a pillow under her arm or lower back because she would not roll on her own. It usually took 3-4 staff to do this. When asked if she noticed any skin issues Staff F stated she had one open area by her tailbone but it was not big. Staff F stated she was off when the bigger wound was discovered but when she came back to work they told her about it. She indicated the resident was incontinent of bowel and bladder. When the resident first came to the facility she would let staff know when she needed changed but when she started to decline she would not use her call light to be changed so they would just check and change her. On 2/22/24 at 8:40 AM the ARNP stated she was not aware that Resident #11 had wounds prior to the wound found on her buttock. When asked on the day she went to the facility to assess the wound what kind of mattress Resident #11 was laying on she indicated a regular mattress. She added after she completed her assessment she did order an air mattress for the resident as well as an order to insert a Foley catheter. The ARNP indicated the wound was located on Resident #11's coccyx and could be seen if you separated her butt cheeks. If they were not separated you could see there was something there but could not see the entire wound that way. She was unsure how long it took for the wound to develop but added Resident #11 has poor nutrition, would refuse cares at times which included repositioning but she could not speak for what took place the week prior to finding it. She added since she was incontinent of urine a catheter was inserted to promote wound cleaning. When asked if she felt the facility did what they could to prevent this wound from developing she indicated she was not sure what they were doing to prevent it from happening since she was admitted . On 2/22/24 on 9:21 AM the DO stated when she went to the facility February 16th that was the first time she saw Resident #11 and the first time she was aware of any skin issues. She was asked if you could see the wound without separating her butt cheeks, she stated it was a large wound and once the dressing was removed you could see it. The wound was not small and it's not hidden. She has had patients of that size with the same wound and would need to separate the fatty tissue to see it. She added this wound did not just happen, it was past that point because it was advanced. She added she was unsure when it started. When she went to see the resident on February 16th, she was lying on her side, uncovered and staff had her butt cheeks separated. With the size of the wound she believed you could see it if you went in to do cares. Once she assessed the wound she debrided it, she was concerned about Resident #11 being in pain but she slept through it. When asked what stage the wound was she stated stage IV because she could probe bone during the treatment. Her assessment note would be in the resident's medical record. When asked if this wound was avoidable or unavoidable she indicated she does not use those terms. She has seen a lot of residents in situations where they are prone to the development of wounds or susceptible to pressure ulcers because they are bed bound, hardly out bed, does not move themselves, or needs to be repositioned. The resident was immobile, had chronic medical conditions and at high risk of pressure wounds so it's not black and white when it comes to avoidable and unavoidable. On 2/22/24 at 9:34 AM and 2/26/24 at 10:27 AM attempts were made to speak with Staff I Unit Manager. At the conclusion of the survey, no return call received. On 2/22/24 at 11:31 AM the DON stated total body skin assessments are completed upon admission and once a week. When asked how they are completed she stated whenever they have time to do them, they are to do a head to toe to look at all the skin either in the shower or before getting out of bed. The DON indicated when Resident #11 was admitted the assessment documented redness to her buttock but unsure what interventions were put in place and she would have to look. When asked about offloading she stated Resident #11 would be repositioned frequently, with pillows to keep pressure at a minimum. They would attempt to get her up in the wheelchair throughout the day but did not do well with that. She believed they would attempted to get her up for an hour a day. She had a standard pressure relieving mattress prior to getting the air mattress. Resident #11 weighed 318 pounds and felt the pressure relieving mattress was sufficient for her because it was wider than a standard mattress. When asked where the skin assessments were from 12/7/23-12/22/23 she obtained daily skin assessment sheets from her office. She was able to find assessments on 12/8/23: groin was red with treatment in place and 12/22/23: no new skin issues noted. The DON shown the TARs that lacked documentation of the Z-guard being signed out as completed and she stated awesome. When asked who completes those treatments, she stated the nurses do. When asked about the new wound she stated once her butt cheeks were separated you could see it was there: sacrum, coccyx, buttocks but was not sure on exact measurements. There was redness like shearing on her butt cheeks that were visible during cares and baths. When asked if the wound was visible during cares she stated not the entire area, would, had to lift the skin up but you could see there was excoriated areas. When asked what her expectations were while the nurses completed skin assessments she stated staff should be lifting the breasts and folds, looking between toes and spreading the resident's butt cheeks to look for any skin issues. When she spoke with nurses about what had happened they acknowledged they were not separating the resident's butt cheeks to look for any skin breakdown. She educated nurses on how to complete skin assessments, did a facility ski[TRUNCATED]

Based on staff interview, pharmacist interview, physician interview, clinical record review and facility policy review, the facility failed to prevent significant medication errors which included: Staff A, LPN crushed morphine extended release medication 90 milligrams (mg) and administered it to Resident #1. The facility also administered 16 mg of Dexamethasone (steroid) instead of 4 mg as ordered for Resident #2. Additionally, Resident #3 received a narcotic medication on an as needed dose without an order. On 8/2/23 at 1:30 PM, the State Agency (SA) notified the Administrator and Director of Nursing (DON) of the Immediate Jeopardy of F 760 significant medication error. The Immediate Jeopardy began on 7/24/23 at 6:40 AM when Staff A, LPN crushed morphine extended release medication 90 milligrams and administered it to Resident #1. The facility removed the immediacy on 8/3/23 at 8:25 AM with the following removal plan: 1. The DON or designee re-educated licensed nurses and certified medication aides (CMA) regarding facility policy Medication Administration and Medications Not to Be Crushed. Education initiated 8/2/23 at 2:00 PM. All nurses and CMA's are educated prior to working their next shift. 2. The DON completed corrective action and one-to-one education on above listed topics with licensed nurse/CMA identified as being deficient in their practice resulting in this citation. This was completed on 8/2/23. 3. The DON or designee identified all residents with orders to crush and administer medication and reviewed medication storage to ensure medications not to be crushed were labeled as such. This was completed on 8/2/23. 4. The DON or designee will randomly observe medication passes for five (5) residents each week with orders to crush medications to ensure compliance. 5. The Administrator implemented a QAPI PIP as a means to gather and process information from the observations. Findings will be reported at the monthly QAPI committee meetings for a minimum of three (3) months. The facility lowered the scope and severity from a J to a G after the SA verified the facility staff had implemented the education and additional corrective actions. The facility reported a census of 108 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15 points and had the following diagnoses: cancer, deep vein thrombosis and diabetes mellitus. The MDS identified Resident #1 required staff supervision for most activities of daily living. The MDS identified Resident #1 complained of pain occasionally and the worst he rated the pain level was 9 out of 10. The MDS documented the resident received opioid medication 6 of the last 7 days. The Care Plan dated 7/5/23 identified Resident #1 with the problem of pain related to pancreatic cancer and directed staff as follows: -Administer pain medication as ordered. -Educate resident regarding side effects of the pain medication and the potential for falls: dizziness, drowsiness, nausea, constipation, and notify physician as needed. -Refer to opioid orders for black box warnings. A review of the Facility Incident Report dated 7/31/23 had documentation of the following: On 7/24/23 at 6:40 AM Resident #1's long acting Morphine Sulfate 90 mg was crushed with is morning medications due to the resident's decreased alertness. A review of the July 2023 MAR (Medication Administration Record) revealed the following orders: Morphine Extended Release oral tablet 30 mg one tablet every 8 hours. Morphine Extended Release one tablet 60 mg tablet every 8 hours. On 6/24/23 both of the above doses were signed out as given at 6:00 AM. Naloxone Hcl 0.4 mg/ml give 0.4 mg IM every 30 minutes PRN (as needed) for sedation x 6 hours one dose signed out as given on 7/24/23 at 12:09 PM. A review of the Progress Notes dated 7/24/23 at 12:01 PM, revealed Staff A, LPN documented the following: Hospice nurse gave Narcan 0.4 mg at 10:15 AM. Electronic medical record would not allow her to enter 10:15 and this nurse gave him a dose at 12:00 PM. Resident #1 was talking after Narcan was given. A review of the Progress Notes dated 7/24/23 at 1:09 PM, revealed Staff B, Nurse Practitioner, documented the following: Resident received 90 mg extended release Morphine this morning crushed. Hospice nurse reports resident more lethargic with pulse ox in the 70's. After discussion with hospice medical director and primary care physician, the decision was made to give Narcan for respiratory distress for the next 6 hours. One dose IM (intramuscular) was given. Resident became more alert with improved speech, pulse ox in the 80's. Order left in the facility to repeat Narcan for the next 6 hours for respiratory distress. Requested close monitoring for 2 hours. A review of the Progress Note dated 7/25/23 at 11:23 AM, revealed Staff A, LPN documented Resident #1 was seen by this nurse at 7:30 AM this morning, he was alive and breathing. No respiratory distress observed, no signs of pain or discomfort. At 8:25 AM, this nurse observed resident chest not raising and falling. Upon assessment no pulse, no BP (blood pressure) noted. In an interview on 7/31/23 at 11:17 AM, Staff A, LPN reported she did not pay attention when she crushed the Morphine Extended Release pill when she gave it to him sublingually on 7/24/23. When the hospice nurse came in that morning, she asked what he had for pain and when she told her, the hospice nurse stated, you shouldn't have crushed it. Staff A also reported she usually had a CMA scheduled to help her pass medications and that day, there was no CMA scheduled and she had a total of 33 residents that she had to check blood sugars on 12 residents that morning. In an interview on 7/31/23 at 1:11 PM, Staff D, NP reported if a resident receives a long acting opioid crushed, it could cause respiratory distress. She stated if a hospice resident had problems with swallowing, other routes that could have been ordered for pain medication could have been sublingual. In an interview on 7/31/23 at 3:10 PM, Staff D, RN reported that before she left the faciity on [DATE] she gave report to Staff A, LPN. She did not witness it, but stated Staff A gave the Morphine ER to the resident before Staff D left the facility. Resident #1 did not have other routes ordered to administer pain medication and on that day, he was not able to swallow any liquids. In an interview on 8/1/23 at 11:09 AM, the consultant pharmacist reported if Morphine Sulfate ER had been crushed and given sublingually, she would want to have the resident observed closely and have Narcan ready as it could cause severe respiratory depression. In an interview on 8/1/23 at 12:18 PM, the ADON (Assistant Director of Nursing) reported when she spoke to Staff A, they reviewed the blisterpack which contained the Morphine ER. The label which provided instructions not to crush was in very small font, and very difficult to read if a nurse is trying to administer medications to 33 residents. When asked what could have been done to prevent the error, she reported the nurse should have followed the 5 rights of medication administration and it would have helped to have an agency staff come in to help pass medications. In an interview on 8/1/23 at 2:13 PM, the DON (Director of Nursing) reported for the unit Resident #1 resided, the facility tries to staff with one nurse, one CMA (Certified Medication Aide) and 3 CNAs. On 7/24/23 there was no CMA scheduled. She stated there is no unit secretary to answer the phones while the nurse passes medications and the nurse is expected to answer it. That morning, Staff A also was responsible for 33 residents and when there is no CMA to help pass meds, the nurse is responsible for checking blood sugars, giving insulins and medications, skin checks, processing orders which involves calling pharmacy, entering the orders into PCC, tube feedings, and wound care. When asked what could have been done to prevent the error, she reported the blisterpack labeling could have been different to make the do not crush instructions easily identifiable. In an interview on 8/2/23 at 8:06 AM, Staff M, RN reported the error could have been prevented if the MAR's and blisterpacks had instructions not to crush on non-crushable medications. The facility's policy titled: Medication Administration dated as last revised 5/3/22 had documentation of the following: -Review MAR to identify medication to be administered. -Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. -Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. -Administer medication as ordered in accordance with manufacturer specifications. Do not crush medications with do not crush instructions. -Report and document any adverse side effects or refusals.

Based on clinical record review, staff and physician interviews, the facility failed to adequately monitor laboratory values for one of four residents on [MEDICATION NAME] (anticoagulant) resulting in an immediate jeopardy to resident's health and safety. Resident #3 was hospitalized for [REDACTED]. The facility census was 128 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required supervised assistance with transfer, walking, toileting and limited assistance for dressing and bathing. Laboratory results for the INR completed on 5/1/18 revealed a results of 1.6. [MEDICATION NAME] increased from 3 milligrams (mg) to 4 mg. Laboratory results on 5/7/18, revealed the INR was 1.9 with an order to increase from 4 mg to 5 mg. Laboratory results on 6/11/18, revealed the INR was 1.6 with no new order. Laboratory results on 6/22/18, revealed the INR was 2.2 with an order to recheck in one month. A history and Physical dated 6/22/18, documented the INR goal was to be between 2-3. Laboratory results on 8/3/18, revealed the INR was 2.1, with no new order. Progress notes dated 8/3/18 at 10:47 a.m., documented a call was placed to the new physicians office for clarification on all medications since assuming care of the resident. The resident had no further INR laboratory tests completed after the 8/3/18 results but continued on [MEDICATION NAME] 5 mg daily. Progress notes dated 9/23/18 at 1:15 p.m. documented the resident having intermittent confusion, skin warm and pale and complaining of increased pain and labored breathing with audible wheezing. A call to the Advanced Registered Nurse Practitioner (ARNP) was placed. Progress notes date 8/4/18 at 1:00 p.m., documented the physician was notified of the INR results of 2.1. Awaiting return call. Progress notes dated 8/4/18 at 1:06 p.m., documented the physician returned the call with no new orders at this time. A consultant Pharmacists Medication Regimen Review form dated 9/10/18, documented the resident takes [MEDICATION NAME] ([MEDICATION NAME]) and chart does not appear to have an INR in the chart within the last month. Verify that the lab has been completed. On 9/19/18, the follow through documented INR done outside of the facility, facsimile sent to physician. Progress notes dated 9/19/18 at 11:07 a.m., documented a call was placed to the physician regarding questionable medication therapies needing clarified. Resident also requesting new medication for restless legs. Awaiting return call. Progress notes dated 9/20/18 at 3:41 p.m., documented the physician office returned the call regarding restless legs and request for medication. The office will check back after discussing with the physician. Progress note dated 9/23/18 at 9:43 a.m., documented a call out to primary care physician regarding nose bleed this morning. Resident complained of feeling weak, vital signs obtained oxygen saturation was 89 percent with oxygen. Skin warm and pale and blood sugar 260. Resident reports she had a few episodes in the past week. Bowel sounds active and had bowel movement this morning. Progress noted date 9/23/18 at 9:51 a.m., revealed an order for [REDACTED]. Progress notes date 9/23/18 at 1:15 p.m., documented family concerned with residents intermittent confusion. Call out to Advanced Registered Nurse Practitioner (ARNP) due to residents complaint of increased pain and labored breathing. Audible wheezing noted. Progress notes dated 9/23/18 at 1:30 p.m., documented call to the ARNP as family requested resident to be seen in emergency room due to pain and breathing concerns. The ARNP ordered to try and treat exacerbation of [MEDICAL CONDITION] and have an ARNP evaluate the resident in the morning. Family agreed and [MEDICATION NAME] was increased along with an oral antibiotic and nebulizer treatments four times daily. Progress notes date 9/23/18 at 3:04 p.m., documented resident displaying signs of difficulty breathing, unable to stay awake, answered questions inappropriately. Noted to be very confused, oriented to self, [MEDICAL CONDITION], oxygen saturation 74 percent with 4 liters per mask, pale in color, cool to touch, diaphoretic and capillary refill was slow. Call placed to physician. Progress notes dated 9/23/18 at 3:43 p.m., On call physician returned call and resident sent out via ambulance. A Hospital history of present illness form dated 9/23/18 at 5:04 p.m., documented the resident reported increased nausea and fatigue since last night but that she has not been feeling well over the past few days. The resident has acute on chronic shortness of breath (SOB) as well as a cough that was productive of blood and sputum since yesterday. The resident takes [MEDICATION NAME] for a history of blood clots. The resident reported having some dark stools over the past few weeks as well as a recent nose bleed. Laboratory results at the time of the emergency visit included a hemoglobin of 4.0 ( normal 11.0-17.0); INR- 9.6 and occult fecal blood positive (should be negative). Upon further discussion with the facility, it appears the resident has not had an INR check since early August. In the meantime the resident has been on NSAIDS for various pain issues and on multiple rounds of antibiotics with fluoroquinolones (antibacterial agents). Additionally, nursing staff indicated the resident has had easy bruising and bleeding recently which has not been fully addressed. Suspect the resident has developed an obvious [MEDICATION NAME] coagulopathy causing [MEDICAL CONDITION] and leading to her acute blood loss [MEDICAL CONDITION] with evidence of endorgan (damage to major organs) dysfunction such as [MEDICAL CONDITION], acute [MEDICAL CONDITION] and ischemic changes on the Electrocardiography (EKG) and cardiac tests. The resident was given a total of four units of packed red blood cells and given Vitamin K and Kcentra. Current medications the resident was on at the time of the emergency visit included [MEDICATION NAME] 5 mg daily by mouth to be adjusted as needed by prescribing physician. Laboratory tests on 9/28/18 revealed a hemoglobin of 8.1 and an INR of 1.2. During interview dated 9/27/18 at 8:57 a.m. Staff A, licensed practical nurse, LPN prepared a written statement of her actions beginning 8/3/18. Staff A had contacted the physician office regarding the resident's current medications and laboratory orders. Staff A stated she informed the physicians nurse the physician needed to sign off on the resident's current medication, provide any new orders for medication changes, hard scripts for all narcotics and a schedule for laboratory draws. Staff A had gone on vacation for two weeks beginning 8/4-18/18. During interview on 9/27/18 at 11:03 a.m., Staff B, LPN reported she reviewed the resident's chart and noted there had not been an order for [REDACTED]. During interview on 9/26/18 at 2:57 p.m., the assistant director of nursing (ADON) reported the resident had recently obtained a new physician and primary care provider. She reported it was her understanding from talking with Staff A the new physician was completing laboratory tests, including the INR in her office. She reported the resident' clinical record had no documentation of the resident's INR results and the scheduling of any laboratory tests. During interview on 9/27/18 at 8:00 a.m., the director of nursing reported she had reviewed the resident's hard chart and computer charting and no other documentation of calls by staff to the resident's physician regarding requests for INR tests or results. The resident's physician had told Staff A her office would do their own laboratory tests. She reported progress notes did not document any signs or symptoms of bruising, dark stool or nose bleeds. On 9/23/18 the resident began to show distress in breathing and oxygen saturation levels dropped prompting calls to the ARNP and subsequent hospitalization . During interview on 10/1/18 at 2:25 p.m., the resident's physician reported she became the resident's physician on or about 8/3/18. She stated it was the facility's responsibility to complete INR laboratory tests and [MEDICATION NAME] orders, as she was not managing either the [MEDICATION NAME] or corresponding laboratory tests. She reported she had not seen any documentation from her nurse of any conversation or correspondence related to the residents [MEDICATION NAME] or INR values. To abate the immediate jeopardy the facility educated all nurses on 9/24/18 and 9/26/18, regarding the need to obtain an order for [REDACTED]. On 9/24/18, all residents (currently 9) on anticoagulant therapy were reviewed to ensure orders were complete and accurate with dosing instructions and frequency of laboratory monitoring. An anticoagulant flow sheet was prepared and was audited by the director of nursing or designee at least weekly. Due to the above corrections the immediate jeopardy was corrected on 9/24/18 and will be considered a past non-compliance IJ. No revisit of plan of correction s required.

Based on observation, record review, and interviews, the facility failed to ensure one (1) of six (6) residents was free from possible abuse (Resident #6). Record review identified Resident #6 relied upon two (2) staff to provide assistance for transfers, bed mobility, ambulating, and toileting assistance. Record review and observation showed Resident #6 had a bruise on the left side of his/her forehead and left upper eye lid. Interview with the nurse practitioner and resident's family revealed the resident's injury had been a result of a substantial hit to the affected area and not a result of the padded right arm rest on the resident's wheelchair. Staff that provided care to the dependent resident revealed no one knew how the resident's sustained the injury. The facility reported a census of 111 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 3/11/17 indicate Resident #6 had [DIAGNOSES REDACTED]. The assessment indicated the resident sometimes had the ability to make him/her(self) understood and understood others. The MDS revealed Resident #6 had severe cognitive impairment and short term and long term memory deficits with continuous inattention, disorganized thinking and an altered level of consciousness. The MDS revealed Resident #6 did not exhibit other behaviors symptoms, such as physical symptoms such as hitting or scratching him/her(self). The MDS revealed the resident did not have [MEDICAL CONDITION] (hallucinations or delusions). The assessment indicated the resident required extensive assistance of 2 staff members for bed mobility, transfers, ambulation, locomotion and toilet use. The MDS revealed the resident as always incontinent of bladder and frequently incontinent of bowels. The MDS revealed Resident #6 had no falls since admission/entry or reentry or prior assessment whichever is more recent; and used a wheelchair and walker for ambulation. A Care Plan with a target date of 6/29/17 had the following focus areas: The resident is alert and oriented times 1 (to person) with severe long and short term memory problems due to dementia. The resident responded with short responses/body language. The resident's mood appeared stable but he/she can be anxious/frustrate at times. The resident can be resistive with cares and to other residents on occasion. When sitting in the lounge and staff should monitor him/her and keep the resident away from others. Staff should sit/position Resident #6 an arm's length reach from other residents. The care plan identified the resident had a history of [REDACTED]. The care plan identified he/she needed extensive assistance of 2 staff members with transfers, bed mobility, ambulation, toileting and on 3/27/17, staff to assist Resident #6 to and from meals/activities. Resident #6 liked to sleep in the recliner in the lounge area at times and staff should offer to assist him/her to bed so that he/she can rest. Resident #6 uses a special reclining wheelchair as his/her primary mode of locomotion. When awake, staff should keep him/her in a visible area when awake. An Occupational Therapy (OT) Plan Of Care dated 3/27/17 indicated the resident displayed forward moderate kyphosis (rounding/describe the abnormal condition of the vertebral column) as well as a right lateral lean. A Medication Administration Record [REDACTED]. An observation 4/19/17 at approximately 10:30 a.m. revealed the resident positioned in a TIS chair as staff propelled him/her down the hallway with a golf ball sized hematoma on his/her left forehead with purple bruising surrounding the area and purple bruising on and around the resident's bilateral eyes. An observation 4/26/17 at approximately 10 a.m. revealed the right and left arm rest of the resident's TIS chair with approximately 3/4 of an inch to 1 inch of padding attached to the rest itself. An Injury form dated 4/17/17 at 8:40 a.m. and revised at 4:29 p.m. indicated the resident had an injury of unknown origin further described at a bruise on the left side of his/her forehead and left upper eye lid that measured 6 centimeter (cm) x (by) 18 cm red and purple in color. An Injury form dated 4/17/17 at 8:40 a.m. and revised at 4:29 p.m. and with an entry dated 4/19/17 revealed the following entry: Summary of findings for 4/17/17. Staff that worked the 3 p.m. until 11 p.m. shift on Sunday 4/16/17 and Sunday night 11 p.m. until 7 a.m. had been interviewed about the bruising found to the resident's forehead at breakfast on 4/17/17. The staff members voiced that no bruising had been noted at meal time on 4/16/17. The 2 staff members that assisted the hour of sleep (HS) cares between 7 p.m. and 9 p.m. stated that no bruising had been noted. Staff reported the resident had often been resistive with cares, would hit and strike at them with his/her arms and kick with his/her legs. The resident had a curvature of his/her spine and often sat bent over at the waist and leaned to the right. Staff that worked the 11 to 7 shift on the North hall voiced he/she had been toileted and slept in his/her wheelchair in the lobby area. Staff that assisted the resident with toileting around 6:30 a.m. to 7 a.m. voiced he/she had been resistive with cares however staff verbalized no observation of bruising at that time. At approximately 8:30 a.m. the resident had been observed in his/her wheelchair bent over with hair that covered his/her face in the dining room. When staff repositioned the resident to assist with breakfast and the bruising had been noted and immediately reported to the charge nurse and the Administrator. Also noted the resident had his/her head resting on the right arm rest area where the bruising had been noted so an arm bolster had been applied to the right arm rest. Progress Notes forms revealed the following entries: a. 4/17/17 at 4:29 p.m. - During breakfast the resident had been noted to have a bruise on the left side of his/her forehead. The area had been swollen, purple and red in color and the skin intact. The resident rested in the chair and took his/her morning medications. Neurological checks as within normal limits (WNL). b. 4/18/17 at 5:25 p.m. - The resident continued on follow up charting for the bruise on the left side of the forehead. The skin had been intact, purple and red in color with no swelling noted. c. 4/19/17 at 12:30 a.m. - The resident had a head injury to the right side of the head from and unknown source. There had also been significant bruising around the eyes. d. 4/20/17 at 10:35 a.m. - The resident with a large bruise to the right side forehead which extended out to both eyes from an unknown source. An observation 4/20/17 at 4:05 p.m., revealed the resident positioned on the toilet with obvious kyphosis (lump on the back) on the resident's left side of his/her back and a spinal curvature which resulted in the resident positioned forward and to the right side. During an interview 4/20/17 at 5:02 p.m., Staff L, Certified Nursing Assistant (CNA) confirmed she worked the night shift Sunday 4/16. The staff member indicated the resident slept all night in the TIS chair in the lounge area and she never checked or changed the resident through the night. The staff member confirmed around 6:15 a.m. to 6:30 a.m. herself and Staff K, CNA transferred the resident to the toilet with the use of a gait belt while Staff K remained with the resident the entire time. Upon completion the staff members cleaned the resident up, stood him/her, pulled up the pants and positioned the resident in the TIS chair and returned him/her to the lounge area. The staff member confirmed when the resident sat in the TIS chair and/or on the toilet he/she leaned forward with his/her head down. The staff member indicated she never observed a bruise on the resident's forehead and/or face that morning and never observed the resident having hit his/her head. During an interview 4/20/17 at 5:14 p.m., Staff K confirmed the only time he assisted the resident with cares on 4/16 into 4/17/17 had been when when he transferred the resident per gait belt to the toilet and back to the wheel chair with the assistance of Staff L. The staff member indicated he never left the resident unattended in the bathroom, the resident never hit his/her head during cares and there had been no bruising present on the resident's forehead and/or facial features. During an interview 4/20/17 at 3:31 p.m., Staff D, CNA confirmed she worked the day shift on 4/17/17. When the staff member arrived at work she observed the resident sitting in the TIS chair in the lounge area however his/her head had been down so she could not see the resident's face. The staff member denied having provided any cares for the resident prior to the discovery of the hematoma/bruising. When the staff member first observed the area after breakfast it had been red and protruding as if it had just started. The staff member stated the area had not been as large as it appeared presently. During an interview 4/20/17 at 2:31 a.m., Staff A, CNA confirmed she worked the day shift on 4/17/17. When the staff member arrived at work she observed the resident sitting in the TIS chair in the lounge area with his/her head down however she did not look at the resident long enough to analyze anything. The staff member indicated between breakfast and lunch she observed the goose egg on the resident's forehead with no bruising initially then the bruising appeared and kept spreading throughout the day. During an interview 4/20/17 at 1:55 p.m., Staff I, CNA indicated he had not known where the resident had been when he arrived at work on 4/17/17. The staff member could not recall if he had taken the resident to the dining room for breakfast. The staff member felt the first time he had contact with the resident had been in the dining room for breakfast. The resident had been positioned in the TIS chair with his/her head down with his/her hair a little bit in front of his/her face. The staff member sat down to feed the resident and observed the bruise on the resident's forehead but he could not recall if there had been bruising on the resident's eye. The staff member immediately reported the observation to Staff J, Licensed Practical Nurse (LPN) and then went to assist other residents at another table. During an interview 4/20/17 at 2:14 p.m., Staff B, CNA confirmed he/she worked the day shift on 4/17/17 however she never provided any cares for the resident that morning. At 8:45 a.m. to 9 a.m. a nurse came to her and asked if she had provided cares for the resident that morning because the resident had a bruise on his/her face. When the nurse told her that she looked at the resident and observed a goose egg area with bruising on his/her forehead with no bruising on the resident's eyes however by the end of the shift both eyes had been black and blue in color. During an interview 4/20/17 at 1:20 p.m., Staff J indicated when she arrived at work on 4/17/17 the resident had been positioned in the TIS chair in the lounge area with his/her head down with hair over his/her face. The staff member received report with no information provided about the resident. The staff member indicated between her arrival at work and breakfast, which started at 7:30 a.m. she did not see anyone take the resident to the bathroom however she thought Staff I propelled the resident to breakfast. As she passed morning medications Staff I came to her and said, you are going to be mad, you have to see the resident's face. When she approached the resident his/her head had been bent down so when she repositioned the resident's head back she observed a goose egg with bruising down to his/her left eye lid. The area had been less protruding than it appeared presently. The staff member reported the incident to Staff M, Registered Nurse (RN) who began an investigation as she started an assessment and reported the injury of unknown origin to the Nurse Practitioner (NP) and the resident's son. During an interview 4/20/17 at 2:40 p.m., Staff J confirmed the resident's bruising worsened throughout the day and spread over the resident's nose and to both eyes however the staff member never applied ice. During an interview 4/20/17 at 3:02 p.m., Staff M indicated around 8:30 a.m. she observed the resident in the dining room positioned in his/her chair, leaned to the right and his/her hair over his/her face. Staff I came over to feed the resident and when he sat the resident up, he said oh my what is that, I am going to tell Staff J right now. At that point the staff member looked at the resident and said oh my gosh as the area had been red and raised with some bruising around the area but not a goose egg at that point and the staff member felt it had been a fresh area. At that point the staff member initiated an investigation. The staff member indicated she attempted application of ice later in the afternoon however the resident refused the intervention. The staff member indicated as the day proceeded the bruising became darker and by 4/18/17 there had been a bruised pocket on the resident's left eye and on 4/19/17 the bruising progressed to both eyes. During an interview 4/20/17 at 8:58 a.m., a family member indicated he/she had not felt the resident could have received a lump like that by moving around in a chair and that someone had not been telling the truth. During an interview 4/20/17 at approximately 9:35 a.m., a family member stated he/she felt the resident could not have sustained the injury from the arm rest of the wheelchair because the resident always leaned to the right and the area had been on his/her left side of the forehead. Review of a History and Physical form dated 4/18/17 at 9:20 p.m. included the following documentation from a Nurse Practitioner: a. Head and Face - a left forehead contusion/hematoma without laceration. Dependent swelling and bruising of the left eye. b. Eyes - Not able to view the left eye due to swelling. c Psychiatric - Judgement: alert and impaired insight. The patient's speech exhibited incoherence. The patient displayed significant memory loss which required supervision. d. Assessment - Head contusion e. Discussion/Summary - Head contusion with unknown even per staff investigation. The resident hunches forward in the wheelchair and now the eye had been [MEDICAL CONDITION] also. During an interview 4/21/17 at 11:36 a.m., the Nurse Practitioner (NP) indicated a hematoma developed soon after an injury and could have been large. The bruising on the resident's eyes and face had been gradual and she felt the bruising had been a result of pooling of blood. The NP felt the resident's injury had been a result of a substantial hit to the affected area and not a result of the padded right arm rest of the resident's wheelchair. An Abuse/Neglect and Reporting Policy revised 9/16 identified that no one should be subject to abuse or neglectful behavior is the most critical step in detecting and preventing abuse. The policy revealed it is necessary for the center to adopt and institute an abuse, neglect prevention system to include protection of residents as well as identifying and investigating all allegations of abuse or mistreatment. The policy defined abuse according to the federal rule F223 as Abuse the resident has the right to be free from physical and mental. The intent of the federal rule 483.13 (b) revealed the resident had the right to be free from all types of abuse including physical abuse; and that residents must not be subject to abuse by anyone including staff, family or volunteers serving the resident. The intent of federal rule 483.13c revealed that each resident had the right to be free from mistreatment, and neglect. The policy defined neglect as the failure to provide the goods and services necessary to avoid physical harm. The policy revealed Injuries of Unknown Source should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury had not been observed by any person or the source of the injury could not have been explained by the resident: and, 2. The injury had been suspicious because of the extent of the injury or the location of the injury, e.g., the injury had been in an area not generally vulnerable to trauma, or the incidence of injuries over time. The policy identified components of addressed reporting and responding as follows: The policy directed the center to ensure that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown source are reported immediately to the administrator of the center and to other officials in accordance with state law including the state survey agency. The policy identified that CMS (Centers for Medicare & Medicaid Services) believes immediately means as soon as possible but should not exceed 24 hours after discovery of the incident in the absence of a shorter time frame requirement. Once reported , the facility should conduct a timely, thorough, objective investigation of all allegations of abuse, neglect, mistreatment of [REDACTED]. The procedure revealed any alleged allegation or actual witness incident of abuse, neglect, injury of unknown origin must be reported immediately to the charge nurse and or immediate supervisor 24 hours a day/7 days a week. The policy listed 8 steps for the center to complete including: the Administrator or DON will initiate a preliminary investigation and notify the State Health Department immediately upon discovery of the incident/allegation. Witness statement will be obtained and if there is reason to believe an employee committed an act of abuse, the employee will be suspended; complete the Final Investigative Summary Report will be communicated to the State Health Department within 5 business days from the discovery of the incident; and report any valeted allegation which would indicate unfitness for services as a nurse aide or other facility staff to the State Nurse Aide Registry or Licensing Agency or Authorities. Review of the facilities Your Rights and Protections as a Nursing Home Resident form (not dated) included the following: You have the right to have been free from verbal, sexual, physical and mental abuse. If you feel you have been mistreted (abused) or the nursing home isn't meeting your needs (neglec), report this to the nursing home or state agency or other local officals.

Based on record review, facility policy and staff interviews, the facility failed to ensure 7 of 9 residents received adequate supervision to protect against abuse/hazards from others. Resident #4 grabbed/squeezed Resident #6's neck; and had incident/s of resident to resident altercation with Resident #2 and Resident #3; Resident #7 slapped Resident #5. Documentation on behavior monitors identified Resident #1 and Resident #3 pushed and hit each other. Facility census was one hundred twenty-five (125) residents. There were nineteen (19) residents on the CCDI (chronic confusion and dementing illness) unit. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 10/22/16, assessed Resident #4 with short and long term memory impairments. The resident had the following continuously present signs and symptoms of [MEDICAL CONDITION]: inattention, disorganized thinking, altered level of consciousness. The MDS identified the resident with physical behaviors directed towards others 1 to 3 days out of 7. The resident rejected care 4 to 6 days out of 7. The resident wandered 1 to 3 days out of 7. The resident was independent with transfers and ambulation in the room. The resident required supervision with ambulation in the corridor. The resident had [DIAGNOSES REDACTED]. An ARNP (advanced registered nurse practitioner) visit dated 11/23/15 revealed staff phoned the ARNP last Friday (11/20/15) to report behaviors of grabbing at staff ' s neck/s, hitting, pinching, pacing, refusing medications and grabbing other people's food. An ARNP visit dated 4/25/16 revealed the resident intimidated staff as he/she is aggressive. a). Incident: A behavior monitoring sheet dated 10/31/16 at 2:20 a.m. and documented by Staff A RN (registered nurse) revealed Resident #4 squeezed the back of Resident #6's neck. Staff identified on the behavior monitoring form, the interventions following the incident as reality orientation and redirection. Staff A documented that the resident sometimes behaves in this type of behavior in the comment section of the form. The form also revealed that Resident #6 was OK and had a slightly red neck. A behavior monitoring sheet dated 10/31/16 at 3:20 a.m. and documented by Staff A RN revealed Resident #4 touched another resident, causing the other resident to scream. The form revealed Resident #4 had multiple [DIAGNOSES REDACTED]. The resident's behavior escalated with touching other residents at times. Staff A documented Resident #4 walked down the hall. Resident #6 stood with his/her back turned from Resident #4. Staff A looked out the window (of the nurses station) and watched other residents. Staff A witnessed Resident #4 touch the back of Resident #6's neck. Resident #6 screamed out and did not know what happened. Resident #6 placed his/her hand on his/her neck. Staff A sat the resident down. The resident's neck appeared slightly red and the redness disappeared in a minute or two. On a page of typing paper dated 11/3/16 at 8:45 a.m., the DON (director of nursing) documented a representative was notified about the incident between Resident #4 and Resident #6. The representative asked whether or not charges would be pressed and the DON informed her that no charges would be pressed however the facility had done an internal investigation and the State of Iowa was investigating. The DON documented Resident #4 ' s roommate out of his/her room and he/she is having 1:1 sitter at this time. On a page of typing paper dated 11/3/16 at 3 p.m., the DON (director of nursing) documented she spoke with Staff B. During the conversation, the DON documented that Staff B said Resident #4 touched the back of Resident #6's neck with one hand. Interviews: On 11/7/16 at 10:54 a.m. Staff B CNA (certified nurse aide) stated Resident #6 stood by the nurses station and when Resident #4 reached the nurses station, he/she grabbed the back of Resident #6's neck. Resident #6 screamed ow that hurts. Staff B identified it as a quick squeeze and the back of Resident #6's neck got alittle red. Staff B stated the redness went away. Staff B stated it was a quick squeeze and more than just a touch. On 11/8/16 at 2:45 p.m. Staff B demonstrated where the residents were and where Staff B was when the incident occurred. Staff B identified herself as 1 to 2 feet from the incident with a clear view. After the incident, Resident #6 had a red line on his/her neck where Resident #4's right hand went in and squeezed the back of the neck. Afterwards, Staff B saw Resident #6 run his/her hand over the neck area once and a couple hours the later the redness was gone. Staff B denied that she told the DON Resident #4 just touched the back of Resident #6's neck. On 11/4/16 at 1 p.m. Staff A RN stated she witnessed an incident around 3:30 a.m. on 10/31/16. She saw Resident #6 standing in the lounge area in a night gown. Resident #6's back faced the hallway and the front of the resident faced the lounge tables. Staff A identified Staff B CNA (certified nurse aide) sitting in a chair against the wall in the lounge area. Resident #4 came down the hall and came up behind Resident #6 and touched the back of Resident #6's neck with his/her open right hand. Staff A stated Resident #4 just laid his/her hand on the back of Resident #6's neck without applying pressure and Resident #6 screamed. Staff A stated she calmed the resident. The resident shook after the incident. Staff A stated she informed Resident #4 that his/her behavior wasn't nice and Resident #4 did not acknowledge what Staff A said. Staff A stated she completed 2 behavior sheets. She stated on the first behavior sheet she wrote Resident #4 squeezed Resident #6's neck because that is what Staff B CNA stated. Staff A stated Resident #6 grabbed his/her own neck after the incident and that was why it was red when Staff A saw it and it was gone in minute. Staff A reported the red (area) as a handwidth in size and slightly red on the same side that Resident #4 and Resident #6 put their hands on. When asked why she rewrote the first behavior sheet, Staff A stated she sat down and thought about the incident and wrote the second report. She estimated she was 4.5 feet away from the incident and Staff B was about 2 feet away. Staff A stated Resident #4 previously went up to residents and brushed his/her hand over their shoulders. Resident #4's care plan dated 5/2/16 identified the resident with behavior symptoms. The care plan revealed Resident #4 liked to walk and could kick or become combative with cares. An addendum to the care plan dated 11/9/16 identified the resident had a private room and 1 to 1 supervision. A MDS with assessment reference date of 9/21/16 assessed Resident #6 with a brief interview for mental status (BIMS) score of 3 (severe cognitive impairment). The resident had delusions, physical behaviors directed at others 1 to 3 days out of 7 and behaviors of wandering and rejection of care. The resident required extensive staff assistance with ambulation. Resident #6 had [DIAGNOSES REDACTED]. Observation showed, on 11/3/16 at 1:06 p.m. Resident #6 in the CCDI unit. The resident walked independently throughout the unit. On 11/8/16 at 3:09 p.m. the surveyor asked the DON what the facility did after the incident to prevent Resident #4 from touching the necks of residents, the DON stated the facility just used the same 5/2/16 intervention of keeping the resident away from other residents. She stated the intervention was in place prior to 5/2/16 but did not provide the actual date the intervention was implemented. On 11/9/16 at 5:55 a.m. the Director of Operations verified the intervention following the incident was to keep the residents separated. B). Incident approximately 6 months prior involving Resident #4 and Resident #2: On 11/7/16 at 10:41 a.m. Staff C CNA stated she witnessed an incident involving Resident #4 and Resident #2 about 6 months ago. She stated Resident #4 came up behind Resident #2 and tapped Resident #2 on the shoulder. Resident #2 then slapped Resident #4 on the upper body and Resident #4 then slapped Resident #2 hard across the face. Staff C stated she reported the incident to the nurse on duty but did not remember who the nurse was. A MDS with assessment reference date of 6/12/16 assessed Resident #2 with a BIMS score of 4 (severe cognitive impairment). The MDS identified the resident with hallucinations and no behavior symptoms other than daily wandering. The resident was independent with transfers and ambulation. The resident had [DIAGNOSES REDACTED]. Review of Resident #2 and Resident #4's record did not identify the incident. On 11/8/16 at 11:52 a.m. the DON confirmed there was no documentation available that identified the facility investigated the incident or assessed the residents for injury. She stated the facility was not aware of the incident. C). Resident #3 Incident: A MDS with assessment reference date of 10/7/16 assessed Resident #3 with a BIMS score of 3 (severe cognitive impairment). A post fall assessment/huddle dated 6/24/16 at 11:15 p.m. revealed staff found Resident #3 on the floor in his/her room. The resident sustained [REDACTED]. When the facility questioned Resident #3 about the incident, Resident #3 stated Resident #4 (roommate) pushed him/her. The intervention after the incident was to bring the resident to the lounge. On 11/8/16 at 10:40 a.m. the DON identified Resident #3's roommate on 6/24/16 as Resident #4. On 11/10/16 at 8:30 a.m. the Director of Operations stated they moved Resident #4's roommate from his/her room and now have a staff monitoring the resident one to one. Resident #4's roommate was Resident #3. 2. A MDS with assessment reference date of 9/16/16 assessed Resident #7 with short and long term memory impairments and severely impaired decision making skills. The resident had physical and verbal behaviors directed at others and rejection of care 1 to 3 days out of 7. The resident required extensive staff assistance with transfers and ambulation. The resident had [DIAGNOSES REDACTED]. On 11/7/16 at 9:01 a.m. Staff D CNA stated she observed Resident #7 slap Resident #5 across the face a couple weeks ago. Staff D stated they separated the residents after the incident. Staff D stated the residents sat by each other and Resident #7 reached out and slapped Resident #5 across the face after scolding Resident #5. Staff D stated she reported the incident to a nurse. Staff D stated she was fairly new so she didn't know the nurse ' s name. On 11/8/16 at 10:45 a.m. Staff D stated the slap was not hard enough to cause redness but she heard a noise when the slap made contact with Resident #5's face. Staff D stated it was more than a tap. A MDS with assessment reference date of 8/11/16 assessed Resident #5 with short and long term memory impairments and severely impaired decision making. The resident was rarely/never understood by others and the resident could rarely/never understand others. The resident required extensive staff assistance with transfers and ambulation. The resident had [DIAGNOSES REDACTED]. Review of Resident #7 and Resident #5's record failed to contain any information about the incident. On 11/8/16 at 11:52 a.m. the DON confirmed there was no documentation available that identified the facility investigated the incident or assessed the residents for injury. She stated the facility was not aware of the incident. Observation showed on 11/8/16 at 4:10 p.m. Resident #5 seated in a recliner within arm ' s reach of Resident #7. Both residents appeared calm. Observation showed on 11/9/16 at 5 a.m. Resident #7 seated in a recliner with a resident within arm ' s reach on each side of him/her. The resident was calm. A care plan dated 6/28/16 identified Resident #7 with a problem of behavioral symptoms. The resident could become agitated and upset during care. The care plan contained an intervention dated 6/28/16 that revealed staff should keep the resident in the lounge in a wheelchair and arm ' s length away from residents of agitated. Another intervention dated 6/28/16 directed staff to keep a resident an arm ' s reach away from Resident #7 because sometimes residents that speak in different languages upset Resident #7 due to inability to understand. 3. A MDS with assessment reference date of 10/3/16 assessed Resident #1 with a BIMS score of 4 (severe cognitive impairment). The MDS identified the resident with verbal behaviors directed at others, rejection of care and wandering 1 to 3 days out of 7. The resident required limited staff assistance with transfers and ambulation. The resident had [DIAGNOSES REDACTED]. A behavior monitoring record dated 10/22/16 at 8 p.m. revealed Resident #1 constantly followed another resident and tried to hit the other resident. Resident #1 yelled get out of here to other residents and staff. The resident hit and pushed other residents. In the added comments from nursing section of the form, Staff E RN documented the resident yelled and hit the other resident. The behaviors lasted for more than 30 minutes. A MDS with assessment reference date of 10/7/16 assessed Resident #3 with a BIMS status score of 3 (severe cognitive impairment). A behavior monitoring record dated 10/22/16 at 8 p.m. revealed Resident #3 pushed furniture and pulled the other resident's blanket. The behavior form identified the resident pushed and hit other residents. In the added comments from nursing section of the form, Staff E RN documented the resident started pushing a walker against the other resident and also hit the other resident and was combative with staff. The surveyor attempted to contact Staff E RN who documented the residents pushed and hit each other. Staff E did not return phone calls. Staff E worked PRN at the facility. The record failed to identify Staff E assessed the residents after the incident, even though Staff E documented physical contact was made. 4. The facility dependent adult abuse prevention policy revealed the facility would provide an environment respecting the rights and dignity of each resident. It is the policy of the facility to provide an environment free from abuse including physical injury and assault. The policy indicated any allegation, or witnessed, resident abuse will be reported and investigated promptly and thoroughly to protect the well-being of the residents.

Based on observation, clinical record review, facility policy and patient/family and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self or other residents (Residents #1, #2, #3, #6, #8, #10, #12, #13 and #15). The sample consisted of 9 residents. The facility reported a census of 138 residents. Resident #1-Staff failed to supervise the resident's feet during transport in a wheelchair. The staff did not apply foot pedals to the wheelchair. The resident fell from the chair and hit the bed frame which resulted in nose and facial bruising. Resident #2-Staff left the resident unattended in the bathroom at the sink. The resident fell backwards and sustained 2 lacerations to the head. Resident#3-had a history of [REDACTED]. The resident was identified as needing staff to stay in the bathroom. Resident #6-fell in the bathroom and then scooted into the bedroom which caused pressure wound areas to the buttock. Resident #8-had a fractured lower leg due to lack of supervision. Resident#10-had been placed in the bathroom and left unattended. The facility had identified the resident required stand by assistance. Resident#12-had a history of [REDACTED]. Observation revealed the resident was left unattended in the bathroom. Resident #13-had a history of [REDACTED]. Observation identified the staff failed to provide stand by assistance while the resident remained in the bathroom. Resident #15-did not receive adequate supervision and had an altercation with another resident in the dementia unit. As a result of the altercation, the resident had swelling to the right wrist, required a wrist brace and had a dislocated finger. Findings include: The facility used the following color magnets with the use of the Morse Fall Scale assessment. The magnets helped identify resident ' s needs in order to prevent falls. The indicators were: Green- The resident could be up independently with or without assistive device. Yellow- the resident required staff assistance when up and may be left unattended with access to the call light in the bathroom Red- The resident could be up with assistance and stand by in the bathroom 1. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date 8/15/14, which reflected the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15. A score of 10 identified the resident with moderately impaired cognition. The resident had no signs and symptoms of delirium. The resident required limited assistance of one staff with transfers, ambulation in the room, toileting and personal hygiene and extensive staff assistance for locomotion off the unit and bathing. A "balance during transitions and walking" test identified the resident as not steady, only able to stabilize with staff assistance when moving from seated to standing, walking, turn around while walking and moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had no falls with injury since the previous assessment. The resident used a walker and wheelchair. A fall risk assessment, dated 5/17/14 identified the resident as a "yellow" fall risk. The Care Plan, updated on 8/18/14, identified a fall risk and directed the staff to ambulate the resident with the assistance of one staff person, use a gait belt and front wheeled walker. The Physician visit form dated 8/12/14 reflected the physician was called to the resident ' s room due to increased swelling of the left lower extremity. The physician. The resident ' s leg had [DIAGNOSES REDACTED] (redness) and warmth, with small oozing areas. An ace wrap was ordered to both legs for swelling and an antibiotic was ordered and a complete blood count. The physician's order [REDACTED]. The Interdepartmental Documentation Form (IDF) dated on 8/14/14 at 7:00 p.m. reflected the results may reflect mild pulmonary edema. The IDF notes dated 8/15/14 at 3:20 a.m. revealed the resident had a pulse oximetry of 86%. The nurse applied oxygen at 2 liters per nasal cannula and the pulse oximetry elevated to 92% during the night. The progress note identified the resident had a trace of pitting edema to the right ankle and 2+ pitting edema to the left ankle, displayed appropriate judgment and insight and oriented to person, place and time with intact memory. The assessment identified [DIAGNOSES REDACTED]. Lorazepam, an antianxiety medication, Lasix, a diuretic, and potassium tablets were ordered. The physician ordered to leave the oxygen off if the resident's pulse oximetry was 90% or greater. The IDR notes dated 8/19/14 at 7:50 p.m. reflected the resident fell over backwards while standing at the sink in the resident ' s room. The resident had asked the certified nursing assistant to do something for her/him so the aide did not see the fall occur. The resident ' s pulse oximetry registered 85% on room air. The staff placed the resident on oxygen at 2 liters per nasal cannula and the pulse oximetry went to 93%. A Post Fall Assessment, dated 8/19/14 at 7:50 p.m. revealed as Staff FF, certified nursing assistant (CNA), assisted Resident #2 with bedtime cares, the resident fell backwards and sustained 2 lacerations to his/her head, each measured 2 centimeters in length. The resident was sent to the hospital by ambulance. A CT (Computerized Tomography) revealed the resident had no acute bleed or skull fracture. The IDF form reflected on 8/20/14 at 9:25 a.m. the facility received a telephone call from the hospital. As the hospital prepared to return the resident to the facility, the resident ' s blood pressure bottomed out (dropped rapidly) and the resident became unresponsive. The family was at the bedside and requested comfort cares. On 9/15/14 at 1:24 p.m. Staff G, registered nurse (RN) was interviewed and stated she was at the end of the hall when a CNA called for assistance and discovered Resident #2 was on the floor with his/her head near the sink. Staff G stated the resident kept requesting to be transferred back to bed, and when his/her head was moved; blood was noted on the floor. The resident didn't know what happened just said he/she didn't feel well. Staff G stated the resident had medications changed and receiving Lasix and potassium and was recently treated for [REDACTED]. Staff G stated the resident was sick and not feeling well. Staff G stated she assessed the resident, cleansed the lacerations and the resident was transferred to the hospital per the family member's request. Staff G stated the hospital called the facility at 10:30 or 11:00 p.m. and planned to transfer him/her back to the hospital. Staff G stated the facility later learned that as the resident was prepared to return to the facility when his/her blood pressure bottomed out and the resident later passed away. Staff G stated Resident #2 was impatient and wanted things right away and had decreased safety awareness. Staff G stated if the resident said go get something, "I would've gone away to get it." Staff G did note a recent change and thought that he/she had decreased strength and less endurance, but was steady. Staff G confirmed awareness that the resident was a yellow fall risk which indicated he/she was safe to be left alone in the bathroom and was able use the call light. Staff G stated Resident #6 could stand at the sink and brush his/her teeth with the walker but wanted someone in the room due to a risk of falls. On 9/15/14 Staff EE, CNA, stated she would not leave Resident #2 alone because of balance concerns. Staff EE stated the resident required one staff to assist with cares and was a yellow fall risk. Staff EE stated she always kept Resident #2 in arm's reach. On 9/15/14 at 3:00 p.m. Staff FF, CNA, stated Resident #2 asked her to move a towel from near the sink to the recliner and as she turned away from the resident she heard the walker move and "down (he/she) went." Staff FF admitted she did not use a gait belt in the resident's room because Resident #2 would remove it and refuse to wear it. Staff FF stated she always used the gait belt while out of the room, but as soon as he/she entered his/her room, she would remove the gait belt. Staff FF stated the resident would not walk to supper the evening of the fall and was incontinent of urine which was unusual for Resident #2. Staff FF confirmed awareness of residents that require staff assistance also require a gait belt and that was part of the CNA orientation. Staff FF stated she provided cares for Resident #2 many times and the resident doesn't usually lose his/her balance. Staff FF stated she was not more than 2 arm length away from the resident when he/she fell . On 9/10/14 at 11:10 a.m., Staff UU certified nursing assistant was interviewed and stated she had worked at the facility on the day Resident #2 fell . Staff UU stated the resident would get really shaky and staff would need to hold the resident (up) with the gait belt. Staff UU continued to state the resident would get pretty unsteady and she would not leave the resident alone. On 9/10/14 at 11:15 a.m., Staff S (restorative aide and certified medical assistant) was interviewed and stated staff would need to help the resident with a gait belt and could see the resident change when the oxygen level would decrease. The resident would get shaky. Staff S stated she would not leave the resident alone even if she wasn ' t shaky because the resident was not steady. The facility policy titled Gait Belt Policy, updated April 2011, directed that gait belts to be used in transferring residents or ambulating residents who require assistance as indicated on the resident's Care Plan, and "not following any step in this policy could result in disciplinary action up to and including termination." 2. Resident #1 had a MDS assessment with a reference date 8/18/14, which reflected Resident #1 had a BIMs score of 14 out of 15 . A score of 14 identified the resident did not have cognition problems. The MDS reflected the resident's admitted as 5/7/14. The resident had no signs and symptoms of delirium. The resident required limited assistance of one staff with transfers, ambulation, toileting, personal hygiene and extensive assistance of one staff for ambulation on and off the unit. A "balance during transitions and walking" test identified the resident as not steady, only able to stabilize with staff assistance when moving from seated to standing, walking, turn around while walking and moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had no falls with injury since the previous assessment. An Admission/Annual/Quarterly Fall Assessment, dated 8/6/14, identified the resident at a " green " fall risk. This resident could be up independently with or without assistive device. The Care Plan, dated 5/20/14 and updated 8/18/14, identified the resident as a "red" fall risk. The Care Plan approaches directed staff that the resident needed assist of one for ambulation and transfers. The approaches included and directed the staff that the resident used a walker and a wheelchair as needed. The resident should wear proper well maintained footwear, and needed to wear gripper socks or shoes at all times. A Red fall risk indicated that the resident required assist of one staff when up and required staff to stand by when in the bathroom. On 9/8/14 at 2:10 p.m. Resident #1 stated he/she fell when a "nurse" provided assistance in the bathroom. Resident #1 was able to recall Staff HH assisted him/her to the bathroom and he/she felt rushed. The resident stated Staff HH assisted and propelled the wheelchair quickly and it felt like " we were flying. " Resident #1 stated he/she tried to stand independently while Staff HH was behind and held the wheelchair and Staff HH was not ready. Resident #1 could only remember "everyone flying around after the fall " and was unable to recall if he/she felt dizzy prior to the fall. Resident #1 stated most of the time two (2) staff provided assistance and that all staff members used a gait belt. The resident stated he/she thought the gait belt was applied while in the bathroom. Staff HH did not respond to the Department of Inspection and Appeal's requests for an interview. In a written statement she provided to the facility on [DATE], Staff HH wrote she assisted the resident in the bathroom for cares before bed. Staff HH stated she then transferred the resident into a wheelchair to assist him/her to bed. Staff HH wrote she did not place the foot pedals on the wheelchair prior to transfer. Staff HH held her/his feet straight out in front. Staff HH wrote as she closed the bathroom door Resident #1 independently propelled his/her wheelchair towards their bed and attempted to stand independently from the wheelchair. In the time that she closed the bathroom door, the resident stood and fell forward out of the wheelchair and hit the edge of the bed frame and lay on side. The resident voiced complaints of nose and right knee pain. The written statement did not indicate if a gait belt was used at the time cares were provided. On 9/15/14 at 3:21 p.m. Staff K, registered nurse (RN), stated Staff HH rushed to the nurse's station and said Resident #1 tipped from the wheelchair. Staff K stated upon entering the resident's room, she noted Resident #1 on the floor with his/her head under the bed and complained of pain in his/her face and right leg but was able to move the affected leg. Staff K stated there was blood near the resident's nose and he/she had black eyes that appeared as a bruise. Staff K was unable to recall if a gait belt was in use at the time of the incident, and stated the resident fell from the wheelchair and her first thought was foot pedals. On 9/15/14 at 2:13 p.m. Staff GG, certified nursing assistant (CNA), stated Staff HH stated she was transferring Resident #1 to his/her bathroom and she got the resident off the toilet and back into the wheelchair. Staff HH told Staff GG that the resident was self-propelling the wheelchair and his/her feet got stuck under the wheelchair and "kind of criss crossed" and he/she fell forward and hit his/her head on the bedframe. Staff GG stated Resident #1 usually picked his/her feet up but that she always placed foot pedals prior to transporting a resident in a wheelchair. Regardless of distance, foot pedals should be on the wheelchair when transporting. Staff GG stated Staff HH was usually the aide for Resident #1. Staff GG stated she offered to assist Staff HH transfer Resident #1 and Staff HH declined assistance. Staff GG stated she noted Resident #1 was more weak and had informed Staff C, RN and Resident Care Coordinator. Staff C informed Staff GG to use 2 staff or a Hoyer lift and use our judgment if the resident was unable to stand. On 9/15/14 at 2:34 p.m. Staff C, Resident Care Coordinator, stated at huddle (meeting) the staff reported Resident #1 was "getting weaker" and that she advised to use 2 staff if needed. Staff C stated she observed Staff GG transfer Resident #1 independently without a gait belt and she "ran " to assist the aide. After that incident we "huddled" and I said let's watch for change. Staff C stated she could not recall if she updated the resident ' s Care Plan but knew the resident was in the questionable change from 1-2 phase. Staff C confirmed the resident ' s care plan failed to include gait belt to transfer then stated the facility policy is if the resident requires assistance of one then a gait belt is required. Staff C stated she did not discipline Staff G at that time and was unable to recall if she notified the Director of Nursing or facility Regulatory Consultant. Staff C stated she never observed Staff HH transfer a resident without a gait belt or foot pedals and that no staff had reported concerns regarding the use of gait belt or foot pedals. 3. Resident #8 had a MDS assessment with a reference date 6/28/14. The MDS reflected Resident #8 was unable to complete a Brief Interview for Mental Status (BIMS) due to impaired cognition. The MDS identified the resident's admitted as 10/10/12. The resident displayed signs and symptoms of delirium such disorganized thinking. The resident required extensive assistance of one staff for bed mobility, and was totally dependent upon assistance of 2 or more staff for transfer from bed. The resident used a wheelchair and did not ambulate. The resident required limited staff assistance with dressing and toileting. A "balance during transitions and walking" test identified the resident as not steady, only able to stabilize with staff assistance for surface to surface transfers and activities such as moving from seated to standing, walking, turn around while walking and moving on and off toilet did not occur. The resident had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A fall risk assessment, dated 8/15/14, identified the resident as a "red" fall risk. A red fall risk reflected the resident required staff assistance when up and required staff to stand by the resident when in the bathroom. Risk factors identified included a fall history within the past 3 months, impaired gait/transferring and overestimates/forgets/limitations. The Care Plan, dated 9/27/13 and updated 6/28/14, identified the resident as non-ambulatory and used a wheelchair for mobility and required staff assistance to propel the wheelchair. The same Care Plan identified a Hoyer lift and 2 staff were required for transferring the resident. (A Hoyer is a mechanical life which lifts then suspends the resident in a sling for transfer. The facility required 2 staff to assist with all mechanical lift transfers.) A physical therapy evaluation, dated 8/28/13 and signed by the therapist on 8/28/13, assessed the resident was unable to bend the right leg and had no right knee flexion. The facility form titled "Post Fall Assessment/Huddle," dated 8/15/14, revealed Resident #8 was found on the floor sitting parallel to the bed on the floor mat. The Accident/Incident Report, dated 9/12/14, indicated Resident #8 sustained a skin tear which measured 1 cm x (by) 1.4 cm. A Final Report of an x-ray, dated 9/18/14, revealed markedly osteopenic bones with acute mildly comminutes fracture through the proximal right tibial metadiaphysis (fracture of lower leg tibia bone) The Emergency Department physician note, dated 9/18/14, assessed Resident #8 presented to the emergency department via ambulance with a large bruise present below the right knee. On 10/6/14 at 4:43 p.m. Resident #8's family member stated she visited the resident for lunch and he/she complained of right leg pain. The nurse practitioner stopped by to assess and didn't see anything below the right knee and she (nurse practitioner) thought it was a leg cramp. The family member stated at approximately 1:30 p.m. Staff SS, CNA, stated she would change (the resident) and brought the Hoyer and someone else in and they transferred the resident. The family member stated he/she was screaming and I watched and Staff SS didn't do anything. The family member then went home but returned to the facility around 7:00 p.m. Resident #8 was in a wheelchair upon her return to the facility and fell asleep right away. At approximately 7:00 p.m. I asked Staff FF and Staff WW, both CNAs; to help the resident to bed and when they pulled the resident's pants down noted a large red bruise. Staff J, LPN, thought it was a blood clot and arranged for transfer to the emergency department. The physician discovered the resident had a broken leg. The family member voiced concerns about how that type of injury could occur when the resident doesn't walk or propel the wheelchair and stated no facility staff member can provide an answer. The family member stated the night prior to the discovery of the fractured leg, Resident #8 was transferred to a different hospital per ambulance for evaluation and later that same night returned to the facility. The family member stated that Resident #8 did not complain of pain while away from the facility or upon return to the facility. On 10/7/14 at 9:50 a.m. the radiologist, stated the resident's bones showed some osteopenia which was more severe in the ankle/foot. The radiologist stated the comminuted fracture would require more force than a bump. On 10/7/14 at 1:28 p.m. the emergency room physician confirmed recollection of the resident and stated that type of fracture (comminuted) would require significant impact to fracture both the tibia and fibula, and in his opinion it would be difficult for someone not to know there was an injury. The physician stated based upon the black and blue color of the bruise and edema to the extremity the injury was at least 12-24 hours old and occurred within 48 hours. The emergency room note revealed the resident entered the emergency room at 10:45 p.m. On 10/7/14 at 1:20 p.m. the facility ARNP (Advanced Registered Nurse Practitioner) confirmed she evaluated Resident #8's right lower extremity around lunch time per request of the resident's family member. The ARNP stated she pulled the resident's pant leg up over his/her knee and there was no bruise, increased edema or complaints of pain at that time and thought the resident had a leg cramp. The ARNP stated she did not complete any documentation at that time because it was a "fly by stop in the hall" and at that time it didn't seem urgent at all. On 10/13/14 at 6:02 p.m. the orthopedic surgeon confirmed that while the resident had osteoporosis, a simple bump would not break the tibia and fibula, rather would require some degree of impact. The orthopedic surgeon stated that while a person with severely osteopenic bones could sustain a fracture from a "bump" this resident did not have that degree of osteoporosis. Staff interviews as follows: a. On 10/7/14 at 2:02 p.m. Staff SS stated she showered Resident #8 the same morning that the fracture was discovered. Staff SS stated there was no bruise observed at the time of the resident's shower. Staff SS stated there were always 2 staff present for the Hoyer (mechanical lift) transfer. Staff SS stated she was aware the resident's legs did not bend and staff are always very cautious of the position of residents' legs when transferred per Hoyer (lift). Staff SS stated after dinner Staff QQ assisted with transferring the resident to bed and then left the room while she provided incontinence cares. The resident's family member was present. Staff SS stated she observed some swelling and slight redness in the resident's lower extremities but the resident's family member stated the ARNP evaluated them and there were no concerns. Staff SS stated she informed the nurse of her observation and the resident's family member stated the ARNP was aware. Staff SS stated the resident did not complain of pain or exhibit any behaviors, such as combative, during the shower or incontinence cares. Staff SS confirmed she was the last staff member to provide incontinence cares during the day shift and the resident's family member was present while cares were provided. b. On 10/7/14 at 2:43 p.m. Staff QQ, CNA, stated she assisted Staff SS transfer Resident #8. Staff QQ stated she is able to speak the same language as the resident and family member and neither the resident nor the family member offered any complaints of pain at the time of Hoyer lift transfer after lunch. Staff QQ stated she did not observe the resident's leg at that time because there were no complaints voiced. Staff QQ stated the resident's family member was present at the time of transfer and did not verbalize any concerns at that time. c. On 10/6/14 at 3:24 p.m. Staff WW, CNA, stated the resident was sleeping upon her arrival at approximately 3:00 p.m., which was somewhat unusual. Staff WW confirmed she assisted Staff XX, CNA, transfer Resident #8 with the Hoyer before dinner (supper). Staff WW stated Staff FF, CNA, informed them that she provided 3:00 p.m. incontinence cares and when they got the resident up for dinner (supper) he/she held his/her leg and said "boli boli" (pain). Staff WW stated she noted the swelling in the resident's right foot but did not look at the resident's leg. Staff WW stated after the resident was placed in his/her wheelchair the resident's family member returned and took the resident to eat. Staff WW stated Staff XX and Staff YY transferred the resident back to bed after supper. Staff WW stated when she returned to the resident's room after the resident was transferred to bed the family member was crying and showed her the bruise on Resident #8's right leg and stated the other CNAs and the nurse had already observed the area. Staff WW stated she did not know what happened and heard about the fracture the next day. d. On 10/6/14 at 3:44 p.m. Staff XX, CNA, stated the day the fracture was discovered, Resident #8 was on Staff FF's list and Staff FF completed incontinence cares at 3:00 p.m. At 5:00 p.m. Staff FF was on break so Staff XX and Staff WW transferred the resident from bed to his/her wheelchair per Hoyer. Staff XX stated the resident's incontinence brief was dry at the time of transfer and the lift sheet was already placed under the resident by Staff YY when she provided incontinence cares. (Staff XX stated they usually place the lift sheet under residents when incontinence cares are provided at 3:00 p.m. because there are so many residents that require Hoyer transfer and doing so saves time.) Staff XX stated when they (Staff XX and Staff WW) got the resident up they noticed his/her right foot was swollen and the resident complained of pain. After the resident was positioned in the wheelchair the family member arrived and took the resident to dinner in the activity room per usual routine. Staff XX stated they did not inform the nurse of the swelling or pain because the day shift stated he/she had swelling. After dinner at approximately 7:30-8:30 p.m. Staff XX and Staff FF transferred Resident #8 from his/her wheelchair to bed and he/she complained of pain. The aides then took the resident's pants down and noted the bruise along a line of the resident's leg and notified the nurse. The nurse assessed and arranged to transfer the resident to the emergency room /hospital. Staff XX stated the resident's family member was present during the transfer and confirmed she told the ARNP about the pain/swelling earlier in the day. Staff XX stated she had no idea how the resident's fracture occurred and confirmed the resident's right leg is always straight out (doesn't bend). Staff XX stated at times Resident #8 resisted incontinence cares but they tell the resident they have to complete the cares and if said lovingly the resident allows. Staff XX stated occasionally they have to leave the room and approach at a later time but usually a loving tone of voice is effective. e. On 10/6/14 at 4:17 p.m. Staff FF confirmed she completed incontinence cares at the beginning of the 3 to 11:00 p.m. shift. Staff FF stated when she entered the resident's room the resident was asleep so she didn't change the resident's pants. Staff FF stated the resident grabs at his/her pants to pull them up at times. Staff FF stated she pulled the resident's pants down to mid-thigh (demonstrated by pointing her fingers to her own mid thighs) and the resident did not resist. During this action, the resident woke up and said "nika nika" (which means no no) then he/she kissed Staff FF's hand. Staff FF stated Resident #8 did not complain of pain at the time cares were provided. Staff FF then stated instead she just pulled the resident's pants down "a little bit" because the resident was saying "nika nika so just a little bit" and then she let him/her rest. Staff FF confirmed knowledge the resident's right leg is always straight out and cannot bed at the knee. Staff FF stated the head of the resident's bed is up approximately 30 degrees (demonstrated by using a piece of paper to indicate placement). When asked how she was able to pull the resident's pants down by herself if the head of the bed is elevated, Staff FF responded that she pulled the resident's pants down on one side and then pulled the other side down. Staff FF then stated she "kinda pushed" him/her to one side and pulled his/her pants down. Staff FF stated the resident can hold a side rail while she rolled the resident. Staff FF stated she has to "push (him/her) a little" and then he/she can help hold the side rail. Staff FF stated Resident #8 did not complain of pain when she rolled the resident to pull his/her pants down. Staff FF stated the aides hold the resident's legs during a Hoyer transfer. Staff FF denied placement of the Hoyer lift sheet under the resident because he/she does not like to stay in bed. Staff FF stated she doesn't ever see a Hoyer lift sheet under the resident. Staff FF then again used a piece of paper to demonstrate that the head of the resident's bed was elevated approximately 30 degrees and stated the resident's feet rest on the bed. Staff FF then stated "I don't even have to roll (him/her)" just pulled his/her pants down to here (and points to an area on her own body just under her navel) and he/she said "nika nika" and pulled his/her blanket and pants up. Staff FF stated Resident #8 went right back to sleep. During this portion of the interview, Staff FF changed her statement regarding how/where she pulled the resident's pants to three (3) times. (She stated/demonstrated she pulled the resident's pants to mid- thigh, then stated she rolled the resident side to side to pull the resident's pants down one side at a time and had to push the resident to his/her side to complete this task, then stated/demonstrated she only pulled the pants down to just below the navel area.) Staff FF then stated they (Staff FF, Staff XX and Staff WW) were all surprised that Resident #8 was asleep, and that she informed Staff XX and Staff WW the resident refused check and change so they could get the resident up for dinner, then went to break. (Staff FF's prior statement indicated she completed incontinence cares.) Staff FF then stated she did complete incontinence cares at the beginning of the shift. Staff FF stated after dinner Resident #8's family member stated the resident's foot was swollen that day. After dinner when we (Staff FF and Staff XX) transferred the resident to bed he/she was crying and holding his/her leg. We checked and saw it and the family member was "totally crying" and said "what happened to (him/her)" as the resident held his/her leg. Staff FF stated Resident #8 did not cry in pain. Staff FF stated they notified the nurse and the resident was transferred to the hospital. Staff FF stated she had no idea what happened. Staff FF confirmed she was part of a prior investigation when she failed to use a gait belt to transfer a resident (Resident #2) and the resident fell and sustained lacerations to his/her head. Staff FF stated she would tell the nurse if an injury occurred and if any accidental injury occurred while she provided cares to the residents. f. On 10/7/14 at 7:43 a.m. Staff P, registered nurse (RN), stated she was made aware of the resident's fractured leg when she phoned the emergency room to see if the resident was admitted to the hospital. Staff P stated she was also working when Resident #8 returned from the emergency room the night prior. Staff P stated she completed a full assessment and noted no skin concerns and no resident complaints of pain. Staff P stated she was shocked to learn the resident sustained [REDACTED]. She then phoned the Director of Nursing to notify her of the fracture and completed a head to toe assessment upon the resident's return to facility. Staff P

Based on clinical record review and staff interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision from hazards in the environment. Unannounced to the nursing home staff, Resident #1 left the nursing home through an unsecured door without the facility staff knowing his/her whereabouts for approximately 15-20 minutes. The exit door had been left unlocked and not alarmed. Staff interviews determined the nursing staff had not been aware of instructions to lock the exit door. Record review identified the resident had a [DIAGNOSES REDACTED]. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 144 residents of which 22 resided on the Chronic Confusion and Dementing Illness (CCDI) unit. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 6/13/13, Resident #1 had both short and long term memory deficits with severely impaired cognitive skills for daily decision making. The MDS identified Resident #1 showed signs and symptoms of delirium in the manner of continuous inattention (easily distracted or difficulty following what was said) and disorganized thinking (the resident ' s thinking was incoherent). Resident #1 had weekly behaviors of rejecting cares 1-3 days; and daily wandering behavior. The assessment identified Resident #1 was independently mobile and required limited assistance of one staff with dressing, eating, toilet use, personal hygiene and bathing. The assessment revealed Resident #1 had been [DIAGNOSES REDACTED]. The facility completed an Elopement Risk assessment dated [DATE] which identified Resident #1 had cognitive impairments, with poor decision-making skills and or pertinent [DIAGNOSES REDACTED]. The intervention following the assessment was for staff to apply and utilized a Code Alert (CA) bracelet. Resident #1's plan of care dated 6/13/13 revealed he/she wandered within the unit (CCDI) and had been identified as an elopement risk. Resident #1 ' s photography had been on the Elopement Risk Picture Document. The care plan directed nursing staff to ensure the resident was wearing a Code Alert (CA) bracelet on his/her left ankle and the CA battery must be checked daily to assure functioning. The plan of care noted the CA check must be recorded on the log of the neighborhood the resident resided on. The plan of care also requested nursing staff do complete an elopement risk assessment quarterly and as needed. Accident/Incident Report dated 8/15/13 at 7:45 p.m. for Resident #1 documented Resident #1 had been found walking in McCauley parking lot wearing day clothes and gripper socks. The resident had been assessed and no injuries or skin issues were noted. The report noted Resident#1 had last been seen at 7:20 p.m. at the dining room table. The report documented the contributing factor to the incident had been the new door alarms not working. Nurse's Notes dated 8/15/13 indicated Resident #1 alert and oriented x 1 with impaired short and long term memory. The resident ' s vision and hearing were adequate, but his/her speech garbled and the resident was unable to make needs known. Resident #1 used signs and gestures to communicate. In an interview on 9/4/13 at 6:44 p.m. Staff G, dietary supervisor, stated he went to his car around 7:40 p.m. and discovered a resident (Resident # 1) walking in the parking lot. Staff G obtained the assistance of another employee sitting outside the nursing home and together they escorted Resident #1 back into the nursing home, and to the CCDI unit. In an interview on 9/5/13 at 10:35 a.m., Staff A, Registered Nurse, indicated she worked the evening shift on 8/15/13. Upon arriving to work there were (sub)contractors working on the CCDI unit doors. Staff A indicated she was given no special instructions regarding supervision (of residents), while the work on the doors was being conducted. Early in the shift the workers were working on the emergency exit door (door G or ambulance door) and at 5:00 p.m. the workers moved to the court yard exit door. At around 7:00 p.m. the workers left the unit through the emergency exit door(door G). The workers did not announce they were leaving for the day or that they had left the emergency exit door unlocked and alarms deactivated. Staff A reported at around 7:30 p.m. she left the nurse's station area to check on a resident and instructed Staff B to remain in the common area (dining room/lounge) to supervise. Staff A returned around 7:45 p.m. at which time a telephone call revealed Resident #1 had been found in the parking lot and was being escorted back to the unit. Upon checking the unit doors, Staff A discovered the emergency door exit (door G) was unlocked and not alarmed. Staff A stated she was unaware as to how to lock and reactivate the emergency door alarm and called administration for assistance. Staff A reported she had been told by Staff C, the Resident Care Coordinator, that the workers had left the doors unlocked before (7/25/13). In an interview on 9/5/13 at 4:00 p.m. Staff B, certified medication aide, indicated she was working the evening shift on 8/15/13 with Staff C, certified nurse aide and Staff D certified nurse aide. Following supper staff stated getting residents ready for bed. At one point Staff A asked Staff B to remain in the dining room area as she left for a short time. Staff B stated five minutes later Staff A returned and Staff B began attending to other residents. As Staff B was leaving the area, the telephone rings and she answered it. A facility employee informed her that a resident (Resident #1) was found in the parking lot. Staff B reported Staff A and her immediately responded and went to the main entrance of the unit. Staff B stated Resident #1 and the facility employees are at the door. Staff A and B escorted Resident #1 back to the dining room then proceeded to check the doors, discovering the emergency exit door (Door G) was unlocked. Staff B reported earlier she had seen a couple of workers working on the emergency door. Staff B revealed she was given no instructions on checking the emergency doors once the workers left. In an interview on 9/4/13 at 6:28 p.m. Staff C, certified nurse aide, indicated he was working the second shift (3:00 p.m. to 11:00 p.m.) on 8/15/13. Upon arriving to work the technicians (workers) were working on the alarm system and going in and out of the unit (CCDI). Staff C stated he received no special instructions and was working as normal. After supper, Staff C took the supper cart back to the kitchen and returned with snacks. Resident #1 was sitting in a chair and refused a snack. Later, Staff C left the common area to give a resident a shower and during that time Resident #1 eloped. Staff C was informed by Staff A of the elopement and immediately begin checking for all residents. One resident thought to also be missing was found in another resident ' s room. In an interview on 9/4/13 at 5:32 p.m. Staff D, certified nurse aide, revealed she was working at 2:45 p.m. to 11:15 p.m. shift on 8/15/13. Staff D reported at around 7:15 p.m. to 7:20 p.m. she took a resident to her room to help her to bed. Staff D returned to the dining room to get another resident and escorted that resident to her room. While in the room, Staff D noticed Resident #1 outside in the parking lot with another nursing home employee. Staff D quickly finished with the resident and went to inform Staff A. Staff A was already aware of the elopement by that time. Staff D stated she last saw Resident #1 sitting in the dining room at 7:15 p.m. to 7:20 p.m. Staff D reported the electricians left the unit at 7:30 p.m. and did not let anyone know or give instructions regarding the new alarm system. In an interview on 9/4/13 at 6:10 p.m. Staff E, activity certified nurse aide, reported she was working 11:00 a.m. to 7:30 p.m. on 8/15/13. Upon entering the unit that day the front entrance doors were wide open with construction workers at the door. After lunch the workers moved to the emergency door (G door). Then before supper, they moved to the backyard door. After supper Staff E started doing an activity. The workers were still working on the back door. At around 7:00 p.m. the workers moved back to the emergency door (door G) and Staff E stated she was unaware as to when they left. Staff E reported she left at around 7:25 p.m. Staff E stated she received no instructions regarding supervision of residents while the construction work was happening. Staff E admitted she knows from experience that residents need to be closely watched to prevent them from getting into the workers space and or equipment. In an interview on 9/5/13 at 1:00 p.m. Staff F, certified medication aide, she reported working the day shift on 8/15/13. At 8:30 a.m. two workers came to the unit and started working on the doors. Staff F reported throughout her shift she assigned an aide to monitor residents around the construction and did periodic head counts (every 30 minutes) until the workers leave at 2:30 p.m. Staff F revealed she asked the workers as they were leaving if there was anything she needed to know about the doors. She was told there was a new code. Staff F reported she noticed the red light on the emergency door (door G) was not " ON " or flashing, but thought nothing of it as there was no lights on the door prior to the new installation. Staff F stated she left at 3:00 p.m. all residents were present and accounted for on the unit. Staff F reported she did not physically check the doors prior to leaving. In an interview on 9/5/13 at 3:30 p.m. the Resident Care Coordinator (RCC) reported on 7/25/13 the emergency door (door G) on the unit was discovered ajar and not alarming. She reported when the door was pulled shut, magnetized shut and no alarm were sounding at this time. All residents were present and accounted for. The RCC was later informed that a worker installing the crash bar system on the door had used the door as an exit that day. The RCC put together "Huddle Notes" addressing the new alarms on the doors and instructing staff not to use the emergency door for anything other than ambulances. The memo was posted and had the instructions of activating the emergency door alarm. The RCC stated when activated properly the red light will blink rapidly next to the crash bar. The RCC reported at some later point the emergency door (G door) crash bar alarm was no longer using the red blinking light as an indicator that it was activated. The information was communicated verbally to staff. The RCC reported there was no established procedure in place during the installation of the crash bars and new alarm system addressing supervision or checking the doors after workers left. The RCC reported following the elopement, staff were now instructed to position themselves near the door when they are being worked on and to ensure the doors are locked and alarms activated. The Huddle notes dated 7/25/13 documented the following: As you may see, we have new alarms on our doors. Please see my note in the nurses ' station regarding the alarms on our doors. Do not use our ambulance door except for ambulances. In an interview on 9/5/13 at 9:41 a.m. the Director of Nursing (DON) reported prior to the installation of the "Resident Guard" system the front main entrance doors had a key pad to enter and exit and no local alarm, the emergency door (G door or ambulance door) had a key pad to exit and an alarm that sounded at the nurse's station and the courtyard door had a key pad to enter and exit and an alarm at the nurse's station. The DON reported on August 15, 2013 the sub-contractors were working on the CCDI unit doors beginning late morning. Staff were to monitor the doors to ensure resident safety and allow contractors to do their work unimpeded. Staff positioned themselves on both shifts to monitor doors and residents. During the day shift staff positioned themselves by the emergency door and were able to monitor the front door as well. On the evening shift staff were in the dining room monitoring both the emergency door and courtyard door. The DON reported following the facility investigation they determined the nurse (Staff A) did not use critical thinking skills to ensure resident safety on the unit. Staff A observed the contractors leave that evening and did not make sure the unit was secured after they left. As the charge nurse, Staff A had the responsibility for the safety and security of the unit. On August 19th, 2013 Staff A was suspended pending further review. The DON reported Staff A admitted she should have been more accountable for the unit and the door after the contractors left. The DON provided the Resident Guard Installation Timeline: On February 5, 2013 workers began installing crash bar hardware on the emergency and courtyard exits. The crash bars were installed, but not activated as the old alarm systems remained in place. On July 9, 2013 contractors arrived and began installation on the "Resident Guard System". The contractors continue their work July 9-12, 2013, July 15-18, 2013 and July 23-24, 2013. A second contractor was involved in connecting the crash bar system. During the installation process the contractors pulled their original personnel off the job and sub-contracted the remaining work to a more local provider. On August 13, 2013 the sub contractors arrived to finish the installation. All original alarm systems remained in place. On August 15, 2013 the elopement took place (Resident #1 ' s elopement). The nursing home attempted to contact the installation contractors and discovered one connecting the crash bar system had quit. On 8/16/13 the contractor came to the facility and inspected all the doors. The DON reported after the installation the main entrance doors to the CCDI unit had a key pad alarm to enter and exit as well as a "Resident Guard" which sounds if a resident wearing a Resident Guard bracelet (CA) is near the door. The alarm sounds at the key pad and nurse's station as well as activates a red light at the nurse's station. The emergency door (G door or ambulance door) now has a 15 second delay crash bar system. The alarm will sound when pressure to the crash bar is applied and will open after 15 seconds of continuous pressure. The alarm sounds at the doors key pad, the nurse's station panel and a red light was activated at the nurse's station. The door alarms can be deactivated by the key pad code. The crash bar was reset and reactivated using a key and indicates armed when the red light on the crash bar begins blinking. If the crash bar system was not activated (flashing red light) a secondary alarm system will still sound and light up at the nurse's station if the door was opened. The courtyard exit had only a key pad system requiring a code to unlock and a door bell to open the door from the outside. If the door remains open in excess of 10 seconds the alarm will sound at the key pad, nurse's station and light activate at the nurse's station. The facility corrected the IJ on 8/16/13 when the contractor came to the facility and inspected all the doors. The facility also completed the following to correct the IJ: On August 19, 2013 the sub contractors returned to continue the installation. The contractors were spoken to regarding the resident elopement and needed to keep the doors locked. Staff were assigned to the workers to ensure resident safety. The contractors work through August 23, 2013 and return on September 3, 2013 and complete the installation on September 4, 2013. After the elopement on 8/15/13, the resident ' s care plan had been updated with the following information: Staff to check door operations for blinking light on ambulance door. Keep resident visible to staff at all time while awake. Resident alert bracelet added to right ankle (8/20/13). The facility also completed the Elopement Risk Assessment on 8/15/13. These actions lowered the deficiency from a scope and severity of J level to D level.

Based on observation, record review and staff interviews, the facility failed to protect residents from hazards in the environment when resident beds were placed in such a manner that the side of the beds was against a baseboard heater or the head of the bed in front of a baseboard heater. Resident #1 was found between the bed and the heater. The resident received second degree burns from the baseboard heater unit. Twenty-nine rooms had the head of the bed positioned against the baseboard heating units. Thirty-five rooms had beds positioned against the wall, parallel to the baseboard heating units. The facility identified a census of 149 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 4/5/13, which identified [DIAGNOSES REDACTED]. The MDS assessment documented the resident scored 9 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognitive skills for daily decision making. The MDS assessment documented the resident required limited assistance with bed mobility, transfers and ambulation and extensive assistance with dressing, toilet use, personal hygiene and bathing. The plan of care dated 4/5/13, identified the resident had a problem with a risk of falling related to Parkinson's, weakness and being unsteady. Approaches included keeping the bed in the lowest position, call light within reach, keep environment free of clutter, keep personal items within reach, observe frequently and provide toileting assistance before and after meals, activities and as needed. The Nurse ' s Notes dated 5/31/2013 (Late Entry) revealed the resident was calling for help and was found by a Certified Nursing Assistant at 3:25 a.m. Staff D documented finding the resident with head and right hand on the heating unit. The resident ' s upper body was positioned between the wall and the bed. The nurse (Staff D) and the nursing assistant put the resident in bed and the nurse performed an assessment. The resident had a temperature of 102 (normal 98.6 degrees Fahrenheit), respirations- 18 (normal 16-20), pulse -118 (normal 60-100) and pulse oximeter- 96% (normal 96-100 oxygen saturation level). Staff D notified the physician and sent the resident to the hospital for treatment. Staff D administered Tylenol because the resident voiced right hand pain and a headache. The resident ' s hand had a red appearance with a burn area on the top of the head, which was caused by the heater. On 6/5/13 at 11:35 p.m. Staff C, Certified Nurse Aide, CNA was interviewed and stated he/she worked the overnight shift on 5/30/13 and first saw the resident at around 11:30 p.m., at which time the resident was in bed sleeping. At 1:20 a.m., Staff C assisted the resident to the bathroom and provided him/her with a snack. Staff C assisted the resident to bed at 1:35 a.m. At 2:30 a.m., Staff C checked on the resident and found him/her sleeping quietly in bed. Staff C attended to call lights and at around 3:00 a.m., noticed co-workers in the resident's room. Staff C helped with the preparation to go to the hospital. Staff C stated he/she knew the resident could move around during sleep, but had never known the resident to get in between the bed and wall. Staff C stated was never aware the heaters worked. If the residents were cold, then obtained a blanket and if the residents were hot, then would open a window. On 6/5/13 at 11:05 p.m., Staff D, Licensed Practical Nurse, was interviewed and stated he worked the overnight shift on 5/30/13. At around 3:25 a.m., an aide reported the resident was found almost falling off his/her bed. Staff D immediately responded to the room and found the resident with his/her upper body between the bed and wall and his/her feet and legs still on the bed. The resident's right hand and top of his/her head was on the heater. The resident was quickly assisted back into bed and assessed. Minutes after removing him/her from the heater, blisters started to appear. Staff D observed the burned areas and prepared the resident to be sent to the hospital. Staff D stated he gave the resident an analgesic for pain. A hospital History and Physical report dated 6/2/13, and completed by a physician, documented the resident had apparently fallen out of a low rise bed and was stuck between the bed and the space heater. The resident had obvious burns to the head, right upper extremity and right upper back. The resident was admitted with four percent second degree burns to his/her right upper arm, three percent second degree burns to his/her right upper back and a 1 by 6 centimeter (cm) blister on the top of his/her head with some hair missing. Photographs of the resident ' s burns were obtained from the hospital. The photographs identified burns to the head, ear, face, shoulder, back and arm. The Physician admission orders [REDACTED]. The Treatment record revealed the Physician ordered all open areas be cleansed with normal saline, apply generous amounts of Bacitracin cream, cover with oil emulsion gauze, place 4 by 4 dressing on top of the oil emulsion gauze and secure with a stockinet/flexnet stocking. Observation on 6/6/13 at 1:00 p.m., noted 78 rooms in the facility with secondary baseboard heating units. The wall thermostat covers were removed in every room. Twenty-nine rooms had the head of the bed positioned against the baseboard heating units. (Room# 100, 102, 105, 110, 112, 131, 132, 133, 135, 139, 141, 143, 153, 200, 203, 205, 206, 209, 211, 214, 215, 247, 252, 256, 257, 258, 260, 261, 263) Thirty-five rooms had beds positioned against the wall, parallel to the baseboard heating units. (Room# 101, 103, 104, 107, 109, 111, 115, 117, 130, 134, 136, 137, 138, 150, 151, 152, 154, 155, 156, 157, 201, 202, 207, 208, 213, 216, 217, 231, 240, 251, 253, 254, 255, 259, 264) Fourteen rooms had the beds positioned away from contact with the baseboard heating units. (Room# 204, 230, 232, 233, 234, 235, 236, 237, 238, 239, 241, 243, 245, 262) On 6/6/13 at 11:40 a.m., Staff E, Maintenance Supervisor, was interviewed and stated there was no preventative maintenance protocols for the electric baseboard heating units. The only maintenance involvement was when the heating units quit working or where damaged; then the heating unit was replaced. Staff E stated following the incident involving the resident, the baseboard heating unit was set at 80 degrees and the maximum temperature the register rose to was 144 degrees. Staff E stated all thermostat covers are missing and he was told they were removed some time ago for painting and never replaced. Staff E stated the facility is currently ordering new thermostat covers which can be locked. The thermostat temperatures will be set by Staff E. On 6/6/13 at 2:39 p.m., Staff F, Maintenance, was interviewed and stated the thermostat covers for the electrical baseboard heating units were removed 6-12 months ago while remodeling and painting. Record review of a service provider's service report dated 6/3/13, revealed the baseboard heating unit in the resident's room functioned properly. The thermostat was set at 80 degrees and the register temperature reached 145 degrees after 20 minutes. Note: At the time of the complaint investigation, the complaint was coded as a " K " immediate and serious jeopardy. By 5/31/2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " E " level. The facility had deactivated the baseboard heaters. As of the exit date of 6/17/2013, the facility had failed to: ? Install locked covers over thermostats to prevent tampering. ? Change the location of beds or heaters (facility plans to located the heaters on the ceiling and remove the baseboard heaters). ? Continue to monitor thermostat temperatures once heaters are activated as a secondary heat source.

Based on observation, record review, facility policy review, and climatologist and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the elements in the environment. The health service supervisor failed to plan for and direct the nursing care services to ensure safety when a resident transferred from the dementia unit. The facility failed to revise the care plan when the facility had been aware Resident #13 removed a clip alarm and required a pressure alarm. The sample consisted of 14 residents and the facility reported a census of 114 residents. Findings include: 1. Resident #1 had an admission MDS (Minimum Data Set) assessment with a reference date of 7/10/2012 which identified [DIAGNOSES REDACTED]. A score of 0-7 identified severe impairment of cognitive function. The MDS documented the resident had physical behavioral symptoms, verbal behavioral symptoms, and wandered daily. The initial care plan dated 6/28/12 documented the resident walked independently and staff placed a Wanderguard device on the resident (a device used to alert staff of the resident exiting through a door with a code alert alarm). The Nurse's Notes reflected the following: On 6/28/12 at 12:30 p.m. the resident arrived at the facility for admission. The resident walked independently. On 6/28/12 at 10:20 p.m. the resident wandered about the building throughout the evening shift and required constant supervision. Staff notified the resident's physician and the resident ' s family agreed to have the resident spend the night in the Chronic Confusion or a Dementing Illness (CCDI) unit. On 6/29/12 at 11:30 a.m. the resident socialized with other residents in the lounge across from the nurse ' s station. On 6/29/12 at 5:40 p.m., the resident exited the building through the northeast dining room door into an enclosed courtyard (however not secured). Staff S, (Registered Nurse), documented the resident wore a Wanderguard bracelet on the left ankle however the door the resident exited did not have a code alert alarm but did have a regular door alarm. Staff S documented staff responded to the alarm a few minutes later and the resident returned to inside the northeast dining room. Staff S contacted the on call nurse, Staff M (Registered Nurse). Staff M directed Staff S to transfer the resident to the CCDI unit and this would not be considered an elopement because the resident exited the building to an enclosed court yard. On 6/29/12 at 9:00 p.m. the resident stated he/she was leaving and walked toward the door at the end of the central hallway. At that time the resident transferred to the CCDI unit. On 7/9/12 at 11:05 a.m. the Director of Nursing and the surveyor checked all door alarms and code alert alarms. The northeast dining room door alarmed when opened out to the courtyard. The alarm sounded at the door and at the northeast nurse's station. Staff must push the button in the box located at the far left of the door and push the reset button on a control panel located behind the northeast nurse's station. Examination of the courtyard revealed the area was not enclosed as the courtyard had an open gate leading to a sidewalk at the far corner. On 7/10/12 at 2:47 p.m. Staff C, Director of Nursing, stated the following Monday after the incident, Staff J, (Registered Nurse), approached him and stated the resident eloped from the facility to an unsecured courtyard. Staff J stated the gate was unlocked and the incident should be considered an elopement. Staff C consulted Staff D, Regulatory Compliance Nurse, and started an investigation. Staff C stated the dietary aide (Staff N), observed Resident #1 exit the building through the northeast dining room door. Staff T (Certified Nursing Assistant) informed Staff N that Resident #1 was a visitor. Neither Staff C nor Staff T confirmed shutting the alarm off. Staff S stated she heard the alarm sound (beep) 3 or 4 times and stop at the central nurse's station. Staff S heard the alarm again. Staff S proceeded to the northeast dining room and met Staff J in the dining room. Staff C stated Resident #6 opened the door and Resident #1 walked back into the building. Staff C stated the second time the door alarmed Staff J shut the alarm off at the door and at the nurse's station. On 7/10/12 at 3:03 p.m. Staff S (Licensed Practical Nurse), was interviewed and stated at 6/29/12 at 5:25 p.m. she was sitting behind the central nurse's station with Staff O. Staff S heard the door alarm sound (beep) 4 times and then cease. Staff S heard the alarm again and so she proceeded to the northeast dining room. Staff N walked by the central nurse's station. Staff S asked Staff N if she checked the alarm. Staff N stated Staff T told her a visitor exited the building. Staff S arrived at the northeast dining room where Staff J stood at the door. Staff S stated the resident returned to the facility. After the incident, the resident sat in the recliner in the lounge area across from the nurse's station. Staff S phoned the on call nurse Staff M. Staff M instructed Staff S to place the resident in the locked unit until management can investigate on Monday. Staff S stated the facility admitted the resident on 6/28/2012 and he/she followed staff around the building but displayed no exit seeking behaviors. On 7/10/12 at 3:27 p.m. Staff J (Registered Nurse) was interviewed and stated on 6/29/12 around 5:15 p.m. to 5:45 p.m. she heard the door alarm. Staff J stated she walked down the hallway and the alarm stopped. While walking down the hallway, she met Staff T, who stated a visitor went out the door. Staff J proceeded to the northeast dining room to verify the information and observed Resident #6 open the door to let Resident #1 back into the facility. Staff J stated she silenced the alarm. Staff J questioned the dietary aide if she had access to the pictures of the elopement risk residents. The dietary aide replied no. Staff J assisted the resident to the central nurse's station and told the nurse assigned to the resident, Staff S, to start the elopement procedure. Staff J examined the courtyard after the incident and stated the gate was not secured Staff J reported to Staff C and Staff D the following Monday that the gate in the courtyard was unlocked. Staff J stated Staff C thought the gate was locked but Staff J stated she checked the gate at the time of the elopement. On 7/10/12 at 3:48 p.m., Staff T, (Certified Nursing Assistant) was interviewed and stated on 6/29/12 she took her supper break at 4:45 p.m. to 5:15 p.m. Staff T stated she heard the door alarm. Staff T observed Staff N in the dining room. Staff N informed Staff T that a visitor went out the dining room door. Staff T stated she saw a man outside but didn't think much of it as a visitor had went out the northeast hallway door recently. Staff T stated she did not turn the alarm off. Staff T stated Staff J walked down the hallway and asked who went out the door. Staff T stated a visitor had exited the facility. Staff T stated when she returned to the dining room the resident had returned from the courtyard. On 7/10/12 at 4:44 p.m. Staff N (Dietary Aide) was interviewed and stated on 6/29/12 around 5:00 p.m. she witnessed a man walk into the northeast dining room and walk out the door. The door alarm sounded. Staff N stated Staff T walked down the hallway and looked out the dining room window. Staff N stated she did not shut the alarm off and unsure of the person that had silenced the alarm. Staff N stated she proceeded to the kitchen. Staff N could not recall training on the door alarms but the facility have since had in-services. On 7/10/12 at 5:54 p.m. Staff O (Licensed Practical Nurse) was interviewed and stated on 6/29/12 she had orientation with Staff S. Staff O stated before dinner around 6:30 p.m. to 7:00 p.m. she heard the door alarm in the northeast dining room sound once then stopped. Staff O heard the alarm again and proceeded to the dining room. Staff O stated the resident returned to the building and walked back to the central nurse's station with Staff S. Staff O stated staff assisted the resident to a recliner in the lounge area across from the nurse's station. Staff O stated the resident fell asleep and she transferred the resident at 9:00 p.m. to the CCDI unit. Staff O stated when the staff admitted the resident to the facility on [DATE]; the resident wandered in the hallways and tried the exit doors. The resident made vague statements about leaving and meeting someone. Staff O stated staff found it difficult to redirect the resident. On 7/11/12 at 8:00 a.m., Staff M (Resident Care Coordinator), was interviewed and stated as the nurse on call, she received a call in the evening of 6/29/12. Staff M stated Staff S had informed her that Resident #1 exited the building through the northeast dining room into the enclosed courtyard. Staff S stated the resident returned to the building within a few minutes and had no injuries. Staff M stated she called the Administrator to assess the situation as an elopement. Staff M stated the gate in the courtyard was locked. Staff M stated she returned a call to Staff S and stated the situation was not an elopement and to move the resident to the locked unit. As Staff C and Staff D proceeded with the investigation, they discovered the northeast courtyard door as not locked. On 7/11/12 at 8:10 a.m. Staff P (Licensed Practical Nurse) admitted the resident on 6/28/12 to the central area of the facility. The family had informed Staff P that the resident had resided in a locked unit prior to admission and did not want the resident placed in the CCDI unit. Staff P stated the Resident Care Coordinator, told her to apply a Wanderguard bracelet to the resident's ankle due to prior behaviors. Staff P stated she did not complete an elopement assessment using the elopement assessment decision tree. Staff P stated when she finished her shift, the resident sat in the activity room with his/her family. Staff P stated the resident did not make any comments about leaving or display any exit seeking behaviors. Staff P worked 6/29/12 during the day time hours. Staff P stated the resident rested in the lounge area in a recliner across from the nurse's station. The resident did not wander or display any exit seeking behaviors. On 7/11/2012 at 8:55 a.m., Staff G (Resident Care Coordinator for the CCDI Unit) was interviewed and stated on about 3 occasions Resident #1 had approached the exit door and hit buttons on the keypad but had displayed minimal exit seeking behavior. On 7/11/12 at 10:50 a.m. Staff Q and Staff R (Maintenance) were interviewed and stated they checked the door alarms every Friday at 1:00 p.m. Staff Q stated the northeast dining room door alarms at the door and the northeast nurse's station. The staff needs to shut the alarm off at the box to the left of the door frame and at the control panel at the nurse's station. The surveyor exited the building through the door into the courtyard and found the gate at the far corner unlocked. Staff Q and Staff R stated the gate in the courtyard had never been locked. On 7/11/12 at 11:00 a.m. Resident #6 was interviewed and the resident had no recall of the events on 6/29/12. On 7/11/12 at 11:08 a.m. Staff H (Resident Care Coordinator) stated the resident was admitted to the facility on [DATE]. The resident had come from another facility and had resided in the locked unit. Staff H stated the family did not want the resident placed in the locked unit. Staff H stated staff placed a Wanderguard on the resident due to previous wandering behaviors and did not utilize the facility Elopement Decision Tree. Staff H stated the resident and family stayed in the activity room most of the day. The resident enjoyed looking outside. When family left around 4:00 p.m. the resident became upset and started wandering. Staff could not redirect the resident. Staff H stated the resident spent the night in the locked unit. On 6/29/12, the resident returned to the central area. Staff H stated the resident spent the day in the lounge across from the central nurse's station in a recliner and when she left at 4:00 p.m. the resident had no exit seeking behaviors. Staff H had no knowledge of the elopement until the following Monday. During an interview on 7/11/12 at 2:45 p.m. Staff J stated when the door alarms; she was located in a resident ' s room providing care. Staff J stated the northeast dining room had a control panel also where staff could shut the alarm off. Staff J opened the door in the northeast dining room. The surveyor stood at the northeast nurse's station and saw and heard the door alarm trigger on the control panel. Staff J silenced the alarm by flipping the button on the control panel in the northeast dining room. The alarm continued to sound at the nurse's station which indicated the staff needed to shut the alarm off at the door and at the nurse's station. On 7/11/12 at 3:40 p.m. Staff L (Administrator) was interviewed and stated she received a call from Staff M on 6/29/12 at approximately 8:00 p.m. Staff M informed her Resident #1 had attempted to leave the facility but staff accompanied him to the enclosed courtyard. Staff L wanted to ensure the resident's safety by transferring the resident to the locked unit. Staff L stated she thought the gate in the courtyard remained locked. On 7/11/12 at 4:00 p.m. Staff I (Certified Nursing Assistant) was interviewed and stated she worked on 6/29/12 on the northeast wing and took her supper break 4:00 p.m. to 5:00 p.m. Around 5:15 p.m. she observed Resident #1 outside in the courtyard. Staff I approached the northeast lounge door to check on the resident. As she approached the door, the resident turned around and walked back to the northeast dining room door. Staff I stated she could not leave the northeast lounge as 2 residents needed constant supervision. Staff I stated she heard the alarm behind the nurse's station but stated another nursing assistant turned the alarm off. Staff I stated Staff J went to the northeast dining room. Staff I remained in the northeast lounge area. On 7/12/12 at 11:13 a.m. the Office Manager was interviewed and stated during employee orientation, she took the employee on a tour and orientated the employee to the door alarms. The facility provided the staff with an employee hand book and explained the elopement procedure. The facility instructed staff to respond to the alarm and verify the person leaving the facility. On 7/12/12 at 3:22 p.m. Staff EE, (Certified Nursing Assistant) was interviewed and stated she worked the evening shift on 6/29/12. During rounds, Staff S told the staff Resident #1 independently ambulated but needed close monitoring. The prior shift told Staff the resident used the call light if needed assistance. Staff EE stated she last saw the resident at 3:30 p.m. when the resident rested in the central lounge in a recliner. The Resident Elopement/Missing Resident policy dated 6/7/12 documented the definition of an elopement was a resident with impaired decision making abilities leaves the building without knowledge or authorization of staff. The Resident Elopement/Missing Resident policy dated 6/7/12 documented the following procedure: a. Residents shall be assessed upon admission, quarterly, change of condition, and as needed for wandering behaviors and elopement risk using the "Elopement Risk Assessment Decision Tree" b. Residents with wandering behaviors/elopement risk shall be address in the comprehensive care plan no less than quarterly or more often if necessary. c. Residents with wandering/elopement risk shall be identified on a picture list posted at the receptionist desk and nurse's stations. d. Nurse aide assignment sheets will identify resident at risk for elopement and will monitor the resident's location several times a shift. e. A code alert safety alarm bracelet (wanderguard) will be worn by residents determined to be at risk for elopement. f. A photograph for identification shall be maintained in the medical record of each resident with wandering behaviors. g. On return to the facility, the facility must be assessed for injury or change in condition and the resident ' s responsible party and physician shall be notified as well as the unit charge nurse, on call supervisor, director of nursing, and administrator. h. On assuring the resident's safety, an investigation will be conducted to determine reasons for elopement. i. An incident report shall be completed and refereed to the Safety Committee for review and recommendations. j. Functioning of the code alert bracelets will be checked on each 3-11 shift using the manufacturer's battery check apparatus and documented in the code alert bracelet log sheet. k. If a code alert door is found to be not working, the charge nurse is to be immediately notified and after checking the door and confirming such, a staff person is to be designated to monitor the door. l. The charge nurse is to notify the on call nurse, the Director of Nursing, and the Administrator. m. As soon as possible, the Administrator will contact maintenance for repairs. n. Until the door is repaired, the door will be monitored 24/7 by assigned staff. The employee handbook dated October 2006 only included a-f. The employee handbook did not provide instructions how staff should response to door alarms. Staff also failed to complete the elopement decision tree assessment upon admission as directed by the facility policy. The climatologist was telephoned on 7/16/2012 at 9:06. The climatologist reported the temperature at the time of the elopement to be 93 degrees Fahrenheit with a heat index of 103 degrees Fahrenheit. 2. The MDS assessment tool dated 3/16/12 documented Resident #15 had [DIAGNOSES REDACTED]. The resident scored a 9 on the Brief Interview for Mental Status which identified poor orientation and poor recall. The MDS documented the resident required moderate assistance for transfers, walking, dressing, toilet use, and personal hygiene. The MDS documented behavioral symptoms and wandered. The care plan dated 3/16/12 documented the resident wandered within the facility and wore a Wanderguard bracelet each day. The care plan reflected the resident transferred to the secured unit on 5/1/12. The Nurse's Notes dated 2/25/12 at 8:00 p.m. documented the nurse received a call from the sheriff's office. The resident called 911 to report he/she could not locate his/her spouse phone number and car keys so he/she could go home. The Nurse's Notes documented the resident put on a coat and stated he/she needed to find the car so he/she could leave. A Behavioral Monitoring Sheet dated 3/1/12 at 2:00 p.m., documented the resident wanted to leave the facility with spouse. A Behavioral Monitoring Sheet dated 3/8/12 at 6:00 p.m. documented the resident stated he/she drove a car to the facility and parked it in the parking lot. A Behavioral Monitoring Sheet dated 3/11/12 at 10:30 p.m. documented the resident stated he/she could not find the car keys. The resident wanted to leave to go home and stated he/she felt incarcerated. The Nurse ' s Notes reflected the following: On 4/28/2012 at 4:00 p.m. Staff FF (sat at the front desk) called and stated the resident walked around the parking lot without a walker or wheelchair. The nurse's notes documented a CNA went to front desk to assist the resident back to the resident's room. On 4/28/12 at 4:20 p.m. Staff GG, CNA reported the resident went to the room and spoke on the phone with spouse. On 4/28/12 at 4:45 p.m. the nurse called the on call nurse. On 4/28/12 at 5:35 p.m. the resident approached the nurse. The resident wore a coat and in a wheelchair. The resident asked to leave for pizza. On 4/28/12 at 5:40 p.m. The Director of Nursing instructed staff to provide 1 to 1 supervision of the resident. On 4/28/12 at 5:50 p.m. the resident ate in the dining room. 1 to 1 documentation began on 4/28/12 at 6:00 p.m. The door alarm weekly checks dated 4/16/12 revealed all door alarms functioned properly. The door alarm weekly checks dated 4/23/12 documented maintenance did not complete the weekly checks. The code alert bi-weekly inspection report dated 4/16/12 documented all 5 code alert doors functioned properly. The code alert bi-weekly inspection report dated 4/23/12 documented maintenance did not complete the checks. The code alert log for the 3-11 shift dated 4/28/12 documented the resident's code alert bracelet batteries functioned properly. On 7/16/12 at 1:50 p.m. observation revealed the front door had a 15 second delay. The surveyor pushed the door to open without entering the code (1 and # simultaneously) on the keypad. The door did not open and beeped 5 times. The door released after 15 seconds and the alarm sounded loudly until staff entered a code in the keypad to the left of the door frame. On 7/12/12 at 11:19 a.m. Staff DD, Office Manager was interviewed and stated she worked the Friday before the incident on 6/27/12. Staff could not recall if the code alert sounded that day and stated the code alert had malfunctioned in the past. Staff DD stated at times the code alert alarm would sound when the resident exited but not when the resident entered. On 7/12/12 at 1:37 p.m. Staff Q (Maintenance) was interviewed and stated the maintenance personnel checks the door alarms and code alerts weekly but did not complete checks on 4/23/12 due to staffing issues. Staff Q stated the other maintenance staff person did not work that day so the checks did not get performed. On Monday 4/30/12, the maintenance person called the company of the code alert system. Staff Q stated the company sent a repair team on Monday or the first thing Tuesday. Staff Q stated he checked the next door alarm and code alerts again on 5/4/12. Staff Q had no knowledge of nursing checking the alarms. The repairman work report identified that a repairman repaired the doors on 5/4/2012 and 5/7/2012 On 7/12/12 at 3:30 p.m. Staff P (Licensed Practical Nurse) was interviewed and stated on 4/28/12 at 4:00 p.m. the front desk receptionist Staff FF called her and told her Resident #15 had left the building through the front door. Staff P proceeded to the front lobby and met the resident and Staff FF at the activity room. Staff P stated she did not hear the door alarm. Staff P stated earlier in the shift the code alert functioned as a resident with a Wanderguard went outside. Staff P stated she assessed the resident, obtained vital signs, and documented the information on an incident report. Staff P stated she checked the resident's code alert bracelet and found the batteries functioned. Staff P stated she did not check the front door alarm or code alert system. The Maintenance person came to the facility later and checked the doors. Staff P stated she did not think the resident used the code to disarm the front door alarm. Staff P stated currently she checks the back door code alert system daily at 1:00 p.m. Staff P resets the door and observation revealed Staff P does not wait to see if staff responds to the alarm. Review of Staff P's written statement revealed she last saw the resident at 2:45 p.m. Staff P checked the code alert system at the front door and the employee entrance at 6:15 p.m. The system functioned properly. Staff P stated she checked the resident's code alert bracelet and it functioned properly. On 7/12/12 at 3:52 p.m. Staff CC (CNA) was interviewed and stated the evening of 4/28/12, he visualized the resident at the beginning of the shift. Staff CC observed the resident resting in bed around 4:00 p.m. Staff CC denied an observation of the resident walking to the front door and stated he did not hear the code alert or door alarm sound. Staff CC did not think the resident could disarm the door alarm by pushing the buttons on the keypad. Staff CC stated prior to the incident, the resident had a routine day. On 7/12/12 at 4:15 p.m. the Director of Nursing stated staff started supervising the door on 4/30/12 after the discovery of the code alert system malfunction. On 7/16/12 at 8:31 a.m. Staff C was interviewed and stated Staff P called on 4/28/12 to report Resident #15 had exited the front door. Staff FF worked at the front desk on 4/28/12. Staff FF went to the bathroom and Visitor A sat at the front desk. Visitor A witnessed Resident #15 exit the building through the front door to the parking lot. Upon return to the front desk, Visitor A informed Staff FF of the elopement. Staff FF returned the resident to the facility and called Staff P. Staff P called Staff C but did not tell him the door alarm did not sound. Staff C stated staff did not check the door alarm or code alert alarm at the time of the incident or the days after until he started the investigation on 4/30/12 when he discovered the malfunction of the code alert system. Staff C had staff supervise the front door at all times until the code alert was repaired. Staff C implemented daily code alert checks by nursing starting 5/5/12. Staff C stated the code alert malfunctioned again on 5/8/12 and the facility installed a back- up code alert system placed in the front hallway by the conference room. Staff C stated he was unsure why the front door alarm did not sound. Staff C stated the resident possibly entered the code on the keypad to silence the door alarm. During an interview on 7/16/12 at 9:56 a.m. Staff FF, receptionist, stated on 4/28/12 around 4:00 p.m. Visitor A came to facility. Staff FF went to the bathroom while Visitor A sat the front desk. When Staff FF came out of the bathroom, Visitor A stated a man walked outside and looked confused. Staff FF stated the alarm did not sound at the door and the code alert did not sound. Staff FF looked outside and saw the code alert bracelet on the man's wrist and identified the man as Resident #15. Staff FF called to the central nurse's station and informed the nurse the resident exited the building. Staff FF proceeded to the parking lot and brought the resident back inside the facility. The code alert did not sound when they came back into the facility. Staff FF stated the front door alarmed many times due to a birthday party activity and had to assist many visitors with the code to exit the front door. In Staff FF's written statement she wrote she assumed the resident figured out the code to exit the front door so the door alarm did not sound. Staff FF wrote she did not recall the code alert alarm sounding the entire day. Staff FF wrote the party had ended before the incident and activity at the front door had quieted. During an interview on 7/16/12 at 10:15 a.m. Visitor A stated on 4/28/12 at 4:00 p.m. she came to the facility to bring some items to Staff FF. Staff FF went to the bathroom and asked Visitor A to watched the front desk. Visitor A stated Staff FF remained in the bathroom for 45 seconds-1 minute. Visitor A watched a man stand at the front door for several seconds then walk out the door. Visitor A stated the man did not touch the keypad to the left of the door. The man walked to the parking lot, wandered around, and looked confused. Staff FF returned from the bathroom and Visitor A told her a man left the facility and looked confused. Visitor A stated the door alarm did not sound. Staff FF identified the man as Resident #15 and called the central nurse's station. The nurse arrived within a couple minutes. Visitor A stated the resident sounded upset and spoke of finding a car. Visitor A then left the facility. During an interview on 7/16/12 at 11:35 a.m. Staff P stated on the way to the front door, she met Staff GG, Staff FF, and the resident at the activity room. The resident wore a button down shirt, khaki pants, tennis shoes, and a spring jacket. Review of Staff GG's written statement revealed the resident stated he/she wanted the car and to talk to his/her spouse. Staff GG safely returned the resident to the room at 4:10 p.m. The resident called the spouse and calmed down. Note: At the time of the survey investigation, the deficiencey was coded as a "J", immediate jeopardy to resident health or safety. By 7/6/2012, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. Staff were immediately inservicedto safety plan for resdients at risk for elopement, to the definition of the facility elopment policy. The staff were inserviced to respond to each person which exits an alarmed door. Pictures of elopement risk residents were posted and staff made aware of the residents identified. As of 7/17/2012, the facility needed to: ? Continue to inservice employees regarding the facility elopment policy. ? Monitor staff response to elopement attempts and the implementation of the facility policy. ? Continued identification of residents at an elopment risk and staff awareness ? Assessment and safety interventions for residents once discharged from the dementia unit. Review interventions in the elopement policy to direct staff the procedure when the alarm sounds (check for resident out side of door-facility). 3. A quarterly MDS with a reference date of 5/29/12 identified Resident #13 with the following Diagnoses: [REDACTED]. The resident scored 9 out of 15 on the BIMS (Brief Interview for Mental Status). The score revealed impairment of both memory and cognitive function related to daily decision making skills. The MDS indicated the resident felt down on several days, depressed, or hopeless, tired, and felt bad about self or felt like let family down. The MDS coded the resident with no behaviors present. The MDS coded the resident with no functional limitations in range of motion of any extremity and used a walker and wheelchair for all mobility. The MDS inaccurately coded the resident with no falls since admission or the previous assessment. The resident care plan reviewed on 5/29/12 identified the resident at high risk for falls related to the [DIAGNOSES REDACTED]. A care plan intervention dated 3/8/12 revealed the alarms were removed due to the resident made no attempts to self-transfer. A Post Fall Assessment/Huddle form indicated the resident sustained [REDACTED]. The form identified the bed in a low position at the time of the fall with a bed alarm checked and a N/A ( not applicable) written after the check. The immediate approach added to the resident care plan directed staff to put a floor mat beside the bed. This intervention did not appear on the pocket care plan used by the CNAs. The post fall assessment identified the call light not within the resident's reach at the time of the fall. A Post Fall Assessment/Huddle form dated 4/7/12 at 3:30 p.m. indicated the resident fell in the room when he/she stood up from the chair and attempted to pick up a pencil from the floor. The resident ' s knees buckled and the resident fell on the floor. Again no staff observed the actual fall. No safety devices checked in place at the time of the fall. The immediate post fall approach added to the care plan directed staff the resident not to be in the room unattended unless in bed resting. The post fall assessment did not identify if any safety alarms in place at the time of the fall. The form identified the resident ' s call light not within the resident's reach at the time of the fall. A Post Fall Assessment/Huddle form dated 4/19/12 at 1:15 p.m. identified the resident in the room trying to self-transfer from the wheelchair into the recliner chair. The form identified the fall witnessed by a staff member. The form indicated both a bed alarm and personal safety alarm in use and functioned at the time of the observed fall. The care plan did not reflect a date when the resident began to use the alarms again. The immediate approac

Based on observation, record review and interview, the facility failed to provide adequate supervision for 1 of 6 residents reviewed (Resident #5). The facility identified a census of 147 residents. Findings include: 1. Resident # 1 had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment tool dated [DATE], Resident # 1 demonstrated cognition (ability to think, recognize safety concerns, etc). The resident was totally independent with walking and transfers. The resident did not have a history of falls. The Admission/Annual/Quarterly Fall Assessment indicated a resident whose total Morris falls assessment score was "green", was safe walking and transferring independently. A score of "yellow" indicated the resident needed staff assistance when walking and transferring, but could be left unattended in the bathroom. A score of "red" indicated the resident needed staff assistance when up and while in the bathroom. Per the Post Fall Assessment/Huddle, Resident #1 fell on [DATE] at 8:00 p.m. The resident reporting falling while trying to close the blinds and since the chair was in the way, and the resident couldn't use his/her walker. No body observed the fall. The resident reported left shoulder pain, but denied the need for medication. The resident's Morris' score was "green," or independent, prior to the fall. The resident's Morris score changed to "yellow", or needing assistance, post fall. The new intervention added to the care plan was a Physical Therapy (PT) evaluation. Per the [DATE] 9:30 p. m. Morris Fall Scale, the resident's gait changed to shuffling and unsteady and the resident had experienced 2 falls in the last 3 months. Per the [DATE] 11:00 p. m. Post Fall Assessment/Huddle, Resident #1 fell . The resident reported the fall occurred while getting ready for dinner. The resident was found sitting upright on the floor, half-clothed. The roommate turned on the call light to alert staff to the need for assistance. The resident sustained [REDACTED]. The resident required assist of l staff, but did not always comply. The resident's Morris Fall Scale Score post fall changed to was "red," or requiring assistance/attendance while up and while in the bathroom. In an attempt to prevent further falls, the facility implemented a personal safety alarm (small 2 piece portable alarm attached to the resident's clothing and a stationary object such as a wheelchair or a bed), and a bed alarm. Per the resident's [DATE] care plan, the resident's score fell in the "red" fall risk area on [DATE]. On [DATE], the resident used a personal alarm to alert staff when the resident was on the move. On the same date, the resident had a bed alarm. On [DATE], the resident used a wheelchair as a primary means of moving about the facility. Per the [DATE] 0430 Nurse's Notes, resident # 1 attempted to turn off his/her alarms. The [DATE] 9:30 p. m. nurse's notes revealed the resident's roommate alerted staff Resident # 1 on the floor. The resident experienced pain of 7 on a ,[DATE] scale. The resident's left foot was externally rotated. The resident was transported to a local emergency room for evaluation. Per the [DATE] 7:00 p. m. Post Fall Assessment/Huddle, resident # 1 was found on the floor of the resident's room. The resident was on his/her left side. The resident's wheelchair was to the resident's right. The resident's left arm was out of the his/her shirt. The resident reported trying to change into pajamas and complained of severe left hip/leg pain. The resident stated he/she removed his/her personal alarm to get undressed. Per the [DATE] 10:40 p. m. Major Injury Determination Form, Resident # 1's roommate alerted the staff to Resident #1's fall. The form revealed Resident #1 was frequently confused and used a wheelchair due to a recent decrease in balance and coordination. Per the [DATE] Pilot Progress Notes, Resident # 1 sustained a fractured left hip. Per the [DATE] 11:35 am Residency Progress Note, the resident # 1 also diagnosed with [REDACTED]. Per the nurses notes, at [DATE] 5:00 p. m., Resident # 1 returned to the facility. On [DATE] at 11:15 am., Resident # 1 was admitted to hospice. On [DATE], at 11:25 a.m., Resident # 1 passed away. Per the [DATE] doctor's order, the resident died of natural causes from the disease process. On [DATE], at 4:05 p. m., Staff A said the staff did rounds and checked to ensure alarms and other fall prevention interventions were in place and functioning between every shift. Staff A didn't know if resident # 1 had manipulated his/her alarm. Staff B, on [DATE], at 4:15 p. m., said that he/she was not aware of any times the resident # 1 removed or turned off the alarm. On [DATE], at 4:34 p. m., Staff C said that he/she thought staff were to try another placement for a personal alarm if a resident tried to turn off, remove or disable a personal alarm. Staff C said that Resident # 1 removed his/her personal alarm more than just the evening the resident fell and sustained a fracture. The resident would be told by staff to not take off the alarm. The resident would say, "Yes", and then forget being told. Staff C had told other staff about Resident # 1 taking off the personal alarm. One evening, around 4:30 p. m., staff found Resident # 1 walking unassisted to prayers without his/her personal alarm. Since the resident was independent, he/she didn't seem to remember he/she no longer was independent. On [DATE], at 10:05 a. m, Staff G said Resident # 1 forgot safety factors quite a bit. The resident would forget his/her walker and Staff G thought Resident # 1 removed the alarm, perhaps, one time prior to the [DATE] fall. Staff G didn't know when, specifically, the resident removed the personal alarm. On [DATE], at 11:20 a. m., Staff H, the unit manager, said that none of the staff reported Resident # 1 previously removed the alarm and there was no documentation of same. Staff H said Resident # 1 did not express wanting to have the alarm off, nor had Staff H t seen the resident attempt to remove the alarm. On [DATE], at 2:09 p. m., Staff N said it was difficult for Resident # 1 to get used to the personal alarm. The resident would try to get up unassisted, and the alarm would go off. Staff N reported this kind of drove the resident "nuts" and the resident said to throw the alarm in the trash. Staff N denied seeing Resident # 1 try to remove or turn off the alarm. Staff N thought it was too long of a reach for the resident. Staff N reported if Resident # 1 activated the alarm, he/she looked for the source of the noise. Staff N had found Resident # 1 holding the string/clip part of the alarm while looking for the source of the noise as the alarm sounded.