Every finding on record at Bloomfield Care Center

Based on record review, resident interview, and staff interviews, the facility failed to consistently provide restorative services for 2 of 4 residents reviewed for rehabilitation/restorative services (Resident #2 and Resident #3). The facility reported a census of 41 residents. Findings include: 1.Review of the Minimum Data Set (MDS), dated [DATE] revealed Resident #3 scored a 12 of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The diagnoses list included stroke, hemiplegia/hemiparesis, and depression. The review of the MDS indicated resident dependent with sit to lying; chair/bed to chair transfer; and needed substantial/maximal assistance to roll left to right.Review of Resident #3's Care Plan dated 3/31/26, revealed a Focus area to address Restorative Program to left upper and lower extremity. Interventions include, in part:a. Communicate with therapy and discuss changes in restorative programs that may indicate a need for formalized therapy evaluation.b. Educate resident of restorative program needs and participation schedule; encourage resident to participate in restorative programs.c. Follow therapy recommendations as applicable.d. Provide PROM (passive range of motion) exercises per resident needs; and re-evaluate restorative needs per guidelines. Review of a document titled Restorative Aide Exercise Program dated 3/30/26 revealed: Resident: [Name redacted, Resident #3]. Frequency: 5 x week. a. UPPER EXTREMETIES: checked PROM, 1. Shoulder with an x 2. Elbow (with no x ) 3. Wrist (with no x ) 4. Fingers (with no x )- Left UE (upper extremity).b. LOWER EXTREMETIES: checked PROM 1. Hips 2. Knee 3. Ankles [no x's present on 1, 2 or 3] - Left LE (lower extremity).During an interview on 7/30/26 at 9:11 AM, Resident #3 stated he had asked staff about doing range of motion with him, but no one ever did. Resident #3 stated he did not receive range of motion exercises. During an interview on 7/29/26 at 12:51 PM, Staff A, Occupational Therapy Assistant (OTA) queried if resident's pain in left shoulder could be from the lack of mobility and Staff A stated yes. Staff A stated the facility had cut back on the restorative program based on resident census and the restorative aide now worked the floor until noon and then worked restorative for 4 hours a day. Staff A stated when residents discharged from therapy, therapy then sent the residents to a restorative program. During an interview on 7/29/26 at 4:30 PM, Staff B, Certified Nurse Aide (CNA) queried on the restorative program and Staff B stated the facility cut back on the program. Staff B asked the last time Staff B did restorative with Resident #3 and Staff B stated he hadn't worked with Resident #3 since the facility made the changes to the program and he believed that as at the end of May. Staff B stated he used to do PROM on the left upper and lower extremity to help Resident #3 from tightening up and Staff B thought it helped with Resident #3 pain. 2. The MDS assessment dated [DATE] revealed Resident #2 scored a 5 out of 15 on the BIMS exam, which indicated that cognition severely impaired. The diagnoses list included Parkinson's disease, non-Alzheimer's dementia, history of falling, anxiety disorder, and depression. The MDS indicated the resident used a wheelchair and a walker and required partial/moderate assistance with upper and lower body dressing, roll left to right; sit to lying; sit to standing; and chair/bed to chair transfer.Review of Resident #2's Care Plan dated 9/9/25 revealed a Focus area to address Restorative upper and lower extremities. Interventions included:a. Communicate with therapy and discuss changes in restorative programs that may indicate a need for formalized therapy evaluation.b. Educate resident of restorative program needs and participation schedule.c. Encourage resident to participate in exercise activities.d. Encourage resident to participate in restorative programs.e. Follow therapy recommendations as applicable.Review of a document titled Restorative Program dated 9/11/25 revealed: Resident: [Name redacted, Resident #2]. Goal: To maintain upper extremity strength, activity tolerance and level of function with ADL's (Activities of Daily Living).a. Range of Motion: Both arms.green theraband.20 repetitions. elbow flexion/extension, IR/ER (internal rotation/external rotation), scapular retraction, shoulder flexion and horizontal abduction. b. Other programs: Peg board, ring arch or bean bag toss standing with FWW (front wheeled walker), gait belt, and assist x 1. Toileting tasks with FWW, gait belt and assist x 1. (encourage patient to do as much as possible)Review of the Plan of Care Response History for task Restorative AROM (active range of motion) upper and lower extremities 15 minutes per day as tolerated. Look Back: 30 days revealed one entry: 7/1/29 at 1:59 PM - Amount: Response Not Required. During an interview on 7/30/26 at 9:31 AM, Staff A, OTA stated restorative was beneficial to the residents because it helped keep them active and engaged when therapy couldn't be justified anymore. Staff A stated residents needed ROM, strengthening and ambulation. Staff A stated most therapy departments would say the restorative program was important. Staff A stated restorative would be good for Resident #2 to keep him active and without the restorative program, residents had a risk of decline in mobility. During an interview on 7/30/26 at 9:53 AM, Staff B, CNA queried the last time he completed restorative care with Resident #2 and Staff B stated he didn't know and would have to look and see. Staff B stated all the residents were on the restorative program unless they were in therapy. During an interview on 7/30/26 at 10:03 AM, the Assistant Director of Nursing (ADON) queried on the restorative program and the ADON stated when time allowed staff did restorative care with the residents. The ADON stated the facility cut back on the restorative program and if short, the restorative aide worked the floor and restorative would not get done. During an interview on 7/30/26 at 12:32 PM, the Director of Nursing (DON) queried if restorative services would be beneficial and the DON stated yes in general she did. The DON stated staff were supposed to be helping residents with ROM and walking them. The DON asked about Resident #3 restorative program and the DON stated PROM exercise per Resident #3 needs and the DON thought staff would do a little bit of that every day when they changed him and did plain daily cares. The DON stated the restorative program cut back due to low census and now the restorative aide worked the floor. During an interview on 7/30/26 at 1:33 PM, the Administrator stated when census increased to 45 residents, Staff B would be used more for restorative care. The Administrator stated the facility just recently cut back on the program about 4-6 weeks ago. The Administrator stated the facility needed a process to educate the CNAs more on doing the restorative exercises with the residents. Upon request for a facility policy on regarding restorative services, a facility representative responded via email on 7/30/26 at 2:08 PM, stating that no policy regarding restorative care available.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure nursing staff administered the right medications to the right resident for 1 of 3 (Resident #2) residents reviewed for significant medication error. The error caused Resident #2 to become unresponsive and required hospitalization. The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS), dated [DATE], list of diagnoses for Resident #2 included heart failure, diabetes (a disease which caused abnormalities in blood sugar), and non-Alzheimer's dementia. The MDS listed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A 2/10/26 11:53 a.m. Health Status Note documented the resident sat in her wheelchair at the table with her eyes closed and staff was unable to arouse her. The resident did not respond to the nurse. Staff C, Nurse Practitioner (NP) attempted to arouse her with no response and gave an order to send the resident to the ER (emergency room). A 2/10/26 12:20 p.m. Communication with Physician Note stated the resident received another resident's medication in error: amoxicillin (an antibiotic) 500-125 milligrams (mg), quetiapine (an antipsychotic) 400 mg, and levetiracetam (an anti-seizure medication) 750 mg. The facility reported the medication error to the hospital. A 2/11/26 11:39 a.m. Communication with the Outside Vendor Note stated the hospital called and reported the resident admitted around 9:30 a.m. and that she was more alert today and talked. The hospital stated they would keep her one more day to make sure her blood pressure was stable. A hospital History and Physical, dated 2/14/26, stated the resident presented to the ER due to becoming unresponsive at her care facility. In the ER, the resident was able to be aroused and awakened and follow commands but would then quickly drift back to sleep. Due to the resident being significantly sedated, the hospital decided to place her in observation for monitoring. The next morning the resident was still quite sleepy, sitting upright with her eyes closed and mouth open and sedated. The resident reported that she felt groggy. In the afternoon, the resident ate soup and because of her poor mental status, began coughing and sputtering and had some gurgling that followed that episode. The note stated over the last 3 days, she slowly improved but due to her inability to move due to the medication error her strength diminished to the point where she needed significant assistance to move around as she would at her facility. The decision was made to place the resident in the hospital's skilled nursing unit for continued strengthening and medication adjustments until they could get her to the point where she was prior to the recent incident. The note listed significant findings as encephalopathy (disease or damage to the brain)/sedation secondary to a medication error and low blood pressure, and low heart rate, presumably due to the medication error as well.A 2/26/26 admission Note stated the resident readmitted to the facility. During an interview on 6/10/26 at 2:00 p.m., Resident #2 stated she was in the dining room and became drowsy. The staff was saying her name and she could hear them. After that, for 2 days she didn't know anything. She stated her daughter was at her bedside the whole time but she didn't know she was there. Her daughter later said by the way she looked, she thought she was going to die. She stated she still didn't feel like she was back to baseline after the incident. She stated she still can't do things like she did prior to the incident and stated she cannot carry out therapy per normal.On 6/1/26 at 8:59 a.m., Staff D, Certified Nursing Assistant (CNA) stated at the time of the incident, the resident was in the dining room and had a hard time waking up. Staff D described her as druggy. She stated staff took her out of the dining room and to her room and subsequently the ambulance arrived. On 6/11/26 at 9:06 a.m. Staff B, Registered Nurse (RN) stated the resident was in the dining room and she had her eyes closed and this was not like her. She stated the resident wouldn't wake up so she rubbed her chest. The resident opened her eyes but closed them again. She stated Staff C was present and directed to call an ambulance. She stated later on, she found out the resident received the wrong medication from Staff A, Certified Medication Aide (CMA). On 6/11/26 at 10:46 a.m. via phone, Staff A, CMA stated on the day of the incident, she passed morning medications and everyone came at her so she was not focused. She stated at the time of the noon medication pass, she realized she gave the resident the wrong medications and went right to the Assistant Director of Nursing (ADON) and told her what happened. She stated during the medication pass, she received multiple questions and could not safely administer the medications while this happened. She stated that day was horrible. Residents were trying to get up and it was not safe for one person to complete all of the medications. She stated she did not refer to the MAR while she prepared the resident's medications but rather went by memory. Staff A stated she should have stopped and double checked. She stated after the incident, the facility disciplined her and observed all of her medication passes for a week. On 6/11/26 at 11:06 a.m., Staff C, NP stated on the day of the incident she saw the resident earlier and then an hour later she was unresponsive. Staff C stated she was afraid it was a stroke. She stated she then found out the CMA administered the wrong medication and said that two of the medications, levetiracetam and quetiapine were sedating. She stated the resident subsequently admitted to the hospital. On 6/11/26 at 12:05 p.m., the Director of Nursing (DON) stated that the resident had a change in status and they determined she received medications intended for another resident. She stated Staff A went through the medication cards without following the MAR. The DON stated staff could not do this from memory and had to follow along with the MAR in order to check the correct dose, order, and medication. The facility policy Medication Administration-Medication Pass, revised 5/2023, stated the purpose of the policy was to ensure safe and accurate preparation and administration of medications. The policy directed staff to compare the Medication Administration Record (MAR) with the medication label for accuracy.

Based on observation, review of kitchen dishwasher checklists, U.S. Food and Drug Administration Food Code 2017, and staff interviews the facility failed to monitor the dishwasher to ensure proper sanitization of resident dishes and utensils. The facility reported a census of 42. Findings include: During an observation on 11/17/25 at 10:55 AM, the dish washer noted to have a low temperature. Review of the Dishwasher Temperature/Sanitizer Checklist revealed the following: a. For the month of September 2025, 15/90 entries were made documenting the wash temperature, rinse temperature, and the sanitizer parts per million (PPM)b. For the month of October 2025, 13/93 entries were made documenting the wash temperature, rinse temperature, and the sanitizer PPMc. For the month of November 2025, 4/48 entries were made documenting the wash temperature, rinse temperature, and the sanitizer PPMDuring an interview on 11/17/25 at 11:00 AM, the Dietary Manager acknowledged the incomplete dish machine temperature logs. During an interview on 11/19/25 at 11:15 AM, Staff C, Dietary Aide, explained the dish machine sanitizer is tested three times per day, correlating with meal times. The ideal range is 50 ppm. This along with the dish machine temperatures are written in the log book. The Dishwasher Temperature/Sanitizer Checklist directed staff to record the temperature or test strip results prior to washing dishes for each meal. Wash and rinse water temperatures should both be 120 degrees or above. The chlorine sanitizer test strip should test at 50ppm or above. The U.S. FDA Food Code 2017 section 4-703.11 Hot Water and Chemical noted equipment food-contact surfaces and utensils shall be sanitized by the following: a. Chemical mechanical operations using a solution b. Contact time of at least seven seconds for a chlorine sanitizing solution with a minimum temperature of 120 degrees

Based on clinical record review, facility policy review and staff interviews, the facility failed to update and personalize resident Care Plans for 3 of 17 resident Care Plans reviewed (Resident #1, #21, and #30). The facility reported a census of 42.Findings include: 1.The Minimum Data Set (MDS) Assessment completed on 10/3/25 revealed Resident #1 with Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses include anemia, cancer, muscle wasting, pain and rheumatoid arthritis. The MDS documented no pressure injuries a the time of the assessment and noted Resident #1 was a risk for the development of pressure injuries. Interventions listed on the MDS for skin treatment include pressure reducing device for chair and bed, turning/positioning program, nutrition/hydration interventions, and application of ointment/medications. The MDS documented Resident #1 with a significant weight loss. The Skin Evaluation Pressure Wound Assessment for Resident #1 completed on 11/2/25 identified a Stage II pressure injury to the right lower buttock. The EHR revealed the following Physician Orders for Resident #1: a. Apply 40% Zinc and xeroform secure with additional smaller comfort foam border line with soft silicone adhesive due to a right lower buttock Stage II pressure injury initiated 11/5/25.b. Mighty Shake two times per day for diet supplementation initiated on 11/6/25.The EHR Census tab noted Resident #1 transitioned to Hospice services on 11/12/25. The Care Plan obtained on 11/19/25 listed Resident #1 at risk for alterations in skin integrity related to poor oral intake. It did not include an update for the newly identified Stage II pressure injury. Interventions included administer treatment as ordered, encourage good nutrition, encourage repositioning, provide preventative skin care, and use pillows, positioning devices as needed. It did not include specific resident-centered interventions as noted in the MDS Assessment. The Care Plan also listed Resident #1 with altered nutritional status but did not notate the significant weight loss. Interventions included providing diet as ordered, offer snacks/meal substitute as appropriate, monitor weights, and for signs/symptoms of aspiration. It did not include resident-centered interventions related to significant weight loss or the Stage II pressure injury. The Care Plan did not include an update for Resident #1 transition to hospice. 2.The MDS Assessment completed 9/10/25 revealed Resident #21 with a BIMS score of 15 indicating intact cognition. Diagnoses include chronic obstructive pulmonary disease, chronic respiratory failure, diabetes, and seizure disorder. The MDS documented the presence of 2 unstageable pressure injuries. Interventions include pressure reducing devices for chair and bed, nutrition interventions, pressure injury care, application of non-surgical dressings and ointments/medications. The Skin Evaluation Pressure Wound Assessment for Resident #21 completed on 11/12/25 documented the following: a. Stage II pressure injury to the left heel (date of onset 10/22/25).b. Stage II pressure injury to left second toe (date of onset 7/30/25).c. Vascular wound to left third toe (date of onset 10/22/25).d. Vascular wound to left outer heel (date of onset 10/27/25).The Care Plan obtained on 11/19/25 listed Resident #21 at risk for alterations in skin integrity. It did not include an update for the Stage II pressure injuries nor the vascular wounds. Interventions include administer treatment as ordered, encourage good nutrition, encourage repositioning, observe skin condition with cares, and provide preventative skin cares. It did not include specific resident-centered interventions as noted in the MDS Assessment, including wound care consult with podiatry and wound care clinic. 3.The MDS Assessment completed on 8/6/25 revealed Resident #30 with a BIMS score of 3 indicating severe cognitive impairment. Diagnoses include cerebrovascular accident (CVA), chronic kidney disease, hemiplegia, and non-Alzheimer's dementia. The MDS documented Resident #30 with a significant weight loss. Physician Orders listed a Mighty Shake mixed with iced cream (one time per day) for weight loss. This was initiated on 10/22/25.Dietary Progress Notes, written by the Registered Dietitian (RD), revealed the following: a. On 11/10/25 at 7:48 PM, a significant weight loss of 10.2% identified. Resident receiving daily Might Shake mixed with ice creamb. On 8/11/25 at 2:38 PM, a significant weight loss of 5% identified. History of weight fluctuations. No changes recommended at this timec. On 3/31/25 at 11:15 PM, a significant weight loss of 6.7% identified. Resident receiving [NAME] Breeze supplement as ordered. No changes recommended at this timeThe Care Plan obtained on 11/19/25 listed Resident #30 at potential risk for altered nutritional status. Interventions included to provide diet as ordered, offer snacks/meal substitutions as appropriate, monitor weights, and assess for signs/symptoms of aspiration or swallowing difficulty. The Care Plan did not include updates regarding on-going weight loss, which were assessed as significant. The Care Plan did not include specific resident-centered interventions regarding changes to nutritional status. During an interview on 11/19/25 at 420 PM, the MDS Coordinator explained that Care Plans are coordinated with the MDS Assessments. The Director of Nursing (DON), Assistant Director of Nursing (ADON), or the MDS Coordinator can update resident Care Plans at any time. Discipline-specific staff, such as Activities or Dietary, complete their own updates. During an interview on 11/19/25 at 4:35 PM, the DON noted that all of the interdisciplinary team members have a responsibility to update Care Plans. During a follow-up interview on 11/20/25 at 12:00 PM, the DON explained specific pressure injuries, regardless of staging or timeframe, are not typically added to resident Care Plans. The DON noted transitions to Hospice are usually added to Care Plans. This was an oversight for Resident #1. During an interview on 11/20/25 at 12:30 PM, Staff B, Regional RD, indicated nutritional components of the Care Plan should be updated to reflect changes to a resident's nutritional status. This would include significant weight changes. Specific supplement regimens typically are not listed on a resident's Care Plan. Instead a generic statement identifying the use of a nutrition supplement can be used. The Care Plan Policy, revised 3/25, noted the following: a. After the comprehensive assessment is completed, the facility will put in place person-centered Care Plans outlining care for the residentb. These will be reviewed and revised by the interdisciplinary team after the completion of the MDS assessments when applicable and with changes that warrant a Care Plan revision

Based on clinical record review, facility policy review and staff interviews, the facility failed to follow professional standards of care for 2 of 17 residents reviewed. Staff did not update the clinical record to add an identified medication allergy (R#21) and did not notify the physician with blood sugar results (Resident #6) as ordered. The facility reported a census of 42.Findings include: 1.The Minimum Data Set (MDS) Assessment completed on 9/10/25 revealed Resident #21 with Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The electronic health record (HER) revealed the following Physician Orders for Resident #21 on 11/2/25: a. Discontinue Cefepime intravenously every 12 hours. b. Add medication to list of possible allergies. c. Watch resident closely for further signs of allergic reaction, such as difficulty breathing or swallowing, hives, etc, for the next three days. Orders were noted and acknowledged by facility nursing staff on 11/2/25. Orders were also reprinted for the Medical Provider signature with the comment allergic reaction changing antibiotic. The Allergy tab of the EHR, obtained on 11/18/25, documented the following allergies: Gabapentin, Metformin, and Sulfa antibiotics. Cefepime was not listed. During an interview on 11/18/25 at 5:05 PM, the Assistant Director of Nursing (ADON), noted Resident #21's possible allergic reaction to Cefepime and the need to change antibiotics. During an interview on 11/20/25 at 12:00 PM, the Director of Nursing (DON) explained allergies are reviewed and entered into the EHR upon resident admission. New allergies which are identified afterwards do not happen that often. Newly identified allergies should be entered into the EHR once identified. This information can then be relayed during morning meetings or in the staff communication book. The DON was not aware of Resident #21's Cefepime allergy. The facility did not have a policy addressing resident allergy documentation. 2. The MDS assessment dated [DATE] revealed Resident #6 scored a 10 out of 15 on the BIMS, which indicated cognition moderately impaired. The MDS revealed a diagnoses list which included diabetes mellitus (DM). The Care Plan revealed a Focus area dated 2/26/25 for resident at risk for complications related to diabetes mellitus. The interventions dated 2/26/25 indicated to monitor glucose levels as ordered and report to practitioner per parameters Review of the EHR revealed a Physician Order, dated 1/20/19 to Check fasting blood glucose level weekly on Tuesday. Notify physician if BS <60 or >150. one time a day every Tue related to Type 2 DM without complications Review of the Blood Sugar Summary in the EHR revealed the following blood sugar levels a. On 8/5/25 at 7:55 AM: 169 mg/dl (milligrams per deciliter) b. On 8/12/25 at 7:53 AM: 196 mg/dl c. On 8/19/25 at 7:34 AM: 196 mg/dl d. On 8/20/25 at 8:52 AM: 154 mg/dl e. On 9/9/25 at 7:46 AM: 195 mg/dl f. On 10/28/25 at 8:21 AM: 162 mg/dl g. On 11/4/25 at 7:28 AM: 238 mg/dl Review of the EHR revealed a lack of documentation to indicate the physician notified of the blood glucose readings above 150 mg/dl as ordered. During an interview on 11/20/25 at 11:22 AM, Staff A, Registered Nurse (RN) queried on Resident #6 blood glucose order and she stated she didn't believe there was anything specific to the order, like having to notify the provider but Staff A would need to look. Staff A reviewed Resident #6 order and Staff A stated the order indicated blood glucose checks once a week and notify provider if not within the parameters. Staff A stated they faxed the provider for day-to-day things and called them for emergent issues. Staff stated the notification should be in the progress notes. During an interview on 11/20/25 at 12:32 PM, the DON queried on Resident #6 blood glucose order and she stated it seemed like an odd order and was put in before she worked at the facility. The DON stated the nurses were supposed to notify the provider if the blood sugars not within the parameters. The Facility Physician Orders/Transcription of Orders revised on 7/2023 revealed the following: a. Physician's orders will be received by a licensed nurse, therapist, or dietician b. The order should be entered into the resident's medical record exactly as it was stated/written by MD (Medical Doctor)/ NP (Nurse Practitioner)/ PA (Physician Assistant) c. Active orders should be followed and carried out as written/transcribed.

Based on observation, clinical record review, facility policy review and family and staff interviews, the facility failed to evaluate effectiveness and revise fall interventions in an effort to prevent future falls for 1 of 3 residents (Resident #25) reviewed for falls. The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS indicated resident needed partial/moderate assistance with chair/bed to chair transfers, and used a manual wheelchair for mobility which he could propel independently. The MDS list of diagnoses included Parkinson's disease and non-Alzheimer's dementia. The MDS documented Resident #25 had 2 or more falls with no injury and 2 or more falls with injury (not major injury) since the last assessment.The Care Plan revealed a Focus area revised on 9/17/25 for resident at risk for falls, and when in wheelchair remove pedals to decrease tripping hazard. The interventions dated 2/26/25 indicated assistance with ambulation and transfers as needed.During an interview on 11/18/25 at 2:27 PM, Resident #25 wife stated Resident #25 had multiple falls and would trip over his foot pedals, so the facility implemented to removal of the foot pedals when Resident #25 sat in his wheelchair. During an observation at 11/19/25 at 3:14 PM, Resident #25 sat in his room and stood up by his recliner. The Administrator came into his room and handed Resident #25 his walker and the Administrator helped him sit down.Review of an Incident Report Note dated 8/30/25 at 10:43 AM revealed Describe Situation: Reported to this nurse by [name redacted] Registered Nurse (RN). Resident found on floor in B hall hallway. Resident was in front of his wheelchair, with his knees on his foot pedals and hands on the found in front of him. Assessment completed and no signs of injuries noted. Resident assisted back into wheelchair. This nurse asked resident if he fell, resident stated yes. This nurse asked resident how he fell and he stated he was reaching for something. Neuros started since fall was unwitnessed.Preliminary Recommendations, if any, for consideration as further preventative measures: Resident not to have foot pedals on wheelchair while he is sitting, will educate staff.Review of an Incident Report Note dated 8/31/25 at 6:45 PM, revealed Describe Situation: Resident found on the floor with wheelchair pedals under buttocks, leaning to the left side, resting head on nurse's cart. No marks to left side of head. Resident was sitting at nurse's station in wheelchair for frequent visual checks. Staff had seen Resident within last 5 minutes.List Relevant Interventions That Were In Place At The Time of The Incident: Resident was in wheelchair, had skid socks on, sitting at nurse's station for frequent visual checks. Preliminary Recommendations, if any, for consideration as further preventative measures: NONEReview of an Incident Report Note dated 9/1/25 at 6:30 PM, revealed Describe Situation: This nurse called from report d/t (due to) Resident having a witnessed fall in dining room. Resident stood up et (and) went to step over pedal et fell, landing on a foot pedal on the left buttock. All extremities move per baseline. Denies pain. Smiling et talking with staff. Assisted x 3 with mechanical lift transferred from the floor to the wheelchair et brought to nurse's station.List Relevant Interventions That Were In Place At The Time of The Incident: Was in dining room with staff/ frequent visual checks. Preliminary Recommendations, if any, for consideration as further preventative measures: Educating staff et placing sign in Resident's room stating wheelchair pedals only to be on during transfers.Review of an Incident Report Note dated 9/17/25 at 6:20 PM, revealed Describe Situation: Aides was pushing another resident to edge of dining room when this nurse entered dining hall. Resident is laying on floor on left side with feet towards wheelchair. Wheelchair right foot pedal is caught on table leg. When staff asks resident what happened he states he does not know he fell on the floor. Resident denies hitting head.List Relevant Interventions That Were In Place At The Time of The Incident: resident was sitting in wheelchair with nonskid socks on.During an interview on 11/20/25 at 9:51 AM, Staff D, RN queried on Resident #25 fall interventions like foot pedals and Staff D stated when Resident #25 was pushed in the wheelchair he needed foot pedals, but anytime Resident #25 at the nurse's station, the foot pedals needed to be removed. Staff D stated the intervention was on the fall report and on a note on Resident #25 door in his room and staff educated on the foot pedals. Staff D did not recall when the intervention was put in place.During an interview on 11/20/25 at 10:12 AM, Staff E, RN queried on Resident #25 fall interventions and Staff E stated staff took off Resident #25-foot pedals at times when Resident #25 sat in his wheelchair. Staff E stated the staff didn't remove the foot pedals unless Resident #25 messed with them, but the foot pedals were usually off because Resident #25 leaned forward and messed with them. During an interview on 11/20/2025 at 10:43 AM, Staff F, Certified Nurse Aide (CNA) queried on fall interventions for Resident #25 and Staff F stated Resident #25 was supposed to have his foot pedals on unless Resident #25 was moving because it was a fall hazard. During an interview on 11/20/25 at 10:50 AM, Staff G, CNA asked about Resident #25 fall interventions and Staff G stated when Resident #25 in his wheelchair, his foot pedals needed to be off so he didn't hurt his feet or trip over them when Resident #25 tried to stand up.During an interview on 11/20/25 at 12:37 PM, the Director of Nursing (DON) queried on the process of evaluating falls and the DON stated the management team discussed falls every morning and reviewed the when, why, and where the fall occurred. The DON stated they evaluate what happened and how to fix it. The DON queried on the interventions for the fall on 8/30/25 and the DON stated they did a medication evaluation. The DON asked about the interventions for the falls on 8/31 and 9/1/25 and the DON stated the intervention was to remove Resident #25-foot pedals for both of those falls. The DON queried on the fall on 9/17/25 and the DON confirmed the foot pedals on the wheelchair when Resident #25 fell and the foot pedals needed to be off when the resident sitting. The DON stated she put communication for Resident #25-foot pedals to be removed on 9/15/25. The DON stated the intervention for Resident #25 fall on 9/17/25 was to reeducate staff and told them Resident #25 pedals should be off.Review of the facility policy titled, Fall Occurrence, dated 2/2024 revealed a Purpose statement which declared: It is the policy of the facility to ensure that residents are evaluated for falls risks and implement interventions to minimize risk for falls and/or risk for injury from falls. The Procedure step #6 directed Additional intervention(s) will be implemented post fall. IDT may change the intervention(s) if IDT (Interdisciplinary Team) investigation identifies a more appropriate intervention for the individual fall

Based on clinical record review, policy review, and staff interviews, the facility failed to develop and implement a discharge plan which focused on the resident's goal to return home, in the event alternative therapy services could not be obtained for 1 of 3 residents (Resident #1) reviewed for discharge planning. The facility reported a census of 34 residents. Findings include: Review of the Minimum Data Set (MDS) assessment tool, dated 3/26/25, for Resident #1 revealed a list of diagnoses which included heart failure, diabetes (a disease which caused abnormal blood sugars), and unsteadiness on his feet. The MDS indicated the resident required partial to moderate assistance with rolling from right to left, standing, transferring, and eating; substantial to maximal assistance with showering; and dependent for toileting hygiene. The MDS Brief Interview for Mental Status score of 15 out of 15, indicated intact cognition. The MDS documented Resident #1 had an ostomy (a surgically created opening, called a stoma, on the body's surface, allowing waste to exit the body when the normal elimination process was disrupted) and received insulin (a medication used to lower blood sugars) injections. During an interview on 6/17/25 at 9:13 a.m., Resident #1's wife stated during her husband's stay they were very dissatisfied with therapy services. She stated on 4/29/25, her spouse was provided a NOMNC (Notice of Medicare Non-Coverage, written notice that Medicare providers must give beneficiaries when their Medicare covered services are ending) indicating his skilled care would no longer be available after 5/6/25. She stated her husband [Resident #1] signed the NOMNC, but she was never made aware of any appeal process. During a follow up interview on 6/18/25 at 10:35 a.m., Resident #1 wife stated she was called the day her husband got notice of skilled care ending on 5/6/25, and at some point, she declined home health services. She stated referrals were made to different facilities for further therapy. She explained she knew Medicare would not provide skilled care. Resident #1's wife stated at discharge her husband was in a wheelchair, and two aides brought him out to the car and assisted him into the vehicle. She stated the facility did not provide a wheelchair. She further explained after discharge from the facility she took her husband to a hospital. She stated he did not qualify for a hospital admission. She stated on 5/8/25 after an overnight hospital stay she picked him up and took him to a hotel as she was unable to get Resident #1 into her home due to the narrow entryway and 4 steps. Review of the Care Plan, dated 3/21/25, revealed a Focus areas to address: a. Risk of falls. b. Assistance with ADL's (activities of daily living which include tasks such as transferring, showering, eating, personal hygiene, etc.). c. Risk of nutritional status related to diabetes. d. Risk of alteration in skin integrity related to diabetes. e. PASRR (Preadmission Screening and Resident Review - an assessment used to evaluate for a serious mental illness, intellectual disability, resident offered the most appropriate setting, and needed services provided for setting). f. Psychotropic medication used related to neuropathy (pain caused by peripheral nerve damage). g. Advanced Directives. h. Resident states he never has pain. The Care Plan lacked a Focus area to address discharge goals and planning related to the resident/family members request for referrals for alternative therapy services or for his return home in the event such services could not be obtained. Review of the electronic health record (EHR) revealed a Communication - with Resident note, dated 4/29/25 at 3:58 p.m. Note Text: This nurse, and [name redacted] SW (Social Worker) spoke with the resident about NOMNC with the last day of therapy indicated as 5/6/25. Resident agreeable, sings NOMNC, and verbalizes plan is to return home 5/7/25. This nurse and [name redacted] SW ask if resident would like to us to notify wife and he is agreeable to us calling his wife. Review of a Communication -with Family/Related Party note, dated 4/30/25 at 8:31 a.m. Note Text: Spouse called at this time to inform SW that she would like information to be sent to [name of three facilities redacted] for therapy services after resident's therapy services ends here on 6\5/6/25. Resident will not be staying after services end and will discharge the morning of 5/7/25. Review of the 5/5/25 Nurse Practitioner (NP) Discharge Summary revealed a History of Present Illness section, which documented, in part . His insurance has denied continuation of skilled therapy at the facility and he prefers to transfer to another facility to continue physical therapy. He plans to discharge on Wednesday [5/7/25]. He continues to have difficulty standing and is unable to ambulate, which was necessary for him to return home where he lived with his wife. An Order Note dated 5/5/25, listed the following orders: discharge to a skilled facility on 5/7/25, PT (physical therapy) and occupational (OT) to evaluate and treat at the new facility, continue current medications and treatments. Review of a Communication with Family Related Party note, dated 5/6/25, revealed the resident's representative stated if other facilities did not accept the resident, she would take him home. Review of the EHR revealed a Instructions for Discharge document, dated 5/2/26 revealed: III. Therapy section which indicated, in part: 4. If other, please specify: Recommend 24 hour care including either home health or hospice care for follow up after SNF (Skilled Nursing Facility) d/c (discharge). Electronically signed by [name redacted] Occupational Therapist on 5/6/25. A Communication with Physician note, dated 5/7/25, listed an order to discharge to home. Review of the EHR revealed a lack of documentation to indicate assessments completed and discharge planning occurred for Resident #1 to address: a. Specific needs related to: transfer ability, safety/supervision needs, and equipment needed for safe transition to home. b. The caregiver's capacity and ability to care for the resident such as how she would assist him with transfers and if she had a support system. c. The living situation including any potential challenges or difficulties such as accommodation needed to get into the home, stairs within the home, location of bathroom, etc. d. A discussion with the resident regarding the implications and/or risks of being discharged to a location that was not equipped to meet his needs and if he felt safe returning home. During an interview on 6/18/25 at 11:46 a.m., Staff B, Registered Nurse (RN) stated the resident required quite a bit of care including transfer assistance, ostomy care, showering, and oral care. She stated his assistance needs remained pretty much the same during his stay. During an interview on 6/18/25 at 12:41 p.m., Staff A, Physical Therapy Assistant (PTA) stated the facility sometimes conducted a home assessment if the resident lived close but not always. Staff A stated the facility talked to the resident's wife about his post-discharge care and she said that she would be able to stop by the house throughout the day on days she worked. Staff A stated she did not feel that the resident should be alone. On 6/18/25 at 12:06 p.m., when queried about discharge planning for Resident #1, the MDS Coordinator stated the resident's wife requested referrals to other facilities after his discharge from this facility, however those facilities did not accept him. The MDS Coordinator stated that the resident's spouse stated if other facilities did not accept him, she would take him home. During a phone interview on 6/19/25 at 1:44 p.m., the Administrator stated the only policy the facility had related to discharge was the bed hold policy. She stated the resident's wife was insistent on taking the resident home. She stated if the Nurse Practitioner thought the resident was unsafe, he would have discharged against medical advice (AMA). She stated she didn't know if therapy carried out an assessment regarding the wife's ability to care for the resident at home or if they carried out a home assessment. The Administrator stated she felt the resident's spouse was capable of transferring him and the spouse never made any comments to them that she could not handle it. The Administrator stated she didn't see any additional paperwork other than the Discharge Instructions when asked about a discharge notice. The Administrator stated they felt that since the spouse was a nurse she could take care of him. Review of the facility policy Bed Hold and Return Policy, revised 10/2023, revealed a Purpose statement which declared To ensure that residents are made aware of facilities bed hold and return policy before and upon transfer or when taking a therapeutic leave from the facility.

Based on clinical record review, policy review, and staff interview, the facility failed to provide the resident or resident's representative 30 day written notice before discharge, with instruction on how to appeal for 1 of 3 residents (Resident #1) reviewed for discharges. The facility reported a census of 34 residents. Findings include: Review of the Minimum Data Set (MDS) assessment tool, dated 3/26/25, for Resident #1 revealed a list of diagnoses which included heart failure, diabetes (a disease which caused abnormal blood sugars), and unsteadiness on his feet. The MDS indicated the resident required partial to moderate assistance with rolling from right to left, standing, transferring, and eating; substantial to maximal assistance with showering; and dependent for toileting hygiene. The MDS Brief Interview for Mental Status score of 15 out of 15, indicated intact cognition. The MDS documented Resident #1 had an ostomy (a surgically created opening, called a stoma, on the body's surface, allowing waste to exit the body when the normal elimination process was disrupted) and received insulin (a medication used to lower blood sugars) injections. Review of the electronic health record (EHR) revealed: a. A 4/29/25 Communication with Resident Note documented the resident received notice of his last day of therapy and stated his plan was to return home. b. A 5/5/25 Order Note listed the following orders: discharge to a skilled facility on 5/7/25, physical therapy(PT) and occupational therapy(OT) to evaluate and treat at the new facility, continue current medications and treatments. c. A 5/7/25 Communication with Physician note listed an order to discharge to home. On 6/19/25, the State Agency requested the Notice of Discharge given to the Resident #1. On 6/19/25 at 1:34 p.m., via email, the Administrator provided Resident #1's Instructions for Discharge in response to the request for a Notice of Discharge. Review of an Instruction of Discharge document in the EHR, dated 5/2/25 at 10:12 a.m., revealed: I. Social Services section: Responsible party: Name and phone number of wife/emergency contact listed. Physician in the Community: Name of primary physician in community listed, and name and phone number of primary physician in facility listed. Discharge Location: 1. Home checked. 1a. If other: Discharging home first and potential admit to another SNF. Pharmacy: Name and town of pharmacy listed. Home Health/Hospice Services:blank/no information (clinical record documented refusal of service), Medical equipment Arrangements: blank/no information listed. Psychosocial: 1. Cognitive Status: a.Alert to person, b. Alert to place and c. Alert to time checked, 2. Psychosocial needs: a. Able to communicate needs checked. 3. Mood and Behavior Patterns: No mood or behavior patterns applicable upon discharge. Comments: 0. Code Status: Full Code. 1. Resident is discharging to home before 10am May 7th, 2025. SW has sent our referrals [facility names redacted] for this resident to continue therapy services. Electronically signed on 5/6/25 by SW. II. Nursing Section: A. Summary: 1. During stay: a. Wound care, c. Medication management, e. Disease management checked. 2 - 9. Most recent weight, blood pressure, temperature, pulse, respiration, blood glucose, O2 sats (blood oxygen saturation), and pain level indicated. 10. Current Diet: Regular. 11. Oral/Eating: Set up/cueing assistance with meals indicated, B. Basic Care Needs: 1. Basic Care Needs: d. Continent, f. Requires assistance with ADL's (activities of daily living) checked. C. Medications: 1. Discharge Nurse to print Order Summary Report and reconcile with discharge orders .checked. D. Skin/Treatment: 1. Skin and treatment orders and education reviewed with patient and/or responsible party and provided within Order Summary Report checked. E. Reconciled Medication List: 1. Yes - current reconciled medication list provided to the subsequent provider. 2. Indicate route of transmission of the current reconciled medication list to subsequent provider: d. Paper-based (e.g. fax, copies, printouts) checked. 3. Provision of Current Reconciled Medication List to Resident at discharge: 1. Yes, Current reconciled medication list provided to the patient, family, and/or caregiver. 4. Indicate the route(s) of transmission .: Paper-based (e.g. fax, copies, printouts) checked. F. Nursing Instructions: Discharge Nursing: 1a. Medications have been reconciled . checked. d. Provide copy of care plan . checked. 2a. Discharge instructions and summary of care reviewed and education provided to resident and/or representative checked. b. Copy of Discharge Instructions and summary of care offered/provided to resident and/or responsible party checked. Document signed on 5/7/25 by Responsible Party Signature (resident signature), and facility MDS Coordinator and SW and summary of care offered/provided to resident and/or responsible party. Document signed on 5/7/25 by Responsible Party Signature (resident signature), and facility MDS Coordinator and SW. III. Therapy section: Therapy during my stay: 1. a.PT (physical therapy), b. OT (occupational therapy) checked. 2. Therapy discharge instruction reviewed with patient and/or responsible part checked. 3. Select all that apply: a. Therapy after discharge. c. Safety tips checked. 4. If other, please specify: Recommend 24 hour care including either home health or hospice care for follow up after SNF(Skilled Nursing Facility) d/c (discharge). Electronically signed by [name redacted] Occupational Therapist on 5/6/25. The Instructions for Discharge document did not give a 30 day notice or include information on how to appeal the discharge. The resident's clinical record lacked documentation of a discharge notice given to the resident or the resident's representative which included the following information: a. The reason for discharge b. The effective date of discharge c. An explanation of the right to appeal the discharge to the State d. The name, address (mail and email), and telephone number of the State entity which received such appeal hearing requests e. Information on how to obtain an appeal form During a phone interview on 6/19/25 at 1:44 p.m., the Administrator stated the only policy the facility had related to discharges was the bed hold policy. She stated the resident's wife was provided discharge instructions but she didn't see another form provided other than this. She stated the resident's spouse informed them he would discharge the morning of 5/7/25. Review of the facility policy Bed Hold and Return Policy, revised 10/2023, revealed a Purpose statement which declared To ensure that residents are made aware of facilities bed hold and return policy before and upon transfer or when taking a therapeutic leave from the facility.

Based on record review and interviews, the facility failed to address the resident's Care Plan for the medical diagnosis of diabetes, and address the resident's diuretic medication for 2 of 5 residents reviewed for unnecessary medications Resident #5, #9). The facility reported a census of 41 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 scored a 12 out of 15 on the BIMS (Brief Interview for Mental Status) exam, which indicated cognition moderately impaired. The MDS revealed a diagnosis of Diabetes Mellitus (DM) and the resident received insulin 7 out of 7 days. The Care Plan lacked a focus area and interventions for the diagnosis of DM. The Electronic Medical Record (EMR) revealed the following diagnosis: a. Type 2 diabetes mellitus with diabetic chronic kidney disease b. Type 2 diabetes mellitus with diabetic neuropathy, unspecified The Physician Orders revealed the following orders: a. ordered 5/16/23- Levemir flextouch subcutaneous solution pen-injector 100 unit/ml (milliliter)- inject 5 unit subcutaneously at bedtime b. ordered 8/23/22- Novolog pen fill solution cartridge 100 unit/ml- inject 16 unit subcutaneously three times a day. Give with meals/hold if <100 c. ordered 6/17/21- check blood glucose level four times a day 2. The Quarterly MDS assessment dated [DATE] revealed Resident #5 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed diagnoses of heart failure and coronary artery disease. The MDS documented the resident received a diuretic. The Care Plan lacked documentation for a focus area or interventions for a diuretic. The EMR revealed the following diagnoses: a. chronic diastolic (congestive) heart failure The Physician Orders: a. ordered 9/8/23 - Lasix oral tablet 20 mg (Furosemide)- give 20 mg by mouth one time a day During an interview on 2/1/24 at 11:07 AM, the MDS Coordinator queried if a resident diabetic and on insulin if she expected it to be addressed on the care plan and she stated yes, it would be. The MDS Coordinator confirmed she didn't see it addressed on Resident #9 care plan. The MDS Coordinator queried if they addressed diuretics on the care plan and she stated yes, they should be on the care plan. The MDS Coordinator asked if Resident #5 diuretic addressed on the care plan and she stated no, and it should be on there. During an interview on 2/1/24 at 11:52 AM, the Director of Nursing (DON) queried on the expectations for diuretics being addressed on the care plan and she stated well, they don't need to be on there. The DON asked her expectation for diabetes to be addressed on the care plan, and she stated she expected if care needed done around the area. The DON asked if Resident #9 need care around the area and she stated yes, they needed to watch for hyperglycemia and hypoglycemia. During an interview on 2/1/24 at 12:38 PM, the DON stated the facility didn't have a policy for care plans. She stated that care plans were something they learned in school, and it was a standard of care.

Based on interview and record review, the facility failed to ensure insulin held per physician ordered parameters. The facility also failed to document if insulin, and blood glucose checks were completed for 1 of 5 residents reviewed for unnecessary medications (Resident #9). The facility reported a census of 41 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS documented a diagnosis of Diabetes Mellitus (DM), and the resident received insulin 7 out of 7 days. The Care Plan lacked a focus area, and interventions for the diagnosis of DM. The Electronic Medical Record (EMR) revealed the following diagnosis: a. Type 2 diabetes mellitus with diabetic chronic kidney disease b. Type 2 diabetes mellitus with diabetic neuropathy, unspecified The Physician Orders revealed the following orders: a. ordered 5/16/23- Levemir flextouch subcutaneous solution pen-injector 100 unit/ml (milliliter)- inject 5 unit subcutaneously at bedtime b. ordered 8/23/22- Novolog pen fill solution cartridge 100 unit/ml- inject 16 unit subcutaneously three times a day. Give with meals/hold if <100 c. ordered 6/17/21- check blood glucose level four times a day Review of the Blood Glucose/Insulin Administration Record dated December 2023 revealed Novolog 16 units administered on the following date when the blood sugar level outside of parameter; a. 12/4/23 at lunch time the blood glucose level revealed 98 mg/dl (milliliters in deciliter) Review of the Blood Glucose/Insulin Administration Record dated December 2023 revealed Levemir 5 units administration on the following dates left blank; a. 12/6/23 at bedtime b. 12/15/23 at bedtime c. 12/29/23 at bedtime Review of the Blood Glucose/Insulin Administration Record record dated December 2023 revealed the following dates the blood glucose level left blank; a. 12/6/23 at bedtime b. 12/15/23 at bedtime Review of the Blood Glucose/Insulin Administration Record dated January 2024 revealed Novolog 16 units administered on the following dates when the blood sugar level outside of parameter; a. 1/4/24 at supper the blood glucose level revealed 95 b. 1/7/24 at supper the blood glucose level revealed 95 Review of the Blood Glucose/Insulin Administration Record record dated January 2024 revealed the following dates the Novolog 16 units administration left blank; a. 1/13/24 at supper b. 1/14/24 at supper c. 1/18/24 at supper d. 1/20/24 at supper e. 1/21/24 at supper Review of the Blood Glucose/Insulin Administration Record record dated January 2024 revealed the following dates the blood glucose level left blank; a. 1/21/24 at supper During an interview on 1/31/24 at 4:10 PM, Staff A, Licensed Practical Nurse (LPN) queried if Resident #9 insulin order had parameters, and she stated no, usually they don't have parameters. Staff A informed the order revealed a parameter of 100 to hold and she looked up the medication, and stated yes, the order documented the parameters and she stated she didn't know when the parameters were ordered, and usually when the resident's blood sugars were low they called the provider. She stated if she believed she would of checked the blood sugar before she gave the insulin when the resident's reading read low. Staff A asked what the blank areas on the Blood Glucose/Insulin Administration Record, and she stated it meant they held the medication. Staff A asked if the medication held, would they document why in the progress note and she stated yes. Staff A confirmed if the medication not documented as given, it revealed the medication red on the EMR. During an interview 2/1/24 at 8:26 AM, Director of Nursing (DON) stated she spoke to the nurses who didn't document the insulin administration, and the DON stated the nurses said they remembered giving the insulin to Resident #9. The DON stated she expected nurses to follow the orders as written. The DON asked if the EMR indicated if a medication given or not and she said it would for their shift but didn't show the next shift if the medication didn't get administered unless they went back and looked. The DON stated she expected staff to be checking to make sure the medication was administered and this was something they worked on. During an interview on 2/1/24 at 12:52 PM, the Corporate Nurse Consultant reported the facility didn't have a policy for medication administration. She stated they followed standards of care and they followed the 5 rights of medication administration liked you learned in school. The Corporate Policy Manual: Personnel/Human Resources, Licensed Nursing Orientation Checklist revised on 5/2002 on the following information for medication: a. Medication Administration Record (MARS), Treatment Administration Records (TARS) b. medication errors c. Medication administration standards of practice (Intramuscular, subcutaneously, eye drops, inhalers, gastric tube)

Based on interview and record review, the facility failed to ensure the resident only received their own medications, and that the resident received the correct physician ordered dosage of their medication for 1 of 10 resident reviewed for medication administration (Resident #5). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS documented diagnoses of depression and anxiety disorder. The MDS revealed the resident took an antidepressant and antianxiety medication. The Care Plan revealed a focus area for antidepressant medication to treat depression and anxiety. The interventions revealed administration of antidepressant medications as ordered by the physician and monitored/documented side effects and effectiveness with all concerns reported. The Electronic Medical Record (EMAR) revealed the following diagnoses: a. depression, unspecified b. anxiety disorder, unspecified The Physician Orders for Resident #5 revealed the following information: c. ordered on 9/7/23 and discontinued on 9/27/23: Paxil (Paroxetine HCl (hydrochloride)) oral tablet 20 mg (milligrams)- give 20 mg by mouth one time a day d. ordered on 9/27/23: Paroxetine HCl oral tablet 30 mg- give 30 mg by mouth one time a day The Incident Report- Medication Report effective 11/26/23 at 6:59 AM revealed the following information: a. Medication Order- include medication name, dose, route, and time administered: medication wrong dose given 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23, 11/22/23, 11/24/23, and 11/25/23. Order read Paxil order tablet 20 mg one time a day every day. b. Description of medication incident: Paxil 30 mg tablets were given orally once a day for the last 10 days c. Assessment of resident including vital signs: resident alert and oriented to person, place, time, and situation, denied pain, vitals signs within normal limits (WNL) blood pressure 117/64, pulse, 60, respirations 16 and regular, pulse oximetry saturation 97% on room air, temperature 97.1. The resident stated she been more sleepy recently. d. Physician notified (include date and time): [redacted name] call on 11/26/23 at 7:15 am e. responsible party notification (include date and time): emergency contact #1 and the Power of Attorney (POA) notified on 11/26/23 at 7:15 am The Incident Report- Medication Report effective date 1/28/24 at 8:46 PM revealed the following information: a. Medication Order- include medication name, dose, route and time to be administered: Resident given medication not prescribed to her. Seoul 300 mg, Trazadone 150 mg, Promethazine 25 mg, along with prescribed medication for her melatonin 6 mg and acetaminophen 650 mg. b. Description of medication incident: environment loud, several things going on in surrounding area. Prepared medication and took it to resident's room. The resident took the medication and discussed pain and needed muscle rub with nurse. c. Assessment of resident including vital signs: 90/52 blood pressure, temperature- 97.6, pulse 68, respirations 16, pulse oximetry saturation 92% d. Physician notification (include date and time): [redacted name] on 1/28/24 at 8:30 PM e. responsible party notification: son on 1/28/24 at 8:35 PM The Review of Resident #23 Physician Orders revealed the following medication orders: a. Promethazine HCl oral tablet- give 25 mg by mouth one time a day b. Quetiapine Fumarate (Seroquel) oral tablet- give 300 mg by mouth one time a day c. Trazadone HCl oral tablet- give 150 mg by mouth one time a day The Review of Resident #5 Physician Orders revealed the resident not prescribed Promethazine, Quetiapine, and Trazadone. During an interview on 1/29/24 at 11:42 AM, Resident #5 stated she received someone else medication. She stated she can't hardly sit up now. She stated she got a good night's sleep out of it. Resident sat on the side of her bed and ate lunch independently during the interview. During an interview on 2/1/24 at 11:52 AM, the Director of Nursing (DON) stated she spoke to the nurse after it happened and the nurse stated she made mistake and got in a hurry. The DON stated she reviewed with staff the 5 rights of medication and stated she was a [NAME] on instructing the nurses to pop the medications, and save it and not to click off the medication until they gave the medication to the resident. The DON stated she instructed the nurse to double check the resident and if in doubt stop, and check what they were doing. During an interview on 2/1/24 at 12:52 PM, the Corporate Nurse Consultant stated the facility didn't have a policy for medication administration. She stated they followed standards of care and they followed the 5 rights of medication administration liked you learned in school. During an interview on 2/1/24 at 1:37 PM, Staff B, Registered Nurse (RN) queried about the medication incident on 1/28/24 and she stated she prepared the medication and took them down to Resident #5, and talked to the resident while she administered the medications and then went back to her medication care, then she realized she given the wrong medications to Resident #5. Staff B stated she gave Resident #23 medications to Resident #5. Staff B stated Resident #23 received her correct medications later in the evening. Staff B stated the DON gave her education after the incident. Staff B asked the expectation of medication administration and she stated to follow the 5 rights to medication administration. Staff B queried how Resident #5 acted after she received the wrong medications and she stated Resident #5 slept heavily, but easily woke up, displayed slurred speech, and used her call light when needed and told the staff her needs. Staff B asked if Resident #5 looked at the medications in her cup prior to taking them and Staff B stated no, she takes the medications and at that time they talked about a muscle rub. During an interview on 2/1/24 at 1:47 PM, DON stated Resident #5 received Resident #23 medication. The DON asked her expectation on staff following the rights to medication administration and she stated she expected them to follow them. During an interview on 2/1/24 at 2:07 PM, the Provider stated she spoke to Resident #5 about the incident when she received another resident's medication and Resident #5 didn't state any concerns. The Provider queried on the expectation for staff to follow the physician orders and she stated for staff to check the name, date of birth, right time, right dose, and follow the physician orders as ordered. The Corporate Policy Manual: Personnel/Human Resources, Licensed Nursing Orientation Checklist revised on 5/2002 on the following information for medication: a. Medication Administration Record (MAR), Treatment Administration Records (TARs) b. Medication errors c. Medication administration standards of practice (Intramuscular, subcutaneously, eye drops, inhalers, gastric tube)

Based on review of job qualifications and interview with staff, the facility failed to ensure that the Activity Coordinator met the requirements of the job. Findings include: On 08/04/22 at 1:51 PM, the Human Resources Director (HDR) stated the Activity Coordinator's date of hire for the Activity Coordinator position had been on 04/16/21. The HDR reported that the Activity Coordinator had enrolled in the certification program but had not completed it. On 08/04/22 at 2:25 PM, the Administrator stated the Activity Coordinator (AC) had completed about one-third of the curriculum for certification. On 08/02/22 at 1:40 PM, the AC reported that she had been working as a cook in the kitchen for the last few months and had not been involved in activities. The AC reported that she had two assistants that assisted her, but no other staff overseeing the activities department. The AC had not been not available for a follow-up interview about her failure to complete the certification. The Activity Coordinator Job Description dated 10/12, year unknown, documented the Qualification as follows; Certification upon completion of the Activity Coordinator's orientation course, approved by the Iowa Department of Inspections and Appeals, within six months of employment.

Based on interviews, record review, and facility document review, the facility failed to allow two residents (Resident (R) 44 and R11) out of a survey sample of 20 residents, the right for self-determination and decision making, by failing to assess for capacity to ascertain the ability to consent for a potential mutual relationship. Findings include: 1. Review of the ''Admission Record,'' located in the ''Profile'' tab of R 44' s' Electronic Medical Record (EMR), documented an admitted [DATE]. R 44' s' diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the R 44' s' ''Minimum Data Set'' (MDS) with an Assessment Reference Date (ARD) of [DATE] documented a ''Brief Interview for Mental Status'' (BIMS) score of six out of fifteen, which indicated the resident had severe cognitive impairment. The MDS further revealed R 44 was administered antipsychotics for two of the seven days reviewed, and antianxiety medications daily. Review of R 44' s' quarterly MDS with an ARD date of [DATE] documented a BIMS of five out of fifteen, which indicated the resident had severe cognitive impairment and was administered antipsychotic, antidepressant, and antianxiety medications daily. Review of a Progress Note, dated [DATE] at 7:12 PM, documented that a Certified Medication Aid (CMA) observed Resident# 11 sitting by another Resident#44 smiling and touching in the dining room. Residents were separated. CMA notified this nurse, and wrote a statement. The Administrator had been notified. During an observation [DATE] at 12:30 PM at the nurses' station, R 11 and R 44 were observed sitting in wheelchairs, facing one another. R11 took his hand and reached over to touch R 44 in the lap area. R11 had been observed to have his belt unbuckled, pants unbuttoned and unzipped. Registered Nurse (RN) 1 witnessed the incident at the same time and immediately came over and removed R11 to his room. RN 1 then returned and asked R 44 if R11 had touched her and she replied, ''I don't think so.'' R 11 did not appear upset but was confused about what happened. Review of a ''Behavior Note'' located in the ''Progress Note'' tab of R 44' s' EMR dated [DATE] at 12:35 PM documented as follows: ''New or Worsening Behavior Observed:: Resident had been sitting at nurse station with male resident holding each other's hands. Both residents were aware that nurse had been watching. Nurse noticed male resident starting to move hand under resident's top touching her abdomen. Nurse and Certified Nurse Assistant (CNA) walked over and redirected both residents.'' Review of R 44' s' medical record lacked documentation that R 44 had been accessed for the capacity to consent to a relationship; or care planned for a relationship with other residents. During an interview on [DATE] at 12:45 PM, RN 1 said the two residents (R11 and R 44) have had a relationship in the past. During an interview on [DATE] at 1:57 PM, Licensed Practical Nurse (LPN) 1 reported that R 44 had been forgetful but had been consensual with kissing R11. LPN1 reported that staff must watch them to make sure they do not get ''too handsy.'' LPN1 reported that R 44' s' family member had been okay with the kissing. LPN1 reported that staff did not allow R11 and R 44 to go into one another's rooms. LPN1 reported that R11 and R 44 stay mostly in the nurses' station and dining room. During an interview on [DATE] at 2:53 PM, Certified Nursing Assistant (CNA) 3 reported that R 44 and R11 had been ''caught kissing in the lobby.'' She reported the staff have told them they need to go to a private place, like R11's room. CNA3 reported that the relationship had been consensual and R 44' s' family member (F 1) had been aware and had been okay with it. During an interview on [DATE] at 3:23 PM, F 1 reported that the facility had told her about R 44' s' relationship with R11. She reported that it was awkward, but she was okay with them kissing. F 1 reported that R 44' s' face lights up when R11 had been near her. F 1 said she wants R 44 to be happy. She said she did not want R 44 to go into R11's room. During an interview on [DATE] at 4:30 PM, Activity Assistant (AA) 1 said R11 and R 44 had been ''together dating.'' She said it started in mid-June and she had been told to redirect them if anything was observed. AA 1 said she had seen them together acting (touching, kissing) as if they were ''dating.'' Observed R11 and R 44 on [DATE] at 4:35 PM in the dining room after the coloring activity. R11 self-propelled himself in the wheelchair over to where R 44 had been. R11 then rubbed her right arm and began rubbing her back. AA 1 then redirected both residents apart from each other. During an interview on [DATE] at 5:07 PM the Director of Nursing (DON), the Administrator, and Social Services Director (SSD), The DON said the first incident with R 44 and R11 had been on [DATE]. The DON reported that she had called R 44' s' family member about the two residents being attracted to one another, and had documented a late entry note today, [DATE]. The DON confirmed she had not documented anything in R 44' s' EMR until today. The DON reported that she had put a communication out to the staff about R 44 and R11 hugging and kissing after the [DATE] incident, but could not produce a copy, reporting that it had ''expired.'' The DON said she had not documented anything in the record until today because she was still ''getting things together.'' The Administrator said R11 would ''seek out affection'' from other women. The SSD said this type of situation had never come up before. The DON, Administrator and SSD all confirmed there had been no process in place to evaluate the capacity of residents to consent to physical relationships. During an interview on [DATE] at 2:11 PM CMA 1 reported that there had been a communication put out to the staff awhile ago stating it was okay for the residents to touch and kiss but should be separated if it ''went too far.'' During an interview on [DATE] at 03:02 PM, CNA3 reported that the nurse told her today, to keep R 44 and R11 apart. During an interview on [DATE] at 8:51 AM, the DON reported that she had instructed the staff on the previous day to keep R 44 and R11 separated until they can investigate the situation and determine what the course of action should be. During an interview on [DATE] 12:51 PM, the Psychiatric Nurse Practitioner (NP), reported that she had seen R 44 monthly but had never been made aware of her relationship with R11 until [DATE]. The NP reported that she did not think R 44 would have the cognitive capacity to consent for a relationship, sexual or non-sexual. The NP reported that she did not think R 44 would be able to say no to physical contact. The NP reported that the facility had called her to evaluate R 44 and R11 on [DATE]. The NP reported that R 44 did not remember the incident with R11 on [DATE] and when asked about a boyfriend, she reported that she did not have any. The NP reported that R 44 then turned the conversation toward her, asking her about her boyfriends and asking her to come up with a list of three. The NP reported then R 44 wanted to talk about their hair. On [DATE] at 12:29 PM, RN 3 reported that on [DATE], CMA 2 reported to her that she saw R11 with his hand under R 44' s' shirt around the ribcage area. She reported that they were together in the dining room. RN 3 reported that CMA 2 separated the two of them and brought R 44 to the nursing station. She reported that R11 followed them. RN 3 told them there was not going to be any of that and R 44 responded, ''what is going on here,'' and was upset they were being separated. RN 3 said CMA 2 wrote up a report of what had happened and put it in the Administrators box. RN 3 reported that when she called the Administrator and told her of the incident, the Administrator told RN 3 if they had been separated that is all she needed to do. During an interview on [DATE] 12:44 PM, CMA 2 reported that she witnessed R11 putting his hand under R 44' s' shirt one other time besides [DATE]. CMA 2 reported it had been ''a while'' ago. She reported that both times she had reported it to the nurse and had written up a report for the Administrator. During an interview on [DATE] at 1:16 PM, the Administrator said she had not been aware of any other physical contact other than hugging and kissing before [DATE]. The Administrator reported because of the physical contact under the shirt, a self-report had been sent to the state on [DATE], as a resident to resident altercation under ''other.'' During an interview on [DATE] at 1:04 PM, F 1 reported that she had been aware of one incident where R11 placed his hand under R 44' s' shirt. F 1 reported that she felt if R 44 did not want to be touched, she would let him know. F 1 reported that R 44 had enough of that in her. F 1 reported that R 44 could not remember any of the interaction with R11 but recognized him when he comes around and he makes her happy. 2. The Face Sheet for R11 indicated that the resident had been admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly Minimum Data Set (MDS) with the date of [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen, which indicated the resident had been moderately impaired cognitively. Review of a document provided by the facility titled Care Plan failed to indicate R11 had possible inappropriate interactions with other female residents or if his capacity to enter into a possible consensual relationship with a female resident had been determined by clinical and social service A Plan of Care Progress Note dated [DATE] documented that the resident's cognitive status changed daily with forgetfulness and confusion and days in which the resident was able to have a full conversation. There was no entry in the progress note which revealed the resident was possibly inappropriate with female residents or if he had been assessed for capacity to decide to enter into a mutual consenting relationship. Review of R11's EMR health status Progress Notes located under Prog Note tab dated [DATE] indicated the resident had been overheard to ask female residents if it was okay if he kissed them. A staff member intervened and informed the resident this had been an inappropriate comment and would pass the incident on to the next shift. Review of R11's EMR plan of care Progress Note located under Prog Note tab dated [DATE] indicated the resident's cognitive status changed daily with forgetfulness and confusion and days in which the resident was able to have a full conversation. There had been no entry in the progress note which revealed the resident had been possibly inappropriate with female residents or if he had been assessed for capacity to decide to enter into a mutual consenting relationship. Review of a document provided by the facility titled Office Clinic Notes, dated ,d+[DATE] indicated staff reported R11 was handsy with residents and distanced during meals as an intervention. Review of R11's EMR health status Progress Note located under Prog Note tab dated [DATE] indicated a Certified Medication Assistant (CMA) observed R11 sitting next to R 44 and R11 and smiling and touching each other. The CMA immediately separated the two residents and alerted nursing. The nurse documented she notified the Administrator. Review of R11's EMR behavior Progress Note, dated [DATE] at 12:35 PM, documented that staff observed R11 placed his hand under the top of R 44 and touched her abdomen. Both the nurse and the CNA walked over to the residents and immediately separated them. Review of R11's EMR mental health Progress Note, dated [DATE] indicated the Psychiatric Nurse Practitioner (NP) had been brought in to evaluate R11 behaviors towards another female resident (R 44). During this evaluation, the resident informed the NP that he did not have a sweetheart. The notes indicated the NP asked the resident if he remembered an interaction between, he and R 44 kissing. The NP notes documented that R11 denied remembering this incident. The NP note documented that R11 had two prior incidents of touching or kissing a female resident within the past six to eight months. The note indicated staff were to continue to monitor R11 for inappropriate sexual behaviors during activities and meals and would follow up in two weeks if the behaviors persist. On [DATE] at 3:08 PM, AA 1 reported that R11 could be touchy with R 44. R 44 would seek out R11. On [DATE] at 4:57 PM, SSD reported that she had gone to speak with the residents who want to be involved in a relationship. SSD was asked how the facility determined capacity for consent. SSD stated it was a team decision. SSD stated therapists typically do not get involved with residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . SSD was asked if the relationship between R11 and R 44 was re-evaluated, and Social Services stated the facility staff met and there was an interdisciplinary team. The Administrator and the Director of Nursing (DON) had been interviewed at 5:03 PM. The Administrator and the DON reported that R11 never attempted to enter into R 44' s' room. The Administrator and the DON reported there had been no information on R11's care plan that addressed his behavior of seeking out affection with another female resident. On [DATE] at 9:10 AM, RN 1 reported that she had not seen R11 be sexually inappropriate with R 44. RN 1 reported that ii had been passed on to keep an eye on the two residents and to separate them if they were getting too close. On [DATE] at 9:23 AM, Licensed Practical Nurse (LPN) 1 reported that she had been the staff member who observed R11 reach under the sweatshirt of R 44 on [DATE]. LPN1 reported that she had seen R11 and R 44 touch each other towards the knees, and both were not being sexual. LPN1 reported that the two residents were too close for her to be comfortable, and the two of them had been separated immediately after this observation. LPN1 reported that the family member of R 44 gave permission for the two residents to kiss but not to be sexual with each other. LPN1 reported there had been multiple conversations with the two residents. LPN1 reported that R11 did not know what she was talking about when she speaks with him about the relationship between, he and R 44. On [DATE] at 3:16 PM, RN 4 reported that she had never seen R11 be sexually inappropriate with R 44 or with other female residents. RN 4 reported that she had told staff to keep an eye on R11. RN 4 reported that R11 had been a friendly man and never saw him single out a certain resident. On [DATE] at 10:01 AM, the MDS Coordinator reported R11's behavior did not reach to the level of deviant behavior. The MDS Coordinator reported that R11 was not that type of man. MDS Coordinator reported R 44 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator reported both R11 and R 44 were friendly people and the facility directed staff to keep an eye on the two. MDS Coordinator reported that the staff monitored the two residents frequently. The MDS Coordinator reported that there was no information on R11 or R 44 relationship in the care plan, and would expect information to be placed in the clinical record. The MDS Coordinator reported that both residents did not remember incidents of them being together. On [DATE] at 12:44 PM, the Psychiatric NP reported that she evaluated R11 on [DATE] and had not placed her notes in the system prior to this interview. The NP reported that R11 had been very pleasant and told her things that were not true. The NP reported that the the facility brought her in to assess R11 yesterday and had never met the resident prior to this appointment. The NP reported that the resident denied having a sweetheart and could only remember his first wife's name and not his second wife. The NP reported that R11 had been capable of entering into a consensual affectionate relationship but not R 44. The NP stated R11 had no history of sexual aggression. On [DATE] at 1:09 PM, the DON and the Nurse Consultant reported that the facility had never had an issue like this before. The Nurse Consultant stated the Physician/NP should have been involved in this.

Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents out of 20 sampled residents (Resident (R) 21 and R35) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly can lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: 1. Review of the RAI Manual, dated 10/01/19, documented that it is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status had been during that observation period) by the Interdisciplinary Team (IDT) completing the assessment. Review of R 21' s' Electronic Medical Rrecord (EMR) Admission Record under the Profile tab revealed R 21 had been admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A Progress Note dated 03/13/22 documented that the resident had been found on the floor with her wheelchair tipped over next to her. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly Minimum Data Set (MDS) dated [DATE] of R 21 documented a Brief Interview for Mental Status (BIMS) score could not be determined by the clinical staff. The MDS documented that the resident had short-and-long-term memory problems. The MDS documented that the resident required extensive assistance with two staff members for bed mobility and transfers. The MDS documented that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/03/22 at 9:52 AM, the MDS Coordinator stated she should have answered yes to the question regarding a fall within the last two to six months. The MDS Coordinator stated she did not complete the MDS correctly for R 21. 2. The Admission Record documented that Resident#35 (R35) had been admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 04/14/22 documented that R35 had a BIMS score of zero out of fifteen which revealed the resident had been severely cognitively impaired. The MDS documented that the resident did not receive an antipsychotic during this assessment period. On 08/04/22 at 12:38 AM, the MDS Coordinator reported she did not document that R35 received an antipsychotic during this assessment period for April 2022, and failed to again enter this information when a modification had been created on this same date.

Based upon observation, interview, record review, and policy review, the facility staff failed to involve one of one residents reviewed for group activities as outlined in the residents care plan, and requested by the resident's health care decision maker. (Resident#41) This resulted in R#41 being left alone for hours without any social interaction. Findings include: Review of the resident's electronic medical record (EMR) documented that R#41 had been admitted to the facility on [DATE]. R#41 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Activity Reassessment and Care Plan Progress Note dated 01/29/22 documented that the activity goal had been met by the following: the resident passively participating in activities, and will continue to encourage attendance to activities of interest per the family, and staff will need to assist. Review of R#41's Annual Minimum Data Set (MDS) with the date of 07/22/21 documented that the resident had not been able to answer questions, so a family member participated in assessment, and reported that doing things with groups of people had been important. The Care Plan with revised date of 07/26/22 documented as follows; The resident would like to be out of the room and in the common area for some time each day, as a goal. A Care Conference Progress Note dated, ''7/28/2022 at 10:01 AM documented that the resident will at times look towards where sound is coming from, attends large group activities. The Care Conference Progress Note documented that the plan of care had been reviewed with the residents family member.' Review of the monthly ''Activity'' calendars provided by the facility documented the following: R41 attended zero group activities in February, March, April or May of 2022. R41 attended one group activity in June 2022. R41 attended two group activities in July 2022. There was no documentation that R41 refused activities. Observed R#41 in room in her wheelchair on 08/02/22 at 2:53 PM. A group bingo activity had been going on in the dining room. Observed R#41 in room in her wheelchair on 08/03/22 at 10:13 AM. A group coloring activity had been going on in the dining room. On 08/02/22 at 1:40 PM, the Activity Coordinator said if R#41 had been up in her wheel chair, the staff tried to get her to activities. She reported that R#41's mother wanted her in group activities. The Activity Coordinator reported that she had been working as a cook in the kitchen for the last few months so she had not been involved in activities. The Activity Coordinator stated there had two assistants to help her. On 08/02/22 at 2:57 PM, Certified Nursing Assistant (CNA) 3 reported it would be a team decision as to what activities R#41 should attend. During her month working at the facility, CNA3 reported the activity staff had not asked R#41 to be taken to an activity. CNA3 reported that she took R#41 to a movie last month thinking it would be a good activity for her to attend. On 08/03/22 at 8:47 AM, the Director of Nursing (DON) reported that it had been the responsibility of the activity's department to make sure the resident had been getting to activities. On 08/03/22 10:11 AM, the Activity Assistant (AA) 1 reported that she or the nursing staff could take R#41 to activities. On 08/03/22 at 3:00 PM, the Activity Coordinator reported that it had been the responsibility of the activity staff and the nursing staff to work together to get R#41 to group activities. The Activity Coordinator reported she did not know when she would be back working in the activity department

Based on observation, interview, and record review the facility failed to ensure one of twenty sampled residents had been provided foot care as needed. (Resident#21). The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The Face Sheet for Resident#21 had documented that the resident had been admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, which indicated the resident had been cognitively intact. The MDS documented that the resident required extensive assistance for bed mobility, but had independent with transfers. The Residents Care Plan documented that the resident had been nutritionally at risk related. The Care Plan did not address toenail/foot care along with her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and interview on 08/01/22, Certified Nursing Assistant (CNA) 1 and CNA2 were in the resident's room. CNA1 removed the blanket covering the resident's feet. Two of resident's toes had been exposed from an opening from a purple cast. The two toes had nails which extended approximately one fourth inch above the tip of each toe. The left leg/foot had a TED hose (long, tight fitting stockings that place mild static pressure on the legs) on, and CNA1 pulled back the opening of the tip of the TED hose and exposed all five toes. The first three toes had toenails which extended approximately one-quarter inch of each of these toes. The fifth toe had an approximate one-quarter inch toenail which extended above the tip of the toe. Both CNA1 and CNA2 reported that they were not permitted to trim resident's toes and stated they refer the condition of the toenails to nursing. During an observation and interview on 08/03/22 at 9:32 AM, Restorative Aide (RA) 1 had been weighing the resident on a scale. RA1 exposed her toes on both feet and reported that the CNAs did not clip the toenails if a resident had diabetes and were to verbally inform the nurse. During this observation, the two toes on the right foot, exposed at an opening of the purple cast had toenails that approximately extended one quarter inch above the tip of the toes. The same was for the first three and fifth toes on the resident's left foot. During an observation and interview on 08/03/22 at 9:37 AM, the Director of Nursing (DON) confirmed the resident's toenails needed to be trimmed and was unsure if nursing would be able to do this or a podiatrist. On 08/03/22 at 12:10 PM, the Administrator reported the resident had been scheduled to see a podiatrist on 08/13/22. On 08/03/22 at 3:35 PM, the DON and the Nurse Consultant had been present. The DON reported that she was unable to locate any referral to podiatry prior the survey week. On 08/04/22 at 12:39 PM, the Administrator reported that the facility did not have a policy on foot care or activities of daily living.

Based on observation, interviews, facility policy reviews, and review of the Environmental Protection Agency (EPA) N list the facility failed to ensure housekeeping staff understood and implemented disinfecting measures for one room out of thirty-five rooms which were occupied. (Resident#39) This failure had the potential to increase the risk of exposure to infectious diseases. Findings include: The facility policy titled Cleaning Procedure for Resident Rooms, dated 02/22/08 documented as follows; Resident Rooms will be clean and clutter free to promote a healthy living environment. Resident rooms containing a resident with a resistant organism should be cleaned last using EPA approved disinfectants. Sink, faucets, faucet knobs, and soap dispensers will be cleaned daily with a disinfecting spray. Floors will be cleaned, swept, mopped, and/or vacuumed daily. If mopping, for general cleaning of a floor, use a neutral cleaner, a couple of times per week. Use white vinegar to control odors. Review of the EPA revealed .EPA does not review effectiveness of common household ingredients like vinegar or rubbing alcohol, so EPA cannot verify how well they work to kill the novel Coronavirus. EPA reviews and registers antimicrobial pesticides, which include surface disinfectant products. The Face Sheet for Resident#39 documented that the resident had been admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 01/14/22 documented that the resident had a behavior of urination, and to have a bowel movement while in bed and would lay in it. The Annual Minimum Data Set (MDS) with the date of 07/14/22 documented that the resident had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen which documented that the resident had been cognitively intact. On 08/02/22 at 11:16 AM, Housekeeper 1 had been in the hallway next to resident's room. The odor of vinegar had been present. Housekeeper 1 reported that she used vinegar to cover the smell of resident's room since the resident would urinate all over his bed and floor. Housekeeper 1 reported she did not use a disinfectant after the application of the vinegar. On 08/02/22 at 11:45 AM, the Housekeeping/Laundry Supervisor reported that the facility used a Quat (quaternary ammonium compounds) previously and the substance would not kill the urine smell. Housekeeping/Laundry Supervisor confirmed that the facility had not been using a quat substance prior to today. On 08/04/22 at 7:19 AM, the Administrator reported that Resident#39's room had been the only room that vinegar was applied to. On 08/04/22 at 11:40 AM, the Housekeeping/Laundry Supervisor reported that the facility used the vinegar on Resident#39's floor only and no other surfaces.

Based on record review and staff interviews, the facility failed to provide the proper assistance with transfers for 1 of 5 sampled (Resident #1) which resulted in significant bruising. The facility reported a census of 60. Findings include: According to the Minimum Data Set assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had short and long-term memory impairments and required total staff assistance with transfers, dressing, toilet use and personal hygiene. The Care Plan updated on 8/7/19 revealed Resident #1 directed the staff to provide assistance of two staff with a total mechanical lift. According to the Late Entry Progress Note dated 9/17/19 at 4:30 p.m., Staff B documented a Nurse Aide summoned her to Resident #1's room. The Nurse Aide reported she pivot transferred Resident #1 from her bed to her wheelchair. The Nurse Aide walked behind the wheelchair to position Resident #1 in the wheelchair. Resident #1 slid forward and twisted her knees. Staff B assessed Resident #1's knees and saw no redness or swelling. Staff B palpated Resident #1's knees and she complained of pain and grimaced. At 7:48 p.m., Staff administered a Tylenol suppository for pain. During an interview on 11/20/19 at 1:00 p.m., Staff A (Nurse Aide) stated on 9/17/19 she assisted Resident #1 up for supper. Staff A stated Resident #1 required a total mechanical lift, but her partner was busy helping someone else. Staff A transferred Resident #1 by herself. Staff A stood in front of Resident #1 and wrapped her arms under Resident #1's arms. Resident #1 held onto Staff A's arms. Staff A stated she did not use a gait belt. Resident #1 stood and maybe took a step as she pivoted and sat down onto the edge of the wheelchair. Staff A stated she moved behind Resident #1 to pull her up in the chair and before she could, Resident #1 fell forward to her right and onto her knee, twisting it. Staff A lifted Resident #1 off the floor by lifting under her arms. Staff A stated she then reported the incident to Staff B. Staff A stated she had returned to work following maternity leave from (MONTH) to (MONTH) 2019 and Resident #1 required a total mechanical lift when she returned. During an interview on 11/19/19 at 1:19 p.m., Staff B (Registered Nurse) stated Staff A summoned her to Resident #1's room. Staff B observed Resident #1 sitting in her wheelchair. Staff A reported she attempted to transfer Resident #1 by herself from the bed into her wheelchair. Staff A stated as she pivoted Resident #1 and sat her down on the wheelchair, Resident #1 slid forward and twisted her knees. Staff A stated she was aware Resident #1 required a total mechanical lift and denied Resident #1 ever hit the floor. Staff B stated she assessed Resident #1 noting tenderness in her knees, but no obvious injury. Staff B told staff B, this is why you follow the care plan. Later that evening Resident #1 guarded her right knee. Staff B failed to document the incident in the progress notes and failed to share what had happened with the on-coming nurse. During an interview on 11/19/19 at 3:40 p.m., Staff C (Registered Nurse) stated during report on the morning of 9/18/19 she was told Resident #1 was complaining of knee pain. Staff C had no knowledge of the improper transfer that resulted in Resident #1 twisting her knee the day before. Staff C stated it was very unusual for Resident #1 to complain of pain, so she contacted the Nurse Practitioner and received an order for [REDACTED]. According to Progress Notes dated 9/18/19 at 7:27 a.m., Staff C documented the Nurse Aide reported Resident #1 grimaced and guarded her left knee during cares. Staff C observed Resident #1 guard and rub her knee. Knee swollen without redness or bruising. Staff C notified the Nurse Practitioner. According to the Progress Notes dated 9/18/19 at 8:40 a.m., the Nurse Practitioner noted Resident #1 had left knee pain and swelling and ordered an x-ray. At 9:45 a.m., Resident #1's x-ray results negative for fracture. The Radiology Report dated 9/18/19 of left knee indicate bone density lateral to femoral component of total knee prosthesis may be part of the patella or even an old bone fragment. An acute bone fragment seems unlikely with no joint effusion. In an interview on 11/19/19 at 12:51 p.m. and 11/21/19 at 2:05 p.m., the Assistant Director of Nursing (ADON) stated changed Resident #1 from a pivot transfer with assistance of two staff to a total mechanical lift transfer with assist of two. The ADON stated Resident #1 had started to decline and one day while assisting Resident #1 in the shower it was evident, she could not bear weight to transfer safely. The ADON stated when implementing a change in transfer status she updates the Care Plan and passes the information along to the nurse for report. The ADON verified the accuracy of the statement she typed on 9/30/19. The ADON stated Staff C informed her on 9/18/19 Resident #1 guarded her legs and had pain. Staff C reported Resident #1 had a pivot transfer, but unaware what happened to cause her leg pain. Staff C then called the nurse practitioner and received orders for an x-ray and pain medication. The ADON stated at this time she did not observe any bruising, but noted some slight swelling to the knees and lower extremities. The ADON stated Staff C stated she had only heard a rumor that staff transferred Resident #1 improperly. On 9/23/19, the staff informed the ADON that Resident #1's condition had changed over the weekend and now had significant bruising to her lower legs. During an interview on 11/19/19 at 4:55 p.m., the Director of Nursing (DON) stated she returned to work on Friday, 9/20/19, and several staff reported Resident #1 had pain in her legs. The DON stated she assessed Resident #1 and found no bruising or discoloration at the time and no pain or discomfort. On Monday, 9/23/19 there was a significant change in condition and Resident #1 was visibly uncomfortable. That same day the DON and the Administrator visited with Resident #1's daughter who was upset. The DON stated she initiated an investigation and interviewed Staff B on 9/24/19. Staff B stated two aides transferring Resident #1 and she slipped out of her wheelchair, but did not hit the floor, so Staff B did not fill out an incident report. The DON stated sometime during that week she had also spoken to Staff [NAME] Staff A stated they got her up and she slipped out of the wheelchair as she was attempting to pull her up from behind. The DON stated she did not initially know Resident #1 required a total mechanical lift. On Friday, 9/27/19, the Corporate Nurse visited and Staff A re-enact the transfer. Staff A failed to use the total mechanical lift as directed by the Care Plan. The facility terminated Staff [NAME] According to the Progress Note dated 9/18/19 at 4:30 p.m., Staff B documented Resident #1 had a light bruise under her left knee and darker bruising on lateral aspect of right leg and under knee. According the Progress Notes dated 9/20/19 at 6:53 a.m., the Nurse Practitioner visited Resident#1 for swelling and bruising in bilateral lower extremities, pain, and limited movement. No falls, but she may have been standing/pivot transferred instead of lift transferred just prior to onset of symptoms. X-ray of left knee done yesterday was negative. Has swelling, bruising, and complains of pain worse since yesterday. The Nurse Practitioner noted Resident #1 had two plus [MEDICAL CONDITION] (swelling), right ankle with ecchymosis (bruising), left calf with ecchymosis, swelling to the left knee with possible effusion. Resident #1 winced with palpation of knees, thighs and hips. The Nurse Practitioner ordered additional x-rays of left femur, hip and pelvis and right knee, femur, hip and pelvis. Review of the Radiology Report dated 9/20/19 of bilateral pelvis, right and left femur and right knee on 9/20/19 revealed no acute fractures or abnormalities. According to the Progress Notes dated 9/22/19 at 10:47 a.m., Staff D (Registered Nurse) documented Resident #1's Primary Care Physician notified and orders obtained for additional pain medications for Resident #1's leg pain. At 2:07 p.m., Staff D summoned to Resident #1's room. Resident #1 had bruising both legs all the way to her feet with swelling of the posterior leg. According to the Progress Notes dated 9/23/19 at 1:39 p.m., the Nurse Practitioner documented Resident #1 had continued knee pain, bruising to bilateral legs and posterior knees, right foot swelling and bruised arch. The Nurse Practitioner ordered an x-ray of the right foot. Radiology report dated 9/24/19 of right foot indicate no obvious fractures or dislocations. No acute right foot pathology. According to progress notes dated 9/25/19 at 8:00 a.m. by the DON, the DON notes Resident #1 with order for a CT scan that afternoon. According to progress notes dated 9/25/19 at 4:25 p.m. by Staff B, Staff B notes Resident #1 returned to facility following a CT scan and notes a family member claims resident has muscle strain-twisting and feels the facility has lied to her about the origins of her mother's injury. Radiology report dated 9/25/19 notes reason for exam osteopenia with history of fall and suspected fracture, CT scan of pelvis and left femur. Impression: negative CT study of the pelvis and left femur for evidence of occult fracture. According to the Progress Notes dated 9/26/19 at 6:00 p.m. by Staff B, Staff B notes Resident #1 with some facial grimacing with movement, but not as much as previously noted. Right foot remains [MEDICAL CONDITION] and bruising on right leg is dark purple with some yellow coloration noted. According to the Progress Notes dated 9/27/19 at 3:28 p.m. by the ADON, the ADON notes bruising to bilateral extremities still present upon assessment, there are no new areas of concern, bruising is in various stages of color and healing. During an interview on 11/20/19 at 2:29 p.m., the Primary Care Physician indicated he was not aware of the total extent of Resident #1's injury in September. He understood the injury was the result of an improper transfer. The Physician reported Resident #1 had a quick decline in (MONTH) and believed her cause of death was due to a [MEDICAL CONDITION] infarction. The Physician stated given the time between the injury and her death, he did not believe the injury had any bearing on her decline or death.

Based on record review, observations and interviews the facility failed to provide necesary services to maintain grooming for 4 of 21 sampled (Resident's #37, #44, #55 and #165) who were unable to carry out activities of daily living. The facility reported a census of 66. 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive impairments. The MDS documented Resident #37 required extensive assistance of 2 staff for hygiene. The Care Plan directed staff to assist Resident #37 with personal hygiene. During an observation on 8/25/19 at 2:09 p.m., revealed Resident #37's face had a quarter inch growth of hair. During an observation on 8/26/19 at 8:11 a.m., revealed Resident #37's face had a quarter inch growth of hair. During an interview on 8/26/19 at 8:54 a.m., Resident #37 reported the staff assited him with shaving and he liked to shave every day. Observation on 8/27/19 at 6:59 a.m., revealed Resident #37's face had a quarter inch growth of hair. 2. The MDS assessment dated [DATE] documented Resident #44 had [DIAGNOSES REDACTED]. Resident #44 had severe cognitive impairments. The Care Plan dated 10/21/19 directed the staff to provide assistance with personal hygiene. Observation on 8/25/19 at 1:24 p.m., revealed Resident #44 sat in a wheelchair in the facility common area. The resident had a dark brown substance below his bottom left lip and was unshaven(had short stubble on his face). Observations on 8/25/19 at 2:06 p.m. and 4:01 p.m., revealed Resident #44 had a brown substance on his face and was still unshaven. Observation on 8/26/19 at 7:00 a.m., revealed Resident #44's face had a clean shave. During an interview on 8/27/19 at 12:18 p.m., Staff Q (Registered Nurse) stated she would expect staff to shave residents before breakfast preferably. During an interview on 8/27/19 at 12:39 p.m., Staff O (Registered Nurse) stated if the facility was short-staffed they are not able to shave residents at times. She stated there was more staffing during the week than the weekends. During an interview on 8/27/19 at 1:27 p.m., Staff N (Registered Nurse) stated the facility razors didn't work well and they needed to get new ones. She stated razors were always a problem if residents didn't have their own. During an interview on 8/27/19 at 5:15 p.m., the Director of Nursing stated the aides were responsible for shaving. She stated staff were always searching for razors to use. During an interview on 8/28/19 at approximately 10:00 a.m., the Administrator stated they did not have a policy related to shaving but used the standard of practice as a guideline. 3. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance of two staff for bed mobility and toileting and extensive assist of one staff for dressing and personal hygiene. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, no cognitive impairment. Review of care plan initiated 10/19/17, included a focus of resident needed assistance with activities of daily living. Interventions included resident needed assist with personal hygiene, assure items are within reach, and assist as needed. Observation on 8/25/19 at 11:18 a.m., revealed Resident #55 had long facial hair on her chin and upper lip. During an interview on 8/25/19 at 11:08 a.m., Resident #55 stated the staff reported the facility did not have a razor and confirmed she would like her facial hair shaved. Observation on 8/26/19 at 8:03 a.m., revealed Resident # 55's facial hair had been shaved. During an interview on 8/26/19 at 8:03 a.m., Resident #55 stated the staff had found a razor and shaved her that morning. 2. The admission record for Resident #165 with admission date of [DATE], included [DIAGNOSES REDACTED]. The base line care plan dated 8/23/18, identified the resident required assistance of one staff for transfers, dressing, and personal hygiene. Observation on 8/25/19 at 11:33 a.m., revealed Resident #165 had long facial hair on her chin. During an interview on 8/25/19 at 11:33 a.m., Resident #165 stated she would like to be shaved. Observation on 8/26/19 at 8:30 a.m., revealed Resident #165's facial hair remained unshaved. During an interview on 8/27/19 at 7:57 a.m., Resident #155 stated the staff had shaved her the day before.

Based on observation, resident interview, and record review the facility failed to provide sufficient staff to meet the resident's needs for 7 of 24 sampled (Resident #19, #23, #30, #50, #54, #58, and #165). The facility reported a census of 66. Findings include: 1. Observation on 8/25/19 at 2:55 p.m. revealed Resident # 58 yelled out and asked for pain medication. Resident #58 reported that his call light was on. Call light monitor screen at nurse's station showed Resident #58's call light activated at 2:53 p.m. At 3:17 p.m., Staff L (Activity Assistant) entered Resident #58's room and responded to Resident #58. 2. The Baseline Care Plan dated 8/20/19 documented Resident #50 had no cognitive impairments. Resident #50 required assistance of one staff for transfers, walking, dressing, toilet use, and personal hygiene. During an interview on 8/25/19 at 10:32 a.m., Resident #50 reported it takes a long time for staff to answer her call light. 3. The Baseline Care Plan dated 8/20/19 documented Resident #165 had no cognitive impairments. Resident #165 required assistance of one staff for transfers, walking, dressing, toilet use, and personal hygiene. During an interview on 8/25/19 at 11:33 a.m., Resident #165 reported the staff does not answer call lights timely, around 30 minutes most of the time. 4. The MDS assessment dated [DATE] revealed Resident #30 had no cognitive impairments. During an observation on 08/25/19 at 03:18 p.m., Staff F (Registered Nurse) assisted Resident 30's husband in their room. Resident #30 told Staff F she needed to go to the bathroom. Staff F told Resident she would send someone in to help her. Staff G (Nurse Aide) entered Resident #30's room a couple minutes later. Resident #30 stated to staff G why isn't anyone coming to help me. Staff G stated Resident #30's light wasn't activated. Resident #30 stated I've been pushing and pushing on it and no one came. Staff G checked the call light and stated it was connected. Staff G tested the call light and stated it was not working. Staff F went into Resident #30's room and staff G reported that the call light was not working but had been working earlier. Staff F stated they would need to get that fixed right away. During an interview on 08/25/19 at 03:19 p.m., Staff G stated Resident 30's call light had not been working when she entered the room but was now working. During an interview on 08/25/19 at 03:19 p.m., Staff F stated Resident #30's call light had not been working. Staff F further stated the call light 'needed wiggled'. During an interview on 08/26/19 at 09:02 a.m., Resident #30 reported her call light did not work the day before. Resident #30 stated the call light had always worked before. Resident #30 stated she sometimes waited 15 to 20 minutes for the staff to respond to the call light. 5. The MDS dated [DATE] revealed Resident #19 had no cognitive impairments. During an interview on 08/25/19 at 02:34 p.m., Resident #19 stated it routinely took 30 minutes for his call light to be answered. Resident #19 further revealed about a week and a half ago his chair was not working he could not put it down. Resident #19 stated after the call light was on 30 minutes he hollered at someone walking by his room for help. 6. The MDS dated [DATE] revealed Resident #54 had no cognitive impairments. During an interview on 08/25/19 at 11:22 a.m., Resident #54 revealed it routinely took 30 minutes routinely for her call light to be answered. 7. The MDS assessment tool, dated 6/27/19, listed [DIAGNOSES REDACTED]. The MDS stated the resident was frequently incontinent of bowel. Resident #23 had no cognitive impairments. During an interview on 8/25/19 at 11:07 a.m., Resident #23 stated he had to wait up to an hour for staff to answer the call light and stated he had to wait an extensive amount of time within this last week. He stated he had an accident with his bowels when they did not place him on the bedpan in a timely manner. He stated, When the urge hits, it hits and stated when he had an accident, he did not like it at all. During an observation on 8/26/19 at 8:45 a.m., Resident #23 requested to use the bedpan. After the resident finished, the surveyor observed Staff O (Nurse Aide) and Staff P (Nurse Aide) provide incontinence care. The resident had had a bowel movement in the bedpan. During an interview on 8/27/19 at 12:26 p.m., Staff R (Licensed Practical Nurse) stated there had been situations where the call light response time exceeded 15 minutes. During an interview on 8/27/19 at 12:39 p.m., Staff O (Certified Nurse Aide) stated sometimes call light response time exceeded 15 minutes. During an interview on 8/27/19 at 4:00 p.m., the Administrator stated the facility was unable to print the last week's call light logs the survey team requested but stated the surveyor could look at them on her computer screen. The Administrator stated the logs only went back the last few days. The logs revealed call light response times exceeded 15 minutes on the following instances: Resident #54: On 8/25/19, for 19 minutes. On 8/26/19, for 20 minutes and 21 minutes. On 8/27/19, for 30 minutes and 21 minutes. Resident #19: On 8/20/19, for 28 minutes. Resident #23: On 8/20/19, for 32 minutes and 23 minutes. On 8/21/19, for 44 minutes. On 8/22/19, for 20 minutes. On 8/23/19, for 16 minutes and 17 minutes. On 8/24/19, for 18 minutes. During an interview on 8/28/19 at 7:57 a.m., the Director of Nursing stated an expectation of staff to respond to call lights within 15 minutes. During an interview on 8/28/19 at 7:57 a.m., the Administrator stated the facility did not have a policy for call lights and followed the standard.

The following deficiency relates to complaint # -C. Based on clinical record review and staff, physician and family interviews, the facility failed to ensure staff used correct technique when inserting a catheter to obtain a urine specimen for one of four residents reviewed (Resident #3). The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired memory and cognition. Resident #3 required the assistance of two with transfers, dressing, toilet use and personal hygiene needs. Resident #3's [DIAGNOSES REDACTED]. The Interdisciplinary progress notes revealed: On 1/19/18 at 1:45 p.m., indicated the nurse went to Resident #3's room to obtain urine per order with 16 French Foley catheter with sterile technique, no resistance, upon insertion, moderate amount of bright red blood came out of the urethra, pressure applied, clot visualized at meatus resident no complaint of pain, resident alert per usual self. On 1/19/18 at 2:15 p.m., indicated nurse called to Resident #3's room due to resident bleeding copious amounts of blood bright red. Pressure was applied without any blood stopping. Primary care physician contacted and requested to apply ice and send Resident #3 to emergency room . On 1/19/18 at 5:45 p.m., Resident #3 returned back to the facility from emergency room with three way catheter. The resident's urine was pink-tinged urine and some bleeding around catheter. Resident obtained urethral tear if bleeding continuous send back to emergency room . On 1/24/18 at 5:45 p.m., Resident #3 catheter's drainage bag had 450 milliliters of bright red tinged blood urine. And small amount of blood around penis. Resident did not have leg strap on and certified nursing assistant retrieved one to prevent pulling. Physician requested staff keep leg strap on and to update her before the removal of the catheter on 1/26/2018. On 1/26/2018 at 6:30 a.m., resident had no urine output. On 1/26/2018 at 6:35 a.m., Resident #3's penis was swollen and that foreskin would not go down over head of penis. The small amount of urine in catheter bag was white and cloudy and had foul smell. On 1/26/18 at 7:15 a.m. Resident #3 was transferred to emergency room and later hospital called to indicate the Resident #3 was being admitted for urinary tract infection [MEDICAL CONDITION]. A faxed physician order [REDACTED].#3. In an interview on 3/13/18 at 4:18 p.m. Staff E, licensed practical nurse (LPN), stated on the afternoon of 1/19/18 she received an order to straight cath Resident #3 for a urinalysis. Staff E asked her co-workers what size of catheter should be used for that procedure and they all agreed a 16 french would be appropriate. Staff E went in with Staff F and proceeded to insert the catheter using sterile technique. Staff E stated she got a little return of urine and started to inflate the balloon when she noticed blood return through the tubing. Staff E deflated the balloon and removed the catheter. Resident #3 started bleeding profusely and she went and got help. Staff E stated she has been a nurse since (MONTH) (YEAR) and has some experience with straight catherizations, but primarily with females. When asked why she would inflate the balloon for a straight cath, which was an in and out procedure, Staff E stated she was not sure. In an interview on 3/14/18 at 9:09 a.m. Staff F, certified nurse aide, stated she assisted Staff E with the catherization of Resident #3 on 1/19/18. Staff F stated she held Resident #3's knees. As Staff E inserted the catheter, she then began to inflate the balloon and almost immediately there was blood flowing back through the catheter. Staff E deflated the balloon and pulled the catheter out and blood squirted out everywhere. Staff F reported, Resident #3 stated, That hurt god dammit that hurt. Staff F assisted with applying pressure and Staff E left to get help. Staff F stated during the catherization process, she never saw a return of urine in the catheter tubing. In an interview on 3/13/18 at 3:32 p.m. Staff G, LPN, stated on 1/19/18 Staff E received an order to straight cath Resident #3 for a urinalysis. Staff G stated she was not in the room during the catherization. Staff E exited the room stating Resident #3 was bleeding; Staff E stated she had inserted the catheter and inflated the balloon. When she deflated the balloon, Resident #3 started bleeding excessively from his penis. Staff G assisted with providing care and getting Resident #3 sent to the emergency room . Staff G stated she was concerned when Staff E stated she had inflated the balloon because a straight cath procedure wouldn't require the balloon to be inflated. Staff G believed Staff E may have inflated the balloon while it was still in the urethra (the tube leading through the penis to the bladder), resulting in the tear. In an interview on 3/13/18 at 3:17 p.m. Staff H, LPN, stated on 1/19/18 Staff E went into Resident #3's room to do a straight catherization. Staff H stated she was not present in the room during the procedure, but Staff E told her what happened. Staff E stated she had inserted the catheter, but not all the way to the Y. Staff E stated she inflated the balloon and didn't get any urine return. When Staff E deflated the balloon, Resident #3 had an excessive amount of bleeding. Staff H stated a straight cath would not require the balloon to be inflated. Staff H believed Staff E likely inflated the balloon while it was still in the urethra, causing the tear. Emergency Nursing Record dated 1/19/18 documented that upon an RN doing a UA via straight cath, the resident's meatus started bleeding. The nurse at the care center did a straight cath on the patient to try to get a UA for recent UTI (urinary tract infection). She noticed acute bleeding after inserting the catheter. The record documented the clinical impression of urethral bleeding and a suspected urethral tear (the report contained no indication the facility disclosed the likely cause for the bleeding/injury). In an interview on 3/13/18 at 11:45 a.m. the Assistant Director of Nursing (ADON) stated in mid (MONTH) Resident #3 received an order for [REDACTED]. The procedure was an in-and-out to obtain a urine sample and there would be no reason on a straight cath to inflate the balloon. When asked if the ADON was aware Staff E had inflated the balloon during the straight cath procedure on Resident #3 on 1/19/18, the ADON stated she had consulted with Resident #3's physician and the physician did not believe the urethra tear was caused by inflating the balloon while still in the urethra. In an interview on 3/14/18 at 9:45 a.m. Resident #3's physician stated she had not been informed until this morning that a nurse had inflated the catheter balloon while still in the urethra of Resident #3 on 1/19/18 which resulted in the urethra tear. The physician stated at the time of the incident she suspected a possible stricture in the urethra or enlarged prostate, but noted the bleeding in those cases is generally minimal. In light of now knowing that a nurse inflated the balloon while in the urethra and that there was excessive bleeding, she had no doubt the inflated balloon caused the urethra tear. The physician stated she was very upset with the facility for not informing her of the inflated balloon issue. The physician stated the ADON called her this morning and informed her of the details involving Resident #3's catherization on 1/19/18. In an interview on 3/14/18 at 10:55 a.m. Resident #3's sister and power of attorney stated she had been informed of Resident #3 going to the hospital on [DATE] related to a urethra tear, but was not informed of the accident which caused it.

Based on observation, record review, and staff interviews, the facility failed to ensure three residents (Resident #2, #5 and #16) received consistent interventions for the care and prevention of pressure ulcers and failed to provide services to promote healing and to prevent the development of new ulcers. The facility reported a census of 59 residents. The sample consisted of 15 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 09/30/13, due to a significant change in condition. The MDS identified Resident #2 with a BIMS (Brief Interview for Mental Status) test and scored 00. A score of 00 reflected the resident had a severe cognitive impairment. The MDS reflected the resident required total assistance from staff for bed mobility, toileting, eating, and hygienic cares and always incontinent of bladder and bowel. The MDS identified the resident rejected cares ( 1 to 3 days during the evaluation period). The MDS assessment of pressure ulcer risk noted the resident was at risk for the development of pressure ulcers and had two Stage III pressure ulcers and two Stage I pressure ulcers. The MDS reflected the resident weighed 96 pounds during the assessment period. Resident #2 had [DIAGNOSES REDACTED]. The quarterly MDS, with a reference date of 12/20/13 added an additional [DIAGNOSES REDACTED]. The MDS identified the resident weighed 74 pounds, significant weight loss and did not exhibit rejection of cares. The resident had 1 Stage II pressure ulcer and 2 Stage III pressure ulcers. The resident had 1 unstageable pressure ulcer. Stages of Pressure Ulcers: A Stage I pressure ulcer is considered intact skin with non-blanchable redness of a localized area, usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. A Stage III pressure ulcer is a full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. The ulcer often includes undermining and tunneling. A Stage IV pressure ulcer is a full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow, stringy substance) or eschar (hard black substance) may be present on some parts of the wound bed. A Stage IV ulcer often includes undermining and tunneling. An Unstageable pressure ulcer is an ulcer which cannot be staged due to coverage of the wound bed with slough or eschar. The resident developed pressure ulcers prior to 9/13/13. Most of the these findings relate to the pressure ulcer after 9/13/13 when Hospice was initiated. The Weekly Pressure Ulcer Progress Report identified the following assessments: Lower back/Spine area: On 09/25/13, a Stage III pressure area located on the right lower back proximate spine measured 1.5 cm by 2 cm by 0.2 cm. white and yellow slough in approximately 75% of the wound with scant yellow/green drainage and white wound edges. On 09/30/13, a Stage III to right lower back measured 1 cm by 1.4 cm by 0.2 cm yellow slough present, undermining present between 2 wounds, treatment of [REDACTED]. Weekly checks with continued daily treatment with Silver Hydrogel ointment. The wound is worsening. On 10/21/13 the area documented combined with area to lower spine to one wound. On 10/21/13 an area at the lower back to be a Stage III combined areas (named #2) measured 3.5 by 2.6 by 0.2 cm with moderate amount of yellow/green drainage with a foul odor. Staff documented the resident to receive continued treatments of Silver Hydrogel daily and to provide comfort measures. On 10/28/13 the area identified as Stage III, measured 3.3 by 2.2 by 0.2 with yellow slough continued. The staff applied a Silver Hydrogel dressings. On 11/04/13 the area identified as Stage III measured 4 by 3 by 0.2 cm, yellow slough present with gray wound edges. The staff continued with Silver Hydrogel and foam dressings. Staff continued to document weekly assessments with wound worsening. Treatments remained Silver Hydrogel foam dressings. On 01/06/14 the staff documented the area unstageable and covered with 90% black/green eschar which measured 4.2 by 5 cm.. The treatment continued of Silver Hydrogel. On 01/13/14 the wound remained unstageable and measured 4 cm by 4.5 centimeters, 100% covered with black/green eschar, moist consistency. On 01/20/14 the staff documented area to be Stage IV and measured 5 cm by 6 cm by 0.4 cm less than 25% covered with eschar. On 01/27/14 the staff documented the area measured 5.2 cm by 5.6 cm by 0.4 cm with full thickness tissue loss, yellow and white purulent drainage with continued treatment with Silver Hydrogel. On 02/03/14 the staff documented the wound measured 5.1 by 4 cm and Stage IV with yellow and white wound base, foul odor and purulent drainage. On 02/10/14 the staff documented the wound measured 5 cm by 4 cm by 0.3 cm pink with no drainage. On 02/17/14 the staff documented area 4.5 by 4 by 0.4 cm healing Stage IV with red beefy tissue. On 02/20/14 the staff documented the area as healing and a Stage IV, pink tissue with granulation and scant yellow drainage that measured 5.2 by 4 by 0.8 cm. ANOTHER WOUND ON SPINE: On 12/09/13 a Stage III pressure ulcer located above (#2 pressure ulcer) measured 0.5 by 0.5 cm, dark red wound bed, yellow slough present, edges dark. A yellow/green drainage is noted. The facility documented the staff would follow up for treatment. On 12/16/13 the staff documented the Stage III ulcer measured 0.7 by 0.7 with gray/yellow slough to wound bed, full thickness with moderate amount of bloody drainage. On 12/23/13 the staff documented the wound measured 1.0 cm by 0.6 cm and a Stage III full thickness pressure ulcer. The wound bed was described as gray and yellow drainage present. On 12/30/13 the staff documented the area as a Stage III and measured 1.0 by 0.1 cm with a gray wound bed and yellow edges present. The treatment consisted of Silver Hydrogel. On 02/20/14 the staff documented the ulcer as healing as Stage III with yellow slough in the wound bed and no drainage present. On 12/09/13 the area was described as an unstageable pressure ulcer. The area measured 0.7 by 1.0 cm with black eschar present, no drainage, hospice /comfort care and would follow up with physician. On 12/16/13 the staff documented the ulcer measured 2 cm by 2.5 cm and black eschar remains over 75% of wound. The wound had 25% yellow slough present with grayish/green drainage. On 12/23/13 the staff reflected the wound remained as above. On 12/30/13 the staff documented the wound measured 3.2 cm by 2.1 cm, remained unstageable and the wound bed had eschar present.. On 1/06/14, the staff documented the wound unstageable with 100% coverage of black/green eschar. The treatment consisted of Silver Hydrogel. On 01/13/14, the staff documented the wound remained unstageable with 100% eschar coverage. Staff continued with Silver Hydrogel treatment. On 01/20/14, the staff documented weekly assessments with the wound unstageable and measured 3.5 by 3.5 cm. The treatments consisted of Silver Hydrogel. On 01/27/14 the staff documented the wound at Stage III, measured 3.8 by 3.2 by 0.3 cm, eschar covered 25% of wound, yellow wound base with red edges and purulent drainage present. On 02/03/14 staff documented the wound at Stage III, measured 3.2 by 3 by 0.2 with black eschar covering 25% of wound, red edges, yellow slough to base. On 02/10/14 the staff documented the wound measured 3 by 3 by 0.2 cm, Stage III pink and no drainage. On 02/17/14 the staff documented the wound measured 3 by 2.8 by 0.2 cm beefy red tissue and no drainage. On 02/20/14 the staff documented the wound measured 3.3 by 2.7 by 1 cm, beefy red/dark pink tissue with granulation and scant yellow drainage. The Right Hip measured the following: Right Hip: On 01/16/14, the staff documented a Stage I pressure ulcer to the right hip which measured 3 cm by 5.5 cm and intact with red skin, nonblanchable, and staff would follow up for treatment. On 01/20/14 the staff documented a Stage I ulcer to the right hip which measured at 4 cm by 3.5 cm and had red intact skin and the wound nonblanchable. On 01/27/14 the staff documented a Stage I ulcer to the right hip which measured 3 cm by 2.6 cm and had light pink intact skin. The area improved. On 02/03/14 the staff documented a Stage I ulcer to right hip which measured 2 cm by 2 cm with intact skin. The area to be faint pink and nearly resolved. On 02/10/14 documented as above. On 02/17/14 the staff documented an area which measured 1.5 cm by 1.5 cm and dark pink with skin intact. On 02/20/14 - no documentation. On 02/24/14 there was no documentation regarding worsening of the ulcer noted during observation of wound care. Left Hip On 02/03/14, the staff documented a Stage I to the left hip which measured 1.3 by 1.6 cm with red intact skin. On 02/10/14, the staff documented a Stage I to the left hip which measured 1.5 by 1.5 cm and pink and nonblanching. On 02/17/14 the staff documented a stage I to the left hip measuring 1.0 by 1.5 cm and faint pink and intact. On 2/20/14 there was no documentation present. Right Shoulder: 02/13/14 - Stage I to right shoulder, measured 2 cm diameter, pink. Staff documented Hospice nurse present and aware. staff documented Hospice would follow up with doctor and family. 02/17/14 - staff documented Stage I measured 2 cm diameter round not open brownish red in color. 02/20/14 - no assessment documented. 02/24/14- no documentation regarding worsening ulcer noted during observation of wound care. Left Shoulder On 09/23/13 Stage I to top of posterior left shoulder measured 0.5 cm by 0.4 cm intact red skin, non blanchable warm to touch. noted would follow up with physician. On 09/30/13 - left shoulder Stage I measured 3.5 cm by 3.5 cm area of redness with 1.5 by 0.5 cm intact non open center with red flaking skin. treatment of [REDACTED]. 11/25/13 staff documented area resolved will continue barrier wipes as preventative. On 12/15/13 - left shoulder -see IDT notes. On 12/23/13 - left shoulder Stage II measured 2 by 1.2 cm, red wound bed with scant bloody drainage treatment of [REDACTED]. On 12/30/13 - Left shoulder Stage II 2.5 by 1 cm red wound bed with yellow edges treatment Exuderm every 3 days. From 12/30/13 to 01/20/14 the staff documented weekly checks and continued treatments with Exuderm every three days and as needed. On 01/27/14 the staff documented the left shoulder at Stage III with gray necrotic tissue measured 2.8 by 2 by 0.2 cm yellow slough with purulent drainage. On 02/03/13 the staff documented the Stage III ulcer measured 2.2 by 3 by 0.3 cm yellow slough with gray necrotic tissue present and would follow up for treatment change. On 02/10/14 the staff documented Stage III with yellow slough with gray necrotic edges and measured 3 by 3 by 0.5 cm. On 02/17/14 the staff documented the area to be 2.6 by 3 by 0.5 cm, green slough and gray edges with 75% eschar present. On 02/20/14 the staff documented the area Stage III measured 2.8 by 3.2 by 1.3 with a small amount of green slough, no eschar and with tunneling (undermining) at the 6 o ' clock area of wound. The resident's Care Plan with a goal date 03/19/14, identified the resident could be resistive to cares, refusing meals, repositioning and medications at times and instructed staff to call by name, introduce self and explain what intentions are, if resistive, leave and approach later or offer different staff. The Care Plan instructed staff to offer foods or liquids when resistive to eating. The Care Plan reflected the resident required assistance with all activities of daily living related to limited mobility and health decline. The staff were instructed to keep the resident comfortable during cares, check for incontinence and assist with incontinency care every two hours and as needed. The Care Plan instructed staff to reposition the resident every two hours and as necessary, but noted the resident may choose not to reposition. The Care Plan noted the resident to be bedfast most of the time, has contractures of the upper and lower extremities and directed the staff to check skin for redness, open areas, cuts and bruises daily with cares. The Care Plan reflected the resident had pressure ulcers to the back and left shoulder. The intervention directed staff to assist with turning and repositioning approximately every two hours and more often as needed or requested. The resident prefers to be positioned on left side, sometimes refuses not to reposition and since is on Hospice, may choose not to reposition and to stay in bed. The Care Plan identified the resident utilized pressure reducing devices on the bed and in the wheelchair and directed staff to off load the feet while in bed and to place a pillow between the resident's knees. According to the Hospice durable medical equipment tracing form, dated 9/26/14 and delivered on 9/27/13, the resident received a low air loss mattress. Review of the Hospice Physician Certification of terminal illness revealed the resident had an admitted for Hospice care on 09/24/13 with a [DIAGNOSES REDACTED]. On 12/26/13, the physician review noted the resident [DIAGNOSES REDACTED]. Observation on 02/19/14 at 11:12 a.m. revealed three certified nursing assistants transfer Resident #2 from the bed to a high backed wheelchair. After transferring the resident in the appropriate manner, the staff placed pillows around the resident for support. The resident appeared to be extremely emaciated, very thin with contractures of all extremities. After the resident had transferred, the Hospice social worker propelled the resident to the dining room for the lunch meal. Observation at 12:45 p.m. on 2/19/14 revealed the resident lying in the bed on his/her left side with limbs pulled up with a pillow under the feet but heels not floating. Observation on 02/20/14 at 7:30 a.m. Staff G, RN entered the resident's room to provide treatment to the pressure ulcers for the resident. Staff H, LPN entered the room to assist. Staff H assisted the resident to turn onto his/her left side. The resident flinched with movement although nodded head yes when Staff H asked if he/she were okay. Staff G removed the old dressing from the resident's back area which had three pressure areas mid back to the right of the spinal cord. Staff G measured each wound to the right of the spinal column which identified the following measurements: #1 (Stage II) measured 0.7 centimeters (cm) Length (L) by 0.8 cm width(W), #2 (Stage IV) measured 5.2 cm L by 4 cm W by 0.8 cm depth (D) #3 (Stage III) measured 3.3 cm L by 2.7 cm W by 1.0 cm D. After washing hands and donning gloves, Staff G obtained the tube of Silvergel ointment and squeezed three areas on a 6 inch by 6 inch foam dressing, placed over the back wounds and secured with tape. Staff H assisted the resident to turn to the right side and bared the resident's left shoulder. Again the resident moaned and grimaced with the movement but stated he/she to be alright when asked by staff. Staff G removed a dressing from the left shoulder which exposed a pressure ulcer to the outer aspect of the left shoulder. The staff member measured the wound to be 2.8 cm L by 3.2 cm W and 1.3 cm depth. The wound appeared to be a Stage IV, although staff considered it to be a Stage III (worsening). The area had tunneling at the 6 o'clock position on the wound. The soiled dressing contained a moderate amount of pinkish drainage. After providing the wound care in an appropriate manner, Staff G placed a clean foam dressing covered with Silvergel ointment over the wound and secured with [MEDICATION NAME] tape. The resident had superficial (Stage I) areas on each hip and to the right shoulder. After completing the cares, the staff placed the resident on the left side with pillows supporting the resident. At 8:30 a.m. after providing pericare, two certified nursing assistants (Staff O and Staff K) positioned the resident to the left side with pillows for support. The staff placed a pillow beneath the resident's feet but did not float the resident ' s heels. At 10:30 a.m. the resident had been observed on the left side with a pillow under the left side in the same position observed at the earlier time. At 11:30 a.m. the resident observed sitting in a reclining wheelchair in the dining room. The resident did not eat any of the pureed diet provided. Review of the food intake logs for 02/20/14 revealed the staff had documented the resident had eaten 100% of the breakfast meal, but also contained an R which indicated the resident had refused the meal. The noon meal intake percentage had been left undocumented. Observations on 02/24/14 at 8:15 a.m. revealed the resident lying in bed on the left side, with the head of the bed slightly elevated. The resident had pillows placed under the left side near the resident ' s waist area to off-set the position but remained mostly on the left side. Observation at 9:05 a.m. revealed the resident remained positioned on the left side. At 9:50 a.m. the resident had been positioned on the right side with the pillow tucked under the left shoulder. At 12:30 p.m. the resident had been observed sitting at the dining room table being fed a hamburger sandwich and glass of milk. Review of the food intake logs for 02/24/14 revealed the staff had documented the resident had eaten 50% of the breakfast meal and 100% of the lunch meal (hamburger sandwich and glass of milk). Review of the clinical record revealed the resident ' s weight had declined steadily for several months. Review of the monthly weights revealed the resident's weight for the past 6 months were: September 2013 -101.8 October 2013 - 96.0 November 2013 - 79.1 December 2013 - 74.3 January 2014 - 76.4 February 2014 - 75.8 The weight loss the resident had shown calculated to be 0.78% in 30 days, 4.7% in 90 days and a significant loss of 25.5% in 180 days. Review of the dietary notes revealed: On 10/01/2013, the dietitian noted the resident remained on a general mechanical soft diet and all oral supplements had been discontinued. The dietitian noted the resident's weight had been 96 pounds however the resident remained on bed rest. The resident had been started on Hospice care due to declining condition and refusing to eat or drink for several days. The dietitian stated the resident had refused offered supplements. The dietitian noted the resident required increased nutritional needs related to poor skin integrity with three decubitus ulcers. On 12/1/2013, the dietitian noted the resident had been receiving a mechanical soft diet, occasionally attended a breakfast meal in the dining room but ate most lunch and supper meals in the dining room and instructed staff to supply banana slices with sugar if requested by the resident and received fortified milk for extra calories and protein. The resident was required to be fed by staff in the dining room. The dietitian noted the resident's weight had been 74.3 pounds on the wheel chair scale with the resident showing a 6.4% weight loss in 1 month and a 24.5% weight loss in 6 months. The dietitian documented the resident remained on Hospice, triggered for significant weight losses at 30 and 180 days. the dietitian recommended staff to continue to obtain weekly weights. The dietitian noted the resident had two Stage III pressure ulcers on the lower back as well as one unstageable area. The dietitian noted the resident's medications and nutritional supplement were discontinued on 09/30/13 by Hospice. The dietitian recommended providing food/fluids for comfort and noted the decline in nutrition anticipated due to advancing medical condition. The dietician did not attempt several small meals or snacks in order to provide nutrition to heal wounds. The IPN dated 1/29/14 at 2:25 p.m. reflected the resident had 2 additional open areas on the right hip and right shoulder with an onset of the ulcers on 1/16/14. The dietician documented the resident ' s intakes at meals minimal and dietary providing fortified milk as resident would accept. The dietician anticipated a decline to advancing medical condition and remains on Hospice. On 02/27/14 the facility supplied three testimonials from staff (dietary manager, restorative aide and bus driver) which reflected the resident had been a picky eater and would have favorite foods that he/she would only want. The staff stated in the written statements that they had supplied the resident with hamburgers from a fast food chain located in another town. The staff noted they would supply the resident with potato chips and soda if the resident desired. The staff noted they would try to make sure that the resident's favorite foods were available and in the facility so if the resident indicated a desire for a certain food, it would be available. The testimonials did not suggest additional small meals were provided or snacks. A written statement from Staff P identified Resident #2 as a picky eater and she did not assist as much in the main dining room for meals. Staff P stated she still brings in hamburgers for the resident along with getting him/her Pepsi for meals. Staff P stated she provided the resident with snacks and drinks from the snack basket when she passed snacks. Staff P stated if the resident ever refused anything then she would always go thru all the different foods I knew he liked until he agreed upon eating something. On 02/25/14 at 2:05 p.m. the Hospice nurse noted when the resident had been admitted to Hospice, the medication and supplements were discontinued at the request of the family and facility staff. She noted she would speak to the family about restarting the supplements to increase nutrition for the resident. Observations on 02/24/14 at 10:40 a.m. revealed Staff G, RN and Staff B, LPN entered the resident's room to provide pressure ulcer cares. Staff G, prepared the supplies on the treatment, as Staff B assisted the resident in position to the left side. The resident flinched and moaned with movement, although indicated he/she alright when asked by staff. Staff G removed the old dressing from the resident's back, changed gloves and measured each wound. The back wounds measured the following: #1 (Stage II) 0.6 cm L by 0.8 cm W, #2 (Stage IV) 4.9 cm L by 3.9 cm W by 1.0 cm depth, #3 (Stage III) 3.2 cm L by 2.4 cm W by 1.0 cm depth. After providing the wound care, Staff G covered the area with a Silvergel covered 6 by 6 inch foam dressing secured with [MEDICATION NAME] tape. Staff G removed the soiled dressing from the resident's left shoulder. The dressing contained a moderate amount of pinkish drainage. Staff G cleansed the area with wound wash, causing the resident to moan. Staff B asked the resident if he/she were alright and the resident shook head yes. Staff G measured the wound as Stage III-IV and 2.4cm L by 3.5 cm W by 1.9 cm depth. After Staff G had completed cares on the left shoulder, Staff B assisted the resident to the left, and exposed the resident's right hip. Staff G cleansed the right hip area which had appeared to worsen from the previous observation. Staff G obtained a measurement of the area 5.3 cm L by 6.0 cm W reddened area surrounding a 1.0 cm L by 0.8 cm W open area. Staff G cleansed the area with wound wash soaked gauze pad, and covered the area with a Silvergel covered foam dressing secured with Mipilex tape. The right shoulder wound also appeared to have worsened, measuring 5.0 cm L by 4.0 cm W reddened area surrounding a 0.3cm L by 2.2 cm L open area. Staff G cleansed the area and covered with Silvergel smeared foam dressing. The left hip area remained superficial and measured 1.3 cm L by 1.8 cm W and no open area noted. Photographs were obtained on 2/24/24 at 11:44. Review of the physician order [REDACTED]. The physician orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. A Hospice referral form dated 09/23/14 indicated the resident had been referred to hospice for refusing food/fluids, and pressure ulcers. Review of the Hospice patient information sheet revealed the resident had been admitted to hospice services on 09/24/13 with an admitting [DIAGNOSES REDACTED]. Physician Notes: On 09/25/13 the physician noted the resident requested Hospice and had left shoulder pressure ulcer and two buttock ulcers with change in wound care. The physician noted the resident started Hospice on 09/24/13. On 10/16/13 the physician documented medications had been discontinued and would discontinue lab work (laboratory tests). The resident had large pressure ulcer to low back and staff attempting to treat (the wound). The doctor noted the resident receives Hospice care. On 11/20/13, the physician documented pressure ulcers appeared the same, no worse and clean. Resident under hospice care. On 12/18/13 the physician documented the resident continues a slow decline, persistent pressure ulcers despite staff care attempts. Review of the doctor's orders and progress notes revealed the physician had reviewed the resident on 01/15/14 and noted the staff are working on pressure ulcers and resident still receiving hospice care. 01/17/14 - A Physician Communication Sheet informed the physician of two Stage I ulcers- both red and nonblanchable, not relieved after turning, right shoulder 1.6 by 1.8 cm and right hip 3 cm by 5.5 cm. The physician responded and directed staff to try to turn the resident every 2 hours. 02/03/14 - A Physician Communication Sheet document, informed the doctor the resident ' s left shoulder pressure ulcer continued to decline, with the current treatment of [REDACTED]. The facility requested a change of treatment to cleanse with wound wash, apply silver hydrogel and cover with foam dressing every day. The physician responded and ordered the current treatment be changed and to perform treatment above (as requested). A second notification dated 02/03/14 informed the doctor of a Stage I to the left hip. The notification informed the physician of the Stage 1 being red in color, intact, measured 1.3 by 1.6 cm in size and resident turned every 2 hours. Staff asked for further orders. The physician responded and wrote, no new orders. On 02/21/14 , a physician notification informed the doctor of a Stage I pressure area to the right shoulder and requested an order for [REDACTED]. The Physician received notifications of skin changes on 12/27/13, 12/15/13, and 12/09/13. with responses to proceed with treatments requested by staff. Review of the Interdisciplinary progress notes from 10/03/13 to 02/24/14 revealed the staff had made numerous notations regarding pressure ulcer assessments and treatments with notification of resident's progress to Hospice and the physician. The facility policy titled Pressure Ulcer Risk Assessment and Documentation instructed staff for prevention to clean skin gently to minimize the use of force and friction after incontinent episodes, and may apply topical barrier agents, may apply moisturizers to dry skin, assist with repositioning immobile residents a minimum of approximately two hours (may need to reposition more frequently), positioning devices such as pillows or foam wedges may be used to keep bony prominences from direct contact with each other. On 02/25/14 at 9:35 a.m. the facility Director of Nursing (DON) stated the facility had been aware of the resident's declining condition and the resident had been refusing to eat for a time. The DON acknowledged the lack of nutrition had probably contributed to the declining health condition of the resident. The DON stated she could not explain why staff were not utilizing the available pain medications for the resident prior to the pressure ulcer care. The DON stated the resident would often refuse to allow the staff to reposition him/her and since the resident had been on hospice for comfort cares, the staff felt the resident had a right to refuse cares, repositioning and to eat. The DON acknowledged that although the staff would attempt interventions with the resident, they were random and not documented. The DON stated the resident had not been seen by a wound specialist regarding the persistent pressure ulcers and Hospice and the Physician directed the wound care. On 02/25/13 at 10:45 a.m. the facility Corporate Quality Assurance Nurse was interviewed and stated she felt the facility staff were doing everything they could within the aspect of Hospice to care for the resident. The Corporate nurse stated the staff did not feel the resident had been having discomfort during pressure ulcer care. The nurse stated the resident had no indication of being uncomfortable during the pressure ulcer care (a person with pressure ulcers of this magnitude would have pain). The nurse also stated she felt the staff knew their residents very well and could read their body language so would know if the resident was experiencing discomfort. Staff G RN, who had provided the pressure ulcer cares stated that in the past when attempting to provide pain medication to the resident, he/she would clamp his/her mouth shut and not accept the offered medication. Staff B, LPN stated when she had asked the resident if he/she were okay (alright) during the cares, the resident shook his/her head yes so assumed the resident was comfortable (the resident had a cognitive impairment). On 02/25/14 at 11:00 a.m. the resident ' s Physician was interviewed by telephone. The Physician stated he didn ' t realize Hospice had discontinued all nutritional supplements for Resident #2. The Physician agreed the nutritional supplement may contribute to the resident maintaining weight and aide in the wound healing of the pressure ulcers, especially if the resident did not eat well. The Physician stated it may behoove the resident ' s healing if the nutritional supplement be restarted. The physician stated the supplement may prolong the " process " but may also assist the resident and improve. The Physician stated the reason the resident had been admitted to Hospice was because of the resident ' s failure, decreased eating and the development of pressure ulcers. On 02/27/14 the facility supplied a letter from the physician that noted the resident's frequent refusal to take adequate nutrition had led to multiple skin issues over the years and have become increasingly more difficult to manage. The physician noted he felt the resident's poor condition are not due to the lack of staff interventions but due to the dying process and felt the issues are unavoidable due to general decline. 2. Resident #

Based on observation, record review, and staff interviews, the facility failed to maintain acceptable nutritional parameters in order to maintain weight (Resident #2). The discontinuing of supplements (2 Cal and [MEDICATION NAME]) will not promote weight gain or maintain a resident's weight and promote healing of pressure ulcers. The facility did not provide attempts to offer frequent smaller meals or snacks to the resident. Facility staff indicated the resident was being offered snacks but there was no documented evidence that it was being completed or a thorough plan for staff to follow if the resident refused. The record did not reflect staff had returned later and had attempted to feed the resident. The sample consisted of 15 residents and the facility reported a census of 59 residents. Findings include: 1. Resident #2 had an annual Minimum Data Set (MDS) assessment with a reference date of 09/30/13 which identified the resident with a BIMS (brief interview for mental status) score of 00. A score of 00 reflected the resident had severely impaired cognitive status. The MDS assessment identified the resident at 2 Stage III pressure ulcers and 2 Stage I Pressure Ulcers. The MDS reflected the resident weighed 96 pounds during the assessment period. Resident #2 had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] added an additional [DIAGNOSES REDACTED]. The MDS reflected the resident to be at 74 pounds with a significant weight loss. The MDS revealed the resident had one Stage II pressure ulcer and two Stage III pressure ulcers. The resident depended upon staff to feed him/her. The Care Plan (no initiated date) with a goal date of 03/19/14 reflected the resident is at a nutritional risk related to being underweight, weight loss and poor appetite and poor skin integrity. Weight loss is expected due to declining medical condition. The interventions directed staff to slice banana with sugar for a snack, provide fortified milk for additional calories, except liquids as desired, and provide a mechanical soft diet. The Care Plan identified the resident needed assistance with activities of daily living and the intervention reflected the staff fed the resident. Observations on 02/20/14 at 7:30 a.m. revealed the resident lying on the left side on the bed. Staff G, RN entered the resident's room for pressure ulcer care. At 8:30 a.m. two certified nursing assistant provided incontinency care and then repositioned the resident back on the left side. The staff stated the resident would get his/her breakfast a little later. At 10:30 a.m. the resident had been observed on the left side with a pillow under the left side in the same position observed at the earlier time. At 11:30 a.m. the resident sat in a reclining wheelchair in the dining room. The resident did not eat any of the pureed diet provided. Review of the food intake logs for 02/20/14 revealed the staff had documented the resident had eaten 100% of the breakfast meal, but also contained an R that indicated the resident had refused the meal. The noon meal intake percentage had been left empty. Observations on 02/24/14 at 8:30 a.m. revealed the resident lying in bed on the left side, with the head of the bed slightly elevated. The resident had pillows placed under the the left near waist area to offset position but remains mostly on the left side. Observation at 9:05 a.m. revealed the resident remained position on the left side. At 9:50 a.m. the resident had been positioned on the right side with the pillow tucked under the left shoulder. At 12:30 p.m. the resident had been observed sitting at the dining room table and being fed a hamburger sandwich and glass of milk. Review of the food intake logs for 02/24/14 revealed the staff had documented the resident had eaten 50% of the breakfast meal and 100% of the lunch meal (hamburger sandwich and glass of milk). Review of the Physician Certification of terminal illness revealed the resident had been admitted to Hospice care on 09/24/13 with a [DIAGNOSES REDACTED]. On 12/26/13 the physician review noted the resident [DIAGNOSES REDACTED]. Review of the clinical record revealed the residents weight had declined steadily for several months. Review of the monthly weights revealed the resident's weight for the past 6 months were: September 2013 -101.8 October 2013 - 96.0 November 2013 - 79.1 December 2013 - 74.3 January 2014 - 76.4 February 2014 - 75.8 The weight loss the resident had shown calculated to be 0.78 % in 30 days, 4.7 % in 90 days and a significant loss of 25.5% in 180 days. The facility weight monitoring policy noted the director of nursing or designee will determine significant weekly and monthly (5% or greater in 30 days and 10% or greater in 180 days) and communicate the information to pertinent staff. Weekly weights are to be reviewed by the DON (Director of Nursing) and the consultant dietitian to identify weight change trends that need to be acted upon quickly. The Consultant Dietitian is to complete a full Nutritional Assessment of residents with an initial significant weight change that poses a nutritional risk. The dietary manger will document interventions for weight loss as implemented and tolerance to the interventions on a monthly basis or as changes are made and to ensure that the care plan had been updated with weight loss interventions. Nutritional interventions are to be initiated by the healthcare team immediately when an unintentional weight loss occurs that poses a nutritional risk (whether significant or not). Interventions may include: additional portions at a particular meal, increased fat and protein in favorite foods, nutrient-dense snacks between meals, supplements between meals or with medication and favorite foods brought in by the family. Review of the dietary notes revealed: On 08/20/13 the dietitian noted the resident's weight at 102 pounds which showed an increase in 180 days, noted the resident ate between a few bites and at 100% of mechanical soft diet. The dietitian noted the resident had been fed by staff in the dining room, required increased nutrition related to poor skin integrity and poor intakes. The dietitian noted the resident received whole milk, 4 ounces of 2 cal supplement three times a day and 4 ounces of [MEDICATION NAME] extra for extra calories and protein. On 09/24/13, the dietitian noted the resident weighed 96 pounds with a 6 pound weight loss in the past month. Documentation noted the resident had poor intake and refusing. Recommended to continue with supplements, but very little intakes. Noted Hospice referrals. The dietitian documented the resident had been offered favorite foods but still refusing. On 10/01/2013, the dietitian noted the resident remained on a general mechanical soft diet and all oral supplements had been discontinued. The dietitian noted the resident's weight had been 96 pounds however the resident remained on bed rest. The resident had been started on Hospice care due to declining condition and refusing to eat or drink for several days. The dietitian stated the resident had refused offered supplements. The dietitian noted the resident required increased nutritional needs related to poor skin integrity with three decubitus ulcers. On 12/1/2013, the dietitian noted the resident had been receiving a mechanical soft diet, occasionally attended a breakfast meal in the dining room but ate most lunch and supper meals in the dining room and instructed staff to supply banana slices with sugar if requested by the resident and received fortified milk for extra calories and protein. The resident was required to be fed by staff in the dining room. The dietitian noted the resident's weight had been 74.3 pounds on the wheel chair scale with the resident showing a 6.4% weight loss in 1 month and a 24.5% weight loss in 6 months. The dietitian documented the resident remained on Hospice, triggered for significant weight losses at 30 and 180 days. the dietitian recommended staff to continue to obtain weekly weights. The dietitian noted the resident had two Stage III pressure ulcers on the lower back as well as one unstageable area. The dietitian noted the resident's medications and nutritional supplement were discontinued on 09/30/13 by Hospice. The dietitian recommended providing food/fluids for comfort and noted the decline in nutrition anticipated due to advancing medical condition. The dietician did not attempt several small meals or snacks in order to provide nutrition to heal wounds. On 09/23/13 the staff notified the physician the resident continues decline and had refused breakfast and lunch. On 10/18/13 the staff notified the physician of a the resident's 5.4% weight loss in 30 days and 9.9% weight loss in 90 days. On 11/07/13 the staff notified the physician of the resident's 13.9% weight loss in past 30 days and 23.2% in 90 days with no dietary recommendations changes at the time. On 12/20/13 the staff notified the physician of a 5.6% weight loss over 90 days and noted the dietician reported decline anticipated due to resident's hospice status, and recommended to continue to encourage increased intake with dietary to provide fortified milk. The doctor agreed to the recommendation. On 01/15/14 the staff notified the physician that the resident had triggered a significant weight loss of 20.4% in 90 days and resident remains on Hospice. No interventions were recommended. Review of the Interdisciplinary Progress Nurses Notes (IPN) revealed the staff did not document interventions attempted to encourage the resident to eat other than physician notifications of the refusals. Review of the dietary intake notes from 11/25/13 to 02/25/14 revealed the resident had intakes of 0 to 100% of foods offered. The notes reflected the resident had refused or staff did not document food intakes for 71 meals in the 3 month periods. The intake notes did not reflect what food the resident had eaten and just reflected a percentage of food eaten. The percentage of the meal eaten should be the percentage of the planned meal served. The nursing notes did not indicate the resident's refusal of meals in the daily notes. On 02/25/14 at 2:05 p.m. the Hospice nurse noted when the resident had been admitted to Hospice, the medication and supplements were discontinued at the request of the family and facility staff. She noted that she would speak to the family about restarting the supplements to increase nutrition for the resident. On 02/25/14 at 9:35 a.m. The facility Director of Nursing (DON) stated the facility had been aware of the resident's declining condition and the resident had been refusing to eat for a time. The DON acknowledged the lack of nutrition had probably contributed to the declining health condition of the resident. The DON stated the resident would often refuse to allow the staff to reposition him/her and since the resident had been on hospice for comfort cares, the staff felt the resident had a right to refuse cares, repositioning and to eat. The DON acknowledged that although the staff would attempt interventions with the resident, they were random and not documented. When asked if the resident had received a psychiatric evaluation regarding the resident's refusal to eat, The DON stated the resident had not as far as she knew. On 02/25/14 at 11:00 a.m. the resident's physician was interviewed by telephone and stated the resident had declined a great deal in the past few months and the resident had stopped eating for a time. The physician noted the lack of nutritional supplements could have contributed to the resident's decline in weight along with the resident's refusal to take food/fluids at times. The physician stated that is one reason the resident had been admitted to Hospice care for comfort measures. On 02/27/14 the facility supplied a letter from the physician that noted the resident's frequent refusal to take adequate nutrition had led to multiple skin issues over the years, and have become increasingly more difficult to manage. The physician noted he felt that the resident's poor condition are not due to the lack of staff interventions but due to the dying process and felt the issues are unavoidable due to general decline. On 02/27/14 the facility supplied three testimonials from staff (dietary manager, restorative aide and bus driver) which reflected the resident had been a picky eater and would have favorite foods that he/she would only want. The staff stated in the written statements supplied that they had supplied the resident with hamburgers from a fast food chain located in another town. The staff noted that they would supply the resident with potato chips and soda if the resident desired. The staff noted that they would try to make sure that the resident's favorite foods were available and in the facility so if the resident indicated a desire for a certain food, it would be available. Hospice Care is care to maintain a resident. The discontinuing of supplements (2 cal and [MEDICATION NAME]) will not promote weight gain or maintain a resident's weight and promote healing of pressure ulcers. The facility did not show frequent smaller meals had been attempted or snacks provided. The consumption record lacked documentation.

The following deficiency relates to complaint -I: Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and assistance devices to mitigate the risk of resident elopement for 1 of 4 residents reviewed. (Resident #1) The facility reported a census of 56 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 5/2/13, which identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3. A score of 3 reflected impaired short and long term memory deficits and severely impaired cognitive skills for daily decision making. Resident #1 was identified as independently ambulatory with a walker and required limited assistance with physical assist of one staff member for dressing, personal hygiene, toilet use and bathing. Resident #1's [DIAGNOSES REDACTED]. The resident ' s Care Plan identified a problem with a history of unescorted walking outside the facility. The approaches directed staff to: a. Check facility alarms daily. b. Check personal and attached alarms daily. c. Staff to help with fewer attempts for unescorted walks as needed. The Interdisciplinary Progress Notes (IPN) dated 6/11/13 at 11:52 a.m. indicated Resident #1 attempted to exit the front door through the construction area and was redirected. The IPN dated 6/22/13 at 10:50 a.m. indicated Resident #1 attempted to exit A wing door and was redirected. The IPN dated 6/29/13 at 2:00 p.m. indicated Resident #1 had two exit attempts that day and was redirected without difficulty. The IPN dated 7/1/13 at 11:00 a.m. indicated Resident #1 had two exit attempts thus far and was easily redirected. The IPN dated 7/3/13 at 10:00 a.m. indicated Resident #1 was out of the building and returned without difficulty. Resident #1 placed on 15 minute checks. The IPN dated 7/3/13 at 2:00 p.m. indicated Resident #1 had three additional exit attempts throughout the day. The IPN dated 7/3/13 at 5:30 p.m. indicated Resident #1 had tried to make multiple attempts to leave the facility and was not easily redirected. The Administrator's investigative report and interview on 7/16/13 at 3:20 p.m. noted the Administrator received a call on 7/3/13 at 9:40 a.m. from the local hospital emergency room nurse informing her that Resident #1 had been found about five minutes earlier in the hospital parking lot. Resident #1 was brought back to the facility without incident. The Administrator initiated an investigation, interviewed all staff and determined that no door alarm sounded that morning. The only door in the facility, accessible to residents, that can be deactivated at the door is the temporary entrance door located in the dining room. The front door entrance is currently under construction and would be challenging to exit with a walker. Construction staff were interviewed and did not see anyone exit through the construction site that morning. The dining room entrance alarm (prior to the elopement) was easily deactivated by a simple push button mechanism. The Administrator concluded that absence an alarm sounding, Resident #1 must have pushed the button, deactivated the door alarm and exited or exited as a visitor came in or left. The Administrator also noted the code alert system (Wanderguard alarm system) that was in place at the front entrance prior to construction was demolished and not re-installed at the dining room entrance. The Administrator indicated she did not realize the Wanderguard system was not in place until after the elopement. Resident #1 was care planned for a code alert bracelet to alert staff when Resident #1 was near the entrance door. Weather conditions per the internet at the time of the elopement were sunny and 66-69 degrees Fahrenheit. Observations on 7/15/13 noted all exit doors within the facility were alarmed and functioning properly. The dining room entrance door had a key pad (installed 7/9/13) and required a code to exit and a door bell type button to enter. The entrance door alarm, once activated, can only be deactivated by inputting a code at the door. All other door alarms can be deactivated at the nurse's station. There was no Wanderguard system in place. In an interview on 7/16/13 at 2:47 p.m. the Director of Nursing (DON) stated approximately 6-8 weeks ago construction began on the front entrance of the facility. A code alert system (Wander guard) was in place at the front entrance. Four residents, Residents #1, #2, #3 and #4, were assessed as elopement risks and were wearing the code alert bracelets. During the construction, the Wanderguard system was torn out and not re-installed at the new temporary entrance in the dining room. The DON stated it was brought to her attention later that the Wanderguard system was not in place and whether the Care Plans should be amended to remove the use of the Wanderguard. The DON stated no, because she believed the Wanderguard system would be re-installed and functioning before too long. In an interview on 7/16/13 at 10:00 a.m. Staff A, Dietary Aide, stated on 7/3/13 at 9:05 a.m. she saw Resident #1 trying to open the exit door in the dining room. Staff A prevented Resident #1 from exiting and informed Staff B that Resident #1 was attempting to exit. Staff B escorted Resident #1 up to the nurse's station. At 9:15 a.m. Staff A stated she went on break. Staff A stated it was common for Resident #1 to exit seek and often set off the door alarms. Staff A stated she was on break from 9:15 a.m. to 9:30 a.m. In an interview on 7/16/13 at 11:19 a.m. Staff B, Certified Nursing Assistant, stated she remembered seeing Resident #1 around 8:30 a.m. when helping the nurse pass medications. Staff B stated she may have last seen Resident #1 (prior to elopement) around 9:05 a.m. when escorting Resident #1 from the dining room. Staff B stated she then went on break. In an interview on 7/16/13 at 10:10 a.m. Staff C, Dietary Manager, stated that on 7/3/13 at around 9:00 a.m. she saw Resident #1 at the exit door in the dining room looking out. Staff C redirected Resident #1 back towards the nurse's station. Staff C stated she went on break from 9:00 a.m. to 9:15 a.m. On 7/16/13 at 10:44 a.m. Staff D, Certified Nursing Assistant, was interviewed and stated on 7/3/13 she was working the day shift and assigned to A hall. Staff D had interactions with Resident #1 that morning, but noted no exit seeking behaviors. Staff D went on break at 8:50 a.m. and returned at 9:05 a.m. Resident #1 was seen sitting in the dining room. Staff D stated Resident #1 ambulates freely within the facility and will attempt to exit the facility, setting off door alarms. On 7/16/13 at 10:30 a.m. Staff E, Certified Nursing Assistant, was interviewed and stated on 7/3/13 she was working the day shift and assigned to A hall. Staff E could not recall all the times she saw Resident #1 that morning, but recalled the last time (prior to elopement) was at 9:15 a.m. when she saw Resident #1 ambulating in A hall prior to her break (9:15 a.m. to 9:30 a.m.). Note: At the time of the complaint investigation, the complaint was coded at a " J " , immediate and serious jeopardy. By 7/9/2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " D " level. The facility put a key pad device on the door instead of the previous push button device, located inside the exit door. As of the 7/23/2013 exit conference, the facility needed to continue to monitor the functioning of the new key pad alarm to prevent resident elopements. Note: At the time of the complaint investigation, the complaint was coded at a " J " , immediate and serious jeopardy. By 7/9/2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " D " level. The facility put a key pad device on the door instead of the previous push button device, located inside the exit door. As of the 7/23/2013 exit conference, the facility needed to continue to monitor the functioning of the new key pad alarm to prevent resident elopements.

The following deficiency relates to facility reported Incident # -I. Based on observation, record review, and interviews, the facility failed to provide adequate supervision from hazards during transfers for four of five residents reviewed. Resident #1 sustained a laceration to the scalp and epidural hematoma when he/she fell out of a sling and hit his/her head on the floor during an EZ lift transfer. Staff interviews determined the staff performing the transfer failed to check the sling to ensure the loops were secure to the sling. The facility failed to plan for and direct nursing services to ensure staff used the correct sling for safe transfers for Residents #2 and #4; and failed to follow the EZ Lift Manufacture Lift Operating Instructions for Resident #1, #2, #3, and #4. The facility reported a census of 61. Findings Include: The facility used the mechanical EZ Lift for transferring non weight bearing residents. The EZ Lift manufacturing Operations Instructions included after the sling straps are attached to the lift hanger hook that staff are to push the "up" button and lift the resident until there is tension on the wings of the sling, making sure all the loops on the sling are securely hooked on the sling. Then smooth the sling wings under the residents thighs with a slight pull on the outside of the seam on the wings. The video training instructions also included that staff are to ensure the appropriate size of sling is used for the resident and no other sling should be used but the EZ Lift brand for the safety of the resident. EZ Sling Sizing Chart revealed a small sling would fit a weight of a 70-100 pound resident, the medium would fit a weight of a 90-220 pound resident, a large would fit a 190-320 pound resident. Review of the information submitted to State of Iowa by the Administrator dated 12/19/11 revealed at 3:45 p.m. on 12/16/11 Resident #1 was transferred from his/her wheel chair by 3 staff members using a EZ Stand lift after the resident was placed in the sling. Staff reported the upper left strap came off the lift bar and the resident fell backward out of the sling onto the floor by the side of the bed. The resident sustained [REDACTED]. 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #1 required the assistance of two staff member for bed mobility, transfer, dressing, for toileting and personal hygiene. The MDS revealed [DIAGNOSES REDACTED]. The MDS documented a weight of 169 pounds and a height of 64 inches. The Care Plan dated 08/07/07 or Resident #1 indicated the resident required assist of two staff members for mechanical transfers to and from the wheelchair. A History and Physical dated 12/16/11 identified Resident #1 admitted to the hospital following a fall from a mechanical lift (Hoyer) resulting in a laceration to the scalp and epidural hematoma. Resident admitted for continued monitoring and care of the head injury. Review of Physician admission orders [REDACTED]. The orders included will be on hospice service now on return to the facility, staff to assess the wound staples of the head for signs and symptoms of infection, bed rest until 12/20/11 and then Hoyer lift for transfers. During an interview on 12/21/11 at 4:51 p.m., Staff G, CNA, stated she/he had been working at the facility for 5 months and he/she had been orientating Staff D who is a new hire CNA to the facility. Staff G, CNA (Certified Nurse Aide) revealed he/she assisted with the transfer of Resident #1 along with two other CNA's, Staff H and D, on 12/16/11 around 3:45 p.m. Staff G stated he/she hooked up the upper left hoops to the lift hooks and the bottom left hoops to the lift. Staff G stated he/she was sure the upper left hoops were in place as the resident was lifted and Staff D operated the controls of the lift. Staff G reported he/she went to the guide the resident's legs for transfer. Staff G indicated as the resident was being moved with the lift towards the bed the left upper strap came off and the resident fell backwards out of the sling to the floor landing on his/her back. Staff G further indicated she did not know how the left hoop came off the hook and at first thought the hoop broke but after the fall the hoop was intact. Staff G reported she did not check the right side of the sling before transferring the resident and the resident had been sitting in an upright position in sling and had not been moving in the sling. Staff G stated he/she did not know what size of slings resident's are to use and did not know where to find that information. During an interview on 12/21/11 at 4:35 p.m., Staff D, CNA, reported he/she is still in orientation and had been orientating with Staff G. Staff D reported on 12/16/11 sometime before 5:00 p.m. he/she assisted with the transfer of Resident #1 from the wheel chair to the bed. Staff D indicated that Staff G, CNA, and Staff H, CNA hooked up the slings to the lift. Staff D did not recall what staff member had been on what side of the resident when they hooked the sling to the lift. Staff D reported he/she had been at the controls of the lift and operating it. Staff D reported that he/she did not check the hoops to ensure they were connected after applying tension to the sling, Staff D stated no one instructed her that she/he had to perform this safety step. Staff D after lifting resident out of wheel chair she/he pulled the lift back from the wheel chair and started to rotate the lift and move it towards the bed. Staff D reports the resident had been by the bedside in the lift sling when all of a sudden the resident fell out of the sling onto the floor landing on the his/her back. Staff D indicated that he/she did not hear any noise prior to the resident falling. Staff D stated the resident had been sitting in the sling in an upright position and not moving and Staff G had been guiding the resident's feet prior to fall. Staff D stated she/he is not aware of the size of slings a resident is to have, and did not know where to find that information. During an interview on 12/21/11 at 3:44 p.m. H, CNA, indicated she/he was assisting with a transfer on Resident #1 along with Staff D and Staff G. Staff H reported the resident had been in the wheel chair and she/he had hooked up the right side of the sling hoops to the lift hooks and Staff G had been on the left side and hooked up the left sling hoops to the lift hooks; however Staff H stated he/she did not check the left side prior to transfer. Staff H indicated as the lift that had been operated by Staff D lifted the resident from the wheel chair Staff H moved to the other side of the bed and Staff G assisted with guiding the resident's feet. Staff H stated she/he heard a loud pop sound right before the resident fell out of the sling on the left side to the floor. Staff H thought at first the sling hoop broke but after the incident they checked the sling and it had not broke. Staff H stated she/he never checked if Staff G hooked up the sling in the same hoops as he/she did. Staff H stated he/she is unaware of what size sling a resident is to have for transfers and did not know where that information is at. During an interview on 12/22/11 at 11:19 a.m., the EZ Lift representative stated he had been called by the facility to come and check out the EZ Lift and sling that had been used during Resident #1 transfer and fall. The representative indicated he inspected the lift and found it in safe working condition, however the hanger bar had been missing the optional green caps that he replaced at the time. The representative inspected the sling which had been placed in a sling bag and found it free from tears and all of the loops were intact with no signs of frayed or broken stitching. The representative stated the sling size he inspected had been a large EZ Sling, although the weight of the resident per sizing chart a medium sling would have been a better fit depending on the shape of the resident. The representative indicated using a larger sling would not cause the hoops to come off the hooks of the lift. The representative indicated the only explanation of why the hoop came off the hook of the lift is that it had not been in place. Observation on 12/22/11 at 9:50 a.m. revealed Resident #1 sitting in wheel chair in room with two staff members in room (Staff I and Staff J). The staff members hooked the sling that had been in place under resident to the EZ Lift hooks. The staff proceeded to do the following: lift the resident out of the wheel chair and transferred him/her to the bed and disconnected the left sling from the lift hooks and remove the sling from under the resident. Staff failed to check placement of the sling hoops after applying tension to the sling and to smooth out the sling under the resident's legs as advised by the manufacture. Review of the sling revealed it was a large size EZ sling with a replace date of 05/08. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS revealed Resident #4 required the assistance of two staff member for transfers and toilet use and assist of one staff member for bed mobility, dressing, and personal hygiene. The MDS revealed [DIAGNOSES REDACTED]. The MDS documented the resident weight of 109 pounds and a height of 58 inches. Review of the care plan with updated date of 11/17/11 included instructions for staff dated 12/3/11 to change resident to an EZ Lift (Hoyer) due to resident unable to cooperate with an EZ Stand aid and safety of the resident. Observations on 12/21/11 at 4:27 p.m. revealed Resident #4 lying in bed Staff E, CNA, and another CNA into room and placed the lift sling under the resident and hooked the straps of the sling to the lift hooks. Staff proceeded to lift the resident with EZ lift and transferred to the wheel chair. Staff failed to check for hoop placement or smooth out the sling after tension had been applied to the sling. Review of the sling revealed staff using a large EZ Sling for weight of 190-320 pounds; review of resident weight revealed a current weight of 109 pounds. The size of the sling being used on Resident #4 for transfers with the EZ Lift was verified with Staff B to be an EZ Lift sling in a size large. During an interview on 12/22/11 at 10:22 a.m., Staff E indicated after Resident #4 had been transferred to the bed he/she changed the size of the EZ sling from a large to a medium as the large sling had been the incorrect size. Review of the sling in resident's room revealed a medium EZ Sling size medium with a replace date of 12/08. 3. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 had a score of 15 out 15 for BIMS (Brief Interview for Mental Status). The MDS revealed Resident #2 required the assistance of two staff member for bed mobility, transfers and toilet use, and personal hygiene and assist of one staff member for dressing and locomotion. The MDS revealed [DIAGNOSES REDACTED]. The MDS documented the resident weight of 277 pounds and a height of 69 inches. Review of the plan of care for Resident #2 included resident to be transferred with the assist of the EZ Lift. Observations on 12/21/11 at 4:31 p.m. revealed Resident #2 sitting in wheel chair in room with the lift sling in place and two CNA staff members present (Staff H and Staff C). Staff connected the sling hoops to the EZ Lift hooks and proceeded to lift and transfer resident to the bed. Staff failed to check that the hoops were connected and to smooth out the Hoyer sling after tension had been applied to the sling. Review of the sling used for the transfer reviewed the sling had been a Medicare brand and large in size and not the EZ Brand sling as recommended by the EZ Lift manufacture. The manufactures recommendations are to use a EZ Lift Sling and according to resident's weight which indicated a sling large in size. Observations on 12/22/11 at 10:10 a.m. along with Staff B of Resident #2's lift sling revealed the brand to be Medicare and large in size. Observations at 1:50 p.m. revealed staff had changed the lift sling to a large EZ Lift sling large in size and had removed the Medicare sling from the resident's room. 4. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #3 had a score of 5 out 15 for BIMS (Brief Interview for Mental Status). The MDS revealed Resident #3 required the assistance of two staff member for bed mobility, transfers and toilet use, and personal hygiene and assist of one staff member for dressing and locomotion. The MDS revealed [DIAGNOSES REDACTED]. The MDS documented the resident weight of 119 pounds and a height of 63 inches. Review of the resident's safety plan included instructions for staff that resident is to be transferred with EZ Lift (Hoyer) for all transfers dated 6/7/11. Observations on 12/22/11 at 10:04 a.m. revealed Resident #3 sitting in wheel chair in room with 2 CNA staff members present (Staff K and Staff L) . The EZ Lift sling in place and staff hooked the hoops to EZ Lift hooks then transferred the resident to bed. Staff failed to check after applying tension to the sling that the hoops were all connected and to smooth out the sling under the resident's legs as recommended by the manufacture. Observations of the sling used to transfer resident revealed an EZ Sling of medium in size and with a replacement date of 12/08. Interview on 12/21/11 at 4:46 p.m., Staff C indicated that the lift slings had different colors but he/she is unaware what the colors indicate. Staff C stated he/she is did not know what size of slings residents are to use and did not know where to find this information. During an interview on 12/21/11 at 2:38 p.m., 12/22/11 at 3:40 p.m., and 12/22/11 at 2:26 p.m., the Director of Nursing (DON) indicated that through the facility investigation they did not know how the left lift strap came off the lift hook on Resident #1 resulting in the resident's fall. The DON further indicated the facility has no weight chart in place to determine the size of sling to be used on residents and when a resident is assessed to be an EZ Lift it is done by a team effort but nothing in place for size of sling to be used. The DON reported the past year the orientation for CNA's included transfer with the EZ Lift by another CNA and return demonstration to the CNA providing the orientation. Now the orientation includes the training video recommendations of the EZ Lift manufactures. The DON stated that the facility is currently working on replacing all EZ lift slings with replace date of 2008 with new slings and that the facility will now place a number on the sling when put in use that will coordinate with a roster that will have the date that the sling had been placed in use. The DON further reported that the facility is monitoring the ongoing use of EZ Sling use and that she is doing checks on all staff to ensure they are appropriately transferring residents with the use of the EZ Lift and that nursing administration will be involved on return demonstrations of staff skills of transferring a resident. The DON indicated that the size of the lift sling will be placed on the residents' care plan. During an interview on 12/21/11 at 2:30 p.m. the Administrator reported not all staff have been retrained on the EZ Lift on transferring residents, that there are 6 staff members that have not watched the video. On 12/22/11 at 2:30 p.m., the Administrator indicated that all staff had been retrained on the recommended manufacture video training on the EZ Lift.

The following deficiency relates to complaint -C: Based on clinical record review and staff interviews, the facility failed to plan for and direct nursing services to ensure Resident #2 received adequate supervision against hazards. Resident #2 fell and fractured his/her left wrist when ambulating. Staff interviews revealed the resident required stand by to contact guard assistance, while other staff reported the resident required the assistance of one staff or no assistance as the resident was independent with ambulation. After the fall, Resident#2 started using a quad cane which had previously been discouraged since the resident did not use it correctly. The facility reported a census of 54 residents with 3 residents reviewed for falls. Findings include: According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 7/27/11, identified Resident #2 with a Brief Interview for Mental Status (BIMS) score of 7 indicating impaired short and long term memory deficits and cognitive skills for daily decision making. Resident #2 required limited assistance with physical assist of one staff with bed mobility, transfers, locomotion, dressing, personal hygiene, toilet use and bathing. Resident #2's [DIAGNOSES REDACTED]. Resident #2's plan of care identified a goal for no falls requiring out of facility treatment by 8/22/11 with approaches which included: a. Physical therapy to increase strength and ambulation. b. Assist and supervise with ambulation as (the resident) requested. c. Keep room well lit and free of clutter. d. Do not change items in room due to poor vision. e. Safety: one person assist with transfers f. Ambulation: one person assist. The plan of care documented the goal had been met on 7/28/11. Therapy Recommendations dated 5/27/11 indicated Resident #2 was to use walker as tolerated to increase balance and sense of safety. Use gait belt and stand by assist with verbal cues for direction. The physical therapist recommended Resident #2 needs to be told where he/she was going and where to turn. Tinetti Assessment Tool dated 6/3/11 indicated Resident #2 with a score of 22 noting Resident #2 as a moderate risk for falls. According to the Interdisciplinary Progress Notes dated 5/15/11 at 7:35 p.m., Resident #2 had fallen during a shower when the shower chair tipped forward. In an interview on 8/16/11 at 3:39 p.m. Staff G indicated she had been summoned to the B-wing shower room on 5/15/11 by the aide when Resident #2 fell . Staff G indicated she had not seen the safety belt latched, but remembered that being an issued related to the fall. a. According to the Interdisciplinary Progress Notes dated 6/21/11 at 8:30 p.m., identified Resident #2 ambulated with walker and stand by assistance of 1 staff. Interdisciplinary Progress Notes dated 7/18/11 at 6:50 a.m. indicated Resident #2 was found lying on left side in front of door to hallway. Resident #2 had been incontinent of bladder. A 5cm x 4cm hematoma on left side of head and a 5cm x 2.4cm skin tear on left elbow with bruising with complaint of pain with movement or touching. Late entry note indicated Resident #2 was not wearing skid socks at the time of the fall and his/her wheel walker was sitting by the closet. Resident #2 was sent to the hospital at 7:45 a.m. and returned at 10:30 a.m. with a reported left distal radial fracture (wrist fracture). The following staff interviews revealed inconsistent levels of assistance provided to the resident prior to his/her fall on 7/18/11.(Some staff stated the resident required stand by to contact guard assistance, while other staff reported the resident required the assistance of one staff or no assistance as the resident was mostly independent with ambulation) : In an interview on 8/16/11 at 1:44 p.m. Staff A indicated and wrote in her statement the following: Resident #2 had been evaluated for physical therapy treatment on 5/13/11. A plan of care was determined in which Resident #2 would be working on extremity exercises, safety in sit to stand transfers and ambulation. The resident had been using a quad cane and hand held assistance of one aide to walk. The plan of care included changing from a quad cane to a front wheel walker on admittance. Staff A documented Resident #2 used the quad cane incorrectly and declined to switch to the front wheel walker until 5/27/11. Resident #2 was always in need of stand by assistance, using a gait belt and verbal cueing for safe transfers and ambulation. Physical therapy was discontinued on 6/3/11 as Resident #2 was moderately independent, but who still needed stand by assistance and verbal cueing. Staff A documented Resident #2 had been less anxious when discharged from physical therapy because of his/her increased safety and balance using the walker. In an interview on 8/16/11 at 2:00 p.m. Staff B indicated and wrote in her statement the following: she had worked day shift and was familiar with Resident #2. Staff B indicated she understood Resident #2 needed assistance with all activities of daily living including assist with transfers and ambulation. Staff B noted she would remind Resident #2 to use the call light, but noted Resident #2 would get up by his/herself. Even after Resident #2's fall on 7/18/11, he/she still tries to get up unassisted. In an interview on 8/17/11 at 10:22 a.m. Staff C indicated and wrote in her statement the following: she had worked with Resident #2 since admission to the care center. Resident #2 needed assistance with all his/her ADLs and one assist with ambulation due to limited vision. Since his/her recent fall the resident uses the call light but prior to that he/she did not and would get up to ambulate on his/her own. The resident ' s roommate also puts his/her call light on to alert staff for Resident #2. In an interview on 8/16/11 at 3:20 p.m. Staff D indicated and wrote in her statement the following: she had worked with Resident #2 since his/her admission in May 2011. Staff D indicated that during the first two weeks Resident #2 was admitted he/she was frequently up and ambulating in his/her room by him/her(self) but needed the assistance of one staff. Staff D indicated it was determined Resident #2 needed the assistance of one staff with transfers and ambulation. Staff D indicated Resident #2 was good about using the call light system. In an interview on 8/16/11 at 3:32 p.m.Staff E indicated and wrote in his statement the following: he worked the evening shift and was familiar with Resident #2. Staff E indicated Resident #2 had vision problems and needed some help, but was mostly independent. Since falling, Resident #2 was now determined a mandatory assist of one with gait belt and walker. In an interview on 8/17/11 at 10:30 a.m. Staff F indicated she assessed Resident #2 prior to admission. Resident #2 had been independently mobile using a quad cane at home. Resident #2 was switched from the quad cane to a wheel walker with recommendations to use the walker and gait belt when assisting with transfers and ambulation. Staff F acknowledged awareness that Resident #2 would often get up unassisted, but wanted to retain as much independence for him/her as possible. Staff were instructed to stay alert to his/her toilet use needs and to be checked upon during rounds.Staff F indicated she did not consider using an alarm system due to Resident #2's anxiety and belief that the alarm may startle the resident and actually cause a fall. b. The following progress notes identified the resident used a quad cane for assistance with ambulation when it was already known the resident used the quad cane incorrectly: According to the Interdisciplinary Progress Notes dated 7/20/11 at 11:00 a.m., the fall from 7/18/11 had been reviewed by the fall committee with recommendations for the resident to wear skid socks and assist up with walker in reach. At 12:03 p.m., that documentation identified one staff assist the resident to the lunch with a gait belt and the resident using a quad cane. According to the Interdisciplinary Progress Notes dated 7/23/11 at 6:15 p.m., Resident #2 left arm cast had been assessed as intact. The note identified the resident ambulated to and from the dining room with the assistance of one staff and used his/her cane.

Based on record review, staff and resident interviews and review of the facility policy/procedures, the facility failed to investigate and report inappropriate sexual behaviors by Resident #4 to Resident #3, #6, and #7. The facility staff had observed Resident #4 touching other residents and failed to ensure each resident was free from physical abuse and failed to reported such abuse to the Iowa Department of Inspections and Appeals. The facility identified a census of 69 residents and the incidents involved 4 of 9 residents (Residents #3, #4, #6, #7). Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment, with an assessment reference date of 8/16/10 which identified short and long term memory deficits and moderately impaired cognitive skills for daily decision making. Resident #4 required extensive assistance with physical assist of two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #4 required supervision with mobility, but otherwise independently ambulatory. The MDS indicated the resident displayed the following behaviors: daily wandering with resistance to cares, verbally abusive, physically abusive and socially inappropriate/disruptive behaviors 1-3 days per week. Resident #4's [DIAGNOSES REDACTED]. The care plan dated 7/26/10 identified a problem with a history of socially inappropriate sexual displays toward staff/peers. The facility provided a goal that the resident would accept redirection without agitation at the time of inappropriate sexual behavior and will have no physical contact resulting in injury to self or others. The approaches directed staff to: a. Report inappropriateness to the charge nurse or social worker for documentation. b. Sit or redirect resident away from peers he/she has shown interest in related to inappropriate actions. c. Be alert to medication which may increase sexual inappropriate behavior. On 9/15/2010 at 12:19 p.m. Staff A (Social Worker) was interviewed. Staff A stated upon Resident #4's return from the hospital, a care plan sheet dated 7/26/10 was implemented. Staff A continued to state the resident had a history of [REDACTED].#4 grabbing staff (sexually inappropriately) and knew of Resident #4 touching the peer's arms and thighs in the past but not of anything that had occurred recently. Staff A indicated she had no knowledge of Resident #4 ever touching a peer's breast or groin area. In an interview on 9/9/10 at 3:29 p.m. Staff B (Certified Nursing Assistant) indicated she/he had known Resident #4 since admission to the facility on [DATE]. Staff B indicated Resident #4's behavior had been getting much worse and became more and more aggressive and violent. Staff B indicated Resident #4 has had many occasions (6-12) that she/he had personally witnessed in which he/she touched residents (Resident #6) on their breasts and bottom areas. Resident #4 had also touched female staff ' s breasts and bottom areas when care provided. Staff B indicated one intervention she/he used was to keep Resident #4 away from Resident #6. Staff B also indicated one afternoon (7/13/10) she/he walked by Resident #3's room and discovered Resident #4 standing at Resident #3's bedside with his/her genitals exposed and in the face of Resident #3. Staff B separated the residents and informed the charge nurse (Staff C) of the incident. In an interview on 9/10/10 at 2:46 p.m. Staff C (Registered Nurse) confirmed knowledge by Staff B that Resident #4 was found in the room of Resident #3 and displayed his/her genitals. Staff B stated neither resident touched each other. Staff C indicated he/she did not necessarily consider the event as sexually inappropriate as Resident #4 had a history of [REDACTED]. The Interdisciplinary Progress Notes dated 7/13/10 at 6:15 p.m. and written by Staff C indicated Resident #4 was found in a peer ' s room by an aide with the resident ' s genitals exposed. The resident was known to urinate in unusual places and unknown if that was the reason. The Interdisciplinary Progress Notes reviewed for Resident #3 noted no entry which described the incident in which Resident #4 exposed his/her genitals to Resident #3 on 7/13/10 at 6:15 p.m. In an interview on 9/14/10 at 12:35 p.m. Staff D (Registered Nurse) indicated she/he had seen Resident #4 rubbing the breasts of Resident #6 and #7 on 7/15/10. Staff D separated Resident #4 from Resident #6 and #7 and reported her observations to Staff E. Staff D indicated she did not complete an incident report contact the physician or report the incident to the victim's family. Staff D reported the incident to the family member of Resident #4. The Interdisciplinary Progress Notes dated 7/15/10 at 10:40 a.m. and written by Staff D, indicated Resident #4 had been inappropriately sexually rubbing peers and grabbing staff in the crotch area. The Interdisciplinary Progress Notes reviewed for Resident #6 noted no entry describing the incident in which Resident #4 rubbed the breast of Resident #6 on 7/15/10 at 10:40 a.m. The Interdisciplinary Progress Notes reviewed for Resident #7 noted no entry describing an incident in which Resident #4 rubbed the breast of Resident #7 on 7/15/10 at 10:40 a.m. In an interview on 9/14/10 at 10:27 a.m., Staff E (Director of Nursing) indicated she had known Resident #4 all of her life. Staff E described Resident #4 as being combative, would head butt and attempt to bite staff. Staff E indicated it is reported to her that Resident #4 touched a female resident on her upper chest, above her breast and that she is aware that Resident #4 had grabbed at staff members. Staff E denied ever informed of Resident #4 touching the breast of Resident #6 or any other resident and denied awareness of the incident which involved Resident #3 when Resident #4 exposed his/her genitals. In an interview on 9/9/10 at 1:11 p.m. Staff F (Certified Nursing Assistant) indicated Resident #4 can be resistive to cares and combative. Resident #4 had also touched Staff F between her legs and required redirecting. Staff F indicated Resident #4 had touched Resident #6 on his/her breasts numerous times and she had reported this to Staff E, Staff J and the charge nurse. Staff F could not recall the specific dates and times of the incidents, but noted it happened weekly. Staff F knew of no specific interventions implemented to keep Resident #4 away from other residents. Staff F believed it unsafe for residents and staff to have Resident #4 in the facility. In an interview on 9/9/10 at 4:15 p.m. Staff G (Certified Nursing Assistant) stated she had witnessed Resident #4 follow residents into their rooms. On one occasion Staff G witnessed Resident #4 crawling into the bed of Resident #3 while Resident #3 lay in bed. Staff G successfully redirected Resident #4 out of the bed. Staff G indicated Resident #4 had been vulgar, requesting staff to get in bed with him/her and had touched her and other staff inappropriately. Staff G indicated there are currently no known interventions to address these behaviors other than to redirect Resident #4 when the behavior occurs. In an interview on 9/14/10 at 11:30 a.m. Staff H (Certified Nursing Assistant) stated on at least three occasions she/he had witnessed Resident #4 touch Resident #6 on the breast and groin areas and had reported these events each time to the charge nurse. In an interview on 9/9/10 at 12:08 p.m. Staff I indicated she/he had witnessed Resident #4 touching other residents inappropriately, noting the behavior usually occurs after lunch. Staff I indicated she/he had witnessed Resident #4 touching Resident #7 on the breast but could not recall the specific date or time. In an interview on 9/9/10 at 11:34 a.m. Staff K (Certified Medical Assistant indicated she/he witnessed Resident #4 touching Resident #6 in the peri area, over the clothing. Staff K noted the residents were separated. In an interview on 9/9/10 at 3:20 p.m. Staff L (Certified Nursing Assistant) stated she/he had witnessed Resident #4 display inappropriate sexual behavior towards herself and staff and had heard Resident #4 had been sexually inappropriate with other residents, specifically Resident #6. In an interview on 9/9/10 at 11:56 a.m. Staff M (Certified Nursing Assistant) stated she/he had heard Resident #4 had touched staff and residents inappropriately (sexually) but had never experienced or witnessed this herself/himself. In an interview on 9/9/10 at 11:05 a.m. Staff N (Certified Medical Assistant) stated she had heard of Resident #4 touching staff and peers sexually inappropriately, but had never experienced this personally or witnessed the behavior. In an interview on 9/9/10 at 4:38 p.m. Staff O (Certified Nursing Assistant) stated she/he had never experienced or witnessed Resident #4 inappropriately touching staff or residents, but did hear about an incident in which Resident #4 exposed his/her genitals to Resident #3. In an interview on 9/9/10 at 4:03 p.m. Staff P (Certified Nursing Assistant) stated Resident #4 had made sexual comments to her and requested she take her clothes off and get into bed with him/her. Resident #4 had never touched her. Staff P indicated she knew of no intervention implemented to keep Resident #4 from touching other residents. In an interview on 9/9/10 at 5:01 p.m. Staff Q (Registered Nurse) stated she had heard about Resident #4 grabbing staff and residents sexually inappropriately, especially Resident #6. In an interview on 9/9/10 at 10:26 a.m. Staff R (Licensed Practical Nurse) stated on 8/8/10, Resident #4 attempted to touch another resident and would be redirected. Staff R also identified an incident on 9/4/10 in which Resident #4 in the room of another resident. The resident stated Resident #4 wouldl not leave his/her room and Resident #4 attempted to touch him/her. Staff R could not recall the name of the resident. The Interdisciplinary Progress Note dated 8/8/10 at11:00 a.m. and written by Staff R indicated Resident #4 attempted to touch the breast of another resident and successfully redirected. The Interdisciplinary Progress Note dated 9/4/10 at 11:00 a.m. and written by Staff R indicated Resident #4 was found in another resident's room. The resident asked Resident #4 to leave his/her room and claimed Resident #4 attempted to touch him/her. In an interview on 9/9/10 at 11:15 a.m. Staff S (Certified Nursing Assistant) stated Resident #4 would make sexual comments to her, but had never attempted to touch her. Staff S indicated she/he had heard about Resident #4 touching other residents in a sexually inappropriate manner, but had never witnessed this behavior. In an interview on 9/15/10 at 9:19 a.m. Staff T (Certified Nursing Assistant) stated she found Resident #4 in the bed of another resident on one occurrence. The resident was not in the bed or room at the time. In an interview on 9/9/10 at 3:07 p.m. Staff U (Registered Nurse) stated some of the aides reported Resident #4 had touched them in inappropriate areas. Staff U indicated she had never witnessed Resident #4 touch residents inappropriately nor have that reported to her. In an interview on 9/10/10 at 11:06 a.m. Staff V (psychiatrist) indicated he/she was aware of Resident #4's behavioral problems related to prolonged [MEDICAL CONDITION]. Staff V indicated he/she was aware of Resident #4's sexually inappropriate touching of other residents and noted Resident #4 had been hospitalized on several occasions and made several medication adjustments in an attempt to better manage his/her behavior without over sedating Resident #4. In an interview on 9/10/10 at 12:55 p.m. Staff W (primary physician) stated he/she as unaware of Resident #4 touching other residents sexually inappropriately. Staff W noted he/she was made to believe the grabbing was inadvertent or unintentional. In an interview on 9/10/10 at 1:22 p.m. Resident #4's family member stated the facility staff had notified him/her and informed him/her of his family member touching other residents in sexually inappropriate ways. In an interview on 9/9/10 at 1:36 p.m. Staff J (nurse manager) stated she had never known Resident #4 to do any inappropriate touching of other resident body parts or been informed by staff of this behavior. Staff J indicated the facility protocol for when a resident touches another resident in a sexually inappropriate manner is for the staff member to fill out an incident report detailing the event. Staff J researched the incident report history for Resident #4 through January 2010 to present (9/10/10) and noted no incident reports related to Resident #4 touching other residents in a sexually inappropriate manner. In a separate interview on 9/10/10, Staff J indicated the 1:1 supervision of Resident #4 initiated on 7/15/10 through 7/19/10 was due to Resident #4's aggression. Staff J stated she/he unware of the incident on 7/13/10 or on 7/15/10 which involved Resident #4 touching other residents in a sexually inappropriate manner. In an interview on 9/15/10 at 12:40 p.m., Resident #8 stated both males and females had entered his/her room from time to time. Resident #8 indicated on one occasion he/she slept when Resident #4 entered his/her room. Resident #8 first was scared, then realized it was Resident #4 and had known the resident wanders. Resident #8 indicated Resident #4 never attempted to touch him/her. In an interview on 9/15/10 at 12:45 p.m. Resident #9 indicated both males and females enter his/her room on occasion. Resident #9 identified Resident #4 as a common wanderer. Resident #9 noted Resident #4 never attempted to touch him/her. On one occasion Resident #9 remembered Resident #4 came into Resident #8's room. Resident #8 told her there is a strange man/woman in his/her room and it frightened him/her. According to Resident #3 Minimum Data Set (MDS) assessment with assessment reference date of 7/26/10, identified Resident #3 having short and long term memory deficits with moderately impaired cognitive skills for daily decision making. Resident #3 requires limited assistance with physical assist on one staff with ambulation. According to staff, Resident #3 is independently capable of moving away from harm or other residents if needed. The Minimum Data Set (MDS) assessment with a reference date of 7/12/2010, identified Resident #6 had short and long term memory deficits with moderately impaired cognitive skills for daily decision making. Resident #6 required supervision, but otherwise was independently mobile with a walker. According to the facility staff, Resident #6 could independently be capable of moving away from harm or other residents if needed. According to the Minimum Data Set (MDS) assessment for Resident #7 with an assessment reference date of 7/19/10, Resident #7 had short and long term memory deficits with severely impaired cognitive skills for daily decision making. Resident #7 was identified as totally dependent on others for bed mobility, transfers and ambulation and incapable of moving away from harm or other residents if needed. The facility policy/procedure for resident to resident occurrences identified the following areas in which the facility failed to implement: Policy: Employees of our health care facilities will make every effort to protect residents from sexual offense perpetrated by another resident. Procedure: 3. Prevention of resident to resident occurrences include: a. If a prospective resident has been identified as having risk factors, the facility will determine if it is able to meet the individuals ' needs while protecting the other resident's right to safety. b If the facility admits an individual with the potential for challenging behaviors, said behaviors will be clearly identified on the resident's care plan with specific interventions designed to avert resident to resident occurrences. 4. Any employee, who directly observes, overhears or is told of one resident infringing on the rights of another resident by sexual advances shall immediately report and seek assistance of their supervisor to intervene to protect the rights and insure the safety of the individuals involved. 6. Responding to resident to resident occurrences may include: a. Notifying the victim's responsible party. b. Notification of the involved parties attending physicians. 7. The administrator or designee will conduct a comprehensive internal investigation and initiate whatever action he/she deems to be necessary to insure the safety and well being of the residents. 8. If an allegation of mistreatment is substantiated and resulted in actual or potential harm to another resident, appropriate action must be implemented to prevent reoccurrence. Note: At the time of the complaint investigation, the violation was coded at "J", Immediate and Serious Jeopardy Level. By 9/10/2010, the facility had implemented 15 minute checks of Resident #4 and began to inservice the staff regarding inappropratie sexual behaviors, the need to document the behaviors and staff interventions to the behaviors. The grid placement was lowered to an "E" level. As of 9/29/2010, the facility continued to need to: ? Provide inservices about inappropraite sexual behaviors, necessary documentation of the behaviors and the interventions provided as a result of the behaviors. ? Continue to supervise Resident #4 and document inappropratie behaviors and interventions implemented so residents are kept safe and unharmed. ? Continue to follow the facility policy/procedures for resident to resident occurrences and notify the appropriate staff, physician and responsible parties.