Every finding on record at Casa De Paz Health Care Center

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure 1 of 6 resident's (Resident #11) care plan was updated to reflect their transfer status. The facility reported a census of 70 residents.Findings include:The quarterly Minimum Data Set (MDS) assessment with a reference date of 7/1/2026 documented Resident #11 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented Resident #11 had impairments to her bilateral lower extremities and utilized a wheelchair. Resident #11 required substantial/maximal assistance to go from a sitting to lying position and lying to sitting position. She was also dependent on staff to go from a sitting standing position, chair/bed transfer to chair transfer and a toilet transfer. The following diagnoses were listed for Resident #11: right tibia fracture, anemia, multiple sclerosis (MS), lack of coordination, repeated falls, weakness, reduced mobility, need for assistance with personal care and chronic pain syndrome. The Care Plan Focus Area with an initiated and revision date of 6/10/2026 documented Resident #11 had self-care deficit as evidenced by requiring assistance with Activities of Daily Living (ADLs), impaired balance transitions requiring assistance and/or walking, incontinence. The Care Plan documented Resident #11 did not ambulate, utilized a motorized wheelchair that she can self-propel. The Care Plan also documented during transfers Resident #11 required one person to assist with a stand-pivot transfer (SPT). On 7/9/2026 at 9:25 AM Staff B Certified Nursing Assistant (CNA) stated when transferring Resident #11, they use two staff and a mechanical lift. On 7/9/2026 at 9:31 AM Staff C CNA stated when Resident #11 would like to get out of bed, they will use a mechanical lift with two staff present. On 7/9/2026 at 9:36 AM Staff D CNA stated Resident #11 can roll side to side in bed but if she wanted out of bed, they would use the assistance of two staff and a mechanical lift. On 7/9/2026 at 3:04 PM Staff E CNA stated when they assist Resident #11 out of bed they always use two staff and a mechanical lift. On 7/9/2026 at 3:14 PM Staff F CNA stated they assisted Resident #11 with transfers with the assistance of two staff and a mechanical lift. It has been that way since Resident #11 was admitted to the facility in April. On 7/9/2026 at 3:28 PM Staff A CNA stated Resident #11 required the assistance of two staff and a mechanical lift for transfers. On 7/14/2026 at 10:25 AM the Assistant Director of Nursing (ADON) stated Resident #11's assistance level is with the assistance of two staff and a mechanical lift. When she was informed the Care Plan stated Resident #11 was an assist of 1 staff for a stand pivot transfer. She indicated she would get the care planned changed. The ADON stated the Corporate MDS Coordinator initiates the main Care Plan then the updates are done by herself or the Director of Nursing (DON). The facility provided a document titled Care Plan Revisions Upon Status Change. The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines:The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.Procedure for reviewing and revising the care plan when a resident experiences a status change:d. The care plan will be updated with the new or modified interventions.f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to provide the appropriate interventions when 1 of 3 residents (Resident #10) experienced a hypoglycemic (low blood sugar) episode. The facility reported a census of 70 residents. Findings include:On 7/10/2026 at 9:10 AM observed [NAME] Hall and Memory Hall medication carts had two glucagon IM pens, each in a red plastic container; as house stock, not specific for certain residents. On 7/10/2026 at 9:12 AM observed one glucagon IM pen, in a red plastic container; as house stock, not specific for certain residents.The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 6/8/2026 documented Resident #10 had a Brief Interview of Mental Status (BIMS) score of 9. A BIMS score of 9 suggested mild cognitive impairment. Resident #10 had the following diagnoses listed: diabetes mellitus, heart failure, renal failure, neurogenic bladder, Alzheimer's disease, stroke dementia and anxiety. The Care Plan Focus Area with an initiation and revision date of 6/16/2026 documented Resident #10 had diabetes mellitus. The Care Plan directed staff to administer diabetic medications as ordered. It also directed staff to follow protocol per facility for low blood sugars. Record review of the Census tab, revealed Resident #10 resided on Memory Hall. Review of the June 2026 Medication Administration Record (MAR) for Resident #10 revealed the following orders:Glucagon emergency kit, 1 milligram (mg). Inject 1mg intramuscularly as needed for low blood sugar. The order had a start date of 5/20/2026,Glucose oral packet (dextrose (diabetic use)). Give one packet by mouth as needed for low blood sugar. The order had a start date of 11/17/2023. Review of Resident #10's clinical record revealed the following Progress Note:On 6/6/2026 at 6:14 PM: at approximately 4:00 PM this nurse was notified by a Certified Nursing Assistant (CNA) that resident needed to be checked on. Upon seeing resident lethargic and sweating, a blood sugar was obtained and was 37. Glucagon gel was attempted to be given. At 4:06 PM the paramedics were called and arrived with 10 minutes, an IV was started and Dextrose was given. Resident was responsive upon leaving facility. The responding Emergency Medical Service (EMS) department provided a document titled Patient Care Record dated 6/6/2026. The record documented the following information:Primary Impression: diabetic hypoglycemia,Patient's Level of Distress: severe,Level of Consciousness: unresponsive with a blood sugar of 36 mg/dL,Mental Status: resident unconscious, unable to answer questions.Head, Eyes, Ears, Nose, and Throat: head supported upright by facility staff while seated in a wheelchair. Pink gel-like substance noted within oral cavity and partially protruding from her mouth. Oral glucose administration reported by staff despite resident being unconscious. Chest: snoring respirations noted, respiratory effort present, no obvious respiratory distress beyond decreased level of consciousness. Airway partially compromised by decreased level of consciousness and presence of oral glucose gel within oral cavity, lung sounds are diminished bilaterally. Narrative: upon arrival at the facility, the nursing staff directed them to the resident's room. Inside they found the resident to be unconscious in her wheelchair and exhibiting snoring respirations. The staff was supporting her head and reported that her blood glucose level was 37 mg/dL. EMS personnel noticed glucose paste dripping from her mouth, which the staff had attempted to give her despite her unresponsiveness. The resident was assessed and established IV access to administer dextrose. EMS suctioned her mouth to clear out the remaining glucose paste. Facility staff was advised to never place anything in the mouth of an unconscious resident. The resident became alert and transported to the hospital. On 7/7/2026 at 2:30 PM a Paramedic stated he responded to the facility for a diabetic problem. The EMS crew was told the resident had a low blood sugar and was unconscious. When they arrived to the facility Resident #10 was sitting in a wheelchair, with her head supported upright by a Certified Nursing Assistant (CNA) and the resident was unconscious. He immediately noted a clear pink like gel coming out of the resident's mouth, while she was unconscious. When he asked what it was the CNA told him it was her oral glucose, the nurse was not present. Someone from the EMS team informed staff to never put something in an unconscious person's mouth again. Once they started an IV and administered Dextrose the resident started to wake up and was coughing forcefully. After they transported Resident #10 to the hospital, he went to the dispatch center to find out more information about the 911 call. The 911 caller, a nurse from the facility, had told dispatch she put glucagon gel in Resident #10's mouth. This was a dangerous intervention on that nurse's behalf. On 7/8/2026 at 9:41 AM Staff G Registered Nurse (RN) was asked what she would do if she found a resident with a blood sugar in the 30's and unconscious. She stated she would give a glucagon IM injection that is located in the medication cart then call 911. When asked if she would give the same resident glucose gel, she stated she would not because they would not be able to swallow it. Staff G added they can put the gel on the resident's cheeks and rub it in with their gloved fingers. During a follow-up interview at 11:16 AM Staff G stated she gave Resident #10 her insulin with lunch. After lunch staff came to her and said she was not responding and sweating. Staff G obtained her blood sugar and it was 37. She could not find the glucagon injection, which should have been in the medication cart but it was not in there. She called 911, got the glucose gel and put it around Resident #10's mouth but it was not successful; she did not perk up. Resident #10 sat in her wheelchair, leaning to one side. She was sweating, not able to answer any questions. Staff G stated she attempted to do sternal rubs but received no response from Resident #10. On 7/14/2026 at 10:25 AM the Assistant Director of Nursing (ADON) stated it would not be appropriate to attempt to administer oral glucose gel if the resident was unconscious. If the resident was unconscious, she would expect staff to obtain the glucagon IM from the red box within the medication cart. She added there are certain residents that have order for the glucagon IM if they experience low blood sugars. The ADON acknowledged she was not aware of the nurse giving Resident #10 glucose gel until after the fact. They did educate Staff G on making sure the resident is able to swallow prior to administering oral glucose gel. The resident needs to be able to sit upright and swallow. The facility provided a document titled Hypoglycemic Management. It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode.Compliance Guidelines:3. Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner.5. If the blood glucose reading is 70 milligram per deciliter (mg/dL) or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered.

Based on record review, staff interviews and facility policy review, the facility filed to ensure proper documentation was completed after 1 of 3 residents (Resident #11) sustained a fall. The facility reported a census of 70 residents. Findings include:The quarterly Minimum Data Set (MDS) assessment with a reference date of 7/1/2026 documented Resident #11 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented Resident #11 had impairments to her bilateral lower extremities and utilized a wheelchair. Resident #11 required substantial/maximal assistance to go from a sitting to lying position and lying to sitting position. She was also dependent on staff to go from a sitting standing position, chair/bed transfer to chair transfer and a toilet transfer. The following diagnoses were listed for Resident #11: right tibia fracture, anemia, multiple sclerosis (MS), lack of coordination, repeated falls, weakness, reduced mobility, need for assistance with personal care and chronic pain syndrome. The Care Plan Focus Area with an initiated dated of 4/6/2026 documented Resident #11 was at risk for falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment and/or the use of medications that may increase falls risks related to diagnoses of right fibula and tibia fractures, pain, and MS. The Care Plan encouraged staff to following the facility's fall protocol related to falls i.e.: initiation of neurological assessments, fall report/investigation, immediate interventions and long term interventions. Record review on 7/7/2026 revealed the following Progress Notes:6/15/2026 at 6:31 AM an as needed (PRN) pain medication was administered,6/15/2026 at 8:41 AM the PRN pain medication was effective, 6/15/2026 at 3:18 PM a PRN pain medication was administered, 6/15/2026 at 3:20 PM daily skilled charting: skilled services provided with treatment by a licensed therapist at last 5 days/week. There are no complaints of pain/signs of non-verbal pain. Musculoskeletal Status: fractured right ankle, cast present, weight bearing as tolerated. Remains on skilled level of care for right ankle fracture, 6/15/2026 at 4:38 PM a PRN pain medication was effective,6/15/2026 at 11:20 PM a PRN pain medication as administered,6/16/2026 at 3:06 AM resident complains of pain on her left leg, that felt stabbing and radiating from toe proximal to dorsal. Resident complained that pain is from impact of earlier incident in her room with Physical Therapist, that led to her leg getting bent over. Resident #10 had a PRN pain medication at 11:00 PM and by 1:00 AM she indicated the pain was unbearable, on call provider was called and explained the situation. Provider suggested the resident to sent to the emergency room (ER),6/16/2026 at 4:28 AM PRN pain medication was effective, 6/16/2026 at 7:16 AM PRN pain medication was administered, 6/16/2026 at 8:35 AM PRN pain medication was effective, 6/16/2026 at 10:01 AM resident is skilled for fracture to right ankle,6/16/2026 at 10:30 AM resident left the facility to go to urgent care,6/16/2026 at 2:23 PM resident left the facility for a MRI,6/16/2026 at 7:00 PM Late Entry: Occupational Therapist (OT) came and got nurse. Resident lowered to ground after standing with therapy and getting tired. Could not slide over to the bed, resident was transferred to bed with a mechanical lift. There lacked a Progress Note when the fall took place on 6/15/2026 from the nurse on duty. Record review of the Assessment tab revealed the only fall follow-up assessment was completed on 6/17/2026. The tab lacked an initial assessment charted from a fall that took place on 6/15/2026.On 7/9/2026 at 3:51 PM Staff H Registered Nurse (RN) stated on the day Resident #10 fell she was working with the OT when she had to lower her to the floor because she could not complete the transfer. Once he assessed Resident #10, it took three staff and a mechanical lift to get her off the floor and to her bed. While he completed his assessment on the resident, she did not complain of pain until early morning hours. When asked why this fall or assessment was not charted, he stated he called the Director of Nursing (DON) to notify her but she told him it was not a fall. He asked what he needed to document and the DON told him he did not need to because it was not a fall. Staff H stated usually they would fill out a fall form but since she was assisted to the floor he did not do one. On 7/14/2026 at 10:25 AM the Assistant Director of Nursing (ADON) stated if a resident is lowered to the floor, it is still considered a fall. When asked what kind of assessment should be done if a resident is lowered to the floor, she stated a risk assessment. This explains what happened, any injuries at that time, fall risk assessment and who was notified. When the ADON was told there was no progress note documented by Staff H in reference to the incident, she stated they were not told until later that she was lowered to the floor. She acknowledged Staff H should have completed a note. The facility provided a document titled Fall Prevention Program. The policy indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy defined a fall as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if they had not caught themselves or had not been intercepted by another person - this is still considered a fall. If there is a loss of balance during supervised therapeutic interventions and the resident comes to rest on the ground, floor, or next lower surface despite the clinician's effort to intercept the loss of balance, it is considered a fall.Policy Explanation and Compliance Guidelines:9. When any resident experiences a fall, the facility will:a. Assess the resident.b. Complete a post-fall assessment.c. Complete an incident report.d. Notify physician and family.e. Review the resident's care plan and update as indicated.f. Document all assessments and actions.g. Obtain witness statements in the case of injury.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling foods that were open with open dates. The facility reported a census of 71 residents.Findings include:During continuous observation on 4/6/26 from 10:20 AM to 10:40AM during the initial kitchen tour revealed:a. Four large plastic cereal containers with no open dates noted. b. A five gallon bucket of flour with no open date noted. c. Half eaten bowl of soup with spoon in bowl in the freezer of the fridge/freezer. Interview on 4/6/25 at 10:25 AM with Staff B dietary aide revealed that the half eaten bowl of soup with a spoon should not have been in the freezer. Interview on 4/7/26 at 10:20 AM with the Certified Dietary Manager (CDM) revealed that her expectations would be for items to be labeled and dated when they are opened. The CDM further revealed that half eaten bowls of soup should never be in the freezer. Interview on 4/7/26 at 10:37 AM with the Administrator revealed that she would like to see items in the kitchen labeled and dated when they are opened. Review of a facility provided policy titled, Food Safety Requirements with a copyright date of 2025 indicated staff will label, date, and monitor refrigerated food, including, but not limited to leftovers, so it is used by its use-by date.

Based on observation, infection control policy, and staff interview, the facility failed to perform proper hand hygiene and failed to adhere to infection control guidelines during wound care for 1 of 2 residents observed (Resident #2). The facility reported a total census of 71 residents.Findings include:Observation on 4/8/26 at 9:57 AM, showed Staff F, Registered Nurse (RN), donned a gown and gloves, then placed a barrier on the wound cart. With gloved hands, Staff F accessed her pocket to retrieve the wound cart key, unlocked the cart, and obtained necessary supplies (solution, ointment, kerlix, gauze, and q-tips), placing them on the barrier. While gloved, Staff F manually contacted the kerlix and gauze as she removed them from their packaging, placing the removed items back onto the potentially contaminated barrier surface. Staff F subsequently removed and discarded the gloves but failed to perform hand hygiene before donning a new pair of gloves. Staff F then removed and discarded Resident #2's right toe dressings, removed the soiled gloves, and again failed to perform hand hygiene before donning a third pair of gloves. Upon completion of the wound care and dressing change, Staff F removed gloves, failed to perform hand hygiene, and placed supplies back into the wound cart before finally performing hand hygiene.The Clean Dressing Change policy dated 2025 summarized the facility's policy aimed to provide wound care in a manner that decreased the potential for infection and cross-contamination. Compliance guidelines emphasize strict protocols for hand hygiene, glove use, maintaining a sterile field, and managing multiple wounds.During an interview conducted on 4/8/26 at 10:39 AM with the Director of Nursing (DON), the Infection Preventionist (IP), and Staff F, the DON indicated that she had already addressed the dressing change procedure with Staff F, emphasizing proper handling of dressings to prevent contamination, appropriate glove change intervals, and the necessity of performing hand hygiene immediately before and after changing gloves. The IP reported she planned to conduct the same education with the entire nursing staff.

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal History Record Check Request SING form check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 71 residents.Findings include: Review of facility provided document titled Employee New Hire by Time Period dated 4/6/24 at 11:15 a.m., revealed Staff A, Certified Nursing Assistant (CNA) documented a hire date of 2/2/26. The personnel file for Staff A revealed documentation of a criminal background check through the Iowa Criminal History Record Check Request SING form completed 4/7/26 at 11:43 a.m The file lacked a background check prior to Staff A working in the facility. Review of facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy with an updated date of 7/8/24 revealed The facility will conduct a state specific criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under their state specific code (481 Iowa Administrative Code S 58.11(3). The facility will conduct a criminal record check and dependent adult/child abuse registry check on all current employees and other individuals engaged to provide services to residents who have criminal convictions or founded abuse determinations after hire, or where the facility received credible information that an employee has had a criminal conviction or a founded abuse determination after hire. See Iowa Code S 135C.33(7)). Interview on 04/07/26 at 2:37 p.m., with the Administrator revealed the background check should have been completed prior to Staff A starting.

Based on observations, record review, interviews, and policy reviews, the facility failed to include the necessary healthcare information within the baseline care plan regarding the presence and utilization of a Bilevel Positive Airway Pressure (BiPAP) machine to prevent decline or injury related to diagnoses of sleep apnea, lung disease, and obesity for 1 of 19 residents reviewed (Resident #46). The facility reported a census of 71 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #46 documented diagnoses of sleep apnea, lung disease and obesity. The MDS failed to indicate Resident #46 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.Observation on 4/6/2026 at 1:37 PM showed a BiPAP on Resident #46's bedside table. Later observations showed Resident #46 also used the BiPAP for naps.The Baseline Care Plan for Resident #46 failed to show the need or usage of the BiPAP machine.In an interview on 4/8/26 at 1:48 PM, the Director of Nursing (DON) reported no knowledge of Resident #46 having or using a BiPAP machine at the facility.In an interview on 4/8/26 at 3:08 PM, the Administrator reported the receptionist performed resident inventory and did not question the resident having a BiPAP machine. The Administrator reported the DON would contact the physician. In an interview on 4/9/26 at 8:59 AM, Resident #46 reported bringing the BiPAP to the facility when recently admitted .The Baseline Care plan policy dated 2025 identified the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.In an interview on 4/9/26 at 9:20 AM, the DON reported unawareness of the BiPAP. She confirmed the admission process required change to address BiPAP usage upon resident entry and affirmed that staff should have identified and addressed the machine.

Based on clinical document review, observation, staff interview, and policy review the facility failed to assist residents with activities of daily living by not assisting with fingernail trimming for 1 of 1 residents (Resident #8) reviewed. The facility reported a census of 71 residents. Findings include:Review of Resident #8's Minimum Data Set (MDS) dated [DATE] indicated Resident #8 required maximal assistance with personal hygiene. The MDS further indicated that Resident #8 had diagnoses of non-Alzheimer's dementia, and anxiety disorder.Review of Resident #8's Care Plan with a revision date of 2/19/26 indicated staff were to keep Resident #8's fingernails short. Observation on 4/6/26 at 2:32 PM revealed Resident #8's fingernails to be long at this time with debris under the nails. Interview on 4/7/26 at 12:10 PM with Staff C, Certified Nursing Assistant (CNA) revealed that the bath aid usually cuts residents fingernails, unless the resident is diabetic then the nurse is to trim the nails. Staff C then confirmed Resident #8's fingernails were long and had build up under them with old food at this time. Interview on 4/7/26 at 12:22 PM with Staff D, Registered Nurse (RN) confirmed that nurses trim fingernails of residents with diabetes, and the bath aid then trims the other residents fingernails. Staff D then confirmed Resident #8 is not a diabetic, and the bath aid would be responsible for nail trims. Interview on 4/7/26 at 12:51 PM with the Director of Nursing (DON) revealed that she would expect finger nails to be trimmed as this is a care issue. Review of a facility provided policy titled, Nail Care with a copyright date of 2025 indicated staff will complete routine nail care, to include trimming and filing, that will be provided on a regular schedule.

Based on clinical record review, observation, staff interview, and policy review the facility failed to provide proper transfer techniques while transferring a resident to prevent accidents for 1 of 3 residents (Resident #8) reviewed. The facility reported a census of 71 residents. Findings include:Review of Resident #8's Minimum Data Set (MDS) dated [DATE] indicated Resident #8 required moderate assistance with chair/bed-to-chair transfers, toileting transfers, and walking. The MDS further indicated Resident #8 utilized a walker for a mobility device. Review of Resident #8's Care Plan with a revision date of 2/19/26 indicated Resident #8 had a self-care deficit as evidenced by requiring assistance with activities of daily living, impaired balance during transitions and requiring assistance with walking. The Care Plan further listed an intervention of Resident #8 being transferred with assistance from one staff member. Observation on 4/7/26 at 12:05 PM Staff E Certified Nursing Assistant (CNA) was observed walking Resident #8 from the dining room table to the edge of the dining room without a gait belt. Staff E then left Resident #8 standing at the doors of the dining area, and went back to the dining area. Staff C CNA was then observed walking to Resident #8, and placing a gait belt onto Resident #8. Staff C then assisted Resident #8 to his bedroom. Interview on 4/7/26 at 12:10 PM with Staff C revealed that she walks Resident #8 with a gait belt every time Resident #8 needs assistance with transferring. Interview on 4/7/26 at 12:16 PM with Staff E revealed that she was unaware if Resident #8 was an assist with one staff and a gait belt for transfers. Staff E then revealed Resident #8 has walked by himself as long as she has worked here. Staff E then confirmed Resident #8 puts his walker out in front of him, and leans really far forward. Interview on 4/7/26 at 12:22 PM with Staff D Registered Nurse (RN) revealed that she did observe Staff E assist Resident #8 from the dining room table with his walker and no gait belt. Staff D then confirmed that Resident #8 is an assist with one staff member, and should have a gait belt when assisting with transfers. Interview on 4/7/26 at 12:51 PM with the Director of Nursing (DON) revealed she would have liked to have seen staff place a gait belt on Resident #8 as he is an assist with one staff member when transferring. Review of facility provided policy titled, Use of Gait Belt with a copyright date of 2025 indicated facility staff are to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.

Based on observations, record review, interviews and policy reviews, the facility failed to address the presence and usage of a Bilevel Positive Airway Pressure (BiPAP) machine. The facility failed to obtain a physician's order, failed to obtain proper machine settings, failed to establish or follow a routine cleaning schedule for 1 out of 19 residents reviewed (Resident # #46). The facility reported a census of 71 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #46 documented diagnoses of sleep apnea, obesity, and lung disease. The MDS failed to indicate Resident #46 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Observation on 4/6/2026 at 1:37 PM showed a BiPAP on Resident #46's bedside table. Later observations showed Resident #46 also used the BiPAP for naps. Review of Resident #46's Clinical Physician Orders failed to show orders, settings or a cleaning schedule for the BiPAP machine. In an interview on 4/8/26 at 1:48 PM, the Director of Nursing (DON) reported no knowledge of Resident #46 having or using a BiPAP machine at the facility. In an interview on 4/8/26 at 3:08 PM, the Administrator reported the receptionist performed resident inventory and did not question the resident having a BiPAP machine. The Administrator reported the DON would contact the physician. In an interview on 4/9/26 at 8:59 AM, Resident #46 reported bringing the BiPAP to the facility when recently admitted . The CPAP/BiPAP policy dated 2025 required staff to clean CPAP/BiPAP equipment following current CDC guidelines and manufacturer recommendations to prevent infection. Key compliance steps include:Daily/Per Use: Staff perform hand hygiene and wear gloves. They wipe the machine, clean the mask frame (using soap/water or wipes), and use distilled/sterile water to fill the humidifier chamber, which they must empty and wipe dry after each use.Weekly: Staff wash and air dry the headgear/straps and tubing with warm, soapy water.Maintenance: Staff follow manufacturer instructions for cleaning and replacing filters; only the supplier services the machine. Staff immediately replace equipment if it breaks or remains visibly soiled. Routine replacement requires: face mask and tubing every three months; headgear, non-disposable filters, and humidifier chamber every six months; and disposable filters twice monthly. In an interview on 4/9/26 at 9:20 AM, the DON reported unawareness of the BiPAP. She confirmed the admission process required change to address BiPAP usage upon resident entry and affirmed that staff should have identified and addressed the machine. The DON also confirmed the facility obtained a physician's order for the BiPAP and was actively working to secure the proper settings. When inspectors inquired about a cleaning or supply ordering schedule, the DON stated they would add these steps to the process.

Based on interviews with staff and doctors, chart review and policy review, the facility failed to transcribe accurate medication orders for 1 of 3 residents reviewed. Resident #5 required decarboxylase inhibitor medications for treatment of Parkinson's Disease. After a clinic visit with the neurologist, the staff failed to clarify dramatic order changes. After 12 days of the resident getting the wrong dose, the correct order was received and administered. The facility reported a census of 66 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) The resident required supervision with dressing, toileting, transfers and walking. His diagnoses included; progressive neurological condition, anemia, diabetes mellitus, Parkinson's Disease, adult failure to thrive, and gastrointestinal hemorrhage. The Care Plan, updated on 5/8/25, showed that Resident #5 had communication problems related to Parkinson's and he spoke English and Vietnamese. Resident #5 had muscle weakness, decreased range of motion, involuntary muscle movements, difficulty speaking and restlessness. Resident #5 had a Duopa pump (used to deliver Parkinson's' medications directly to the jejunum of the intestine.) The Duopa pump was not in use and the resident wanted to keep the j-tube (tube in jejunum) in case he needed to go back to using it later. Staff were to administer flushes to the Duopa pump and medications as ordered. Resident #5 was at risk for adverse side effects from anti-depressant medication to aid with the treatment of depression. Staff were to monitor for change in behavior, hallucinations/delusions or suicidal thoughts. Resident #5 had chronic pain, and was at increased risk for injury from decreased function. The Orders tab in the electronic chart showed an a. On 5/8/25 at 8:00 AM, Carbidopa-Levodopa (CD/LD or Sinemet) Extended Release (CR) 25/100 milligrams (mg) give one tab five times a day. This order was discontinued on 8/7/25 at 2:22 PM.b. On 1/30/25 at 7:00 PM, CD/LD 25/100 mg give 2.5 tab five times a day (until cartridges come from his pump, then back to PRN)A Nursing Note dated 8/7/25 at 5:11 PM showed that Resident #5 went to a neurology appointment and returned with the following report: The History of Present Illness narrative indicated Resident #5 was last seen by neurology on 12/2024. He had been doing well on the Duopa, but due to facility requirements, he could no longer maintain the pump while he was there. Since he had been taken off the pump, they had to switch back to oral medication. Unsurprisingly, he had been feeling more ridged, having more spasms. He stated he was 100% worse compared to when being on Duopa. He was on Sinemet 25/100 2.5 tab and Sinemet ER 50/200 one tab at least 6-7 time a day. An Outpatient Medication list include in the report showed the following list: a. Sinemet 25/100 1 tab 4 times a dayb. Sinemet 25/100 take 2.5 tabs 5 times a day, as needed (PRN)The list lacked reference to the extended release that the resident had been taking at the facility. According to The Plan on the summary; Medication regimena. Sinemet 25/100 2.5 tabs 5 times a dayb. Sinemet CR (extended release) 50/200 one tab 5 times a dayThe Medication Changes of the summary showed that as of 8/7/25 at 12:03 PM there were no changes to the medications. The End of Visit medication listed in the summary did not include an extended release;a. CD/LD 25/100 one tab 4 times a day with end date of 8/7b. CD/LD 25/100 2.5 tab five times daily PRNAn order entered at the facility on 8/8/25 at 8:18 AM, included CD/LD 25-100 mg one tab four times a day (until cartridge comes from pump) AND give 2.5 tab ever 5 hours PRN. According to the Medication/Treatment Administration Record (MAR/TAR) From 8/8/25- 8/20/25, the PRN dose was used 31 times. During the same timeframe, Resident #5 did not get any extended release tabs. A Nursing Progress Note dated 8/7/25 at 5:11 PM, showed Resident #5 returned from appointment with change to the CD/LD, ER 25/100 changed to 4 times a day. The nurse called for verification and they indicated they would fax the doctor's dictation notes. A Fax was received and MAR updated. A Nursing Progress Note dated 8/18/25 at 3:01 PM, showed that they called to the neurologist to request more of the medication scheduled rather than having the PRN as bigger dose. Documentation of telephone messages at the neurologist office showed the Director of Nursing (DON) called on 8/18/25 at 3:01 PM, regarding the Sinemet 25/100 and that Resident #5 was getting 1-tab scheduled 4x a day and the PRN wasn't enough. The DON was hoping that he can get 2.5 tabs scheduled 4x day with 1-tab 5x a day PRN. The DON stated that the resident was super stiff with this order. A follow up telephone message dated 8/19/25 at 7:21 PM, from the neurologist to the nursing home said why is he getting 1 tab 4 times a day? He should be getting 2.5 tabs 5 times a day and Sinemet Extended Release 50/200 one tablet 5 times a day. On 10/28/25 at 8:05 AM, the Administrator acknowledged that the summary from the neurologist on 8/7/25 had conflicting information regarding medications. The narrative said one thing, and the initial medication list was different and the ending list. She said staff saw the entry that said no changes to the medications so it did seem contradictory. The Administrator said that the staff would not pay attention to the section of the summary titled Plan. The DON said she called back to clinic after the resident was using so much of the PRN and thought he should have an extended-release tablet. The DON said that they did not call back for clarification orders after the 8/7/25 visit. A facility policy titled; Medication Orders, (no date of implementation) showed that a written transfer order did not require further validation if it was signed and dated by the residents attending physician, unless the order was unclear or incomplete.

Based on interview, record and policy review the facility failed to request and implement physician's orders for monitoring and maintenance of a Gastrojejunostomy tube for 1 of 1 resident reviewed. Resident #5 had a Duapo pump installed in January, shortly thereafter the facility was unable to get the medication cartridges and the pump was not used for over 6 months. Staff failed to get clarification orders on how to maintain the tubing. The facility reported a census of 66 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) The resident required supervision with dressing, toileting, transfers and walking. His diagnoses included; progressive neurological condition, anemia, diabetes mellitus, Parkinson's Disease, adult failure to thrive, and gastrointestinal hemorrhage. The Care Plan, updated on 5/8/25, showed Resident #5 had communication problems related to Parkinson's and he spoke English and Vietnamese. The resident had muscle weakness, decreased range of motion, involuntary muscle movements, difficulty speaking and restlessness. Resident #5 had a Duopa pump (used to deliver Parkinson's' medications directly to the jejunum of the intestine.) The Duopa pump was not in use and the resident wanted to keep the j-tube (tube in jejunum) in case he needed to go back to using the pump. Staff were to administer flushes to the Duopa pump and medications as ordered. Resident #5 was at risk for adverse side effects from anti-depressant medication to aid with the treatment of depression. Staff were to monitor for change in behavior, hallucinations/delusions or suicidal thoughts. Resident #5 had chronic pain, and was at increased risk for injury from decreased function. A Nursing Note dated 1/14/25 at 7:57 AM, showed Resident #5 went out of the facility to get j-tube replaced. An Order dated 11/14/23 at 10:00 PM, showed that staff were to remove the cartridge from the Duopa pump and flush the line with tab water or saline one time a day. The documentation on the MAR/TAR showed that it was not completed, not available, or off. From 1/21/25- 6/25/25 the Nursing Notes and Medication Administration Record (MAR) showed that the Duopa pump was not being used because the medication cartridges were not available due to insurance challenges. On 6/25/25 at 4:35 AM, Resident #5 was found unresponsive. He had a large bloody stool prior to being transferred to the hospital. A Hospital Discharge Report dated 7/7/25, showed that during the hospital course, Resident #5 had acute blood loss and anemia. A Computed Tomography Angiography (CTA) of the abdomen and pelvis showed abdominal distention, severe constipation and the resident passed a large brown stool with a long thin narrow tube. Abdominal x-ray gastrostomy tube projected over the stomach. Gastrojejunostomy tube that was used for CD/LD cartridge placement. Discussed with the nursing home that the tube was no longer functioning and that it would need to be replaced outpatient if he needs to use it again. Proceeded to leave remaining part of tube intact to prevent access from closing. Instructions for use of the Duopa pump, provided to the facility nursing staff included: Evening procedure included a flush the longer straight green connector connect syringe to green connector. Fill a syringe with room temperature tab water and flush the tube, if flushing was difficult, call healthcare provider if unable or have difficulty flushing the tube. Flush the shorter angled connector, fill syringe with room temperature tap or drinking water, push to flush the tube. On 10/28/25 at 8:05 AM, the Assistant Director of Nursing (ADON) said the Primary Care Physician (PCP) was monitoring the tubing for the pump but she did not know how that was being monitoring or what orders she was giving for maintenance. On 10/28/25 at 4:00 PM, the PCP said that she did not know much about the Duopa pump and the tubing that was used or how it was to be maintained. She said it's not like a regular feeding tube and she didn't know if it needed regular flushing. She said that would be a question for the neurologist who prescribed it. She said that the company has trainers come out to teach the nursing home staff how to use it. On 10/30/25 at 9:40 AM, the nurse from the neurologist office said they do not manage the pump tubing after the resident was no longer getting medication administered through the Duopa. They gave orders for flushing related to administration of the medication but once he was no longer using the pump, that would have been the PCP responsibility to monitor or give orders for maintenance. No one from the facility called to get clarification on continued flushing or maintenance while not in use. On 10/30/25 at 8:40 AM, the Gastroenterologist (GI) doctor that had applied the G-j tube for Resident #5 in January said that the tubing for the Duopa was much narrower than a regular feeding tube and he wasn't sure how long it would stay functional. When informed that part of the tubing had passed through the resident's stool in June, the doctor said that he usually recommended that tubing be replace every 6 months. He said that it was possible that the tubing could have started to breakdown. The plastic can become corroded. He said that whoever was monitoring/managing the medications should have given orders for maintenance on the pump and tubing. On 10/30/25 at 9:15 AM, the Director of Nursing and Administrator acknowledged that none of the doctors had taken responsibility for orders or directions on maintenance for the Duopa pump tubing when it was not being used. According to the facility policy titled: Care and Treatment of Feeding Tubes Direction for staff on how to provide the following care would be provided: frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify. Direction for staff regarding the conditions and circumstances under which a tube was to be changed will be provided. When to replace and/or change a feeding tube (generally as ordered/scheduled by the physician when a long term feeding tube comes out unexpectedly, or when the tube was worn or clogged)

Based on observation, interview and record review the facility failed to ensure that resident received dignified and respectful care for 4 of 10 reviewed (Residents #3, #7, #9 and #10). Upon entry to the facility on 8/14/25 it was discovered that 3 residents had urinary catheter bags that did not have privacy bags and were within full view of others. On 8/20/25, Resident #9 expressed that a staff member treated her in a demeaning manner when she raised her voice and got in my face. The facility reported a census of 63 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability) She required total staff assistance with dressing, toileting, hygiene, and transfers. She had an indwelling urinary catheter and was always incontinent of bowel. Her diagnoses included anemia, coronary artery disease, heart failure, hypertension, peripheral vascular disease, renal insufficiency, neurogenic bladder, diabetes mellitus, and chronic respiratory failure.The Care Plan for Resident #7, updated on 2/19/25, showed the resident had a supra-pubic catheter due to neurogenic dysfunction of the bladder, staff were to change the catheter as ordered and to provide catheter care as per facility policy.On 8/14/25 at 12:50 PM, the door to the room on Resident #7 was open and she sleeping in a recliner. She had a catheter bag at the bottom of the chair that was over half full of urine.2) According to the MDS dated [DATE], Resident #10 had a BIMS score of 13 (moderate cognitive deficit.) She was totally dependent on staff for dressing, hygiene, toileting and transfers. She had an indwelling catheter and her diagnoses included: neurogenic bladder, dementia, anxiety disorder, schizophrenia, and respiratory failure.The Care Plan for Resident #10 last updated on 6/3/25, showed that the resident was on hospice services due to terminal condition. Staff were to administer medications as ordered, indwelling catheter, provide catheter care per policy. She had the potential for impaired skin integrity, administer treatments as ordered and monitor for effectiveness. On 8/14/25 at 1:20 PM, the door to the room of Resident #10 was open. The resident was sleeping in bed and a urinary catheter bag hung from the bed frame. There was no privacy bag over the container.3) The Care Plan for Resident #3 updated on 5/17/25, showed that he had an indwelling catheter due to diagnosis of neuromuscular dysfunction of the bladder. Staff were to change the catheter as ordered, and to use a catheter strap, assure that enough slack was left in the catheter between the meatus and the strap. On 8/14/25 at 3:30 PM, Resident #3 was in his room in the recliner. The urinary catheter was hooked to the recliner with no privacy bag and it was over half full of urine.4) The MDS for Resident #9, dated 7/21/25, showed she had a BIMS score of 13 (moderate cognitive deficits.) She required partial assistance with hygiene, dressing, sit to stand and toilet transfers. Her diagnoses included; coronary artery disease, heart failure, dementia, seizure disorder and anxiety disorder.The Care Plan updated on 4/24/25, showed that Resident #9 had post traumatic event of physical assault, and domestic violence. Staff were to encourage her to talk about the event at her own pace, refer to social services as needed. She had the potential for impaired skin integrity and was at risk for edema, swelling and pain. Staff were to administer treatments as ordered.On 8/20/25 at 2:18 PM, Resident #9 was sitting in her room in her wheel chair watching a video. When asked if she had ever been treated disrespectfully by any of the staff she said that earlier that day, Staff A, Certified Nurse Aide (CNA) got in my face and talked down to me. she felt like Staff A was talking down to her and didn't treat her respectfully.On 8/20/25 at 3:09 PM, the Director of Nursing (DON) said that Resident #9 told her about the interaction with Staff A. She said that the staff member had gotten frustrated, but Staff A didn't think her tone was rude to the resident. DON said she was given coaching she will get me a copy.On 8/21/25 at 8:34 AM, Staff B, Certified Medication Aide (CMA) said that all catheters should have a privacy bag even when the residents are in their rooms.According to a Corrective Action note dated 8/20/25, Staff B was instructed to step away from the residents when frustrated, and to be mindful of her tone of voice when speaking to the residents. According to the facility policy titled: Dignity, revised on February 2021, staff promote maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standard of care that compromise dignity were prohibited. Staff were expected to promote dignity and respect and help the residents to keep urinary catheter bags covered.

Based on observation, interview and record review the facility failed to follow physician's orders for 4 of 10 residents reviewed (Res #7, #2, #9 and #10.) Resident #7 required close monitoring related to fluid overload and frequent Urinary Tract Infections (UTI) due to catheter use. Staff failed to notify the physician with extreme weight gain, and failed to change the catheter as ordered. Residents #7, #2, #9 and #10 had treatment orders that were not completed in the months of July and August with no corresponding explanation in the chart. The facility reported a census of 63 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability) She required total staff assistance with dressing, toileting, hygiene, and transfers. She had an indwelling urinary catheter and was always incontinent of bowel. He diagnoses included anemia, coronary artery disease, heart failure, hypertension, peripheral vascular disease, renal insufficiency, neurogenic bladder, diabetes mellitus, and chronic respiratory failure. A review of the MAR/TAR for July and August revealed the following treatments lacked documentation that they had been completed: a. Order dated 4/7/25 at 7:00 PM, Remedy cream to skin on bilateral stumps twice a day (BID.) Completed one time on the 8th and 13th and not at all on the 12th of July. Not completed on August 2nd 3rd and 10th.b. Order dated 5/1/25 at 7:00 PM NY-stop external powder, apply to abdominal folds two time a day for dermatitis. Completed one time on 8th and 13th and not at all on the 12th of July. Not done on August 2nd 3rd and 10th.c. Order dated 7/10/25 at 6:00 AM, cleanse dry and powder abdominal and groin folds and place dry gauze on open areas to abdominal and groin folds daily. Not completed on July 12th or 13th.d. Order dated 7/21/25 at 7:00 PM, bilateral thighs cleanse linear marks on gluteal folds/inner thighs with soap and water, pat dry, apply triad cream every 12 hours. Not completed on August 2nd 3rd and 10th.e. Order dated 7/22/25 at 6:00 AM, right thigh; cleanse wound in right proximal inner thigh near groin with saline, pat dry apply a piece of borderless Mepilex dressing change daily. Not completed on July 27th, August 2nd, 3rd, 9th and 10th.f. Order dated 6/30/25 at 3:00 PM, cleanse SP (supra-pubic) site with wound cleanser, pat dry and apply split 4x4 gauze. Not completed on July 12 or 13th, August 2nd 3rd and 10th2) According to the MDS dated [DATE], Resident #2 had a BIMS score of 7 (moderate cognitive deficit) She used a walker and a wheel chair, and required substantial assistance with dressing, hygiene, sit to standing, toileting and transfers. Her diagnoses included: anemia, deep venous thrombosis, hypertension, diabetes mellitus, thyroid disorder and fibromyalgia.The Care Plan for Resident #2, updated on 4/8/25, showed that she had diabetes mellitus and was at risk for infections due to renal failure. She had a diagnosis of hypertension and was at increased risk for chest pain, difficulty breathing and irregular heart rate. Staff were to administer medications as ordered, monitor blood pressure per physician order/facility protocol. She had chronic pain and was at increased risk for injury from decreased function diagnosis of fibromyalgia,The April MAR/TAR for Resident #2 showed an order for metoprolol 25 milligrams (mg) give 0.5 tablet two times a day, hold if systolic blood pressure (BP) was less than 110 and heart rate was less than 60 beats per minute. The medication was given twice on the 4th, 6th and 7th, once on the 8th, twice on 9th and once on 10th without documented blood pressure or heart rates.The April MAR/TAR showed an order for midodrine 5 mg. three times a day. Hold for systolic BP greater than 100. The medication was given twice on the 4th, 3 times on the 6th, once on 8th, and twice on the 9th without documented corresponding blood pressures.3) The MDS for Resident #9, dated 7/21/25, showed she had a BIMS score of 13 (moderate cognitive deficits.) She required partial assistance with hygiene, dressing, sit to stand and toilet transfers. Her diagnoses included; coronary artery disease, heart failure, dementia, seizure disorder and anxiety disorder.The Care Plan updated on 4/24/25, showed that Resident #9 had the potential for impaired skin integrity and was at risk for edema, swelling and pain. Staff were to administer treatments as ordered. The August MAR/TAR for Resident #9 showed the following orders and missed treatments:Order dated 6/27/24 at 7:30 AM, methol-zinc oxide ointment apply to gluteal crease one time day for skin care. The treatment was not completed on the 3rd, 16th and 17thOrder dated 6/24/24 at 7:30 AM, [NAME] hose apply in the morning and elevate legs when resting. Not done on 3rd, 16th or 17th.Order dated 3/24/25 at 7:00 PM, Biofeeze gel apply to back and knee twice a day. Not done on 3rd, 16 or 17th.4) According to the MDS dated [DATE], Resident #10 had a BIMS score of 13 (moderate cognitive deficit.) She was totally dependent on staff for dressing, hygiene, toileting and transfers. She had an indwelling catheter and her diagnoses included: neurogenic bladder, dementia, anxiety disorder, schizophrenia, and respiratory failure.The Care Plan for Resident #10 last updated on 6/3/25, showed that the resident was on hospice services due to terminal condition. Staff were to administer medications as ordered, indwelling catheter, provide catheter care per policy. She had the potential for impaired skin integrity, administer treatments as ordered and monitor for effectiveness. The August MAR/TAR for Resident #10 showed the following orders and missed treatments:Order dated 7/19/25 at 7:00 AM, apply Steri-strip to skin tear on left forearm twice a day. The treatment was only done once a day on the 3rd, 10th, 16th and 17thOrder dated 2/26/25 at 7:30 AM, apply lotion to areas affected by incontinence daily. Not completed on 3rd, 16th and 17th.Order dated 6/3/25 at 7:30 AM, apply lotion to dry areas on both feet daily. Not completed on 3rd, 16th or 17th.On 8/21/25 at 9:20 AM, Staff C. Licensed Practical Nurse (LPN) demonstrated that many options the nurses had in the electronic chart, to indicated the reason if/when a treatment or medication was not given. The choices then transferred over into the nursing notes. She said that with those options, the space on the MAR/TAR should never be left blank with no explanation.8/21/25 at 10:40 AM the Director of Nursing (DON) said that they had a new nurse that she suspected did not understand the documentation of treatments. She had a charge nurse that was responsible for supervising the new staff member and she would be providing some education to the nurses.A facility policy titled: Medication and Treatment Orders, dated July 2016, showed that orders for medications and treatments would be consistent with principles of safe and effective order writing.A facility policy titled: Indwelling Catheter Insertion, Female Resident; Preparation, Review the residents record and verify physicians order for the procedure.

Based on observations,resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 66 residents. Finding Include: 1. Observation on 4/02/25 at 11:55 a.m., test tray was temped after the last resident on level 1 was served and temperatures were as follows: a. Ham- 103.3 degrees b. Mashed potatoes- 124.8 degrees c. Carrots- 107.1 degrees 2. Observation on 4/02/25 at 12:05 p.m., level 2 room trays were sitting on the kitchen carts ready to pass. Staff A, Certified Nursing Assistant (CNA) began passing meal trays. Staff A verified she was taking meal tray into Resident #59's room. Stopped CNA and had staff check the temperature of the food. The temperatures were as follows: a. Ham- 97 degrees b. Mashed potatoes- 131 degrees c. Carrots- 96 degrees. Kitchen staff removed the tray and returned to the kitchen with the tray to reheat the food to the proper temperature. Interview on 4/02/25 at 12:27 p.m., with the Administrator revealed she expected the food to be served at the safe and proper temperatures. 48004 3. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. During interview on 3/31/25 at 11:04 AM Resident #12 stated the food is disgusting. Resident #12 further revealed the food is cold when it should be hot. 4. Review of Resident #39's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 3/31/25 at 1:05 PM with Resident #39 revealed the food is often cold, and it should be hot. 5. Review of Resident #43's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 3/31/25 at 11:39 AM with Resident #43 revealed the food is often cold when it should be hot. 6. Review of Resident #51's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Interview on 3/31/25 at 11:24 AM with Resident #51 revealed that the food tastes terrible, and that it is cold often when it should be hot. Review of an undated facility provided policy titled, Food Temperatures revealed: a. Hot food temperatures must read no less than 140F when residents are served; cold food temperatures should be below 41F when served.

Based on clinical record review, resident grievances, resident interview, staff interview, and policy review the facility failed to ensure 3 of 3 residents ' personal property was protected from loss or theft (Resident #12, #39, #51) . The facility reported a census of 66 residents. Findings include: 1. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed an admitted [DATE] to the facility from a short term hospital stay. Interview on 3/31/25 at 11:02 AM with Resident #12 revealed she had missing clothing. Resident #12 further revealed she was missing shorts, and pants. Resident #12 stated she had told staff, but did not file a grievance. Review of facility provided inventory list with Resident #12's name and date of 2/27/25 revealed no shorts on the list and 10 pairs of pants. 2. Review of Resident #39's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed an admitted [DATE] into the facility. Interview on 3/31/25 at 1:01 PM with Resident #39 revealed that he has several items missing, and has turned it into the management here at the facility. Resident #39 stated he was missing a hawkeye shirt, socks, underwear, 7 pairs of pants, and an electric razor. Resident #39 then revealed that after 3 weeks of being here the facility finally decided to do an inventory sheet after his items were starting to go missing. Resident #39 revealed he wants his items replaced as he does not have the money to keep buying new stuff. Review of a facility provided inventory list dated 12/26/24 with Resident #39's name revealed Resident #39 had 4 t-shirts (No description), 3 pairs of socks were marked, 6 pairs of underwear, 5 pairs of pants, and 3 pairs of shorts. No electric razor was listed on the inventory sheet. Review of a facility provided grievance form dated 12/2024 revealed Resident #39 filed a grievance 12/13/24 for a missing electric razor as well as missing laundry on 12/30/24. 3. Review of Resident #51's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The MDS further revealed an admitted [DATE] into the facility. Interview on 3/31/25 at 11:23 AM with Resident #51 revealed that she is missing a couple bras. Resident #51 revealed that she has told staff and it has not been replaced. Resident #51 further revealed no grievance has been filed. Review of a facility provided inventory list for Resident #51 with a date of 2/6/24 revealed no bras were marked on the inventory list. Interview on 4/02/25 at 9:43 AM with Staff B Social Services revealed she will give an inventory sheet to new admits and 2nd shift usually helps with filling them out. Staff B then revealed she will ask residents and staff to complete the inventory sheets as soon as possible. Staff B stated the nurses are to update the inventory list in the file. Staff B stated if a resident states something is missing an investigation would be completed. Staff B proceeded that per the facility policy the facility does not replace lost or stolen items. Interview on 4/02/25 at 10:12 AM with the Administrator revealed her expectation would be for inventory lists to be updated, filled out correctly, detailed inventory upon admit, and updated as items come in. Review of a facility provided policy titled, Personal Property with a revision date of August 2022 revealed: a. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 6 residents (Resident #60) reviewed for PASRR requirements. The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 documented diagnoses psychotic disorder, aphasia and diabetes mellitus. The MDS included a Brief Interview for Mental Status (BIMS) score that was not completed. The MDS revealed diagnosis of psychotic disorder. Review of the active diagnosis list in the clinical record revealed the following diagnosis of delusional disorder. The Care Plan with revision date of 3/7/25 revealed the resident takes psychotropic medications. Review of the PASRR dated 3/29/24 revealed the resident had no mental health diagnosis. The clinical record lacked an updated PASRR to include the delusional disorders. Review of the facility provided policy Behavioral Assessment, Intervention and Monitoring revised March 2019 revealed new onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation. Interview on 4/2/25 at 10:52 a.m., with the Social Services Director revealed if a resident's diagnosis is not one the admission PASRR then she would have resubmitted the PASRR. The PASRR should have been resubmitted with the delusional disorder diagnosis listed.

Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch and failed to include enhanced barrier precautions for 3 out of 20 sampled residents reviewed for comprehensive care plans (Resident #39, #48 and #66). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnoses of depression, non-Alzheimer's Dementia and acute respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Fluoxetine (antidepressant medication) daily with a start date of 10/6/24 b. Olanzapine (antipsychotic medication) daily with a start date of 3/20/24 c. Morphine (narcotic medication) as needed with a start date of 3/18/25 Review of the Care Plan with a revision date of 3/14/25 lacked non pharmacological interventions for the antidepressant and antipsychotic medications. The care plan lacked information regarding the usage of narcotic pain medication as well as side effects to watch for with narcotic medication usage and non pharmacological interventions to use prior to medication usage. 2. The MDS assessment dated [DATE] for Resident #66 documented diagnoses of hypertension, hyperlipidemia and non-Alzheimer's dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Rexulti (antipsychotic medication) daily b. Alprazolam tablet (anti-anxiety medication)12 hours as needed Review of the Care Plan with a revision date of 3/15/25 lacked information on the usage of antipsychotic and anti-anxiety medication usage, side effects to watch for and non-pharmacological interventions to use prior to as needed medications. Interview on 4/02/25 at 10:33 a.m., with the Director of Nursing (DON) revealed the care plan should have had high risk medications and side effects on them. The DON further revealed the facility does not usally include narcotic medications on the care plan. 48004 3. Review of Resident #39's MDS dated [DATE] revealed an admitted to the facility of 11/29/24. Review of Resident #39's Electronic Healthcare Record (EHR) page titled Physicians Orders revealed an order for Capecitabine oral tablet 500mg give 4 tablets by mouth 2 times a day for chemotherapy related to malignant neoplasm of the rectum. Observation on 3/31/25 at 1:00 PM revealed a sign by Resident #39's door stating that Resident #39 was on contact and droplet precautions. Review of Resident #39's Care Plan with a revision date of 3/18/25 revealed no documentation of contact precautions, or droplet precautions. Interview on 4/02/25 at 8:53 AM with the Director of Nursing (DON) revealed she would expect care plans to include documentation of contact and droplet precautions. Review of a facility provided policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed: a. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change.

Based on clinical record review, observation, resident interview and staff interviews, the facility failed to prevent accidents and hazards by not properly using a motion detector to prevent a fall that caused the need for an emergency room (ER) visit, facial bruising, laceration to the forehead and the need for pain medication for 1 of 3 residents reviewed (Resident #3). The facility also failed to use adequate transfer techniques while using a mechanical lift for 2 of 3 residents observed (Resident #8 and #44). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of heart failure, respiratory failure and osteoarthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 02, which indicated severe cognitive impairment The MDS also showed Resident #3 dependent for toileting hygiene and baths.The resident also required substantial assistance for transfers. Observation on 3/31/25 at 12:20 PM showed Resident #3 with fading dark purple bruising to the right side of forehead, temple, check, jawline and neck. The Care Plan for Resident #3 identified the resident at risk of falling related to confusion, gait/balance problems, poor communication/comprehension and unaware of safety needs. On 3/8/25 the post fall intervention included a motion alarm initiated to sound a silent alarm when the resident tried to self transfer/walk without staff assistance. The Fall Risk assessment dated [DATE] for Resident #3 identified the resident to be a high fall risk. The Incident Report dated 3/17/25 at 9:15 AM for Resident #3 documented: When CNA entered the resident ' s room to answer the call light resident was lying face down on the floor mat in front of her chair with her face on the tile floor, and the resident was bleeding from her forehead, CNA yelled out for assistance stating that the resident had fallen and was bleeding. When this nurse entered the resident room, the resident was lying on her stomach on the floor mat and the resident was face down on the tile bleeding from her forehead. The call light was still clipped to the resident's shirt, she was wearing slippers on her feet, her motion sensor was turned on but not facing the resident, her arms were under her chest supporting her upper body and her legs were straight out. The Progress Note dated 3/17/25 at 7:33 PM for Resident #3 documented the following: When CNA entered the resident ' s room to answer the call light resident was lying face down on the floor mat in front of her chair with her face on the tile floor, and the resident was bleeding from her forehead, CNA yelled out for assistance stating that the resident had fallen and was bleeding. When this nurse entered the resident room, the resident was lying on her stomach on the floor mat and the resident was face down on the tile bleeding from her forehead. The call light was still clipped to the resident's shirt, she was wearing slippers on her feet, her motion sensor was turned on but not facing the resident, her arms were under her chest supporting her upper body and her legs were straight out. With the Certified Nursing Assistant (CNA) translation resident stated, I was trying to walk to the bathroom when I lost my balance and fell . Pressure applied to residents forehead to stop the bleeding while lying next to resident to keep her stable and trying to keep her from moving around in case of neck or back injury obtained, unable to get original set of vitals due to the position of the resident, the Assistant Director of Nursing (ADON) phoned 911 for ambulance and spoke the provider ' s Registered Nurse (RN) to get orders to send to ER for evaluation, order to transport obtained, message left for family to return telephone call to the facility as soon as possible, ambulance arrived at 9:45 PM and transported resident to the ER. ER phoned with a report. The resident received sutures and computed tomography (CT) scans while in ER and returned to the facility at 3:30 PM. The neurological assessment was performed upon return and multiple messages left for the family to call the facility. The emergency room notes dated 3/17/25 at 1:09 PM for Resident #3 documented: This is a [AGE] year old female who presents here today with complaints of fall. She has a past medical history of hypertension, hyperlipidemia diabetes, gastroesophageal reflux disease, depression and thyroid disease. History was provided by the patient. She was hypertensive, remaining vital signs were stable while in the ER. The physician exam was significant for a two centimeter laceration on the right side of forehead with surrounding abrasion. My differential diagnosis included fall, head injury, laceration, contusion, skull fracture and intracerebral hemorrhage. I therefore ordered a head CT. I independently interpreted the imaging which showed no acute findings. The Progress Note dated 3/17/2025 at 9:40 PM for Resident #3 identified a bandage present on the resident's face that remained intact. The resident complained of mild pain and a standing order initiated for Acetaminophen. The Progress Note dated 3/20/2025 at 5:33 AM identified Resident #3 given tylenol (Acetaminophen) for headache; relief provided. The March 2025 Medication Administration Record (MAR) revealed Resident #3 received Acetaminophen 650 milligrams as follows: March 17th at 7:31 PM, March 19th at 2:16 PM and March 20th at 1:30 AM and 4:08 PM. The Weekly Skin assessment dated [DATE] at 2:12 PM for Resident #3 identified scattered bruising to bilateral upper and lower extremities and the face. Staff inaccurately documented the laceration with sutures to the right side of the forehead as a surgical incision. The Weekly Skin assessment dated [DATE] at 3:53 PM for Resident #3 identified scattered bruising to bilateral upper and lower extremities and the face. Interview on 4/2/25 at 12:07 PM, Staff E, Licensed Practical Nurse (LPN) reported a CNA found Resident #3 on the floor. When Staff E entered the room she noted Resident #3 to be face down with her body on a floor mattress pad and face against the floor tile. Staff E reported she held a towel to the resident's forehead to control bleeding. Staff E reported to prevent further injury she kept the resident in the same position until emergency personnel could arrive. Staff E did not visualize the resident's facial injuries. Staff E recalled the resident to be wearing slippers, with the call light string clipped to clothing. Staff E reported the facility started using a silent motion alarm about two weeks prior to the fall. Staff E stated, the motion alarm was effective. It went off at the nurse's station when the resident moved. Everyone could hear it. Staff E reported no falls had occurred since initiating the motion alarm. Staff E stated, the alarm didn't go off when the resident fell When I checked the alarm it was not pointed at the resident. Staff E denied knowledge of how or why the motion alarm was moved. The Falls - Clinical Protocol dated 2021 indicated: Assessment and Recognition 1. The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about a history of falling. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 2. In addition, the nurse shall assess and document/report the following: Vital signs; Recent injury, especially fracture or head injury; Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.;Change in cognition or level of consciousness; Neurological status: Pain; Frequency and number of falls since last physician visit; Precipitating factors, details on how fall occurred; All current medications, especially those associated with dizziness or lethargy: and All active diagnoses. 3.The staff and practitioner will review each resident's risk factors for falling and document in the medical record. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and retum to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty ar is unsteady in performing this test, additional evaluation should occur. 4.The physician will identify medical conditions affecting fall risk (fur example, a revent stroke ar medications that cause dizziness or hypotension) and the risk for significant complications of falls (for crumple, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant).Falls often have medical causes; they une not just a nursing issue. 5.The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. 6.Falls should be categorized as: Those that occur while trying to rise from a sitting or lying to an upright position: Those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. a. Often, multiple factors contribute to a falling problem. 2. If the cause of a fall is unclear, or it a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or it [NAME] individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. 3. The staff and physician will continue to collect and evaluate in formation until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent fall and to address the risks of clinically significant consequences of falling.Examples of such interventions may include calcium and Vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could be make the resident dizzy or cause blood pressure to drop significantly on standing). 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, it the individual continues to try to get up and walk without waiting for assistance). Monitoring and Follow-Up 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved.Delayed complications such as late fractures and major bruising may occur hours or days after a fall. While signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls.Risks of serious adverse consequences can sometimes be minimixed even if falls cannot be prevented. 3. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has been resolved by addressing the underlying cause. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident falling ( instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 5. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes In an interview on 4/3/25 at 8:40 AM, the Administrator reviewed the Progress Notes and Care Plan then compared the dates with the purchase order of the motion alarm. The Administrator reported that she wanted to make certain staff did not document the use of the motion alarm as a fall intervention if the alarm was not yet available The Administrator confirmed the motion alarm to be present at the facility at the time of the fall. The Administrator stated, it would 've been a whole other problem if they were documenting an intervention they couldn't have been using. The Administrator acknowledged to prevent a fall the motion alarm needed to be pointed at the resident to alert staff of the resident's movement. 2. Observation on 4/2/25 at 8:38 AM revealed Staff C, CNA, and Staff D, CNA transferred Resident #8 from the wheelchair to the bed using a mechanical lift. When Staff C raised the resident out of the wheelchair using the mechanical lift, she failed to leave the wheels of the lift un-braked. When Staff C then lowered the resident into bed using the mechanical lift, she failed to leave the wheels of the lift un-braked. 3. Observation on 4/2/25 at 8:38 AM revealed Staff C, CNA, and Staff D, CNA transferred Resident #44 from the wheelchair to the bed using a mechanical lift. When Staff C raised the resident out of the wheelchair using the mechanical lift, she failed to leave the wheels of the lift un-braked. When Staff C then lowered the resident into bed using the mechanical lift, she failed to leave the wheels of the lift un-braked. The User Instruction Manual dated 2016 for the mechanical lift indicated the lift has two braked casters which can be applied for parking. When lifting, the casters should be left free and un-braked (the only exception is when lifting a patient from the floor). The lift will then be able to move to the center of gravity of the lift. If the brakes are applied it is the patient that will swing to the center of gravity and this may prove disconcerting and uncomfortable. The Lifting Machine, Using a Mechanical policy dated 2001 failed to follow the User Instruction Manual for the current mechanical lift regarding brake usage. In an interview on 4/3/25 at 8:48 AM, the Administrator reported she expected staff to follow the manufacturer ' s instructions for the mechanical lift for brake usage. After the Administrator reviewed the User Instruction Manual she reported staff should not have locked the brakes on the mechanical lift when raising a resident from the wheelchair or lowering a resident into bed.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #48 and #66). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnoses of depression, non-Alzheimer ' s Dementia and acute respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Fluoxetine (antidepressant medication) daily with a start date of 10/6/24 b. Olanzapine (antipsychotic medication) daily with a start date of 3/20/24 Review of the Care Plan with a revision date of 3/14/25 lacked non pharmacological interventions and targeted behaviors for the antidepressant and antipsychotic medications. 2. The MDS assessment dated [DATE] for Resident #66 documented diagnoses of hypertension, hyperlipidemia and non-Alzheimer ' s dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Rexulti (antipsychotic medication) daily b. Alprazolam tablet (anti-anxiety medication)12 hours as needed Review of the Care Plan with a revision date of 3/15/25 lacked information on the usage of antipsychotic and anti-anxiety medication usage, non-pharmacological interventions to use prior to as needed medications and targeted behaviors. Review of facility provided policy titled Psychotropic Medication Use dated July 2022 revealed non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Interview on 4/02/25 at 10:33 a.m., with the Director of Nursing revealed the care plan should have targeted behaviors and non-pharmacological interventions on the care plan and the Social Services Director adds the targeted behaviors to the care plan.

Based on observation, record review, the State Long-Term Care Ombudsman, resident, and staff interviews, the facility failed to provide sufficient oxygen supply for a 1 of 1 resident (Resident #16) during dining. Due to the lack of a sufficient oxygen supply, harm occurred to the resident when she became unresponsive and turned blue. The facility reported a census of 47 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of heart failure, atrial fibrillation, chronic obstructive pulmonary disease, cardiomyopathy, renal disease, diabetes mellitus, anxiety and depression. The MDS identified a Brief Interview for Mental Status (BIMS) of 10, indicating moderate cognitive impairment. The MDS indicated that she needed extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 3/13/23 at 3:25 PM, the Ombudsman reported that she witnessed on 1/26/23 Resident #16 in the dining room for dinner in a wheelchair using a portable oxygen tank. The Advocate said that Resident #16 became gray in color and unresponsive. She said the Certified Nursing Assistant (CNA), went to the hallway and called a nurse for help. The Ombudsman told a Certified Nursing Assistant (CNA) that she thought Resident #15 ran out of oxygen, and the CNA replied no, not yet. The Ombudsman explained that the staff wheeled Resident #16 back to her room and connected her to an oxygen concentrator. The Ombudsman reported that when she inquired who changed the oxygen tanks, the Director of Nursing replied the CNA's. Resident #16's February 2023's Medication Administration Record included an order dated 8/18/22 for continuous oxygen at 2-6 liters per nasal cannula (L/NC) or oxymask. May titrate (adjust) oxygen up to keep sats above 89% every two hours related to acute respiratory failure with hypoxia. On 3/13/23 at 3:50 PM, Staff A, Head Cook, stated she witnessed the incident with Resident #16. She explained that Resident #16 started to turn blue and she became afraid that she was going to die. She stated she kept telling Resident #16 to take deep breaths. Staff A said she hollered down the hall for the nurse to come and change the oxygen tank because the CNA's could not change them. She stated the nurse didn't change it either, but wheeled the resident back to her room. On 3/13/23 at 3:40 PM the Administrator and the Director of Nursing explained that the facility did not have an Incident Report made because they did not know that Resident #16 went unresponsive. The DON stated she spoke with the ombudsman regarding the incident and that she never said that the resident became unresponsive. The clinical record review on 3/13/23 at 3:30 PM lacked a progress note or any type of documentation in Resident #16's chart regarding the incident. On 3/14/23 at 8:15 AM, Staff E, CNA, stated that she witnessed Resident #16 at the dining room table turn bluish. Staff E explained that she told the hospitality aide to take her back to her room and hook her oxygen up to her concentrator. Staff E reported that only the nurses could change the oxygen tanks. She said she did not know if the oxygen tank had oxygen because at the time she passed room trays. She reported that she did not observe Resident #16 become unresponsive, just that she did not talk. On 3/14/23 at 8:20 AM Staff C, CNA, reported that she remembered a mild commotion in the area of the dining room where Resident #16 sat. She stated that she did not know exactly what happened, but added that she did not see a resident become unresponsive. On 3/14/23 at 8:23 AM Staff D, Licensed Practical Nurse (LPN), reported that she only witnessed staff pushing Resident #16 down the hallway from the dining room and that she appeared to be huffing. Staff D could not remember which staff member push Resident #16 to her room. On 3/14/23 at 7:19 PM Staff B, Cook, stated that everyone made it into a bigger deal than what it was. He reported that Resident #16 never became unresponsive. He claimed that Resident #16 was his mother and that he had custody of her. He explained that he would never let anything bad happen to her. Staff B acknowledged that Resident #16 had difficulty breathing but that she had lung disease and it was expected that she would have difficulty. He voiced that he did not know if the oxygen tank had oxygen or not because he observed from out of the kitchen serving window. On 3/16/23 at 9:30 AM the Administrator stated that she expected staff to check and make certain the resident had enough oxygen in her tank to last her throughout her meal.

Based on observation, record review, policy review, staff interview, and Advanced Registered Nurse interview, the facility failed to complete a thorough physical assessment for 2 of 3 residents reviewed (Resident #1 & #3). Resident #1 complained of constipation, experienced vomiting, and requested to be seen by the physician and be sent to the hospital. Resident #1 had emesis during the night of [DATE]-[DATE], and the facility failed to complete a thorough assessment or notify the physician until the resident transferred to the local hospital on [DATE] at 3:30 PM, after the resident complained of pain with distended abdomen and hypoactive bowel sounds. Resident #1 expired in the hospital after being there less than 10 hours. Resident #2 returned to the facility from a hospital stay on [DATE], with last reported bowel movement on [DATE]. The facility failed to complete a thorough physical assessment of Resident #3 until [DATE], when identified the resident had no documented bowel movement for 5 days, or notify the physician until [DATE]. The facility reported a census of 43 residents. The facility's non-compliance with one or more requirements of participation placed residents in the facility in immediate jeopardy, which began on [DATE]. On [DATE] at 5:45 PM the facility was notified of the IJ at F684 and given the IJ Template. Findings Include: 1. The Minimum Data Set (MDS) with a completion date of [DATE], for Resident #1, identified a Brief Interview of Mental Status (BIMS) score of 13 which indicated cognitively intact. The MDS reflected the resident able to make themselves understood and understand others. The MDS coded the resident being independent with transfers, and ambulation; and supervision with physical assist of one staff for toileting and personal hygiene. The MDS identified the resident occasionally incontinent of urine and always continent of bowel. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan with date initiated [DATE], identified a focus area for required assistance with ADL's (activities of daily living) related to activity intolerance, limited range of motion, and pain. Interventions included: preferred to sleep in recliner and independent with mobility ([DATE]), mobility independent with use of walker ([DATE]), independent with toileting ([DATE]), and independent with transfer ([DATE]). The Progress Notes for Resident #1 revealed: a. On [DATE] at 6:01 AM, health status note - the resident complained of nausea and constipation, and had large emesis of undigested food. The resident stated did not feel good. Temperature 98.7 degrees and milk of magnesia given. b. On [DATE] at 12:30 AM, health status note - the resident had 3 small emesis, offered [MEDICATION(S)] (anti-nausea medication) and refused. Assisted the resident to clean and change clothing. The resident requested her physician be notified about the emesis, assured the resident would notify the physician or make an appointment in the morning. c. On [DATE] at 3:30 PM, health status note - the resident bowel sounds remain hypoactive and abdomen distended after 2 suppositories, milk of magnesia, and 10 ounces of magnesium [MEDICATION(S)]. No fecal matter felt upon insertion of suppositories. The resident complained of nausea this shift, no emesis. The resident confused and orientated to person and place. The residents' Primary Care Provider (PCP) notified and the resident transferred to the emergency room (ER) per medical transport. Copy of code status and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . d. On [DATE] at 1:29 AM, health status note - the hospital intensive care nurse called to inform the facility staff the resident had passed away at 1:22 AM. The document titled POC (Point of Care) response history for bowel movements for Resident #1 dated [DATE], revealed: a. On [DATE] at 9:46 AM, medium BM. b. On [DATE] no BM documented. c. On [DATE] no BM documented. d. On [DATE] at 1:53 PM, medium BM. e. On [DATE] at 9:52 PM, medium BM. f. On [DATE] at 4:02 AM, small BM. g. On [DATE] no BM documented. The document titled POC response history for amount eaten for Resident #1 dated [DATE], revealed: a. On [DATE] at 9:50 AM & 1:33 AM ate ,d+[DATE]% and at 6:59 PM refused. b. On [DATE] at 12:50 PM ate ,d+[DATE]% documented twice and at 7:59 PM ate ,d+[DATE]%. c. On [DATE] at 9:16 AM ate ,d+[DATE]% and 1:49 PM ate ,d+[DATE]%. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. Tums (antacid) Chewable 500 milligrams (mg) 2 tablets by mouth every 4 hours as needed for heartburn related to gastroesophageal reflux, order date [DATE]. Administered on [DATE] at 11:20 PM, effective. b. Magnesium hydroxide suspension (milk of magnesia, [MEDICATION(S)]) 400mg/5 ml (milliliters) give 30 ml every 6 hours as needed for constipation, order date [DATE]. Administered on [DATE] at 9:30 AM, effective and [DATE] at 10:00 AM, in-effective. c. [MEDICATION(S)] tablets delayed release 5 mg 1 tablet by mouth every 6 hours as needed for constipation, order date [DATE]. Administered: [DATE] at 5:22 AM, effective; [DATE] at 6:30 AM, ineffective; and 12:48 PM, ineffective. d. Magnesium [MEDICATION(S)] 1.745gm/30ml, give 10 ounces by mouth as needed for constipation, order date [DATE]. Administered on [DATE], in-effective. The facility failed to complete a thorough physical assessment and notify the physician when Resident #1 complained of constipation, experienced vomiting, and requested to be seen by the physician and be sent to the hospital. Document titled Emergency Medical Service (EMS) Patient Care Report dated [DATE] at 3:49 PM, noted at scene at 3:49 PM and departed at 4:02 PM. Patient chief complaint abdominal, with duration one week. Exam at 3:49 PM: Abdomen - bowel sounds absent and rigid. Vital signs at 4:00 PM: blood pressure ,d+[DATE], heart rate 97, oxygen saturation 93% on 2 liters of oxygen, and respiratory rate 32 and rapid. Document titled Emergency Department Provider Notes, from the local hospital, dated [DATE] at 4:15 PM, noted according to the EMS the resident had complained of back pain and emesis. The resident rated pain 10 out of 10 in severity. Review of Systems: Gastrointestinal positive for constipation, nausea and vomiting. Physical Exam: Blood pressure ,d+[DATE] the resident alert & talking, uncomfortable appearing. X-ray Abdomen final result [DATE] at 6:52 PM: findings consistent with high-grade small bowel obstruction. Progress Notes: 4:25 PM, the resident found unresponsive, code blue called. Abdomen distended, possible small bowel obstruction with possible aspiration. 4:41 PM, resident code blue ended. 5:10 PM, heart rate now in the 80's and fluids administered. Document titled Consult, from the local hospital, dated [DATE] at 8:00 PM, noted while in the ER the resident had x-ray of the abdomen that demonstrated high-grade bowel obstruction. While awaiting results the resident had episode of unresponsiveness, code blue called. The resident received approximately 20 minutes of CPR (cardiopulmonary resuscitation). Document titled Nephrology Consult, from the local hospital, dated [DATE] at 10:56 PM, stated the resident had intractable vomiting in the ER and became unresponsive. Blood pressures were very low and abdomen distended. Document titled History & Physical, from the local hospital, dated [DATE] at 12:10 AM, noted impression: probable ischemic bowel secondary to a torsion. Plan: recommend comfort care. Document titled State of Iowa Certificate of Death dated [DATE], noted Immediate Cause of Death: ischemic bowel ,d+[DATE] high-grade small bowel obstruction. The facility document titled Clinical Change in Condition Management dated ,d+[DATE], stated the interdisciplinary team strives to identify and manage all resident's that are experiencing a change in condition. Daily observation and communication is important in changes in a resident that further require investigation. Daily observation includes but not limited to changes in: a. Participation in daily routine b. Physical assessment (cardiovascular, respiratory, mental status, neurological) c. Behavior d. Mobility e. Comfort level f. Response to medications Clinical care management includes routine assessment, evaluation, response to changes in clinical condition and communication with resident &/or family/responsible parties. Procedure: a. Assess resident clinical status when a change in condition is identified. This may include but not limited to: vital signs, lung sounds, pulse ox, mental/neurological status, bowel sounds, skin color/turgor/temperature, and pain. b. Review the resident medical record including but not limited to: primary diagnosis & medical history, lab work, medication changes, change in nutritional status, advanced directives, and allergies. c. Review the resident condition with an RN (Registered Nurse). d. Contact the physician and provide clinical data and information about the resident condition. Document notification and physician response in the resident medical record. Initiate any new physician orders. e. Document on the change in condition data collection tool. f. Follow additional evaluation and documentation requirements in the clinical program manual. g. Document resident condition and location on the 24 hour report. h. Verify that the family/responsible party had been notified. i. Review care plan goals and interventions, modify as directed. Update staff of any changes. j. Review resident at the next scheduled care management meeting as applicable. Document titled Clinical Change in Condition Management, Charting Aid/Change in Condition dated ,d+[DATE], stated: Procedure: a. Document all information on the Change in Condition Data Collection Tool unless otherwise indicated. b. Complete evaluation of the resident change in condition. Evaluation of conditions for Abdominal pain, discomfort, or distention may include; Physical: abdominal palpation, bowel sounds, quantity & description of vomit/diarrhea, hemocult if possible blood, and onset. Medical History: onset/duration/frequency/severity, diet type/changes/average intake, description & date of last BM's, and recent labs. c. Review information with an RN. d. Document notification of the physician, include name and time notified. e. Document notification of the resident and family/responsible party, include name and time notified. f. Refer to the Charting Aid/Unplanned Return to the Hospital. g. Document resident condition and location on the 24 hour report. Document titled Clinical Change in Condition Management, Charting Aid/Unplanned Return to Hospital dated ,d+[DATE], stated: when a resident experienced a change in condition that is unable to be treated at the facility, the resident will be transferred to the hospital. Nursing documentation reflects the resident clinical condition and preparations for transfer to the hospital. Procedure: a. Verify that documentation reflects a timeline of the following: resident clinical status prior to the change in condition, evaluation of the physical data & medical history, name of the physician notified, interventions implemented, resident response to interventions, and name of the family member/responsible party notified. b. Obtain physician order [MEDICAL RECORD OR PHYSICIAN ORDER] c. Complete a skin sweep prior to transfer. d. Complete a Transfer form. e. Document on the Change in Condition Data Collection Tool immediately prior to the transfer. f. Provide a copy of the following documents to the hospital: advance directives/code status, list of current medications, and transfer documents. During interview on [DATE] at 11:00 AM, the EMS, patient primary caregiver stated unit called to the facility on [DATE] at approximately 3:30 PM. The EMS stated received call out to the facility due to a resident with complaints of back and abdominal pain. The EMT stated they were stopped at the door of the facility and informed they were unable to enter the facility. The EMT stated he observed Resident #1 propelling self in wheelchair with her feet towards the nurses' station, pale, no oxygen on, and struggling to breath. The EMT stated he observed brown spots on the hospital gown of Resident #1 and initially thought chocolate, however, later found out stool matter. The EMT stated Resident #1 informed them no BM in 5 days, no urination for 3 days, vomiting for 5 days, and wore oxygen at 2 liters at all times. The EMT stated unaware if facility staff had notified the physician of the residents' condition. The EMT stated the resident did not have emesis in the ambulance in route to the hospital, had after arrived in the ER. The EMT stated Resident #1 abdomen rigid once in the ambulance and oxygen saturation 54%. During interview on [DATE] at 3:59 PM, Staff B Certified Nurse's Aide (CNA) stated only cared for Resident #1 on the day transferred to the hospital [DATE]. Staff B stated approximately half hour prior to the resident going to the hospital, answered call light. Staff B stated Resident #1 stated not feeling well, had emesis on hospital gown, and assisted the resident to change gown. Staff B stated Resident #1 had puffy abdomen. Staff B stated the resident informed her no urine output all day, and Staff B stated she informed the nurse Staff C. Staff B stated Staff C informed her that the resident had urinated, as she had toileted her. Staff B stated Staff C and the MDS Nurse went to Resident #1 room, unaware of what occurred, and then ambulance came for the resident. During interview on [DATE] at 4:05 PM, Staff C RN stated when arrived at work on [DATE] informed Resident #1 had trouble with having a BM and Staff D RN informed her had given the resident a suppository. Staff C stated followed up with Resident #1 and stated had BM and felt better. Staff C stated the resident denied any further complaints on [DATE]. Staff C stated on Monday [DATE], Resident #1 had emesis on the overnight shift, and the resident maybe had nausea &/or emesis on the day shift. Staff C stated had listened to the resident bowel sounds, sluggish and hypoactive. Staff C stated the resident requested a second suppository and gave at approximately 6:30 AM. Staff C stated the resident had order for suppository every 6 hours as needed, and gave a second one at 12:30 PM due to no results from the first one. Staff C stated gave Resident #1 milk of magnesia, magnesium [MEDICATION(S)] and when those medications did not work called medical transport for hospital transfer at approximately ,d+[DATE]:30 PM. Staff C stated Resident #1 had round, soft abdomen, bowel sounds sluggish, and no pain. Staff C stated Resident #1 self-transferred to the gurney, the resident was okay for me and alert and orientated when left the facility. Staff C stated did a complete assessment of Resident #1 at time of abdominal complaints in the morning, however, did not document until around 3:30 PM. Staff C stated assessed Resident #1 in room; lung sounds, heart rate, full set of vital signs. Staff C stated the vitals documented on paper flow sheet by the CNA's, however, obtained own vitals. Staff C stated had called the residents' PCP office a couple of times on [DATE] and informed by the receptionist the clinic was short staff and would return call to the facility when available. Staff C stated the Director of Nursing (DON) called the resident's PCP on personal cell phone that resident being transferred to the hospital. Staff C stated Resident #1 was in the hall when the EMT arrived, had been informed sending to the hospital and the resident wheeling self in wheelchair to the nurse's station. Staff C stated Resident #1 had [CONDITION(S)] and would breathe loud normally; stated attempted to explain to the EMT. Staff C stated the resident a noisy breather per normal. Staff C stated Resident #1 transferred due to no BM's, not respiratory. Staff C stated EMT's allowed into the facility, not stopped at the door. Staff C stated completed the medical transport sheet for Resident #1, why transporting, where to, and who is transporting. During interview on [DATE] at 4:45 PM, Staff D RN confirmed worked the night shift on [DATE]. Staff D stated Resident #1 complained of not feeling well, denied specific complaints. Staff D stated the resident stated unaware of last BM, noted the resident had a large BM the day prior, however, had complained of constipation. Staff D stated gave the resident milk of magnesia per request. Staff D stated Resident #1 had emesis of undigested food, not dark or coffee grounds appearance. Staff D stated checked on the resident throughout the night and reported felt better, and the next morning reported felt better. Staff D stated 2 fell ow residents had emesis same night as Resident #1 and facility staff felt related to the supper eaten on [DATE]. Staff D stated listened to bowel sounds and had some, not real active, and stated not thinking bowel as the resident was not distended and had large BM documented. Staff D stated gave Resident #1 suppository on the morning on [DATE] and had given milk of magnesia the previous night, and the resident had reported feeling better. Staff D stated if Resident #1 did not feel better, would have informed the staff. During interview on [DATE] at 5:09 PM, the Assistant Director of Nursing (ADON) stated when a resident transferred to the hospital there are 2 forms the nurse is to complete in the residents' EHR (electronic health record) titled eInteract Change in Condition form and eInteract Transfer form . The ADON stated the Change in Condition form included information related to the situation/signs and symptoms, vital signs, and background information and the Transfer form contained the resident demographics, where transferring to, the resident contacts, clinical information, devices, treatments, risk alerts, and supplemental information. The ADON stated she expected both documents to be completed when a resident transferred to the hospital. The ADON stated no Physician faxes or Notes for Resident #1 related to physician notification from [DATE] until transfer to the hospital on [DATE]. The ADON stated had been in the room of Resident #1 during the day of [DATE] to review questionnaire for administration of the COVID vaccine booster. The ADON stated the resident complained of constipation and had notified the DON, who stated the resident had a suppository. The ADON stated unaware the resident had any vomiting. The ADON stated asked the resident if ill, and resident stated no just constipated. The ADON stated later in the day the DON had requested a stethoscope to assess the residents bowel sounds due to the resident complained of no BM in 5 days. The ADON stated the DON had reported the resident had a soft abdomen and hypoactive bowel sounds, and the DON requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated Resident #1 not in respiratory distress when in room. The ADON stated returned to Resident #1 room at approximately ,d+[DATE]:15 PM, to administer the COVID vaccine booster and after administration, the resident stated wanted to go to the hospital. The ADON stated the resident stated no BM in 5 days and had not urinated since the day before. The ADON stated the resident stated had been vomiting stool, however, clear liquid emesis observed in the basin. The ADON stated informed the nurse on duty Resident #1's abdomen was hard as rock. The ADON stated spoke with Staff C and had been informed the resident had suppository, magnesium [MEDICATION(S)] without results, and had been into the bathroom with assist from Staff C and urinated more than 30 ml. The ADON stated informed Staff C Resident #1's abdomen hard as a rock, to notify the physician and send the resident to the hospital. The ADON stated Resident #1 abdomen distended and very hard at that point, however, did not believe perforated bowel due to pain. The ADON stated had to leave the facility by 3:30 PM for an appointment and when called the DON to inform of the resident condition, the DON informed the ADON had assessed the resident 2 hours prior and abdomen soft and hypoactive bowel sounds. The ADON stated the DON had left the facility at approximately ,d+[DATE]:30 PM and had assessed Resident #1 prior to leaving. The ADON stated Resident #1 admitted to the hospital with bowel obstruction and died of perforated bowel. The ADON stated Resident #1 only wore oxygen at night while sleeping. During interview on [DATE] at 5:48 PM, Staff E RN confirmed worked when Resident #1 had 3 emesis during the night ,d+[DATE]-[DATE]. Staff E stated the CNA's had assisted the resident and did not observe the emesis. Staff E stated the resident offered [MEDICATION(S)] and refused, as stated felt better after the emesis. Staff E stated after Resident #1 had 3rd emesis, around 3 or 4:00 AM, the resident requested physician notification &/or appointment. Staff E confirmed no assessment completed at that time, had completed earlier in night and bowel sounds hypoactive. Staff E stated the resident had informed her around 7:00 PM, had a telehealth visit and the resident appeared okay. Staff E stated toward early morning the resident confused, however, over weekend was fluctuating up and down cognitively. Staff E stated the resident complained of nausea and wanted to make sure the physician aware. Staff E stated did not send a fax notification due to being the weekend and passed on the information to the day shift nurse. During interview on [DATE] at 6:05 PM, the ADON stated while in the resident room on [DATE], Resident #1 had no pain, not diaphoretic, and not using oxygen as only wore at night. The ADON stated Resident #1 not in respiratory distress at the time. During interview on [DATE] at 8:36 AM, Staff F CNA confirmed worked the day shift on Sunday [DATE]. Staff F stated Resident #1 had not eaten much for breakfast and had asked the resident, stated okay and denied complaints. Staff F stated same at lunch, the resident did not eat much. Staff F stated Resident #1 had not complained of constipation and unaware of vomiting. Interview on [DATE] at 8:41 AM, Staff G CNA confirmed had worked with Resident #1 on [DATE]. Staff G stated the resident had vomited when first arrived at work at 6:00 AM, green in color and gown dirty and assisted to change. Staff G stated around 12 noon Resident #1 had green colored emesis, stated did not feel well, and wanted to go to the hospital. Staff G stated informed the nurse on duty, Staff C RN. Staff G stated had informed Staff H CNA that Resident #1 did not feel well and had vomited, and sweating; as Staff G left shift for the day. Staff G stated Resident #1 had constipation, had stated the medicine not working. Staff G stated Resident #1 had not complained of shortness of breath and did not recall having oxygen on. During interview on [DATE] at 9:04 AM, Staff H CNA stated arrived for work at 2:00 AM on [DATE], however, had not assisted Resident #1 until 2:00 PM. Staff H stated informed the Resident #1 vomiting and being sent to the hospital, requested to assist the resident get ready. Staff H stated entered room and observed emesis on gown Resident #1 had on, assisted to change. Staff H stated the resident did not appear sweaty, overheated, or uncomfortable. Staff H stated Resident #1 wore oxygen at that time, however, did not appear short of breath or in respiratory distress. Staff H stated assisted the resident from recliner to wheelchair and left oxygen on. Staff H stated did not observe the resident after that encounter. Interview on [DATE] at 9:19 AM, Staff I CNA confirmed worked on the floor the afternoon of [DATE]. Staff I stated Resident #1 complained of not feeling well and frequently turned on call light, out of sorts and not acting like self. Staff I stated Resident #1 vomited a small amount, like spit up and green/brown in color. Staff I stated the resident did not complain of hurting, acted goofy. Staff I stated Resident #1 turned call light on multiple times and requested oxygen tubing that was in her recliner beside her; and then requested chair remote. Staff I stated Resident #1 did not complain of shortness of breath and did not observe shortness of breath. Interview on [DATE] at 9:34 AM, Staff J CNA confirmed worked overnight shift on [DATE] into the morning of [DATE]. Staff J stated Resident #1 had vomited 4 times during the night and informed the nurse, Staff E. Staff J stated Resident #1 voiced no complaints of shortness of breath or pain, however, did have oxygen on per usual. Staff J stated the resident had vomited on her gown, and when cleaned off the floor noted to be brown in color. Staff J stated emesis a thick brown liquid. Staff J stated informed the nurse after the first and third emesis, aware of the fourth emesis as well. Staff J stated informed the day shift CNA of the resident emesis during report the morning of [DATE]. Interview on [DATE] at 10:07 AM, Staff A RN stated had worked on [DATE], however, not with Resident #1. Staff A stated Staff C RN had requested Staff A give Resident #1 a suppository, due to the resident complained of no BM ,d+[DATE] days. Staff A stated administered the suppository, however, did not complete an assessment of the resident. Staff A stated the resident did not complain of pain at that time, stood up and suppository administered. Staff A stated Resident #1 had informed her she had been vomiting and Staff C stated already aware. Staff A stated informed by Staff C emesis brown in color. Staff A stated only administered the suppository and returned to her residents, unaware if Staff C had assessed the resident or called the physician. Staff A stated at 1:30 PM, Staff C had informed her the resident had vomited brown 3 times and I informed Staff C that was fecal matter and Staff C did nothing. Staff A stated Staff C proceeded to tell her that Resident #1 just wanted to go to the hospital, and I informed her to send the resident if that is what wanted. Staff A stated the DON and ADON got involved at one point, and sent to the hospital. Interview on [DATE] at 2:59 PM, Staff K CNA confirmed worked on [DATE]. Staff K stated when observed ambulance in parking lot went to Resident #1's room and already in wheelchair with oxygen on. Staff K stated the resident did not have a mask and returned to the nurse's station to obtain a mask for the resident. Staff K stated as returned to Resident #1 room, the resident had propelled herself halfway up the hall towards the nurse's station. Staff K stated Resident #1 not short of breath, however, any time visited with resident would think shortness of breath due to her history. Staff K stated unaware if Resident #1 abdomen hard or distended due to being heavy set. Staff K stated she propelled the resident in her wheelchair from halfway in the hall to the side of the nurse's station where the EMT's were. Staff K stated stopped by the scale at side of nurse's station for the nurse to check the resident's oxygen saturation and informed had just removed the oxygen. Staff K stated the EMT's stated not to worry about checking oxygen saturation, needed to go; due to the nurse unable to get reading. Staff K stated the EMT's assisted the resident to the gurney, the resident able to pivot transfer. Staff K stated at no time did Resident #1 complain of shortness of breath or abdominal pain. Staff K stated had taken the resident $10 around 2:00 PM, per her request; and the resident did report felt like vomiting. Staff K stated did not observe the resident vomit, however, provided with garbage can. Interview on [DATE] at 3:35 PM, the PCP, Advanced Registered Nurse Practitioner (ARNP) for Resident #1 confirmed the resident had a small bowel obstruction upon admission to the hospital on [DATE]. The ARNP stated obviously apparent with a small bowel obstruction you would want to see the resident sooner rather than later. The ARNP stated the outcome could have been different. The ARNP stated with a small bowel obstruction, the sooner the resident is seen the better, however, can't say in this case if it would or would not have made a difference in the outcome for Resident #1. The ARNP stated had not been notified by the facility that Resident #1 had vomited during the night on [DATE]. The ARNP stated the facility had not notified the clinic that Resident #1 had been vomiting on [DATE] or had any complaints. The ARNP stated first notified when the facility sent the resident to the hospital. The ARNP stated she had received notification from the facility on [DATE] regarding a possible drug reaction, however, nothing related to vomiting, constipation, or requesting physician visit. The ARNP stated the facility had her personal cell phone number and consistently called on a daily basis about fell ow residents. The ARNP stated did not understand where the missed communication occurred. The ARNP stated obviously sooner is better with bowel obstruction, and possible decompress prior to a rupture. The ARNP stated didn't know what the outcome could have been for Resident #1, stated where is the communication and assessments. Interview on [DATE] at 1:38 PM, the Director of Nursing (DON) stated expected the resident's PCP be notified if the resident request to be seen. The DON stated if the nurse on duty had notified the clinic, it should have been documented. Interview on [DATE] at 1:45 PM, the ADON stated the whole situation should have been handled differently. The ADON confirmed no fax notifications had been sent to Resident #1's PCP regarding complaints & request for visit on ,d+[DATE] or [DATE]. The ADON stated as mentioned before, the first time aware the resident requested to go to the hospital was when administered the COVID vaccine booster around ,d+[DATE]:15 PM on [DATE]. 2. The MDS with a completion date of [DATE], for Resident #3, identified a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected the resident was able to make themselves understood and understand others. The MDS coded the resident required supervision for bed mobility and set up assistance for toileting. The resident was coded independent with transfers and personal hygiene. The MDS identified the resident being continent of bowel and bladder, with constipation present. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coded the resident received opioids (prescription pain medication with common side effect of constipation) in the last 7 days. The Care Plan identified a focus area for constipation related to decreased activity tolerance and taking an opioid with date initiated [DATE]. The intervention dated [DATE] instructed the nursing staff to follow the facility bowel protocol for bowel management. The Care Plan identified a focus area of ADL (activities of daily living) self-performance deficit related to activity intolerance, confusion, impaired balance, and shortness of breath with date initiated [DATE]. On [DATE], identified cognition intake and balance within normal limits; and on [DATE] identified terminal diagnosis. The interventions included: independent bed mobility ([DATE]), assist as needed for dressing and preferred to wear a gown ([DATE]), independent personal hygiene ([DATE]), transfer to commode with assist of 2 staff for toileting ([DATE]), and assist of 2 staff for transfers ([DATE]). During observation on [DATE] at 1:55 PM, Resident #3 lying in bed with head of bed elevated, oxygen on per nasal cannula, and hospital gown. Resident #3 stated he had an upset stomach and bowels had not moved well. Resident #3 stated last time he had a BM, he was in the hospital. Resident #1 stated had an abdominal x-ray yesterday, a couple of suppositories, and drank little bottle of something. Resident #1 stated possibly had little BM's, however, stated did not eat well either. Resident #1 stated the nurse the day before yesterday, did not feel suppository necessary. Obs[TRUNCATED]

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure an intoxicated resident (#5) did not leave the facility without supervision and to an unknown destination of seven total residents reviewed. The facility reported a census of 59 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #5's [DIAGNOSES REDACTED]. The assessment documented she had a brief interview for mental status (BIMS) score of 15 out of 15, indicating intact memory and cognition. Resident #5 required supervision with transfers, walking and eating, and the assistance of one staff with dressing, toilet use and personal hygiene. The MDS documented that Resident #5 required daily insulin, antipsychotic, antidepressant and opioid medications. The 8/28/18 Care Plan showed a focus area of Resident #5's risk for falling related to gait/balance problems, a history of falls, psychoactive drug use, and [DIAGNOSES REDACTED]. The Care Plan also noted that Resident #5 had diabetes, her blood sugars should be checked and medications administered as ordered. An intervention revised on 11/30/18 instructed staff to report all changes in the resident's level of consciousness, sweating, shakiness or sweet smelling breath to the charge nurse. An intervention initiated on 9/26/18 instructed staff to notify Resident #5's family of changes in condition. The care plan did not address her alcohol and drug dependency issues. A Medical [DIAGNOSES REDACTED]. The (MONTH) 2013 revised Clinical Programs Manual related to Elopement Management instructed: The facility is to immediately initiate procedures to locate any resident suspected of elopement. Notification of appropriate parties will comply with state and federal regulations. Elopement is defined as when a resident leaves the premises or a safe area without authorization and/or necessary supervision. If a resident is identified as cognitively intact, capable of making independent decisions and identified as their own person, has physician authorization and leaves the facility without staff knowledge, the following procedural steps will be taken: Upon return to the facility, the resident will be re-educated on facility procedures of leaving. If the same resident continues to leave without staff knowledge, the interdisciplinary team and physician may individualize the search procedure to address resident patterns. The Procedure: 1. Form a search team. Verify that staff is available to stay with current residents. 2. Notify the supervisor immediately of any suspected elopement. The Supervisor notifies the Administrator and Director of Nursing (DON) if the resident is not immediately located. 3. Search all areas of the facility. 4. Search the facility's immediate grounds and continue to broaden the radius of the outdoor search. Note: Initiate an outdoor search with a second team while the internal search is still underway if there is health threatening weather or a nearby external hazard. 5. Interview staff, other residents and visitors. 6. Notify the family and/or responsible party. 7. Notify the resident's physician. 8. Notify law enforcement and the state agency. The (MONTH) 2013 revised Clinical Programs Manual related to Elopement Prevention instructed the following: Elopement is defined as when a resident leaves the premises or a safe area without authorization and/or necessary supervision. The Procedure: 1. Evaluate all residents on admission for risk of elopement: All new admissions that are at risk of elopement will have interventions to put into place immediately until further assessment is complete. Interventions include but are not limited to: a. Environmental modifications to prevent undetected exit (door alarms, wander alerts). b. Increased frequency of resident location rounds. c. Any resident that has a change in condition that places them at risk for elopement. d. Any resident with a history of elopement/wandering in a prior setting. 4. Place the Elopement Risk Alert form in the elopement risk identification notebook and maintain it in an easily accessible location. 5. Develop the Care Plan with input from the interdisciplinary team and the resident and family/responsible party. 6. Initiate individualized interventions to address risk of elopement. 7. Communicate individualized interventions to the caregiving staff, resident and/or family/responsible party. A Health Status Note dated 10/17/18 at 1:55 p.m. documented that a new prescription had been obtained to administer one [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5 mg/325 mg tablet every 4 to 6 hours as needed (PRN) to Resident #5. A Health Status Note dated 11/15/18 at 8:05 p.m. documented that after Resident #5 called her surgeon's office, he ordered Resident #5's [MEDICATION NAME] to be gradually tapered and ultimately discontinued. A Health Status Note dated 12/11/18 at 12:34 p.m. documented that Resident #5 left the facility to see if staff at an urgent care clinic would order different pain medication. At 3:38 p.m. Resident #5 returned from urgent care without new orders. A Health Status Note dated 12/12/18 at 1:08 p.m. documented that Resident #5 returned to the facility with a new order to discontinue any previous order for [MEDICATION NAME] and to administer [MEDICATION NAME] 5 mg/325 mg every 6 hours PRN for seven days and a recommendation for counseling. A Health Status Note dated 12/19/18 at 9:02 p.m. documented that Resident #5 felt unhappy when the nurse told her she could not administer the narcotic pain medication she requested because she did not have an order. Resident #5 called the Administrator to voice her concerns. A Health Status Note dated 12/20/18 at 9:48 a.m. documented an order to administer one [MEDICATION NAME] 5 mg/325 mg every 8 hours PRN until tablets that remained from a previous order were gone, at which time the order should be discontinued. A Health Status Note dated 12/22/18 at 6:14 p.m. documented that the facility called the on-call doctor in an effort to obtain an order for [REDACTED]. Health Status Notes dated 12/23/18 recorded that at 1:04 p.m., Resident #5 signed herself out saying she would return once she cashed a check; she left via taxi and returned to the facility at 1:24 p.m. At 2:57 p.m. Resident #5's roommate expressed concern because of the weird noises she heard Resident #5 making. Staff D, LPN (licensed practical nurse) documented Resident #5 told her to leave the room after she attempted to check her blood sugar. At 4:09 p.m. Staff D, entered Resident #5's room when she heard her calling out her children's names. Staff D noted Resident #5 acted differently and the resident permitted her to check her blood sugar. Staff D re-entered Resident #5's room to check her vital signs, at which time she saw Resident #5 finishing a 200 ml (milliliter) bottle of vodka. Staff D received authorization to administer Resident #5's medication from the on-call physician, recorded that Resident #5 is her own responsible party and that she reported the incident to the on-call nurse. A Health Status Note dated 12/23/18 at 9:04 p.m. documented that Staff F, LPN found Resident #5's wheelchair by the front door and could not find Resident #5 in the facility at 8:30 p.m. Staff F contacted Resident #5's daughter to see if she picked her mother up. Staff F also noted that Resident #5 had not signed out of the facility. Resident #5's daughter told her she had not seen her mother in a month. After further investigation, Staff F documented that another staff member overheard Resident #5 on the phone asking someone whether they were going to come and pick her up. Staff F recorded that another staff member said she saw Resident #5 leaving the facility with a woman (not a resident). When Staff F called again, Resident #5's daughter expressed concern that her mother may go out and get drunk and not return to the facility because she no longer received narcotic pain medication. Staff F wrote that she spoke to Resident #5 about 7:30 p.m., at which time she seemed alert and oriented, and that she notified the Assistant Director of Nursing (ADON). On 12/24/18 at 12:19 a.m. Staff F documented that Resident #5 had not returned to the facility and had not taken her medication prior to leaving. A Health Status Note dated 12/24/18 at 1:45 p.m. documented Resident #5 returned to the facility at 1:10 p.m. in a friend's personal vehicle. Resident #5 appeared to be intoxicated with stumbling, slurred speech, belligerence with staff and clothes soiled with urine and feces. When asked about her whereabouts, Resident #5 stated she had been everywhere. Resident #5 stumbled into her wheelchair, climbed into bed and started yelling she wanted to go to the hospital as she complained of having chest pain. After staff obtained the order, called the ambulance and notified her daughter, Resident #5 refused to go with the paramedics after they arrived at 1:15 p.m. The nurse notified Resident #5's daughter again and assured her they would monitor Resident #5 for any distress from detoxing from (not having) alcohol. Further assessment revealed that Resident #5 complained of severe lower back pain and of being very tired. Health Status Notes dated 12/26/18 at 6:03 p.m. documented Resident #5 said she wanted something different for anxiety at 4:15 p.m. Staff D wrote that she left a message with the resident's doctor and the physician's nurse called back saying the resident's request may not be addressed that day because of so few staff members in the clinic. Staff D informed Resident #5 they may not get a call until the next day. Resident #5 signed herself out at 5:20 p.m. and said she was leaving with a church friend. At 7:51 p.m., Staff B, LPN documented that Resident #5 had alcohol to drink and was currently in her room yelling and talking to people that were not there. Staff B recorded the resident's roommate expressed concern and asked if anything could be done for the resident. Staff B planned to call the on-call doctor about the resident's condition (however, interview with Staff B revealed she never called the doctor as planned). At 11:32 p.m., Staff B documented Resident #5 was still inebriated, threatened staff and called them vulgar names. Staff B wrote she found an empty bottle of vodka in the resident's garbage can. Health Status Notes dated 12/27/18 recorded that at 5:34 a.m. Resident #5 requested to take a walk outside of the building. The nurse explained that residents are not allowed to just go out for a walk. Resident #5 then re-approached her and requested to go to the hospital, but the resident refused assessment. When asked if she had an immediate need, Resident #5 told the nurse she was having an anxiety attack and in immediate need of care. The nurse initiated calls to obtain an order and to notify the on-call nurse, at which time Resident #5 yelled uncontrollably and demanded to be let out to walk to the hospital. The nurse called an emergency ambulance and it came and took Resident #5 to the hospital. The nurse notified the physician, the Administrator and the on-call nurse and documented Resident #5 as her own responsible party. A Health Status Note dated 12/27/18 at 5:55 a.m. documented hospital staff called to inform facility staff that Resident #5 refused their assistance and was going to leave the hospital and walk to her daughter's house. Resident #5 told hospital staff she would return to the facility by noon that day. Resident #5 eloped from the hospital at 5:50 a.m. The nurse also noted that Resident #5 was her own responsible person. A document dated 12/27/18 at 10:00 a.m. recorded an interview the DON (Director of Nursing) and Assistant DON conducted with Staff B before they ultimately terminated her related to a series of events that occurred during her 6:00 p.m. to 6:00 a.m. shift on 12/26/18. The events involved multiple residents, which included Resident #5. Staff B stated that she had no idea Resident #5 was intoxicated until the end of her shift. However; Staff B documented at 7:51 p.m. that the resident had alcohol to drink and yelled at people not in her room. The Staff B documented that the on-call would be notified, but failed to notify the physician. Staff B documented at 11:21 p.m. that Resident #5 refused medications and was still inebriated; still nobody was notified. When asked, Staff B stated she did not call because she did not feel as though it to be an emergent situation. When asked about conflicting information between what she said and what she documented, Staff B said she did not visually see Resident #5 drinking alcohol and did not see the bottle until morning. However; Staff B documented at 11:32 p.m. that an empty bottle of vodka was in the resident's trash can. Staff B did not give any additional explanation about the incident. An interview on 2/6/19 at 3:45 p.m. with Staff D revealed she knew Resident #5 had a history of [REDACTED]. Staff D said Resident #5 could sign herself out since she was responsible for herself, but she wanted to check to make sure in light of the circumstances. Staff D stated the on-call nurse told her to keep a close eye on Resident #5 once she returned from cashing her check. Staff D said that although Resident #5 returned, they did not think she would because she had not been getting [MEDICATION NAME] anymore. Facility staff wondered if Resident #5 left to find something as a substitute for [MEDICATION NAME], which she did. Resident #5 went to her room once she returned after cashing her check. Resident #5's roommate reported she heard Resident #5 making strange noises. Staff D then talked to the ADON and they felt the resident was on something. Resident #5 initially refused to let her check her blood sugar, but eventually agreed. Staff D went back into Resident #5's room to check her vital signs, at which time she saw the resident take the final chug from a bottle of vodka. Staff D said she suspected that Resident #5 obtained the vodka from a drive through liquor store down the road when she left to cash her check and the resident had a significant history of [MEDICAL CONDITION]. Resident #5 seemed to abstain from alcohol because she seemed content as long as she had access to [MEDICATION NAME]. The LPN said Resident #5 left AMA (against medical advice) last summer, wound up in the hospital after abusing substances and readmitted to the facility after hospitalization . Staff D said that although she was only involved in the 12/23/18 drinking incident, but she believed it happened more than once. On 2/11/19 at 11:15 a.m. Staff D stated she did not really know how big of a bottle she saw Resident #5 drinking, despite documenting 200 ml. Staff D said the resident was really drunk. During interview on 2/7/19 at 8:15 a.m. with Staff F stated that her shift started at 6:00 p.m. on 12/23/18. Staff F said that although she had not been assigned as Resident #5's Nurse, she would have assumed responsibility for her after 10:00 p.m. Staff F remembered seeing Resident #5 at about 7:30 p.m. and the resident did not seem to be intoxicated. Resident #5 might have come up and greeted Staff F. The LPN said she would have referred Resident #5 to her Nurse if she asked for medication. Staff F recalled someone identified an unoccupied wheelchair by the front door as Resident #5's. Staff F said they searched the building and could not locate her. Staff F said the nurse assigned to Resident #5 from 6:00 p.m. to 10:00 p.m. said she heard the resident on the phone asking someone to come and pick her up and someone else told her they saw Resident #5 leave with a woman who did not reside at the facility so they did not search outside. Staff F called the resident's daughter when they could not locate her, who did not know her mother left or where she might have gone, and the facility's on-call person, the ADON. Staff F said nobody told her Resident #5 had been seen intoxicated after finishing the last drink from a bottle of vodka that day. She remembered being told about an incident, but she did not recall it being that day. Staff F spoke with Resident #5's daughter throughout the night about locating her mother and she left it up to the ADON once she notified her. Another nurse had been assigned to Resident #5 at the time she left the building, but she did exactly what she would have done if she was assigned to her. Staff F said she did not know if the facility informed Resident #5's daughter her mother was intoxicated after finishing a bottle of vodka. Staff F said she did not know if they implemented frequent checks after they saw her drinking and would not have known until she assumed responsibility for her at 10:00 p.m. Staff F definitely would have called the physician and monitored Resident #5 very closely if she found Resident #5 chugging the last of a bottle of vodka. An interview on 2/7/19 at 9:15 a.m. with Staff I, LPN revealed that she assessed Resident #5 when she returned to the facility on [DATE] after being gone all night. Staff I stated Resident #5 was very intoxicated and covered in feces; the resident went to lie down. Resident #5 complained of chest pain so she obtained an order to send her to ER. Once the ambulance arrived, Resident #5 refused to go with them. Staff I said she did not know how Resident #5 got back to the facility, she only saw her walk in the door. Staff I stated she did not know Resident #5's history because she only worked at the facility for a short while. Staff I said Resident #5 had been upset recently because physicians refused to prescribe narcotics to her. As a result, Staff I said Resident #5 left and got drunk. An interview on 2/7/19 at 9:40 with Staff C, RN, when asked about her observations of Resident #5 on the evening of 12/23/18 as her nurse, she did not recall the specific events of the evening. An interview on 2/11/19 at 12:15 p.m. with Staff G, RN revealed that she came to work on 12/27/18 at 5:00 a.m. Staff G saw Resident #5 in the front foyer and she smelled alcohol on the resident. Resident #5 was very intoxicated, slurring her words and swearing at the nurse and a CNA, and the resident wanted to leave the building on foot. She said they kept telling her it would dangerous for her to leave because of being very cold outside. Staff G said Staff B had been assigned as the resident's nurse that night, but another nurse was dealing with Resident #5 when she arrived for work. Staff G stated another nurse obtained an order to send the Resident to ER. Staff G said she heard about Resident #5 being intoxicated after being caught with a bottle of vodka a few days before and that Resident #5 should not be able to leave the building without supervision if she is intoxicated. Staff G stated instead, staff should notify the doctor and the resident should be monitored at least every 15 minutes when she is intoxicated. Staff G believed Resident #5 tried to self-medicate after doctors refused to prescribe narcotics to her and knew she had a problem with [MEDICATION NAME]. During an interview on 2/11/19 at 1:05 p.m. with Staff B, she stated the facility fired her, partly because of an incident involving Resident #5 on 12/26/18. Staff B worked the 6:00 p.m. to 6:00 a.m. shift that day and Resident #5 apparently had a lot of behaviors that started on the previous shift. Staff B said Resident #5 told the nurse on the previous shift that she wanted something for anxiety. Staff B said Staff D told her they called the doctor and he refused to prescribe anything for Resident #5's anxiety, which caused the resident to get upset. Staff D told them the resident planned to go to church to take care of her anxiety in her own way. Although the alternative use of the term church was not familiar to Staff B, she said other staff members knew Resident #5 actually meant going to the liquor store rather than church. Staff D told her Resident #5 signed herself out and left the facility. After report, Staff B saw Resident #5 walking in the front door, offering it must have either been a short church service or she didn't go very far. Staff B remembered someone told her they were supposed to be checking on Resident #5 every 15 minutes, but she did not see Resident #5 again until medication pass sometime between 7:30 and 8:30 p.m. Staff B heard someone swearing. Resident #5's roommate approached her and said it was Resident #5 she heard. Staff B figured Resident #5 still felt upset about not getting something for anxiety. After giving the roommate her medication, Staff B entered Resident #5's room and saw her sitting in her chair with her eyes closed and her arms across her chest. Resident #5 did not answer her when she called her name or when asked if she wanted her medication, so Staff B left the room. Resident #5 had a history of [REDACTED]. Staff B sent a Certified Nursing Aid (CNA) into Resident #5's room later when she heard the Resident yelling again. Staff B said it seemed apparent that Resident #5 did not want to communicate with her because she had been in there more than one time and the resident kept her eyes closed and did not say anything. When Staff B saw a CNA carrying garbage out of Resident #5's room she saw an empty bottle of vodka, but did not know the size bottle (guessing it to be the size of her hand). The resident's roommate said Resident #5 talked to people that were not there and from outside the room, Staff B overheard what sounded like Resident #5 yelling and arguing with someone. Staff B said she tried to assess her but Resident #5 turned completely away from her and shut her eyes. Resident #5 said she just wanted to go to sleep when the nurse asked her what she needed. Staff B stated she did not smell alcohol on the resident, so she could not account for her behavior. Despite documenting that she would, Staff B said she never called the doctor. An interview on 2/12/19 at 11:40 a.m. with the ADON revealed that Staff D notified her about mid-morning on 12/23/18 that Resident #5 was going to cash a check and be right back. Staff D expressed concern about Resident #5 leaving and wondered if she should be allowed to go. According to the ADON, Resident #5 had a history of [REDACTED]. The ADON said she authorized Resident #5 to leave. The ADON said she received another call saying the resident returned safely about 10 or 15 minutes later and she then told Staff D to keep an eye on Resident #5 because of her history of [MEDICAL CONDITION] and leaving AMA. The ADON received a call from Staff F later that evening saying that Resident #5 left with a heavyset woman after a CNA opened the door for her. The ADON said the CNA reported that Resident #5 said she would be back later. The ADON told Staff F to let her know when she returned. The ADON said got a very late call saying Resident #5 had not returned yet, sometime after 10:00 p.m. The ADON told Staff F to call her as soon as the resident returned and she would call the Administrator to let her know. The ADON said she called the Administrator as soon as she got off the phone with Staff F. According to the ADON, the Administrator said they should keep reaching out to see if they could find her if Resident #5 left AMA. The ADON said nobody mentioned to her that Resident #5 left AMA. Therefore, the ADON said she did not know if the resident just went out for the night. The ADON said the nurse took the liberty of documenting that she spoke to the ADON about Resident #5 leaving AMA. According to the ADON, she believed she told the nurse to call the doctor for authorization to administer her medication since she had been drinking alcohol. The ADON said if she faced the same situation as Staff F, she would have monitored the resident frequently, assessed and re-assessed the resident if she knew she was intoxicated. The ADON said she did not personally observe Resident #5 to determine if she was intoxicated. Between the time staff saw Resident #5 drinking and the time they discovered her missing, the ADON said it would be hard to say that enough time lapsed for her to be sober enough to leave the facility safely. And it's a fine line because she had been told staff can't stop anyone from leaving. The ADON said if she knew the resident was stumbling over drunk before she left, she would have contacted the doctor immediately to know what to do. The ADON said she never faced a similar situation. When asked, the ADON said she did not know if she would have called the police under those circumstances. The ADON said she would follow the direction of upper management. An interview on 2/12/19 at 12:15 p.m. with the Administrator revealed that although she did not know exactly when they notified her of Resident #5 being missing on 12/23/18; she knew nobody called her during the night after their discovery. The Administrator said she would have expected them to call her and the DON. Staff should have also called the hospital and the police since they found Resident #5 intoxicated before she went missing. The stated the facility was responsible for the resident's safety. If Resident #5 drank a bottle of vodka, it should have been assumed that she was no longer capable of making rational decisions. A subsequent interview on 2/12/19 at 2:30 p.m. with the ADON revealed that she spoke to the Administrator the morning after Staff F discovered Resident #5 missing. The ADON said she told the Administrator about Staff D's concern about the resident leaving the facility with her history of substance abuse. A subsequent interview on 2/12/19 at 3:00 p.m. with the Administrator revealed that she found a text that she sent to the ADON on 12/24/18 at 9:09 a.m. She said she first talked to the DON and ADON about it on 12/24/18. The Administrator considered the text her evidence that the ADON notified her about the incident at some point before the time and date of the text. The Administrator's text informed the ADON that she spoke to their Corporate Nurse Consultant; who asked them to contact the hospitals to see if Resident #5 happened to be there. They were also supposed to contact the police and to inform they wanted to know the status of Resident #5's welfare if police had any interaction with her. According to the Nurse Consultant's instructions, the facility needed to document they contacted each hospital and the police to do a wellness check. The documentation should have also stated that Resident #5 had not been admitted to the hospital and police would do a wellness check if they had contact with her. The Administrator could not find documentation to verify that those things were done. The Administrator said she would have called the Nurse Consultant sooner if the ADON reported Resident #5 as still missing when she first realized it. A subsequent interview on 2/12/19 at 3:15 p.m. with the ADON revealed clarification about what Staff D told her in the mid-afternoon of 12/23/18. The ADON said Staff D told her she saw Resident #5 take the last swig out of a bottle of alcohol. According to the ADON, Staff D did not see her drink the whole bottle. The ADON said she told Staff D to assess Resident #5, take a full set of vital signs and notify the doctor to see if she could receive her medications without any interactions with the alcohol. The ADON said she also told Staff D to check the resident frequently. The ADON also clarified she obtained Staff F's call on 12/23/18 at about 8:35 p.m. Staff F told her they saw Resident #5's wheelchair at the front door. The ADON said Staff F's interviews revealed that Staff J, CNA overheard Resident #5 speak to someone on the phone earlier trying to get a ride. Staff J also said she opened the door and saw Resident #5 leaving with a woman who did not live at the facility. There had been recent discussions about Resident #5 leaving AMA in light of the physicians refusing to prescribe narcotics to her. An interview on 2/19/19 at 12:05 p.m. with Staff J, CNA stated she went in Resident #5's room on 12/23/18 at about 2:00 p.m. at the start of her shift. After a while, the resident's roommate came out of their room expressing concern about Resident #5 acting weird. Staff J entered the room and asked Resident #5 some questions, which she did not respond to, but Resident #5 said she was in pain. Staff J stated she could not smell alcohol, but she did not get very close to the resident. Staff J thought maybe the resident had low blood sugar so she reported it to Staff D. Resident #5 told Staff D to get away from her when she went to check on her. Staff J said she continued on with her duties. Staff J said she heard about 3:00 or 4:00 p.m. that Resident #5 had been drinking. Staff J asked another staff member what they knew about Resident #5's condition and they realized she had been drinking once they found an empty bottle. Staff J next saw Resident #5 around 7:00 or 8:00 p.m. by the front door. Resident #5 called her over to let her out the door; the resident did not ask, but said she was leaving with a visitor. Staff J said she entered the code for them to leave. Staff J thought Resident #5 already signed out, but realized she had not when the nurses were looking for her an hour or two later. Staff J learned Resident #5 left without signing out. She did not know if Resident #5 got in a car or if she walked away, and Resident #5 did not slur her words or stumble on her way out the door. The CNA said she seemed sober, but she acted really mean. Staff J said she could not smell alcohol on her at that time either. Staff J stated she knew Resident #5 should not leave before signing out, but she did not realize the resident had not signed out. Staff J said she never knew Resident #5 had a history of [REDACTED]. An interview on 2/20 at 9:40 a.m. with Staff A, RN revealed that Staff D brought an empty liquor bottle out of a resident's room on 12/23/18 at about 4:00 p.m. and showed it to her. Staff A estimated the size of the bottle as about 6 (inches) tall, 4 wide and about 1 to 1 ½ thick. Staff A said she knew Resident #5 wanted to leave earlier in the day to go cash a check. She and Staff D told Resident #5 there were not any banks open. Staff A said she did not see Resident #5 outside of her room after Staff D showed her the empty bottle, not even in the dining room when she did medication pass. An interview on 2/20/19 at 1:10 p.m. with Staff H, CNA revealed that she did not know Resident #5 had a history of [REDACTED].#5 leaving one night after she had been drinking. Nobody told her to monitor the resident closely in the preceding days before 12/23/18. Staff H said that although they had assigned halls, they assist residents wherever they're needed. A subsequent interview on 2/20/18 at 1:40 p.m. with Staff A revealed she knew Resident #5 had a history of [REDACTED].#5 always asked for pain medication and believed Resident #5 had [DIAGNOSES REDACTED]. Staff A said nobody told her to monitor Resident #5 carefully because of no longer receiving pain medication in the days that preceded the 12/23/18 incident. An interview on 2/20/19 at 2:30 p.m. with Staff E, CNA revealed that she worked with Resident #5 a lot and realized she had a history of [REDACTED].#5 brought alcohol back to the facility and came back drunk a couple of times. Staff E remembered a night they found Resident #5 drunk in her room. Staff E said the resident yelled, screamed and got really mean. Staff E said she also knew Resident #5 had a dependency issue with prescribed narcotics. Staff E said Resident #5 al

Based on observation, record review, family, physician and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 5 of 27 sampled residents. The facility failed to assess significant changes in condition for 5 residents. (Resident #6, Resident # 2, Resident #4 , Resident # 8, Resident #1). The facility identified a census of 56 current residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of [DATE], assessed Resident #6 with a brief interview for mental status (BIMS) score of 13 (no cognitive impairment).The resident had delusions and verbal behaviors 1 to 3 days out of 7. The record did not identify rejection of care. The resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and bathing. The resident did not ambulate. A balance during transitions and walking test revealed the resident was not steady and only able to stabilize with staff assistance in all areas of testing. The resident had falls since the prior assessment. An incident report dated [DATE] at 3:08 p.m. revealed staff observed the resident seated on the floor of the doorway to her room. The resident had to go to the bathroom. The resident stated her ring finger hurt. Staff did not observe injury. A post fall assessment dated [DATE] at 3:08 p.m. did not contain any information other than the resident's vital signs. It was unknown when staff last saw or toileted the resident. A post fall assessment dated [DATE] at 4:08 p.m. did not contain information other than vital signs and that the resident had a pain level of 2 on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain. A progress note dated [DATE] at 3:17 p.m. documented another resident saw the resident fall to the floor. Staff observed the resident in a seated position and the resident said she injured the ring finger of the right hand. The resident could bend the finger and staff did not observe bruising or swelling. Staff placed gripper socks on the resident and assisted her back in the wheelchair. There was no further documentation regarding the resident's finger/hand other than progress notes dated [DATE] at 2:30 a.m. revealed the resident had no new injuries visible. Progress notes dated [DATE] at 3:31 p.m. the resident returned to the facility from the physician with a cast on the right arm/hand. A clinic note dated [DATE] revealed the resident had a 5th metacarpal fracture and the cast must be left on at all times with a sling for comfort. Progress notes did not identify the resident leaving the facility or why the resident had an appointment with the physician. On [DATE] at 9:13 a.m. the Administrator stated the resident went to the physician for something else and when she returned she had a cast on and there was a fracture. The Administrator denied there was any evidence of injury prior to the appointment. On [DATE] at 1 p.m. the surveyor spoke with the van driver that transported the resident to the [DATE] clinic appointment. He denied any type of incident occurred that injured her hand while she was out of the facility. On [DATE] at 9:41 a.m. the surveyor spoke with the ARNP (advanced registered nurse practitioner) who stated the resident had an appointment for her abdominal pain but when she arrived she complained of hand pain. When the ARNP assessed the hand it was extremely swollen with significant ecchymosis and tender. The ARNP said it was obvious the resident had an injury but the facility easily dismisses the resident's complaints and are always angry with the resident. The ARNP stated she ordered a follow up appointment 2 weeks after the [DATE] visit and the facility never sent the resident. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Respiratory A medication review report dated [DATE] contained a physician note and orders after a physician visit. The physician documented the resident's oxygen saturation reading was 89% and pulse was 91. The resident complained of shortness of breath and cough. The resident's temperature was 99.1 degrees. The physician heard rhonchi though the resident's lungs bilaterally upper and lower. The physician ordered [MEDICATION NAME] (antibiotic) 100 milligrams (mg.) for 7 days. Progress notes identified staff documented the resident received antibiotics for [MEDICAL CONDITIONS]/ URI (upper respiratory infection) on [DATE] at 11:18 p.m. and [DATE] at 12:41 p.m The rest of the entries on [DATE] at 9:08 p.m., [DATE] at 9:56 p.m., [DATE] at 9:51 a.m., [DATE] at 6:46 p.m., [DATE] at 9:03 a.m. and [DATE] at 9:19 p.m. stated the resident received the antibiotic for a UTI (urinary tract infection). Progress notes revealed the resident received cough syrup for cough/ congestion/unable to sleep on [DATE] at 7:24 a.m., [DATE] at 8:26 p.m., [DATE] at 10:36 p.m., [DATE] at 7:16 p.m., [DATE] at 4:51 p.m., [DATE] at 9:20 p.m., [DATE] at 11:24 p.m., [DATE] at 12:13 p.m., and [DATE] at 7:42 p.m. The notes did not identify an assessment of the resident when the resident continued to complain of cough and wanted cough syrup. On [DATE] at 5:56 p.m. the resident complained of general pain including the chest. The resident was sweaty and leaning to the left side. The resident exhibited general weakness even with transfers which was unusual for the resident. There was no vital signs or physical assessment documented. Staff notified the physician who directed staff to send the resident to the emergency room (ER). The resident returned to the facility on [DATE] at 4:55 p.m. A hospital history and physical dated [DATE] revealed the resident presented to the ER for chest pain of several days. The resident also reported increased shortness of breath. The resident had 3 plus [MEDICAL CONDITION] of the bilateral lower extremities and was wheezy in the bilateral lung bases. The review of the systems identified positive for cough, sputum production, shortness of breath and wheezing. Positive for chest pain and leg swelling. None of the symptoms identified in the ER was assessed by the facility. The [DIAGNOSES REDACTED]. The resident returned with orders for daily weights and notify the physician if the resident gains 3 pounds in one day or 5 pounds in one week and [MEDICATION NAME] (antibiotic). The resident's [MEDICATION NAME] (diuretic) was increased. A (MONTH) (YEAR) Medication Administration Record [REDACTED]. The entry [DATE] stated to see nurses notes. Nurses notes dated [DATE] at 11:48 a.m. contained the order daily weights and notify physician of the resident gains 3 pounds in one day or 5 pounds in one week and did not contain any weight recording. There was no documentation of the weight itself. Nothing was recorded for [DATE]. On [DATE] the ARNP directed staff to weigh the resident weekly and call if the weight gain was over 5 pounds. TED hose (compression stockings) every morning and off at night. Discontinue [MEDICATION NAME]. A (MONTH) (YEAR) MAR indicated [REDACTED]. The weight on [DATE] was 228.4 pounds and the weight on [DATE] was 235.6 pounds and [DATE] was 236.6 pounds. There was no evidence staff informed the physician. The (MONTH) (YEAR) MAR indicated [REDACTED]. Progress notes dated [DATE] at 7:23 p.m. revealed staff ordered TED hose for the resident. Progress notes dated [DATE] at 7:47 a.m. revealed the TED hose did not arrive from the pharmacy yet. After readmission to the facility from the hospital for [MEDICAL CONDITION] exacerbation and fluid overload, the record lacked evidence there were any respiratory assessments, [MEDICAL CONDITION] assessments or vital sign assessments until progress notes dated [DATE] at 10:09 a.m. revealed staff called the physician at 9:30 a.m. The resident was very weak and had a temperature of 101.1. Blood pressure ,[DATE], heart rate 127, respiration 26 and oxygen saturation 89%. Lung sounds were very coarse and wet sounding throughout. Staff reassessed the resident at 9:55 a.m. and oxygen saturation was in the lower 80's, respirations 32 and more labored. Staff called 911 and the resident left per ambulance. The resident returned to the facility on [DATE] at 4:49 p.m. with [DIAGNOSES REDACTED]. Progress notes dated [DATE] at 10:54 p.m. revealed TED hose were not on. Progress notes revealed the first respiratory assessment, after the [DATE] hospital return, was [DATE] at 10:55 a.m. Lung sounds were clear, vital signs within normal limits and oxygen saturation reading was 93%. There was no [MEDICAL CONDITION] assessment from [DATE] until [DATE]. Progress notes dated [DATE] at 5:47 p.m. revealed there were no TED hose. Progress notes dated [DATE] at 6:59 a.m. revealed staff ordered new TED hose. On the same date at 5:14 p.m. progress notes stated staff could not locate the TED hose. Progress notes dated [DATE] at 7:29 a.m. revealed the TED hose did not arrive from the pharmacy. An entry dated [DATE] at 10:54 p.m. identified the TED hose as not on. On [DATE] at 1:15 p.m. the pharmacy stated they sent TED hose on [DATE]. On [DATE] at 9:21 a.m. the ARNP stated the facility absolutely should have assessed the resident's respiratory status and done the weights as ordered. Facility failure to conduct the assessments contributed to the resident's hospitalization .[MEDICAL CONDITION] causes organ damage and with a proper assessment the situation would have been caught before she got septic. Observation: On [DATE] at 2:30 p.m. the surveyor asked the director of nursing (DON) to accompany her to the resident's room to check the resident's feet. The resident's lower extremities appeared [MEDICAL CONDITION] and the resident did not wear TED hose. Progress notes dated [DATE] at 2:47 p.m. the DON documented the resident had 2 plus [MEDICAL CONDITION] in bilateral lower extremities. The DON contacted the physician's office. On [DATE] at 4:18 p.m. end of the day meeting the surveyor expressed concerns wondering if staff would have noted the [MEDICAL CONDITION] if the surveyor had not taken the DON to the resident's room. On [DATE] at 9:55 a.m. the Administrator stated the facility would have become aware of the [MEDICAL CONDITION] the morning of [DATE] because a staff informed the DON that morning about the resident's [MEDICAL CONDITION]. The ,[DATE] MAR indicated [REDACTED]. Observation showed on [DATE] at 10:30 a.m. Staff B RN wheel the resident down the hall. The resident wore white anklets and no Ted hose. Staff B confirmed the resident did not have TED hose on. On [DATE] at 4:30 p.m. the facility received a verbal order from the physician for ace wraps to bilateral lower legs daily. Observation showed on [DATE] at 8:30 a.m. and 10 a.m. the resident in a wheelchair with legs in the dependent position. The resident's legs were swollen and she did not have TED hose or ace wraps on. [DATE] ER visit: On [DATE] at 7:47 a.m. progress notes identified the resident with a fever of 101 per ear thermometer. The resident was lethargic. The resident's blood sugar was 135. The facility informed the physician. At 10:37 a.m. the resident transported to the ER. The progress notes did not contain lung assessments or vital signs other than the resident's temperature and blood sugar. On [DATE] at 1:15 p.m. Staff B RN stated she listened to the resident's lungs but did not complete blood pressure pulse or respirations. On [DATE] at 2:46 p.m., Staff B stated the resident's lungs sounded good. Staff B didn't think of doing vitals. She stated she did not recall attending an inservice on [DATE]. A late entry revealed Staff B RN assessed the resident's lung sounds with no abnormal sounds identified. The resident had normal respirations and no labored breathing. An after visit summary dated [DATE] identified the reason for the visit was shortness of breath and fever. The [DIAGNOSES REDACTED]. twice a day for 10 days and [MEDICATION NAME] (steroid) 10 mg 3 tablets a day for 3 days, 2 tablets for 3 days, one tablet for 3 days and then stop. 2. A MDS with assessment reference date of [DATE] assessed Resident #4 with a BIMS score of 10 (moderate cognitive impairment). The resident had no behavior symptoms identified. The resident was independent with bed mobility, transfers, ambulation and toileting. The MDS identified the resident with [DIAGNOSES REDACTED]. Progress notes dated [DATE] at 11:57 p.m. revealed the resident received as needed (PRN) [MEDICATION NAME] for shortness of breath. No vital signs or physical assessment. Progress notes dated [DATE] at 7:40 a.m. revealed the resident received PRN [MEDICATION NAME] for shortness of breath. No vital signs or physical assessment. Progress notes dated [DATE] at 10:26 a.m. revealed the resident's [MEDICATION NAME] inhaler for breathing was empty and there was not a new one on hand. Staff charted the [MEDICATION NAME] given earlier was effective. No vital signs or physical assessment. Progress notes dated [DATE] at 8:39 p.m. revealed the resident received PRN [MEDICATION NAME] 0.5 mg for rapid breathing. Progress notes late entry dated [DATE] at 8:47 p.m. revealed the resident was short of breath and requesting to use the commode. The resident was confused and his oxygen was on 5 liters. Oxygen saturation reading was 95% (normal). Pulse was over 100. Staff administered PRN [MEDICATION NAME] and placed the oxygen on 2 liters as ordered. There were no vital signs or physical assessment documented. Progress notes late entry dated [DATE] at 9:07 p.m. revealed the resident remained confused and had difficulty talking due to shortness of breath. The resident appeared calmer and his pulse was below 100. Oxygen saturation reading was 82% (low). Staff administered a scheduled breathing treatment. There were no vital signs or physical assessment documented. Progress notes late entry dated [DATE] at 9:22 p.m. revealed the resident appeared calmer and sleepy now. The resident remained confused. Staff attempted to assist the resident to the commode via EZ stand but the resident was too weak to use it safely. 3 to 4 staff assisted the resident to bed with a gait belt. Staff elevated the head of the bed and applied the C-pap. The resident's oxygen saturation remained in the lower 80's with oxygen at 2 liters. The oxygen saturation was around 88 to 90% when the oxygen was at 3 liters The resident's fingertips were cool but no mottling. There were no vital signs or physical assessment documented. Progress notes late entry dated [DATE] at 9:30 p.m. revealed staff found the resident sitting at the bedside leaning over the bedside table with c-pap intact. The resident was calm and comfortable. There were no vital signs or physical assessment documented. Progress notes late entry dated [DATE] at 10 p.m. revealed nurse aides paged the nurse to come to the resident's room STAT. Staff found the resident lying across the bed with oxygen off and mottling all over the body. The resident had no pulse or respirations. Staff contacted hospice and the physician. The record lacked evidence the facility notified hospice or the physician when the resident experienced a condition change. There were no vitals documented, breath sounds or physical assessments. Staff working on the resident's hall the evening of [DATE]: On [DATE] at 11:33 a.m. Staff I RN (registered nurse) stated she was the resident's nurse that evening. She stated she did not notify the physician or hospice because the prior shift told her they were aware of the resident's condition. Staff I stated the resident was confused and removing his oxygen all day. She heard the information in report. She stated the resident was unable to reapply the oxygen once he took it off. The resident would try but could not get it on correctly. She stated she thought staff last saw the resident when she last documented on him prior to the discovery he expired (30 minutes) She stated she turned the resident's oxygen down because the order was for 2 liters. On [DATE] at 12:27 p.m. Staff J CMA (certified medication aide) stated the resident ate a little and said he was tired. The nurse gave him a breathing treatment around 9:15 p.m. to 10 p.m. and the next thing Staff J knew, the resident was gone. He stated he saw the resident take off his oxygen a couple times. He didn't know if the resident took it off intentionally. They walked the resident to the bathroom and he was weak. Staff J got the nurse because he thought the resident was slow to respond. His speech was slurred. he usually put himself to bed but that night he was too weak. Staff J stated the resident had the oxygen on when he last saw him around 9:15 p.m. He was sitting up in bed and Staff I checked the resident's vital signs. On [DATE] at 2:53 p.m. Staff K CNA (certified nurse aide) stated the resident was short of breath that night. She recalled the resident wanting to get to the bathroom. He got there and just stayed in the chair. He was sliding over so they put him in bed. The resident had no energy and later on expired. She stated the resident had shortness of breath but that day it was pretty bad. She stated the resident took the oxygen on and off and he knew how to do it. She stated she last saw the resident when he got in bed maybe within the hour of when he expired. On [DATE] at 1:46 p.m. Staff L LPN (licensed practical nurse) stated she wasn't sure she knew who the resident was. Hospice nurse: On [DATE] at 9:53 p.m. the hospice nurse stated no one reported the resident's change of condition and she would have wanted to be notified. She stated the resident did not usually take his oxygen off. He was dependent on it. She stated hospice calls the physician if there are changes in the resident's status and the facility should have called her. She would have come to the facility right away and checked when the resident last had [MEDICATION NAME] ([MEDICATION NAME] narcotic) which may help breathing and make sure the resident was comfortable. She stated she was not told of the changes preceding staff finding the resident expired. She stated she was shocked to hear the information from the surveyor. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. at 6 p.m. The resident had routine [MEDICATION NAME] (narcotic) 7.5 mg/325 mg. at bedtime. The last PRN dose of [MEDICATION NAME] was at 7:40 a.m. on [DATE]. A death certificate identified the resident's cause of death as clinical decline due to a consequence of [MEDICAL CONDITION]. 3. A MDS with assessment reference date of [DATE] assessed Resident #2 with a BIMS score of 13 (no cognitive impairment). The resident did not have delusions, hallucinations or behaviors identified. The MDS revealed the resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene and total assistance with bathing. The resident did not ambulate. The resident had an indwelling urinary catheter and occasionally incontinent of bowel. The MDS identified the resident had occasional pain that did not interfere with day to day activities. The resident rated the pain level as a 2 with 0 being no pain and 10 being the worst pain. The MDS revealed the resident had shortness of breath when lying flat. The resident had a surgical wound. The MDS did not identify any other areas of skin impairment. The resident expected discharge to the community. An ADL (activity of daily living) CAA (care area assessment) worksheet dated [DATE] revealed the resident recently admitted to the facility after an acute hospital stay for back surgery, laminectomy. The resident was on strict bedrest and received skilled care for IV (intravenous) therapy. The resident's goal was to work with therapy once he was off bedrest to improve ADL abilities and then return home. A nutritional status CAA dated [DATE] revealed the resident's bed could not be elevated higher than 15 degrees. A pressure ulcer CAA dated [DATE] identified the resident at risk for pressure ulcers. A fax to the physician dated [DATE] informed the physician the resident had increased nausea and vomiting. Review of progress notes failed to identify any nausea or vomiting prior to the [DATE] fax. The physician responded by ordering [MEDICATION NAME] (antiemeitic) 4 milligrams (mg.) twice a day as needed nausea vomiting. Progress notes revealed the following: [DATE] at 4:58 p.m. revealed the resident arrived at the facility per ambulance. [DATE] at 11:56 a.m. staff sent a fax to the physician to report audible congestion. A return fax dated [DATE] revealed the physician responded by ordering [MEDICATION NAME] treatments every 6 hours while awake. There were no lung sound assessments. Progress notes failed to contain any additional information regarding congestion or lung sound assessments. [DATE] at 5:17 a.m. the resident complained of pain across the abdomen and across butt. There was no abdominal assessment of assessment of the resident's bottom. [DATE] at 12:24 a.m. revealed the resident complained of pain across the lower back and butt. The resident rated the pain as a 5. Staff administered [MEDICATION NAME]. There was no assessment of the resident's back or buttocks. [DATE] at 12:23 p.m.,. revealed staff administered [MEDICATION NAME] for nausea. There was no assessment at the time. On the same date at 1:51 p.m. staff documented the [MEDICATION NAME] was ineffective and the resident now vomited dark brown and mucus colored phlegm. There was no assessment at that time. On the same date at 3:10 p.m. revealed staff notified the physician the resident vomited brown red mucus. and that staff administered [MEDICATION NAME]. Staff did not do an abdominal assessment. The resident blood pressure was ,[DATE], pulse 72 and temperature 97.6 degrees. On the same date at 3:13 p.m. staff called the physician again requesting a response since the resident still had dry heaves and vomiting. The physician directed staff to administer another [MEDICATION NAME] and said the dark colored vomit may be bile from the stomach. Staff documented the 2nd shift nurse would administer the [MEDICATION NAME]. Call the physician if the second [MEDICATION NAME] did not help. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. [DATE] at 4:59 p.m. revealed the resident coughed up phlegm and had nausea. The resident had congested lungs throughout. The DON (director of nursing) documented the charge nurse informed the physician of the lung congestion. The record lacked evidence the charge nurse ever documented she notified the physician of the lung congestion when she called him that day. There was no further mention of the resident's lungs or respiratory status until [DATE] at 11:10 a.m. when the resident went to the emergency room (ER) for evaluation of congestion. The resident returned on the same date at 5:42 p.m. with a [DIAGNOSES REDACTED]. [DATE] at 4:12 p.m. revealed the resident continued to have back and leg pain. The resident had an occasional productive cough and no signs of dyspnea. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. [DATE] at 10:33 p.m. staff sent a fax to the physician to update that the resident continued with chest congestion and productive cough. There was no evidence the physician returned the fax or the facility attempted to contact the physician again for a response. [DATE] at 1:27 p.m. a nurse documented the resident's lungs were clear and there was no dyspnea or cough. There was no further assessment of the resident's lungs or vital signs. Skin grid forms dated [DATE] revealed a 5 centimeter (cm.) by 6 cm. red are to the coccyx, a 1 cm. by 1 cm, red blanchable area to the right heel and a 3.5 cm. by 2.5 cm. red blanchable area to the left heel. On [DATE] at 10:09 a.m. the resident's daughter stated she was informed the resident had a red coccyx on [DATE] and the daughter informed the facility about the resident's heels. [DATE] at 2 a.m. revealed the resident had pain in the right side and the resident couldn't sleep with no assessment completed. Staff administered [MEDICATION NAME]/[MEDICATION NAME][MEDICATION NAME] which an entry at 5:08 a.m. identified as partially effective On the same date at 5:06 a.m. the IV antibiotic dose was not available for administration. [DATE] at 7 a.m. the resident had a brown liquid emesis and crackles audible when lungs assessed. The resident had labored breathing. Progress notes dated [DATE] at 10:46 a.m. revealed the resident went to the ER at 7:45 a.m. A death certificate revealed the resident expired on [DATE] at 12:35 a.m. due to aspiration pneumonia. Staff Interviews: Staff Working the overnight shift prior to the [DATE] ER visit: On [DATE] at 1:30 p.m. Staff C RN (registered nurse) stated she worked the overnight shift prior to the resident going to the hospital. She stated she never heard the resident yell that night. That morning at shift change she went in to give the resident his antibiotic and he said he was nauseated. Staff went in and turned the resident and they came out and said he vomited. She stated staff reported it at shift change so the day shift took over the resident's care. On [DATE] at 3:45 p.m. Staff P CNA stated at the end of the night she saw the resident vomit dark material in the emesis basin. He said his tailbone and lower back hurt. She couldn't remember if he had sores. On [DATE] at 1:45 p.m. Staff H CNA (certified nurse aide) stated she worked the overnight shift prior to the resident going to the hospital on [DATE]. The resident was very anxious from 2 a.m. to 5 a.m. He was on the call light and complaining of shortness of breath. Staff H stated she told Staff C but she didn't know if the nurse checked him. The resident looked short of breath and pulled at his oxygen. The resident told her had had his call light on for 3 hours but Staff H stated it had only been 10 minutes. The resident also complained of a rotten gut on previous nights and day shifts. The last time Staff H checked on the resident he had not vomited. At the end of the night, the nurse told her the resident was incontinent of bowel so Staff H went in the resident's room. The resident had yellowish vomit on his face and no bowel movement. Staff H stated he had not vomited all shift until then. Staff H stated the resident wasn't looking good so she asked the nurse to check him. Staff H felt like the resident was in trouble. After that, the resident went to the ER. She stated the resident had vomited at other times . She saw emesis a couple times. Staff H stated she didn't think Staff C was as concerned about the resident as she should have been. Other staff: On [DATE] at 10:30 a.m. Staff F CMA (certified medication aide) stated the resident vomited quite often. On [DATE] at 8:45 a.m. Staff A LPN (licensed practical nurse) stated the resident told her an evening shift CNA put the resident up higher than 15 degrees one time so the resident could eat. Staff A stated she guessed the staff didn't know. That staff was educated. She did not know who the staff was. Staff A also heard that someone tried to get the resident out of bed for an appointment. She did not know who the staff was. On [DATE] at 8:35 a.m. Staff G CMA stated the resident felt like he would vomit a few times but he never did. There were times the resident really struggled to breathe. He was sent to ER a couple times for breathing problems. On [DATE] at 8:53 a.m. Staff M CNA stated the resident vomited on his gown and pillowcase once and she reported it to the nurse. She stated the resident had pain when he was moved. She stated the resident was always on his back except when they changed him. On [DATE] at 1:41 p.m. Staff N RN stated one time the resident was nauseated and she gave him a [MEDICATION NAME]. He didn't vomit on her shift. On [DATE] at 11:25 a.m. Staff O RN stated the resident was congested and in discomfort and she sent him to ER. He came right back to the facility. She couldn't recall nausea and vomiting. Review of the resident's (MONTH) (YEAR) and (MONTH) (YEAR) medication administration records revealed only 1 [MEDICATION NAME] was administered his entire stay (from [DATE] to [DATE]). On [DATE] at 10:09 a.m. the resident's daughter stated when she arrived the morning of [DATE] the resident was sitting up in bed in direct violation of the physician order. On [DATE] at 3:29 p.m. the physician stated the care could have been better related to the lack of assessments and vital signs. No pain medication for 4 days is also a concern. He stated if the facility did conduct assessments and vitals signs appropriately it probably would not have changed the outcome for the resident. It is hard to know the answer that question. Bowels: A hospital dismissal form dated [DATE] revealed the resident's last bowel movement (BM) while hospitalized was [DATE]. Review of the resident's facility bowel records revealed the resident had a medium BM on [DATE] and [DATE]. All other bowel movements recorded were small. On [DATE] at 8:50 a.m. the Administrator stated she conferred with the DON and the MDS nurse and the facility does not count small BMs as a bowel movement. She stated there was nothing in the policy regarding this. On [DATE] a diagnostic radiology report identified the resident with severe distention of the stomach. The impression was that the distention could be from obstructive changes or gastroparesis. A large amount of stool was demonstrated and there appeared to be mild fullness of portions of the colon. Review of facility documentation prior to sending the resident to the hospital on [DATE] revealed no documentation regarding a severely distended stomach. Review of the resident's MARs did not identify any laxative administered. Facility policy titled bowel and bladder continence management did not contain any information about administering laxatives to constipated residents. 4. A MDS with assessment reference date of [DATE] assessed Resident #8 with a BIMS score of 14 (no cognitive impairment). The resident had no behaviors including rejection of care. The resident required extensive staff assistance with bed mobility, transfers, toileting and bathing. The resident had an indwelling urinary catheter and was frequently incontinent of bowels. The MDS identified the resident at risk for pressure sores and at the time of the assessment staff documented the resident had no skin impairment. The MDS identified the resident with [DIAGNOSES REDACTED]. The resident admitted to the facility [DATE]. Progress notes revealed the following: [DATE] at 1:32 p.m. and [DATE] at 11:11 a.m. staff could not complete the resident's daily weights due to scale not working. [DATE] 3:22 p.m. revealed the resident complained of trouble breathing. Staff administered a ProAir inhaler. The resident's oxygen saturation reading was 94% on 3 lite (TRUNCATED)

Based on observation, record review and staff interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 27 residents reviewed. The facility failed to investigate incidents and failed to implement appropriate interventions after incidents for Resident #5, Resident #6 and Resident #18. Resident #6 received a fractured metacarpal. Resident #18 transported to the emergency room for evaluation of head injury. The facility also had hot water temperatures over 140 degrees resulting in hazards. The facility identified a census of 56 current residents. Findings include: 1. On 2/27/18 at 3:25 p.m. the surveyor washed her hands in the women's rest room and the hot water felt extremely hot. The surveyor then checked Resident #9 and Resident #17's room and the hot water was 145 degrees per facility thermometer. The surveyor notified the Administrator and further hot water checks were completed as follows: 2/27/18 at 3:39 p.m. Resident #9 and Resident #17's room measured 143.7 degrees and 143.3 degrees via facility thermometers. Visible steam arose from the faucets when hot water was tested . On 2/27/17 at 4:10 p.m.,. Resident #17 stated the water had been hot for a week. If it gets too hot she cools it with cold water. She didn't report it to anyone. On 2/27/18 at 3:42 p.m. Resident #1's room water temperature was 142.8 degrees and 142.3 degrees via facility thermometer. 2/27/18 at 3:50 p.m. Resident #20 and Resident #21's water temperature was 141.6 degrees and 141.3 degrees via facility thermometers. At that time, Resident #20 stated the water was very hot. She stated she had to turn the cold all the way on when she used the hot water. At that time Resident #21 stated the water was hot but she just turned the cold on when it got hot. The residents stated they didn't report it to anyone, they just turned on the cold water. 2/27/18 at 3:52 p.m. Resident #22 and Resident #23's water temperature was 138.8 degrees and 138.5 degrees via facility thermometer. Both residents denied concerns with the water temperature. 2/27/18 at 3:53 p.m. Resident #25's water temperature was 138.6 degrees and 138.3 degrees via facility thermometers. Visible steam was seen when checking the water. Resident #25 denied concerns with the temperature. 2/27/18 at 3:55 p.m. Resident #26's water temperature was 139.1 degrees and 138.5 degrees via facility thermometers. Resident #26 denied concerns with water temperature. 2/27/18 at 4 p.m. Resident # 5 and Resident #12's water temperature was 140.1 degrees and 139.5 degrees via facility thermometers. Resident #12 stated there water gets awful hot and he has to watch it. He didn't report it to anyone. 2/27/18 at 4:02 p.m. Resident #27's temperature was 139.3 and 138.9 degrees via facility thermometers. He stated the water gets too hot so he uses cold to cool it down. On 3/1/18 at 7:56 a.m. Resident #9 and Resident #17's water temperature was 106.5 degrees per surveyor thermometer. At 9:20 a.m. Resident #5 and Resident #12's water temperature was 109.2 degrees per surveyor thermometer. On 3/1/18 at 10:50 a.m. the maintenance person stated he just checked water temperatures. Resident #26's water temperature was 108.7 degrees. Resident # 9 and Resident #17's water temperature was initially 114 then as the water ran it was 109 degrees. Resident #5 and Resident #12's water temperature was 109.4 degrees. At that time, the maintenance person stated the mixing valve was not functioning. The facility would get one from out of town and have it installed tomorrow. He stated he adjusted the gauge and this morning temperatures were cooler. Since the mixer valve is out, the temperatures are not steady. Yesterday morning the water temperature gauge was set on 150 degrees. Around 9:30 a.m. he turned it down to 138 degrees and yesterday a round 4 p.m. he turned it down to 120 degrees. This morning (2/28/18) water was too cool so around 7:30 a.m. he turned it back up to 138 degrees. On 3/1/18 at 11:40 a.m. Resident # 9 and Resident #17's water temperature was 134.3 degrees. Resident #5 and Resident #12's water temperature was 134.6 degrees. Resident #26's water temperature was 129.9 degrees. On the same date at 11:50 a.m. the maintenance person stated he turned the hot water gauge down to 125 degrees. On 3/7/18 at 11:02 a.m. Resident # 9 and Resident #17's water temperature was 105.9 degrees. Resident #5 and Resident #12's water temperature was 115.1 degrees. Resident #26's water temperature was 107 degrees. Staff On 2/27/18 at 4:20 p.m. Staff T CNA stated she noticed the water was hot in one room one day. She wasn't sure what day. She did not report it. On 2/27/18 at 4:20 p.m. Staff B RN stated the water had been hot but she didn't tell anyone. She just adds cold water. On 2/27/17 at 4:25 p.m. the Administrator stated maintenance checked the water temperatures weekly until the old maintenance person left 2/15/18 and the new one started. On 2/27/18 at 4:38 p.m. Staff A LPN (licensed practical nurse) stated she scalded her hands on the hot water last Sunday in the women's rest room. She stated she did not receive any [MEDICAL CONDITION] it felt like it burned. She did not report the hot water to anyone. A weekly hot water temperature test sheet identified the last time staff checked the hot water was on 2/8/18. At that time, staff checked 3 rooms and the hot water measured 111 degrees in all 3 rooms. A policy in place at the time of the discovery of hot water temperatures undated revealed resident rooms should have a water temperature between 95 degrees to 110 degrees. The policy did not identify frequency of checks. 2. A Minimum Data Set (MDS) with assessment reference date of 5/3/17, assessed Resident #5 with a brief interview for mental status (BIMS) score of 2 (severe cognitive impairment). The MDS identified the resident had difficulty focusing attention and keeping track of what was said. The resident had disorganized thinking and delusions. The resident required limited staff assistance with bed mobility, toileting and transfers. The resident did not ambulate. The resident had functional loss of range of motion of one upper and one lower extremity. A balance during transitions and walking test revealed the resident as not steady and only able to stabilize with staff assistance in all areas of testing. Staff did not test the resident's walking balance. The resident had falls in the month prior to admission and falls since admission. The resident was occasionally incontinent of bladder. The resident admitted to the facility 4/27/17 with [DIAGNOSES REDACTED]. A care plan dated 4/27/17 identified a problem of risk of accidents and injuries. The care plan revealed they would minimize the risk of accidents and injuries by providing appropriate staff assistance in completing ADLs (activities of daily living) and mobility while encouraging the resident's highest functioning level. An intervention dated 4/27/17 revealed the resident used the toilet and directed staff to assist the resident with toileting needs on request. The care plan identified the resident transferred with 1 to 2 staff assist. The care plan also directed staff to keep the call light within the resident's reach and encourage the resident to use it. An incident report dated 5/1/17 at 10:30 a.m. revealed a fall in the resident's bathroom. The resident laid on the floor on the right side with pants down to thighs. The resident used the toilet rail for assist and the one side bent as the resident slid to the floor. The immediate action following the incident was 2 staff assisted the resident from the floor and the resident agreed to ask for assistance from now on. The resident did not sustain injury. A post fall assessment dated [DATE] at 10:30 a.m. revealed staff last toileted the resident at 8 a.m. The post fall assessment identified the intervention following the incident as: remind the resident not to transfer self. The brake on the left side of the wheelchair broke and staff notified maintenance. An incident report dated 5/1/17 at 7:15 p.m. revealed staff found the resident leaning against the bed. The resident tried to get in bed and slipped to the floor. The resident was not injured. The incident report did not identify an intervention following this incident. There was no post fall assessment after the incident. An incident report dated 5/12/17 at 10:15 p.m. revealed the resident's call light activated. Staff answered it and observed the resident on the floor laying on his right side next to the bed. The resident fell out of bed as he slept. The resident was not injured. The incident report did not identify a new intervention following the incident. A post fall assessment dated [DATE] at 10:18 p.m. revealed the bed was in a higher position when the fall occurred. Staff last toileted the resident at 9:30 a.m. After the incident, staff put the bed in low. The care plan did not contain an intervention of low bed. There was no incident report for an incident on 6/1/17 but a post fall assessment dated [DATE] at 9:32 p.m. revealed the resident tried to stand and get into bed. Staff observed the resident laying on his chest on the bed with arm underneath him. Staff assisted the resident to the floor so they could assist the resident into bed correctly. The resident denied pain. Staff last toileted the resident at 6:30 p.m. Following the incident, staff reminded the resident to use the call light. (not effective since resident's BIMS was 2) An incident report dated 8/30/17 at 1:10 p.m. revealed a fall in the resident's bathroom. The resident fell when flushing the toilet. The resident did not sustain injury. The intervention following the incident was to tighten/fix grab bars on toilet. (Toilet bar was also a factor in 5/1/17 incident) The post fall assessment dated [DATE] at 1:10 p.m. revealed the resident used the toilet and he lost his balance when he stood up. The resident denied injuries. Staff observed the resident seated on his buttocks with feet extended straight on the right side of the toilet. The assessment did not identify when staff last toileted the resident. Following the incident, staff assisted the resident to the wheelchair and encouraged the resident to call staff for assistance. The assessment identified that the resident was noncompliant with using the call light. An incident report dated 9/2/17 at 12:30 a.m. revealed an unwitnessed fall in the resident's room at approximately 11:50 p.m. The resident was on his knees with his head between the night stand and bed. The resident stated he was asleep and then on the floor. He rolled the wrong way and fell from bed. The resident did not sustain injury. The incident report did not identify an intervention after the incident. An addendum on the care plan dated 9/3/17 revealed the resident was changed to a scooped/winged edge bed to assist with barrier recognition and an every 3 hour toileting plan. A post fall assessment dated [DATE] at 12:30 a.m. revealed the resident rolled over and fell out of bed. Staff last toileted the resident at 9:45 p.m. Following the incident, staff lowered the bed from normal position. The care plan did not contain the low bed intervention. An incident report dated 9/11/17 at 5:41 a.m. revealed the resident roommate came to the nurse's station and reported a fall. The resident laid on the floor by the bedside. The resident had a scratch and bump on the upper right forehead. The resident reported hitting his/her head on the end of the bed. The resident said the bed moved when he tried to get up. The incident report revealed that immediately after the fall, they locked the bed wheels and lowered the bed. A post fall assessment dated [DATE] at 5:41 a.m. revealed the resident fell trying to get out of bed. Staff observed a scratch to the upper right forehead after the fall. The assessment did not identify when staff last toileted the resident. Following the incident, staff put the bed in lowest locked position. Progress notes dated 9/11/17 at 12:21 p.m. revealed staff would check the resident during the night and awaken him to see if he needed the toilet on rounds. The resident agreed to this. The entry revealed a lowered bed intervention was not appropriate for the resident. (Although staff documented they had lowered the bed on prior incident reports and post fall assessments) A care plan intervention dated 9/11/17 directed staff to wake the resident on rounds to see if he needed the toilet. Progress notes dated 9/12/17 at 1:22 p.m. revealed the facility sent a request for physical therapy and speech therapy orders to the physician. Progress notes dated 9/17/17 at 5:30 a.m., revealed the resident was noncompliant with calling for assistance. The resident also stands and transfers without assistance. Staff gave the resident reminders to call for help but the resident refused. Progress notes dated 9/19/17 at 3:11 p.m. revealed the resident's granddaughter requested the physician see the resident for right shoulder pain and spasms in the right arm and leg. Progress notes dated 9/20/17 at 1:08 p.m. revealed the resident returned from the physician who noted the resident had resolving bruises to the right shoulder from fall and directed staff to administer Tylenol ([MEDICATION NAME]) if the resident wants it. An incident report dated 10/20/17 at 10:26 p.m. revealed the roommate reported the resident fell . Staff observed the resident on the floor with his back next to the bed. There was blood on gripper strips. The resident was noted in bed 20 minutes earlier with urinal available. The resident stated he stood and his foot slipped when he tried to get back into bed. The incident report identified the immediate intervention as: apply gripper socks. A post fall assessment dated [DATE] at 10:26 p.m. revealed the resident tried to get into bed. Staff observed the resident sitting on his buttocks with his legs out in front of him. Staff last toileted the resident at 8 p.m. A physical therapy note while in the hospital from 12/9/17 to 12/19/17 revealed the resident required 2 staff total assistance with supine to sit, sit to supine, sit to stand, stand to sit. The resident was nonambulatory. An incident report dated 1/2/18 at 6 p.m. revealed the resident was on the floor on his hands and knees. The resident dropped the plastic lid from supper tray and slid off the bed when he tried to grab it. Staff observed a lesion on the left ankle measuring 2 centimeters (cm.) by 2 cm. The immediate action after the incident was: encourage the resident to eat in the dining room for closer supervision. There was no post fall assessment for the incident. An incident report dated 1/5/18 at 10:40 p.m. revealed the resident's roommate alerted staff that the resident fell out of bed. The resident sat on the floor leaning against the bed. The resident stated he thought he would go to the bathroom and couldn't make it so he sat on the floor. The report did not identify when staff last saw or toileted the resident. There was no post fall assessment for the incident. Observation: On 1/3/18 at 4:15 p.m. the resident laid in bed in a concave mattress. The bed was regular height. The resident complained of left arm and shoulder pain. Care Plan A care plan dated 7/18/17 with revision on 12/29/17 revealed the resident was at risk for falls related [MEDICAL CONDITION](stroke) with right side weakness and history of falls. The resident had a history of [REDACTED]. Therapy recommended staff assist although resident continued to not use his call light and transfers self. Resident agreed to be checked on at rounds during the night. The resident had a history of [REDACTED]. The care plan contained an intervention dated 9/5/17 that directed staff to toilet the resident every 3 hours. Interviews: On 1/30/18 at 3:12 p.m. Staff S CNA (certified nurse aide) stated the resident sits up on the bed and staff would go in for rounds and find the resident on the floor. The resident tried to self transfer. On 1/30/18 at 3:45 p.m. Staff P CNA stated the residents self transfers and tries to sit up per self. 3. A MDS with assessment reference date of 11/28/17 assessed Resident #6 with a BIMS score of 13 (no cognitive impairment).The resident had delusions and verbal behaviors 1 to 3 days out of 7. The record did not identify rejection of care. The resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and bathing. The resident did not ambulate. A balance during transitions and walking test revealed the resident was not steady and only able to stabilize with staff assistance in all areas of testing. The resident had falls since the prior assessment. A care plan dated 5/20/16 revealed the resident was at risk for falls related to unawareness of safety needs and history of falls. The resident required standby assistance with transfers. The resident was impulsive at times and did not wait for staff assistance. The resident would place self on the floor and crawl to the doorway for staff assistance. When the resident did not receive immediate care she would slide self out of the wheelchair to the floor. The care plan directed staff to toilet the resident before and after meals and offer to lay down or sit in front lobby. The care plan directed staff to have gripper strips in front of the bed and toilet and anti roll backs to the wheelchair. Staff should keep the wheelchair next to the resident's bed locked to allow the resident to self transfer. A noodle to the call cord to allow the resident better grasp of the call cord. An incident report dated 7/13/17 at 1:56 p.m. revealed staff observed the resident on her hands and knees in the doorway of the resident's room. The resident had red areas to both knees. The incident report identified the areas as bruising. A post fall assessment dated [DATE] at 2:56 p.m. identified the resident had pain in her knees after the incident. The resident rated the pain as 5 on a scale of 0 to 10 with zero being no pain and 10 being the worst pain. The resident reported she crawled from the bathroom to the doorway. The post fall assessment did not identify if staff placed the resident in the bathroom or if the resident went in the bathroom per self or how long the resident was in the bathroom. The post fall assessment did not reveal when staff last toileted or saw the resident. A care plan intervention dated 7/14/17 directed staff to remind the resident to wait for staff assistance with pulling up pants when toileting. An incident report dated 7/16/17 at 11:50 p.m. revealed staff found the resident laying in her left side in the doorway of her room. The resident's head was out of the doorway and the resident's legs were in front of the bed. The resident stated she needed to use the bathroom and that she had the call light on. Staff documented the call light was not on. The resident did not sustain injury. The post fall assessment dated [DATE] at 11:50 p.m. did not identify when staff last toileted the resident. The post fall assessment revealed the resident received [MEDICATION NAME] (antipsychotic) at 6:23 p.m. The post fall assessment identified that after the incident staff reminded the resident to ask for assistance. The resident had one sock on and a blue boot to the right foot. Staff reminded the resident to put slippers on when transferring to prevent slipping. An intervention dated 7/17/17 directed staff to apply a noodle to the call cord to allow resident better grasp of call cord when pulling call light. An incident report dated 7/24/17 at 7 p.m. revealed staff heard the resident yell. Staff observed the resident on her knees by the bed. The resident had regular socks on. The resident did not sustain injury. A post fall assessment dated [DATE] at 7 p.m. revealed the resident tried to put herself to bed. The resident had weakness and could not ambulate. The report revealed staff last toileted the resident at 6 p.m. The care plan dated 7/25/17 revealed the intervention as staff reminded to apply nonskid socks or keep feet bare when put to bed. Non skid strips are reapplied next to resident's bed. An incident report dated 8/3/17 at 10:07 p.m. revealed the resident yelled loudly at the nurse's station for assistance to go to bed. Several staff were at the nurse's station and asked the resident to wait a few minutes. The resident continued to yell and then slid out of the wheelchair. Staff then got the resident off the floor via Hoyer lift and got the resident to bed. The resident did not sustain injury. Staff would provide nonskid socks. A post fall assessment dated [DATE] at 10:07 p.m. revealed staff last toileted the resident at 8/3/17 at 9 p.m. The intervention following the incident was to encourage the resident to use the call light and ask for assistance. Progress notes dated 8/12/17 at 9:02 a.m. revealed staff observed the resident on the floor on her left side. A witness stated the resident asked staff to assist her to the toilet and staff told the resident she would help her in 3 minutes. The resident then became upset and began to stand on the right leg but then lowered the left knee to the ground followed by the rest of the resident's body. Staff assisted the resident from the floor and taken to the bathroom. Staff reported the resident did this when she did not get her way and the resident's behavior symptoms have worsened. There was no investigation or incident report available for this incident. Progress notes dated 11/6/17 at 8:10 a.m. revealed at 7 p.m. on 11/5/17 the resident insisted her bed was wet and demanded staff change it. When staff entered the room, the resident yelled at staff. Staff observed the resident scoot to the edge of the chair and lower self to knees to the floor. The resident then laid on the left side and rolled to her stomach. There was no assessment for injury or incident report/investigation available. An incident report dated 11/6/17 at 3:08 p.m. revealed staff observed the resident seated on the floor of the doorway to her room. The resident had to go to the bathroom. The resident stated the left ring finger hurt (wrong finger documented). Staff did not observe injury. A post fall assessment dated [DATE] at 3:08 p.m. did not contain any information other than the resident's vital signs. It was unknown when staff last saw or toileted the resident. A post fall assessment dated [DATE] at 4:08 p.m. did not contain information other than vital signs and that the resident had a pain level of 2 on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain. A progress note dated 11/6/17 at 3:17 p.m. documented another resident saw the resident fall to the floor. Staff observed the resident in a seated position and said she injured the ring finger of the right hand. The resident could bend the finger and staff did not observe bruising or swelling. Staff placed gripper socks on the resident and assisted her back in the wheelchair. There was no further documentation regarding the resident's finger. Progress notes dated 11/7/17 at 2:30 a.m. revealed the resident had no new injuries visible. Progress notes dated 11/8/17 at 3:31 p.m. the resident returned to the facility from the physician with a cast on the right arm/hand. A clinic note dated 11/8/17 revealed the resident had a 5th metacarpal fracture and the cast must be left on at all times with a sling for comfort. Progress notes did not identify the resident leaving the facility or why the resident had an appointment with the physician. On 2/7/18 at 9:13 a.m. the Administrator stated the resident went to the physician for something else and when she returned she had a cast on and there was a fracture. The Administrator denied there was any evidence of injury prior to the appointment. Progress notes dated 2/9/18 at 7:45 a.m. revealed the resident lowered self to the floor. The resident called for assistance and the CNA (certified nurse aide) responded to the call and promised to return after she finished caring for the other resident she worked with. The resident did not hit her head and there was no injury. On 2/12/18 at 2:47 p.m. the DON stated there was no incident report or investigation because the incident was documented as a behavior. The doctor called back regarding the resident's [MEDICAL CONDITION] and said to continue with TED hose. 4. A MDS with assessment reference date of 11/21/17 did not assess Resident # 18's cognitive status. The resident had unclear speech was usually understood others and understood others. The resident required extensive staff assistance with bed mobility, transfers, dressing, toileting, eating, personal hygiene and bathing. In the area ambulation in room staff coded a 7 (indicating the activity occurred once or twice). The resident was frequently incontinent of bowel and bladder. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident admitted to the facility 11/13/17 and had [DIAGNOSES REDACTED]. Incident reports (IR) identified the following falls: 12/4/17 at 1:45 p.m. staff observed the resident lying on the floor in front of her wheelchair next to other resident's foot of bed. There was no fall assessment completed to determine causal factors. The IR identified no injury. Staff placed the resident in bed. A typed paper provided by the Administrator indicated the intervention following this incident as encourage resident to come out to commons area when up in wheelchair. 12/4/17 at 2:10 p.m. staff found the resident on the floor in front of the wheelchair. Staff placed the resident in bed. Under predisposing environmental factors, staff checked other. No other factors were identified such as when staff last toileted the resident. The IR identified no injury. A typed paper provided by the Administrator indicated the intervention following this incident as encourage resident to rest in bed when in room. According to the previous incident at 1:45 p.m. on the same date, staff placed the resident in bed less than 30 minutes before. 12/5/17 at 7:29 a.m. At 5:25 a.m. staff observed the resident on the floor in her room by the bed and the roommate's bed. The resident had an abrasion to the left knee and swelling to the face and back of the head. A post fall assessment dated [DATE] at 7:29 a.m. revealed the resident did not respond when staff asked what she tried to do. The resident had redness and swelling beside and under the left eye and a raised area to the occipital area of the head. Staff last toileted the resident at 4 a.m. A typed paper provided by the Administrator indicated the intervention following this incident as OT (occupational therapy) to evaluate the resident's wheelchair for positioning and need for specialized wheelchair. 12/13/17 at 2:23 p.m. revealed staff observed the resident on the floor between the bed and wall. There was no fall assessment completed to determine causal factors. The IR identified no injury. A typed paper provided by the Administrator indicated the intervention following this incident as A typed paper provided by the Administrator indicated the intervention following this incident as: adjusted bed so wheels don't touch the floor. OT daily note documentation dated 12/13/17 revealed modifications made to wheelchair to increase safety with sitting upright and wheelchair propulsion. 12/14/17 at 3:42 p.m. revealed a visitor observed the resident in the hallway in her wheelchair kicking her legs out against the wall causing the wheelchair to tip backwards. The resident denied hitting her head. Staff assisted the resident into the wheelchair. There was no fall assessment completed to determine causal factors. The IR identified no injury. A typed paper provided by the Administrator indicated the intervention following this incident as: assist resident out of room and to commons area when up in wheelchair. (The resident was out of the room when the fall occurred) 12/31/17 at 9:15 a.m., revealed staff observed the resident sitting on the floor of her room. Predisposing environmental factors was furniture and predisposing physiological factors was weakness/fainted. Predisposing situation factors was ambulating without assistance and improper footwear. A post fall assessment dated [DATE] at 9:15 a.m. revealed staff last toileted the resident at 4 a.m. and the fall occurred at 6:30 a.m. A typed paper provided by the Administrator indicated the intervention following this incident as: education on call light use and staff determined the resident purposely transitioned to the floor from bed. PT notes dated 12/7/17 identified the resident required verbal and tactile cues for balance control during transfers due to disease process. 1/4/18 at 3:16 p.m. revealed the resident fell backwards in the hallway and hit her head on the floor. Staff applied pressure to a wound on the back of the head to stop bleeding and applied ice to a hematoma. There was no fall assessment completed to determine causal factors. A typed paper provided by the Administrator indicated the intervention following this incident as: room change. Progress notes dated 1/4/18 at 11:07 a.m. identified a fall backwards in the wheelchair and the resident striking the back of her head sustaining a 5 cm. by 3 cm. bump with 0.3 cm. by 0.2 cm. cut. The bump on the head grew to 8 cm. by 8 cm. and staff sent the resident to ER (emergency room ). ER notes dated 1/4/18 at 11:32 a.m. identified a laceration to the head due to fall from nonmoving wheelchair. The resident could not communicate regarding the event but did say she had a headache. A CT performed in ER did not reveal an acute intracranial process. The physician documented there was a 0.5 cm. laceration to the back of the head that did not require sutures. The resident needed follow up with primary care provider (PCP) for recheck of the hematoma. The order was to follow up with PCP next week. A care plan dated 1/2/18 revealed an intervention dated 11/13/17 that directed staff to review past falls and determine cause of falls and record root causes. On 2/15/18 at 12:23 p.m. the DON stated the facility did not conduct neuro checks after the head injuries. Observation showed on 2/6/18 at 2:30 p.m. the resident in the center area seated in a wheelchair with anti tip devices. OT notes dated 1/5/18 revealed they worked with the resident and wheelchair vendor to implement temporary wheelchair with anti tippers. OT made wheelchair modifications and implemented a low profile cushion secured to the wheelchair seat and Dycem on top of the cushion. On 2/12/18 at 3:54 p.m. the surveyor asked the DON how a room change was an appropriate intervention for the resident after the 1/4/18 fall since it occurred in the hallway. The DON stated they wanted the resident closer so when she gets excited she will be closer to the center area. The DON stated the resident is self mobile in the wheelchair and gets excited and starts pedaling self. She has strength in her legs to kick them out and that causes her to go backwards. On 3/2/18, the facility abated the IJ when they replaced a mixing valve and updated their policy to ensure water temperatures are completed weekly. These findings lowered the IJ from a J severity level to an D with ongoing monitoring to ensure safe temperatures.

Based on observation, record review, resident and staff interviews, the facility failed to ensure that-a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 4 of 27 residents reviewed. Resident #1 did not have treatments done per order which resulted in infection and insertion of a PICC line for IV antibiotics. Resident #5 developed a pressure sore to the right heel. The area opened on 1/28/18 after staff applied a shoe to the right foot. (The physician previously ordered a heel boot to be worn on 1/17/18 on the right foot at all times) The TAR (treatment administration record) revealed treatment for [REDACTED]. The facility did not notify the physician the area was open until 1/31/18. Resident #7 had a band-aide covering an area on the outer right foot. There was no documentation available regarding the area. Later a wound nurse identified the area as a pressure injury. Resident #2 had a red coccyx for several days before the facility documented the area as present. The resident also had red heels that the family informed the facility of. The facility identified a census of 56 current residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 10/31/17 assessed Resident #1 with a brief interview for mental status (BIMS) score of 15 (no cognitive impairment). The MDS did not identify behavior concerns. The resident required extensive staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident did not ambulate. The resident had functional limitations in range of motion in both lower extremities. The resident used a wheelchair for mobility. The resident had an indwelling catheter and ostomy. The resident had [DIAGNOSES REDACTED]. The resident admitted to the facility 12/14/16. On 1/2/18 at 12:05 p.m. observation showed the resident in a wheelchair seated on a Jay cushion pressure reduction device. During interview the resident stated she had open areas on her bottom. She stated she was at home and came into the facility with them. She stated last week or the week before, a nurse did not perform treatments to her sores for 4 nights and now it's infected requiring antibiotic treatment. On 1/3/17 at 7:35 a.m. observation showed the resident on her back in bed with feet on the bed. The right foot was in a green boot resting on the bed. On the same date at 8:20 a.m. observation showed the resident on her back in bed with right foot in green boot resting on the bed. At that time, Staff A wound nurse stated the resident had a pea sized area on the heel that is treated by wiping it with skin prep. The resident also had areas on the tops of toes that received the same treatment. Observation showed at 9:40 a.m. no change in position. At 9:50 a.m. staff got the resident up from bed via Hoyer lift. Observation showed the resident's entire bottom covered with a white bandage. Staff removed the green boot and put a footie on the resident. The foot rested on the foot rest of the wheelchair. The resident left the facility at 11 a.m. and did not return until 5:30 p.m. On 1/2/18 at 4 p.m. Staff B RN (registered nurse) stated she was one of the wound nurses at the facility. She confirmed Resident #1 did not receive her skin treatment for 4 nights in a row last month. Staff B stated it contributed to the infection the resident has in the wounds at the present time. Staff B stated there was more drainage so she sent the resident to the wound clinic and they had to put in a PICC line to treat infection. Staff B identified Staff C as the nurse that did not perform the treatments. On 1/3/18 at 1:30 p.m. Staff A LPN (licensed practical nurse) identified herself as one of the facility wound nurses. She stated the night nurse did not do Resident #1's treatments at all for the last couple months. The sore got worse and infected and the lack of treatment contributed to that. She stated the night nurse told her she didn't have time to do the treatments. A note from the wound clinic undated revealed the clinic would insert a PICC line today and then directed staff to administer [MEDICATION NAME] (antibiotic) 1 gram daily for a month. A final report dated 12/20/17 identified the resident as having beta lactamase positive peptostreptococcus in the wounds. Measurements 11/24/17 from nursing progress notes: Left ischium 15 cm. by 6.2 cm. by 1.7 cm. Right gluteal crease 1.8 by 1.9 cm. Coccyx 8.4 by 11.9 by 2.4 cm. Right ischium 9.1 by 3 by 1.7 cm. Measurements 12/14/17 from nursing progress notes: Back of right thigh 1.5 centimeters (cm.) by 1.5 cm. by 0.1 cm. Left ischium 12.8 cm. by 6.2 cm. by 1 cm. Right gluteal crease 1.2 by 1.4 cm. Coccyx 8.1 by 10.7 by 2.4 cm. Right ischium 9 by 3.2 by 1.2 cm. Treatments not done between these measurements Measurements 12/21/17 from nursing progress notes: Back of right thigh 1.5 cm. by 1.5 cm. by 0.1 cm. with scant amount of serosanguineous drainage Left ischium 13 cm. by 7.2 cm. by 1.5 cm. scant amount of serosanguineous drainage Right gluteal crease 1.2 cm. by 1.5 cm. by 0.1 cm. red granulation tissue Coccyx 8 cm. by 10.2 cm. by 2.4 cm. with scant amount of serosanguineous drainage. Right ischium 9 cm. by 3.5 cm. by 1.5 cm. The resident begins IV antibiotics today. On 2/12/18 at 12:30 p.m. the director of nursing (DON) confirmed the treatments were not performed sometime between 12/14/17 to 12/21/17. On 1/23/18 at 9:23 a.m. the wound nurse from the wound clinic stated anytime dressing were not changed as ordered, it could contribute to infection. Not doing the dressing changes gives the bacteria a nice warm wet spot to multiply. The resident used Dakins solution and Dakins becomes ineffective once it dries out. The wound nurse stated they inserted a PICC line 12/20/17 to treat the infection and deliver the IV antibiotics every 24 hours for 30 days. She stated the resident's noncompliance did not help matters but since she is noncompliant it is important to do what she allows to treat the sores. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed Staff C LPN (licensed practical nurse) signed she performed the treatment 12/12/17 through 12/16/17. On 1/24/18 at 2:55 p.m. Staff C LPN stated she was the only nurse those nights and she had 4 other major treatments to complete. By the time she got to the resident, she would be asleep. The resident would get angry and was hard to wake up so sometimes she did not get the treatment done. Staff C was signing they were not done but the DON said she couldn't do that. The DON said she couldn't document asleep or only one nurse working. The DON instructed her to mark it off as done and just try to get it done so lots of times that is what Staff C did. She stated she worked 3 times a week and would get the treatment done half the time. She stated she informed the Administrator it was impossible to complete the treatments and the Administrator said she knew that. On 2/6/18 at 1 p.m. the Administrator denied saying she knew that. She stated she spoke with the ADON (assistant director of nursing) when they terminated Staff C and he said he could get the treatments done so they thought Staff C could too. Care Plan: A care plan dated 1/16/17 with revision on 9/28/17 revealed the resident had actual skin impairment related to ulcer that encompasses the ischials, coccyx and buttocks.[MEDICAL CONDITIONS] infection of skin. Resident admitted with these wounds. Resident with long standing ulcers to these areas that are unresolved due to her noncompliance with treatments and refusing to lay down or reposition side to side. She is to be up only for 1 hour at a time but she refuses once she is up. Abrasion to right great toe, ulcer to right heel, open area to right gluteal crease. Right knee abrasion. The care plan directed staff to use a dolphin mattress and pressure reduction to the wheelchair, encourage and assist with frequent repositioning to each shift and document refusals, document refusals, monitor document location, size and treatment of [REDACTED]. resident to have chux under her when in bed, treatments per doctor's orders, weekly skin assessments. On 2/12/18 at 12:30 p.m. the DON confirmed the resident refused repositioning in bed and wheelchair. OT (occupational therapy): An OT note dated 9/20/17 revealed the OT directed staff to replace the Jay cushion with a Vector X seat cushion and also obtain a Rook boot. On 1/25/18 at 12:26 p.m. the rehab director examined the green heel boot the resident used. He stated there was a white boot ordered for pressure in (MONTH) and the green boot was not what was ordered. He stated he didn't know where the green boot protector came from. On 1/31/18 at 1:21 p.m. the OT stated she spoke with the person that wrote the 9/20/17 OT note. She stated he wrote the vector cushion order to indicate the resident needed a high end cushion to get better pressure reduction but then he came to the facility and did pressure mapping and discovered what the resident had in place provided adequate pressure reduction so no change was made. She stated the green boot the resident currently used was also adequate for the heel. An OT discharge summary dated 10/20/17 revealed the current wheelchair pressure cushion was appropriate. The discharge summary stated a new pressure relieving boot ordered and they awaited delivery. The record failed to contain information that the current green boot was adequate and the new ordered boot was not needed. Observation: Observation showed on 1/25/18 at 7:55 a.m. the resident on her back in bed with the right foot in a green foot boot which lay on the bed. Staff A RN identified the resident as on an air mattress. Observation showed the right inner heel with a closed pea sized brown area and a brown area on the resident's toes. At that time, Staff A RN swabbed the areas with skin prep. Observation showed a large white bandage covering the entire coccyx/buttock areas. The bandage contained the date 1/24/18 and staff initials. Staff A identified the initials as hers from yesterday morning, indicating staff did not perform the treatment last night. Staff A confirmed the treatment was ordered twice a day. Staff A removed the large white bandage to expose large deep beefy red sores on the entire coccyx/buttock areas. Guaze 4 by 4's were present increases of the sores. At that time, the DON (director of nursing) stated the areas looked good. Staff A stated a lot of slough was gone and the resident had good fresh tissue present. Staff A scrubbed back and forth on the areas with 1/2 peroxide and 1/2 normal saline. Staff A used a new 4 by 4 to cleanse each area. Staff A then cleansed each separate area with normal saline and sponge dried the areas with clean 4 by 4's. Staff then applied Dakins soaked gauze to the open areas and covered the areas with a new bandage. Staff A then applied a new [MEDICATION NAME] bandage to a small open area on the back of the right thigh. At that time, the surveyor questioned the lack of cleansing of the area prior to applying the new bandage. Staff A stated that is the way the doctor wants it. Review of the (MONTH) (YEAR) treatment administration record (TAR) indicated the resident refused the buttock treatment the evening of 1/24/18. On 1/25/18 at 8:40 a.m. the resident stated she did not refuse the treatment last night. Review of the (MONTH) (YEAR) TAR revealed staff should clean the right back of the thigh wound with normal saline and pat dry prior to applying [MEDICATION NAME] to the wound. (Observation showed staff did not clean the wound). On 1/25/18 at 8:46 a.m. Staff A came to the surveyor and stated yes she normally did clean the right back of the thigh wound but she was nervous when she performed the treatment. She stated the resident got the wounds on the back of the thigh from tape. The record did not contain information of resident repositioning refusals each shift. On 2/13/18 at 11:44 a.m. the DON stated there was no documentation regarding the resident refusing repositioning. A consultation final report identified a hospital admission on 2/8/18. The reason for the consultation was listed as: decubitus ulcers of the sacrum. The report identified the right ischial ulcer measured 8 by 2.2 by 1.3 cm. The right gluteal ulcer measured 21 by 12 by 2.1 cm. The left posterior upper leg ulcer measured 1.5 by 1 by 0.2 cm. The assessment was Stage IV decubitus ulcers of the coccyx, left buttocks and right ischial decubitus ulcers. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. 2. A MDS with assessment reference date of 10/31/17 assessed Resident #5 with a BIMS score of 4 (severe cognitive impairment). The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident had delusions and no other behavioral symptoms including rejection of care. The resident required supervision with bed mobility and transfers. The resident required limited staff assistance with bed mobility, toileting. The MDS identified the resident with functional range of motion impairments of one side of the upper and lower extremities. The MDS identified the resident as continent of bowel and bladder. The skin condition section of the MDS revealed the resident was at risk for developing pressure sores. The MDS identified the resident used pressure reduction in the wheelchair and bed. The resident did not have pressure sores or venous or arterial sores. A Braden assessment dated [DATE] revealed in progress. Observations: On 1/2/18 at 4:35 p.m. observation revealed the resident in bed with no heel protectors on and heels in bed. The resident lay on his back. On 1/3/18 at 4:15 p.m. observation showed the resident in bed with no heel protectors on and heels in bed. The resident lay on his back on a concave pressure reduction mattress. On the same date at 5:15 p.m. the resident remained in bed as before. On 1/24/18 at 4:25 p.m. observation revealed the resident in a wheelchair. The resident had the right foot in a boot. The resident foot was bare with the top of foot and toes exposed. The resident's bare toes hit the resident's athletic shoe when the resident used the left foot to move the wheelchair. The resident came inside from being outside with bare foot exposed. On 2/15/18 at 8:53 a.m. per email the stage climatologist stated the temperature at the Sioux City airport on that date at 4:52 p.m. was 27 degrees with a wind chill of 17 degrees. The resident had a Band-Aid on the fourth and fifth toe of the right foot and a scab was present on the second toe. On 1/25/18 at 7:55 a.m. the resident sat in the dining room with the right foot in a blue boot that rested on the floor with the top of the foot and toes exposed. On the same date at 10 a.m. observation revealed the Band-Aid off the right foot toes. The resident had blood on the tip of the second toe and also a scab on the second toe and blood on the 4th toe. There was blood on the heel protector directly below the toes. At that time, the surveyor summoned Staff B (facility wound nurse) . When Staff B arrived there was blood on the floor from the toes. Staff B stated she knew the resident had scabs on his toes. At that time Staff B stated the resident needed a gripper sock to protect the exposed foot and toes. Staff B cleaned up the blood and threw it in the garbage. Staff B stated it appeared something cut the end of the second toe. She cleansed the area with normal saline and patted it dry with gauze. She then applied triple antibiotic ointment. At that time, observation revealed a large black area on the resident's right heel that Staff B swabbed with skin prep. Staff B stated she thought the heel sore developed from the position the resident's foot laid on the bed due to the right leg contracture. Staff B stated the contracture caused the heel to constantly press into the bed. Staff A left the resident in the wheelchair in the foot protector that rested on the floor. The resident sat with the left heel touching the tips of the toes of the right foot. Observation showed on 1/30/18 at 10:50 a.m. the resident up in the wheelchair with blue boot on the right foot. Staff B removed the boot and a bandage to the right heel. Observation revealed a large open area with dark drainage on the bandage. Also at that time Staff A applied a footie sock over the exposed toes and top of foot. Observation showed on 1/31/18 at 8:27 a.m. the resident in bed with the right foot in the blue boot that rested on the bed directly on the resident's pressure area. At that time, the surveyor summoned the DON (director of nursing) who agreed the pressure area was directly on the bed while in the boot. She stated they ordered the resident a brace to help with the situation. Subsequent observations at 9 a.m. 9:20 a.m., 10 a.m., 10:25 a.m. and 11 a.m. showed the resident in bed with the right foot in the boot that rested on the bed directly on the pressure sore site. At that time, 2 staff were in the room to get the resident up for lunch. Observation showed at 11:40 a.m. the resident at the table with right foot in the boot with the top of the foot and toes uncovered and exposed. The right foot sat on the floor with the resident's left heel resting directly on top of the right 1st and 2nd toes. observation at 12:20 p.m. and 12:55 p.m. showed the resident's right foot on the floor with nothing protecting the exposed toes. The boot rested directly on the floor. A fax to the physician dated 1/17/18 revealed an order for [REDACTED]. A skin wound note faxed to the physician dated 1/26/18 at 6:15 a.m. revealed the right heel pressure sore measured 5.6 cm. by 7.4 cm. [MEDICATION NAME] tissue (not open) dark purple. On 1/13/18 a physician order [REDACTED]. On 2/28/18 at 2:46 p.m. Staff B RN confirmed when she charted [MEDICATION NAME] that meant the wound was not open. Treatment orders dated 1/31/18 revealed the physician ordered the following treatment to the heel: cleanse ulcer to right heel with normal saline, pat dry and apply [MEDICATION NAME] dressing daily. Review of the (MONTH) and (MONTH) (YEAR) TARs revealed staff started the treatment on 2/1/18. Observation revealed on 2/1/18 at 12:08 p.m. the resident with the blue boot on the right foot with the top of right foot and toes exposed. On 2/7/18 at 4:15 p.m. the surveyor asked if the dietician assessed the resident's dietary needs since he had an open area. On 2/8/18 at 9:55 a.m. the Administrator stated the dietician comes weekly and would assess the resident tomorrow. A wound center history and physical dated 2/7/18 revealed the resident would have recommendations for 1 can of Glucerna (protein supplement for healing) daily to meet nutritional needs during the course of healing. The assessment of the wound was identified as :Diabetic heel ulcer Wagner grade II originating as pressure ulcer unstageable nonhealing secondary to diabetes fat layer exposed. They directed the facility to use a ProCare shoe for the right foot. Wagner Grade 2 is a deep ulcer penetration through the subcutaneous tissue, potentially exposing bone, tendon, ligament or joint capsule A wound culture dated 2/7/18 revealed the resident had [MEDICAL CONDITION] resistant staph aureus (MRSA) in the right heel wound. A telephone order dated 2/8/18 at 11:27 a.m. revealed an order for [REDACTED]. On 3/7/18 at 3:03 p.m. the DON stated Glucerna was not ordered and the facility did not ask the physician about ordering it. The information found about the resident needing Glucerna was in a history and physical progress note. A dietary nutrition progress note dated 2/8/18 at 12:28 p.m. revealed the resident had a significant weight loss of 5% in the past 30 days and 10% in the past 6 months. The dietician recommended the physician order [REDACTED]. The dietician documented the resident [MEDICAL CONDITIONS] in the wound. Review of the (MONTH) (YEAR) MAR/TAR revealed an order for [REDACTED]. He didn't know why it was ordered daily instead of BID as the dietician recommended. On 3/8/18 at 12:53 p.m. the physician's nurse stated she could not find an order for [REDACTED]. A progress note dated 2/10/18 at 4:27 a.m. revealed the resident's right heel pressure sore measured 5 cm. by 9.3 cm. by 0.1 cm. with scant serosanguineous drainage. The upper right heel area measured 1.1 cm. by 1.8 cm. Progress notes dated 2/15/18 at 6:48 a.m. revealed Staff A LPN (licensed practical nurse) entered the room to perform the resident's right heel treatment and assessment. There was no bandage on the heel. Staff S cleansed the area and applied a new bandage. Interviews: On 2/1/18 at 2:20 p.m. Staff A LPN stated the resident's heel opened because on Sunday (1/28/18) the CNAs placed a shoe on the right foot causing the heel to open. She stated she had not measured the area since it opened. At that time, the surveyor asked if they could get measurements of the right heel today before the surveyor left. Staff A measured the wound as 5 cm. in length and 9.3 cm. in width. At that time, Staff A also noticed an open area on the back of the resident's heel measuring 1.1 cm. by 2.1 cm. On 1/30/18 at 3:45 p.m. Staff P CNA stated she wasn't sure how he got the sore on his heel. Last week it was bleeding and staff had to change his sheets. Staff P stated the resident's right leg contracture makes the heel go into the bed. On 1/30/18 at 12:54 p.m. Staff R CMA stated the resident's heel was open and there was [MEDICATION NAME] on it when she gave him a bath. She stated his right leg is contracted and the foot scrapes the floor. The resident's heel rests on the mattress when in bed because of the contracture. On 1/30/18 at 3:12 p.m. Staff S CNA the resident's didn't use a heel boot until about a week and a half ago. The resident's heel digs into the bed even with the boot on. 3. A MDS with assessment reference date of 12/4/17 assessed Resident # 7 with a BIMS score of 12 (moderate cognitive impairment). The resident had no behaviors identified including rejection of care. The resident required extensive staff assistance with bed mobility, dressing, toileting and personal hygiene. The resident required total staff assistance with transfers and bathing. The resident did not ambulate. The resident had functional limitations in range of motion of both lower extremities. The resident had an indwelling catheter and was always incontinent of bowel. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident at risk for pressure sores. The MDS identified the resident with 6 venous and arterial ulcers but no pressure sores. A final report dated revealed the resident was hospitalized [DATE] to 11/27/17 with nonhealing diabetic ulcer of the left lower extremity left heel ulcer with exposed tendon and bone, Wagner grade III with wound infection and muscle necrosis. The resident had [MEDICAL CONDITION] of the left lower extremity and positive wound cultures. A Wagner Grade 3 is a deep ulcer with osteitis, abscess or osteo[DIAGNOSES REDACTED]. Observation showed on 1/2/18 at 2:05 p.m. the resident in bed on her back with the head of the bed up. The resident used an indwelling urinary catheter. On the same date at 2:08 p.m. observation showed a foam boot on the left foot. The left foot was wrapped in white gauze that was dated 1/2/18 and that was wrapped in chux and then the foam boot. The resident's left foot laid to the left. The right foot was bare and there was a Band-Aid present on the outer right foot just below the small toe and laid on the bed. The resident laid on a blue pressure reduction mattress. Observations at 2:26 p.m., 4 p.m. and 4:25 p.m. revealed the resident laying in bed as before with no change in feet position. The right foot laid on the bed. At 4:48 p.m. the resident was up in a wheelchair and had a gripper sock on the right foot on pedal and the left foot remained in a boot. Observation showed on 1/3/18 at 8 a.m. the resident in bed with both feet on the bed and the left in a boot and the right foot bare with a band aid on the outer right as observed on 1/2/18. At 9:03 a.m. the right foot remained on the bed. Staff A LPN (licensed practical nurse) provided treatment to the left foot. The left foot had a very large open area. Staff A used Dakins. Hyd[DATE] on gauze and wrapped the left foot with gauze. The band aid remained on the right foot. At that time, Staff A viewed the area on the right outer foot with the surveyor. The area was approximately 25 cent size, deep and open. On 1/3/18 at 11:30 a.m. the hospice wound nurse arrived. The wound nurse stated the area on the outer right foot was a new pressure injury and stated it would be better if the resident's feet were free-floating. The hospice wound nurse note dated 1/3/18 directed staff to apply full strength Dakins solution moistened 4 by 4's or small ABD to the unstageable pressure injury to the right medial foot near the 5th digit (little toe). Secure with Kling and change daily. The wound nurse also directed staff to apply a Prevalon boot to the right lower leg at all times. Review of progress notes did not identify when the area opened or who/when a band aide was applied. A skin grid form dated 11/27/17 identified a 2 centimeter (cm.) by 1.8 cm. scabbed area to the right lateral foot present on admission from the hospital on [DATE]. The skin grid contained dates 12/29/17, 1/5/18 and 1/12/18. The dates did not contain follow up assessments but stated the resident refused measurements because of pain. A MD/nursing communication identified the right lateral foot area present on 11/3/17 when the physician ordered [MEDICATION NAME] and [MEDICATION NAME] to the right lateral ulcer. A hospice wound note dated 11/28/17 directed staff to discontinue all current treatment to the right foot. Staff should monitor for drainage/[DIAGNOSES REDACTED] and notify hospice wound nurse of changes. On 2/1/18 at 1:06 p.m. Staff A LPN confirmed the skin grid form for the right lateral foot was the same area she viewed with the surveyor on 1/3/18. Staff A stated after she viewed the area with the surveyor she got treatment orders for the area. 4. A MDS with assessment reference date of 10/30/17 assessed Resident #2 with a BIMS score of 13 (no cognitive impairment). The MDS revealed the resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene and total assistance with bathing. The resident did not ambulate. The resident had an indwelling urinary catheter and occasionally incontinent of bowel. The resident had a surgical wound. The MDS did not identify any other areas of skin impairment. The resident expected discharge to the community. An ADL (activity of daily living) CAA (care area assessment) worksheet dated 11/1/17 revealed the resident recently admitted to the facility after an acute hospital stay for back surgery, laminectomy. The resident was on strict bedrest and received skilled care for IV (intravenous) therapy. The resident's goal was to work with therapy once he was off bedrest to improve ADL abilities and then return home. A nutritional status CAA dated 11/2/17 revealed the resident's bed could not be elevated higher than 15 degrees. A pressure ulcer CAA dated 11/1/17 identified the resident at risk for pressure ulcers. Progress notes revealed the following: 10/23/17 at 4:58 p.m. revealed the resident arrived at the facility per ambulance. Admission progress notes identified the resident's buttocks were intact and without redness. 10/30/17 at 5:17 a.m. the resident complained of pain across the abdomen and across butt. There was no abdominal assessment of assessment of the resident's bottom. 10/31/17 at 12:24 a.m. revealed the resident complained of pain across the lower back and butt. The resident rated the pain as a 5. Staff administered [MEDICATION NAME]. There was no assessment of the resident's back or buttocks. Skin grid forms dated 11/5/17 revealed a 5 centimeter (cm.) by 6 cm. red are to the coccyx, a 1 cm. by 1 cm, red blanchable area to the right heel and a 3.5 cm. by 2.5 cm. red blanchable area to the left heel. On 2/1/18 at 10:09 a.m. the resident's daughter stated she was informed the resident had a red coccyx on 11/1/17 and the daughter informed the facility about the resident's heels. On 1/31/18 at 8:45 a.m. Staff A LPN (licensed practical nurse) stated the day she saw the resident had red heels the resident's daughter asked her about the heels. That day was the resident's assessment day. Staff A then realized the resident better have something on his heels since he was in bed all day. She stated there was no treatment for [REDACTED]. Staff A stated the resident's coccyx was looking rough when he came and he had [MEDICATION NAME] for it when he came. Review of admission documentation and orders dated 10/23/17 failed to identify any concerns with the resident's coccyx on admission or orders for [MEDICATION NAME]. Facility documentation failed to identify concerns until 11/5/17. On 1/31/18 at 8:35 a.m. Staff G CMA stated the resident's bottom was red. The resident's incision was seeping gooey drainage that was green. On 1/30/18 at 1:45 p.m. Staff H CNA stated the resident did have skin breakdown on his bottom. On 1/31/18 at 11:25 a.m. Staff O RN (registered nurse) stated she thought the area around the surgical back wound was a little red. On 1/30/18 at 3:12 p.m. Staff S CNA (certified nurse aide) stated the resident's bottom was red but not open.

Based on observation, record review resident and staff interview, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 27 sampled residents. Resident #12, Resident #13, Resident #2 and Resident #14 went without needed pain medication. The facility identified a census of 56 current residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date 11/21/17 assessed Resident #12 with a brief interview for mental status (BIMS) score of 11 (moderate cognitive impairment). The MDS identified the resident with occasional pain with the worst pain rated a 6(with 0 being no pain to 10 being the worst pain) in the previous 5 days. The resident had [DIAGNOSES REDACTED]. During observation of medication pass on 1/2/18 at 12:27 p.m. the resident stated he wanted his pain pill. At that time, Staff Q LPN (licensed practical nurse) informed the resident that his pain medication was not at the facility yet. Staff Q then informed the surveyor that the resident had not received his pain medication since he returned from the hospital. She planned to check and see if he still had it ordered. Review of Resident #12's records revealed the resident went to the hospital 12/29/17 and returned 12/30/17. Discharge orders from the hospital dated 12/30/17 revealed the resident returned with [MEDICATION NAME] reordered as before. Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 2/13/18 at 9:49 a.m. the pharmacy stated the first delivery of [MEDICATION NAME] after the 12/30/17 hospital was on 1/9/18. On 2/6/18 at 1:57 p.m., the Administrator stated the resident's [MEDICATION NAME] was increased and they were trying to keep the resident from using [MEDICATION NAME]. She stated the resident has [NAME]D ([MEDICAL CONDITION]) and it's more of a ritual thing for the resident. A (MONTH) (YEAR) MAR indicated [REDACTED]. Upon return from the hospital on [DATE] the MAR indicated [REDACTED] A care plan dated 3/21/17 identified the resident with a problem of potential for pain related to depression and chronic pain. The care plan directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain as needed. 2. A MDS with assessment reference date of 1/29/18 assessed Resident #13 with a BIMS score of 15 (no cognitive impairment). The pain section of the MDS identified the resident in almost constant pain over the previous 5 days. The pain made it hard for the resident to sleep at night and limited day to day activities. The resident identified the worst pain on a level of 7 (on a scale of 0 to 10 over the previous 5 days with 0 being no pain and 10 being the worst pain). A health status progress note dated 1/18/18 stated the resident was at the facility for skilled care and to receive PT (physical therapy) and OT (occupational therapy) . The resident was previously in the hospital for total left knee replacement. The left knee had 27 staples in place with scattered bruising. On 1/30/18 at 3 p.m. the resident stated he had not received any pain medications all day and the facility was out of pain pills for 3 days. He stated he received [MEDICATION NAME] but they were barely helpful. He was supposed to get [MEDICATION NAME]. After visiting with the resident on 1/30/18, the surveyor reported the information to the DON (director of nursing). On 1/31/18 at 8:20 a.m. the resident rated his pain during the time of [MEDICATION NAME] unavailability as 8.5 to 9. He stated he did get a [MEDICATION NAME] yesterday right after he spoke with the surveyor. Progress notes dated 1/28/18 at 2:15 p.m. revealed the resident worked with OT and could not perform full range of motion due to increased pain. The resident was out of [MEDICATION NAME] and the pharmacy would not refill without an original script. Staff administered 2 [MEDICATION NAME] and 2 Tylenol with little pain relief. Progress notes dated 1/30/18 at 3:35 p.m. revealed the resident returned from an appointment with a script to refill the [MEDICATION NAME]. The resident was upset that the PRN (as needed) pain medication ran out. The DON faxed the pharmacy the refill order and got the authorization code to administer [MEDICATION NAME] from the e-kit. The care plan dated 1/31/18 revealed a problem of adjustment issues since having knee surgery and admission to the facility. The resident stated his pain made it difficult to enjoy things. The (MONTH) (YEAR) MAR indicated [REDACTED]. 3. A MDS with assessment reference date of 10/30/17 assessed Resident #2 with a BIMS score of 13 (no cognitive impairment). The MDS revealed the resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene and total assistance with bathing. The resident did not ambulate. The resident had a surgical wound. The MDS identified the resident with occasional pain. The resident rated the pain as a 2 over the previous 5 days. An ADL (activity of daily living) CAA (care area assessment) worksheet dated 11/1/17 revealed the resident recently admitted to the facility after an acute hospital stay for back surgery, laminectomy. Review of admission orders [REDACTED]. give one tablet every 4 hours as needed. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] Progress notes dated 10/26/17 at 11:13 p.m. revealed staff administered one Tylenol 325 mg, for bilateral leg pain. Progress notes dated 10/27/17 at 5:09 a.m. revealed the medication was: ineffective. Progress notes dated 10/27/17 at 1:21 a.m. revealed staff administered one [MEDICATION NAME]/[MEDICATION NAME][MEDICATION NAME] capsule 200/25 mg. for continued complaints of discomfort and resident unable to sleep. On 10/27/17 at 5:09 a.m. staff documented the medication was: ineffective. Progress notes dated 10/27/17 (4 days after admission) at 3:23 p.m. revealed the charge nurse spoke with the physician and the PA (physician assistant) would write a prescription for [MEDICATION NAME]/[MEDICATION NAME] and the pharmacy would bring it that night. On 2/1/18 at 10:09 a.m. the resident's daughter stated she visited almost daily. The resident had a lot of pain when the narcotic pain medication was not available. On 10/26/17 the resident was upset because a nurse told the resident he should not be having pain. On 2/14/18 at 3:29 p.m. the physician stated no pain medication for 4 days was a concern. 4. A MDS with assessment reference date of 12/20/17 assessed Resident #14 with a BIMS score of 15 (no cognitive impairment). The pain section of the MDS identified the resident in almost constant pain. Pain limited the resident's daily activities and affected the resident's ability to sleep. The resident identified the pain as a 6 in the previous 5 days (on a scale of 0 being no pain and 10 being the worst imaginable pain). On 1/30/18 at 9:22 a.m. the resident stated they did not have the next script to get her pain medications refilled. She stated the last pain medication she received was at 6 p.m. the previous night. She stated she hurt and aches all over at this time. She explained she had torn rotator cuffs on both sides and other issues that cause her a lot of pain. She rated her pain as 6 to 7 at the time of interview. She stated she was out of [MEDICATION NAME] and [MEDICATION NAME] both. She doesn't even get Tylenol at this time. She stated she will be going through withdrawals soon. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The resident did not receive the 5 a.m. dose of the [MEDICATION NAME]/[MEDICATION NAME] on 1/31/18. 5. On 1/31/18 at 8:45 a.m. Staff A LPN (licensed practical nurse) stated the pharmacy doesn't let the facility know when the resident is out of refills until they try to reorder the narcotic. Then they have to wait for a script from the physician to get more. She stated Resident #14 needed a refill now. They can't get the medication out of the emergency kit unless staff has a code to open the box. 6. On 1/30/18 at 9:35 a.m. the Administrator stated she was aware there was a problem with initial admission scripts but not on refills.

Based on review of records and manufacturer's guidelines, staff interviews and review of a policy and procedures, the facility failed to ensure Resident #3 received the correct dosage of medication as ordered by the physician which caused a significant medication error and placed the residents at risk of an immediate jeopardy when medications are not measured correctly and administered. The sample consisted of 5 residents and the facility reported a census of 47 residents. Findings include: Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 6/22/17. The assessment identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 1. A score of 1 represented severe cognitive impairments. The MDS indicated the resident continually exhibited inattention, disorganized thinking without fluctuation and required extensive assistance for activities of daily living. The resident received hospice services. The resident's Care Plan identified a problem initiated on 11/22/15. The plan identified the resident had [MEDICAL CONDITION] activity as well as frequent twitching and jerking movements and directed staff to administer medications as directed by the physician. The physician order [REDACTED]. This medication is used for the treatment of [REDACTED]. The Medication Administration Record [REDACTED]. The Progress Notes entry dated 7/25/17 at 1:31 PM documented a CNA reported the resident as not very responsive. The patient did not respond verbally, but opened his/her eyes to voice and stimulation. The resident's blood pressure measured 121/90, pulse 98 (normal is 60-100 beats per minute) and oxygen saturation measured 98% (normal 97-100 %). Staff notified hospice of the resident's declining condition and the agency said they would send staff out (to the facility). On 8/9/17 at 10:12 AM, Staff A (nursing and medical assistant) stated a CNA reported to her the resident jerked may had [MEDICAL CONDITION] activity. Staff A stated she did not notify the charge nurse of this finding, but knew the resident had an order for [REDACTED]. Staff A stated she did not seek assistance from the charge nurse about how to measure the proper dosage. Staff A stated the Director of Nursing (DON) came to her shortly after staff reported the resident with decreased responsiveness. Staff A stated she told the DON she had not been sure how to measure the [MEDICATION NAME] and the MAR indicated [REDACTED]. She said the DON told her the medication should be measured in a syringe but neither of them could locate one to use. Page 7 of the manufacturer's guidelines documents the medication supplied in a bottle of 2 mg/ml solution with a calibrated dropper (graduations of 0.25 ml (0.5 mg), 0.5 ml (1 mg), 0.75 ml (1.5 mg) and 1 ml (2 mg) on the dropper). The guidelines further direct to dispense only in the bottle and only with the calibrated dropper provided. On 7/28/17 at 3:00 PM the pharmacist stated each bottle of [MEDICATION NAME] is dispensed with a reusable dropper that is calibrated to measure the correct dose because dosages are a small amount due to the high concentration of medication. An email dated 7/25/17 and sent to the resident's managing hospice nurse by the visiting hospice nurse, documented the facility staff expressed the concern the resident may have been given too much [MEDICATION NAME] and requested clarification of the order. The visiting hospice nurse compared the order on the MAR indicated [REDACTED]. During interview on 7/27/17 the DON and administrator stated no medication errors were reported so far this month. On 7/28/17 at 10:55 AM, the DON stated there had been an issue with administration of [MEDICATION NAME] to Resident #3 a few days before, but she did not consider it to be a medication error as she felt Staff A did not administer more than the resident's order but acknowledged Staff A did not know how to measure the correct dose and guessed how much of the liquid she administered. The DON stated she did not check with other staff to see if they were competent in measuring the correct dose. When asked how she would expect staff measure the correct amount the DON stated she thought staff could use a [MEDICATION NAME] syringe to measure but she could not demonstrate this and could not locate the dropper that comes with the bottle. The policy and procedures titled Medication Management dated 5/14, documented failure to dispense the correct amount of medication as one of the many types of medication errors. The policy also directed the following guidelines for identifying a medication error: A Staff member who identified a medication error must: Assess the resident immediately upon identification of the medication error, Notify the physician/prescriber as soon as possible, Communicate and collaborate with clinical and, supervisory personnel if unsure how to proceed, Notify nursing administration and complete. Medication Error Report form Review of the resident's clinical record revealed no ongoing assessment of the resident after initial assessment on 7/25/17 at 1:31 PM. An entry completed by the DON on 7/28/17 at 2:37 PM documented the resident's daughter and primary care physician were notified of a possible medication error which occurred on 7/25/17. The Progress Notes dated 7/28/2017 at 5:01 P.M. indicated the resident alert and oriented per the resident's norm. The resident's blood pressure measured 116/72, pulse 78, respirations 20 and temperature 97.2 (normal 98.6). The nurse reoriented the resident to time and place. The lung sounds clear and heart tones regular. The resident had bowel sounds present and active in all four quadrants. The resident denied pain at this time. Note: At the time of the complaint investigation, the complaint was coded as a J, immediate and serious jeopardy. By 8/1/17 the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the D level. The facility provided in-service training about the administration of liquid medications, including [MEDICATION NAME] and concentrated medication and the medication policy and procedures to all nurses and certified medical assistants. The nurses and the medical assistants gave returned demonstrations. As of the 8/23/17 exit conference, the facility needed to continue to: · Continue to monitor staff during medication administration to ensure liquids medications are administered per the physician's orders [REDACTED]. · Continue to provide in-services to licensed nurses and certified medical assistants to ensure compliance with the facility medication policy and procedures.

Based on record review, staff interview and review of the policy and procedures, the facility failed to timely and adequately assess Resident #3 after vomiting brown and fecal odor matter. Although the resident had a history of [REDACTED]. The sample consisted of 5 residents and the facility reported a census of 47 residents. Findings include: 1. Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The same MDS documented a Brief Interview of Mental Status (BIMS) score of 1. A score of 1 represented the resident had a severe cognitive impairment. The MDS indicated the resident continually exhibited inattention and disorganized thinking without fluctuation. The MDS indicated the resident required extensive assistance for completion of transfer, bed mobility, dressing, wheelchair mobility, toileting and hygiene. The resident received hospice services. The Hospice Care Interdisciplinary Team ( IDT) Report dated [DATE] identified the resident's safety at risk due to risk of bleeding and documented caregiver (facility staff) able to verbalize understanding of when to contact hospice and directed staff assess the patient for signs of bleeding: weakness/irritability, restlessness, changes in vital signs, [MEDICAL CONDITION], color and consistency of stool/vomitus, petechia, ecchymosis (bruising) and bleeding from one of more sites. The IDT Report also documented the resident admitted to hospice on [DATE] for the primary [DIAGNOSES REDACTED]. The Progress Notes entry created [DATE] at 7:06 AM by Staff D, temporary agency registered nurse (RN), for the effective date of [DATE] at 5:03 AM documented the resident had dry heaves at the beginning of the shift and just now vomited a large amount of dark brown emesis that smelled like bowel movement (BM). The note documented the resident's temperature as 98.6 degrees (normal), pulse 105 (normal ,[DATE]). respirations 20 (normal ,[DATE]) and blood pressure ,[DATE]. The note indicated the staff positioned the resident on his/her side most of the shift. Staff D documented the resident had no as needed (PRN) medication for nausea. The nurse documented she reported the findings to the oncoming shift. On [DATE] at 2:10 PM Staff D (registered nurse) was interviewed and stated around 9:,[DATE]:45 PM on [DATE] she had been in the resident's room completing a treatment for [REDACTED]. She instructed the certified nursing assistants (CNA's) attending to the resident at that time, to turn the resident to his/her side, place a cool cloth on his/her forehead and to place something near the resident so she/he could vomit into and to obtain the resident's vital signs. The CNA's reported the resident had vomited dark brown material. Staff D did not see the emesis but did see a brown substance on the washcloths. The CNA's reported the emesis smelled like BM. Staff D stated she monitored the resident throughout the rest of the shift and CNA staff did not report any further emesis so she did not complete an assessment of the resident or document the checks she did on the resident through her shift. Staff D stated she felt the resident's condition appeared stable as she/he did not vomit again. Staff D stated although this occurred on [DATE] around 9:,[DATE]:45 PM she did not chart it until [DATE] at 7:06 AM and chose to make the entry effective for the time of 5:03 AM so other staff would know that it occurred on the night shift. Staff D stated she worked from 2:00 PM on [DATE] through 6:00 AM on [DATE]. Staff D stated she likes to chart a summary of resident occurrences at the end of her shifts, rather than around the time they actually occurred. Staff D stated she did contact the on-call hospice nurse and reported the resident's condition and requested PRN medication order for nausea at the end of her shift and also reported the findings to the oncoming nurse. A Progress Notes entry completed by Staff C, temporary agency licensed practical nurse (LPN) on [DATE] at 8:00 AM documented the resident had a foul-smelling emesis at 6:30 AM. The resident's temperature documented as 100.3, pulse 120, respirations 36 and blood pressure ,[DATE]. The entry also documented the resident's former physician's (before being admitted to hospice) nurse and the resident's daughter were notified of the resident's condition. On [DATE] at 2:11 PM, Staff C was interviewed and stated she did not visualize the emesis that Staff E, CNA, reported occurred around 6:30 AM. Staff C stated she knew the resident had a coffee-ground emesis around 8:,[DATE]:00 AM because she saw it when leaving the resident's room after completing his/her roommate's treatment. Staff C stated the resident verbally responded to her at this time as she asked the resident if s/he felt okay and the resident said yes. Staff C stated the resident chattering in his/her usual garbled speech. She asked the CNA's to clean the resident up. Staff C stated she did not assess the resident at this time and did not document her observation; she also acknowledged emesis with coffee-ground appearance usually indicated possible [MEDICAL CONDITION]. On [DATE] at 11:17 AM Staff E (certified nursing assistant) stated she worked 10:00 PM on [DATE] through 2:00 PM on [DATE] and had been assigned to residents living in Resident #3's hallway. Staff E stated the resident vomited multiple times on her shift and she reported them each time to Staff D and Staff C. Staff E stated the resident vomited black/brown foul-smelling liquid and she kept the resident rolled to his/her side with the head of the bed up and checked on him/her frequently through her shift. Staff E stated she tried to keep the resident clean and dry and comfortable and kept cool cloths on his/her forehead throughout her shift. Staff E stated the hospice nurse came to see the resident around lunch time on [DATE] and instructed her to keep the resident's head of the bed up a little bit and keep the resident on his/her side as much as possible. The hospice nurse also informed her the resident could have sips of pop if she/he wanted them. Staff E stated the resident responded verbally to her throughout her shift, but knew the resident did not feel well. On [DATE] at 10:30 AM, the managing hospice nurse for Resident #3 stated she visited the resident around lunch time on [DATE]. The hospice nurse stated she spoke with Staff C who told her the resident vomited during the night and staff had reported it smelled like BM, but subsequent emesis appeared to be like bile. Staff C denied the emesis looked like coffee grounds when questioned. The hospice nurse said she instructed Staff E to keep the resident on his/her side to decrease the risk of aspiration if the resident vomited again and also told her the resident could have sips of 7-UP if requested. The hospice nurse stated she checked the resident's BM record provided to her by the administrator, because Staff C had reported the emesis smelled like BM but the resident's record documented several BM's during that day and the preceding days. A Progress Notes entry made by the hospice nurse dated [DATE] at 12:28 PM documented the resident had emesis 3 times and that she called the physician to request an order for [REDACTED]. A late entry Progress Note entry by Staff B (agency licensed practical nurse) on [DATE] at 10:32 PM documented the resident passed away on [DATE] at 1600 (4:00 PM). On [DATE] at 10:40 AM, Staff A, CNA stated she worked the 2:00 PM-10:00 PM shift on [DATE] and had been assigned to the resident's hall. Staff A stated that she checked the resident at 2:00 PM and found the resident lying in bed on his/her back, a washcloth over his/her forehead with the head of the bed up slightly. Staff A stated the resident's eyes were open and staring off into space. Staff A stated she did not check on the resident again until 4:00 PM at which time she found the resident swimming in brown/back emesis. Staff A stated the resident's skin had a yellowish color and not breathing; Staff A stated the resident not stiff but dead. She and another CNA cleaned the resident up and every time they rolled the resident, large amounts of black/brown liquid ran from his/her mouth. Staff A stated she notified Staff D, charge nurse on another hall, of the resident's death after she cleaned the resident up as she could not locate her charge nurse Staff B. On [DATE] at 2:10 PM Staff D stated that Staff A came to her and reported she thought the resident had expired. Staff D stated she could not locate Staff B so she told the director of nursing (DON). Staff D stated the resident had no pulse, respirations of blood pressure at 4:00 PM and considered this to be the resident's time of death; she then notified hospice the resident had expired. During interview on [DATE] at 9:50 AM the corporate compliance nurse stated she received an email from the nurse consultant on [DATE] after she returned home from the facility on [DATE]. Because of previous concerns identified during past complaint surveys, the corporate nurse consultant monitored resident electronic health record documentation on a daily basis. The nurse consultant expressed concerns about the lack of documentation of resident assessments, etc. She directed the facility to have Staff B complete a late entry regarding the resident's death on [DATE]. Attempts to contact Staff B for an interview through her personal number or through her agency had been unsuccessful. The facility policy and procedures titled Clinical Change of Condition Management dated ,[DATE] directed the following: Overview: The Interdisciplinary team strives to identify and manage all resident/patients that are experiencing a change of condition. Daily observation and communication is important in identifying changes in a resident/patient that requires further investigation. Daily observation includes but is not limited to changes in: participation in daily routines physical assessment (i.e. cardiovascular, respiratory, mental status, neurological) behavior mobility comfort level response to medications Clinical care management includes routine assessment, evaluation, response to changes in clinical condition and communication with resident/patients and/or families/responsible parties. Procedure: 1. Assess the resident/patient clinical status when a change in condition is identified. This may include but is not limited to: vital signs lung sounds pulse oximetry (blood oxygen level) bowel sounds skin color, turgor, temperature pain 2. Review the resident/patient medical record including but not limited to: primary [DIAGNOSES REDACTED].>lab work medication changes changes in nutritional status advanced directives allergies [REDACTED]. contact the physician and provide clinical data and information about the resident/patient condition. Document notification and physician response in the resident/patient medical record. Initiate any new physician orders. 5. Document documented on the Change of Condition Data Collection Tool. 6. Document resident/patient condition and location on the 24 hour report. The Clinical Programs Manual Documentation policy dated ,[DATE] directed the following: 1. Document all information on the Change of Condition Data Collection Tool unless otherwise indicated. 2. Complete evaluation of the resident/patient change of condition. Evaluation of conditions may include, but are not limited to: Abdominal pain, discomfort, distension to assess abdominal palpation, bowel sounds, quantity and description of vomit/diarrhea, hemocult if possible blood.

Based on observation, staff interviews, record review and review of the policy and procedures, the facility failed to assure all residents with pressure ulcers receive appropriate care and services to promote healing, prevention of infection and prevent new ulcers from developing for 5 of 5 residents reviewed. Due to lack of services for the identification, assessment, identification, prevention of wound development and interventions to promote healing, this placed an immediate jeopardy situation for residents at risk and residents with pressure ulcers (Residents #7, #8, #11, #13 and #16). The facility identified a census of 56 residents. Findings include: 1. Resident #7 had a Minimum Data Set (MDS) assessment with a reference date of 5/3/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The same MDS documented a Brief Interview of Mental Status (BIMS) score of 15. A score of 15 represented no cognitive problems. The MDS indicated the resident depended upon staff for transfers, used a wheelchair for mobility, required extensive assistance of two staff members for bed mobility, dressing, toileting and personal hygiene. The MDS indicated the resident had a [MEDICAL CONDITION] (surgical opening in abdomen into colon for collection of stool into a sealed bag) and an indwelling catheter (tube into bladder to drain urine into a bag). The MDS identified the resident had 3 unstageable pressure ulcers present on admission. The admission MDS dated [DATE] documented the resident had an admission date of [DATE] with 3 Stage III pressure ulcers and the largest 1 measured 6 cm x 6 cm x 2.4 cm. The Care Plan problem initiated 1/16/17 and revised on 4/5/17 identified the resident had ulcers on his/her ischial tuberosities (lower buttocks), coccyx and buttock that were present on admission. The care plan further identified the areas are long standing ulcers that are unresolved due to the resident's non-compliance with treatments and refusal to lay down or reposition side to side. The care plan directed the resident only be up for 1 hour at a time, to follow facility protocol for treatment of [REDACTED]. integrity, complete weekly skin assessments per facility policy and to monitor/document location, size and treatment of [REDACTED]. to the physician. The care plan also directed a Dolphin mattress on the bed per physician order [REDACTED]. The Results Details report dated 1/27/17 documented the resident verified as [MEDICAL CONDITION]-resistant staph Aureus (MRSA) positive via nasal swab and [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) positive per rectal swab on 1/19/17. The Skin Grid for Pressure Ulcers documented the following measurements of the coccyx pressure ulcer: On 5/3/17- full thickness wound measuring 6 cm x 5 cm x 2.0 cm with moderate amount of yellow drainage with tissue type G(granular)/S(slough) and wound bed color R (red)/Y(yellow) with no odor. On 5/10/17-full thickness wound measuring 6 cm x 5 cm x 2 cm with moderate amount of serosanguinous drainage with granular wound bed that is red in color with no odor. The next assessment dated [DATE] documented a full thickness wound which measured 23.5 cm x 14 cm x 2.0 cm with moderate amount of serosanguineous drainage with a granular wound bed red in color with no odor. On 6/14/17- full thickness wound measuring 14 cm x 8 cm x 2 cm with moderate amount of serosanguineous drainage with a granular wound bed red in color with no odor. The Skin Grid for Pressure Ulcers documented the following measurements of the right ischial area: On 5/3/17-full thickness wound measuring 13.0 cm x 6.0 cm x 1.8 cm with a moderate amount of yellow drainage with granular and slough tissue present in the wound base that is red and yellow in color with no odor. On 5/10/17-full thickness wound measuring 13.0 cm x 6.0 cm x 1.8 cm with a moderate amount of yellow drainage with granular and slough tissue present in the wound base that is red and yellow in color with no odor. The next assessment dated [DATE] documented a full thickness wound with a moderate amount of serosanguineous drainage with granular wound base red and yellow in color with no odor. The assessment contained the statement that all areas were measured but are not documented on the form or in the Resident Progress Notes. On 6/14/17-full thickness wound measuring 13.0 cm x 6.0 cm x 3.0 cm with a moderate amount of serosanguineous drainage with granular wound base red and yellow in color with no odor. The Skin Grid for Pressure Ulcers documented the following measurements of the left ischial area: On 5/3/17-full thickness wound measuring 13.0 cm x 5.0 cm x 2.0 cm with a moderate amount of yellow drainage with granular and slough tissue present in the wound base that is red and yellow in color with no odor. On 5/10/17-full thickness wound measuring 13.0 cm x 5.0 cm x 2.0 cm with a moderate amount of yellow drainage with granular and slough tissue present in the wound base that is red and yellow in color with no odor. The next assessment dated [DATE] documented a full thickness wound with a moderate amount of serosanguineous drainage with granular wound base red and yellow in color with no odor. The assessment contained the statement that all areas were measured but are not documented on the form or in the Resident Progress Notes. On 6/14/17-full thickness wound measuring 13.0 cm x 5.0 cm x 3.0 cm with a moderate amount of serosanguineous drainage with granular wound base red and yellow in color with no odor. The facility's Skin and Wound Care Management Documentation policy dated 6/2015 directs the grid to be completed weekly until area healed; more frequent documentation may be indicated based on changes in condition of the wound. During an interview on 6/20/17 at 2:35 PM Staff C, RN, stated there had been a lapse in weekly skin assessments because the former Director of Nursing (DON) used to complete them but she left in mid-May 2017. The Progress Notes from the Wound Clinic dated 6/15/17 documented the resident's coccyx ulcer measures 7.7 cm x 12 cm x 2.8 cm, the right ischial ulcer measures 10.4 cm x 4.3 cm x 3.9 cm with a small secondary ulcer that measured 2 .0 cm x 1.8 cm x 01. cm. The left buttock ulcer measured 7.7 cm x 4.7 cm x 3.6 cm. The report documented all areas were selectively debrided and there were some more necrotic areas that were small and debrided as well. The hospital Progress Notes dated 6/15/17 documented the resident's wound culture identified positive for proteus mirabilis, staphylococcus group B and Corynebacterium species. The resident's clinical record contained no wound clinic documentation since 4/27/17. The surveyor obtained wound clinic Progress Notes dated 5/11/17, 5/25/17 and 6/15/17. The Treatment Administration Record (TAR) for June, 2017 directed staff cleanse the sacrum/coccyx, buttock ulcers with normal saline, and apply Dakin's soaked gauze and cover with gauze and ABD pad 2 times per day and to cleanse the right and left ischial spine ulcers with normal saline and apply a [MEDICATION NAME] dressing every 3 days and as needed (PRN). Observation on 6/22/17 at 10:55 AM revealed Staff D, registered nurse (RN), entered the resident's room with supplies to complete the resident's wound treatments. Observation identified a 1,000 cc (cubic centimeters) open bottle of normal saline which contained approximately 800 cc. The bottle contained no date of opening. The label on the bottle documented it delivered by the pharmacy on 6/5/17 and the manufacturer's label identified the bottle as single use only as it contained no [MEDICATION NAME] and to discard the unused portion. Staff D placed a red (biohazard) garbage bag on the resident's bed and washed her hands and put on gloves. The resident turned to lie on the left side. The wounds were not covered by ABD pads, but had a disposable incontinent pad over it that contained a large amount of foul drainage yellow/green and red in color with a foul odor. Observation revealed no [MEDICATION NAME] dressings on the right and left ischial spines. Staff D removed the packing from the resident's wound and then used her right gloved hand to open the resident's bedside table drawers and removed an unopened roll of Kling gauze. Staff D then opened the package of gauze and folded into layers and placed on the bed next to the resident who remained lying on the left side. Staff D then removed her gloves and poured normal saline and Dakin's solution into 2 different cups. Staff D then removed an open package of 4 x 4 gauze from the resident's drawer and then put on gloves. Staff D placed several 4 x 4 gauze pads into the normal saline cup and then cleansed around and into the wound and scrubbed back and forth over the wound bed with the gauze sponges. The wound contained slough tissue between 10:00 and 2:00 and a depth of approximately 3 cm with some undermining in the area. The wound covered the entire coccyx, both buttocks, right and left ischial regions with an adjacent area approximately half-dollar in size with superficial depth, yellow wound base and viable red edges. Staff D continued to cleanse the wound with a back and forth motion over all areas. Staff D then removed her gloves, tore the package of 4 x 4 gauze so she could obtain them more easily, put on clean gloves and then place 4 x 4 gauze into the cup containing the Dakin's solution. Staff D then placed the soaked gauze in the undermined wound edges and then changed her gloves. She then dried the skin around the ulcer with 4 x 4 gauze, changed her gloves, opened the packages of ABD pads and unfolded them and applied skin prep all the way around the wound. Staff D then placed the 2 ABD pads over the wound except for the half-dollar size are on the right ischium. Staff D then use paper tape to secure the ABD pads in place and taped directly over the exposed right ischium ulcer. The tape did not stick to the open skin. Staff D then took a 4 x 4 dry gauze sponge and folded it in half and placed it directly over the right ischium and then taped over it all the dressing edges to reinforce them and taped over the seam of the ABD pads to keep them intact. Wearing the same gloves. Staff D then assisted Staff K, CNA to pull the resident on the bath blanket to the middle of the bed. Staff D removed her right glove, carried supplies to the treatment cart and carried the biohazard bag with the soiled dressings in it to the soiled utility room down the hall. Staff D placed the biohazard garbage in the regular garbage bin and removed the left hand glove. Staff D then went to the treatment cart, obtained the keys from her pocket, unlocked the cart and put away supplies and then went back to the soiled utility room to wash her hands. Observation revealed the resident lay on a Dolphin FIS (fluid immersion simulation) bed. The bed had a fitted sheet on it and Staff L, CNA placed a bath blanket folded into fourths and 2 washable incontinent pads side-by side with the seam between the 2 pads running from head to foot of the bed so the resident's lower back, buttock and upper thighs would rest on them when in bed and assisted the resident to lay on his/her back. The manufacturer's (Joerns) guidelines directed the staff to do the following: Page 12. Recommended Linen: Special linens are not recommend for the Dolphin FIS therapy mattress there is no need for a bottom sheet as the therapy pad should be covering the therapy cells at all times. The patient should never by lying or sitting directly on the therapy cells. Based on a patient's specific needs, the following linens may be utilized: Draw or slide sheet or aid in positioning and to further minimize friction and shearing. Incontinence barrier pad for patients incontinent of urine and/or stool and patient's with heavily draining wounds. Add top sheet, blanket and/or bedspread as needed for patient comfort. Keep the amount of padding between the patient and the therapy mattress or specialty surface at a minimum for optimum performance. Placing excessive pads or sheets between the patient and the therapy mattress or specialty surface may negatively impact performance. The facility's Infection Prevention Two-Tier Transmission Based Precautions: Standard Precautions policy dated 3/2015 directed the following: Procedure: Handwashing 1. Wash hands after touching the following whether or not gloves are worn: blood body fluid contaminated items excretions secretions 2. Wash hands promptly: after gloves removed between resident/patient contact as indicated to avoid transfer of microorganisms to other resident/patient or environments between tasks and procedures on the same resident/patient to prevent cross-contamination of different body sites Gloves 3. Apply clean gloves before touching mucous membranes or non-intact skin 4. change gloves between tasks and procedures on the same resident/patient after contact with material that may contain high concentration of microorganisms 5. remove gloves promptly after use, before touching non-contaminated items and environmental surface, and before going to another resident/patient 6. Wash hands promptly to avoid transfer of microorganisms to other residents/patients or environment. During interview on 6/22/17 at 2:10 PM Staff D stated she cannot apply [MEDICATION NAME] dressings to the right and left ischial spines as the wounds have become one big wound and unable to get the dressing to adhere. She stated the resident goes to the wound clinic and they are aware that it is all one ulcer now. She stated she did not apply the dressing as ordered on 6/17 and planned to document this in the Progress Notes but got busy and did not complete it. She stated she has not contacted the wound clinic to get the [MEDICATION NAME] dressing discontinued. Staff D stated the nurse on Shady Lane is really busy and often does not have enough time to complete all the treatments. She does not sign off that it has been completed; she leaves the box blank. During interview on 6/20/17 at 2:35 PM Staff C, RN stated he has had days where ordered treatments have not been completed for all residents. He has gone to do treatments on residents and found the dressings on the resident dated 2 days before. Staff C stated he has, on occasion, signed off treatments as completed when he did not do them. During interview on 6/22/17 at 12: 15 PM the resident stated his/her wound treatment does not get done 2 times a day on a consistent basis. The resident stated she/he reported this to the wound care doctor each time she/he goes and the doctor has said he can tell it is not being done as ordered. Review of the June, 2017 TAR revealed the resident's sacral/coccyx ulcer treatment not signed off as completed in the evening on 6/9 and 6/13 and in the morning on 6/1 and 6/10. 2. Resident #11 had a MDS with a reference date of 4/26/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 15. A score of 15 represented no cognitive problems. According to the MDS the resident required extensive assistance with bed mobility, locomotion, dressing, toilet use and total dependence with transfers. The MDS identified the resident had 1 unstageable pressure area present upon admission and had [MEDICAL CONDITION]. The resident required the use of a pressure reducing device for chair and bed, turning/repositioning program and nutrition or hydration intervention to manage skin problems. The Care Plan dated 2/22/17 directed staff to encourage and assistance with frequent repositioning while in bed and wheelchair. Monitor/document location, size and treatment of [REDACTED]. Pressure reduction cushion to wheel chair. Review of the History and Physical dated 6/29/17 indicated the resident had an infected left heel diabetic ulcer and chronic coccygeal ulcer. The hospital record identified the resident had [MEDICAL CONDITION]. Orders included antibiotic therapy of [MEDICATION NAME] 2 mg every 24 hours for 6 weeks and ertapenem 1 gram every 24 hour IV. Review of the Order Listing Report dated 6/1/17 through 6/30/17 indicated the following orders: Cleanse sacrum with soap and water, then blot dry, then pack 1 inch Kling roll gauze into opening and cover with unrolled Kerlix gauze to create a large dry gauze pad type dressing. Change every 8 hours for wound care. Irrigate left foot ulcer with 50 cc 1/4 strength Dakin's solution, dry well, pack ulcer with wet to dry 1/4 inch Nugauze plain, dress with Xeroform, fluff and Kerlix. Change daily for left foot ulcer. Review of the Skin Grid for Pressure Ulcers identified a Stage III coccyx pressure ulcer present on admission. The measurements for the wound documented as follows: On 5/3/17-1.5 cm by 1.3 cm with depth of 2 cm. Tunneling 11 o'clock to 2 o'clock 4.7 cm On 5/10/17-1.5 cm by 1.3 cm with depth of 3 cm. Tunneling 11 o'clock 6.5 cm to 2 o'clock 7 cm. On 6/2/17 1.3 cm by 0.6 cm with depth of 3.7 cm. Tunneling 11 o'clock to 2 o'clock 4 cm. On 6/14/17 1 cm by 1 cm with depth of 6 cm. Tunneling 11 o'clock 6 cm & 2 o'clock 6 cm. The facility failed to assess the resident's wounds on a weekly basis. Review of the TAR dated 6/1/17 through 6/30/17 revealed the following treatments not documented completed: Coccyx wound cleanse with Dakin's solution and pack tunneling with gauze impregnated with [MEDICATION NAME]. Cover with ABD every 12 hours- 6/7 AM, 6/9 AM & PM, 6/10 AM, 6/13 AM 6/15 AM & PM. Left heel cleanse with normal saline, apply [MEDICATION NAME], non-adherent dressing and wrap with Karli 2 times a day and as needed. 6/6 AM 6/7 AM 6/9 AM & PM, 6/10 AM 6/13 PM and 6/15 AM & PM. Observation on 6/30/17 at 3:35 PM identified the acting DON (Director of Nursing) complete wound care for the resident. The wounds measured with the following results: Left heel ulcer-5.4 cm by 4.8 cm and depth 1.4 cm Coccyx ulcer-0.5 by 0.5 with 4 by 6 cm macerated moist tissue surrounding wound and depth 2.2 cm. During an interview with Staff J, CNA on 6/22/17 at 1:30 PM, she stated there had been several times no dressing was present on the resident's wounds. Staff J stated the resident did not want to get out of bed if no dressing was on wound. Staff J stated she tells the nurses when no dressing is present and Staff D, RN has told her she could not complete it and did not have time. During an interview with Staff D, RN on 6/15/17 at 11:30 AM, she stated if staff didn't get into the resident's room and it's too late, he/she will not allow the dressing changes. Staff are unable to do treatments until after the medications are passed (administered). During an interview with the resident's family on 6/27/17 at 8:45 AM she/he stated the resident's dressings were found to not be in place and not always changed. The family member stated the resident did develop an infection in the wound on the foot. Some of the nurses ensure the dressing changes are done and some refuse to do it. 3. According to the MDS dated [DATE] Resident #13 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 13 which indicated intact cognition. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. According to the MDS the resident had 1 healed pressure ulcer and 2 venous and an arterial ulcer present. The MDS identified the resident required pressure reducing device for chair, pressure reducing device for bed, application of nonsurgical dressing, ointments/medication and applications of dressings to the feet. The Care Plan dated 2/28/17 directed staff to do the following interventions: derma savers to bilateral lower extremities, elevate bilateral feet at all times when in bed, encourage and assist with frequent repositioning, heel boots on bilateral (both) feet, lotion to feet, heels off mattress at all times, monitor skin daily with cares and with showers and updated medical doctor of any changes in resident's skin integrity as needed, pressure reduction mattress to bed and cushion to wheelchair and skin assessment per facility policy, treatments per wound clinic or physician orders. Review of the Braden Scale dated 2/28/17 identified the resident had a total score of 16 which identified the resident at a low risk for developing pressure sores. Review of the Physician order [REDACTED]. The Physician order [REDACTED]. Review of the wound clinic notes dated 5/3/17 indicated the right calcaneus pressure ulcer acquired 1/17/17 measured 4.4 cm by 1.5 cm with depth of 0.2 cm. The wound clinic classified the wound as a Stage III pressure area with slough and a medium amount serosanguineous (blood and serous fluid) red brown exudate. The wound bed had granulation (new connective tissue) tissue in the amount of (medium) 34% to 66% and red, pink, friable in quality. The necrotic area size (small) with 1-33% adherent slough (dead tissue). The note included a pressure ulcer acquired 12/15/16 to the left lateral foot. The wound measured 0.6 by 0.5 cm with depth of 0.2 cm classified as a Stage III. Review of the Skin Grid for Pressure Ulcers dated 5/10/17 revealed the left heel had pressure areas with the following measurements: On 5/10/17 0.6 cm by 0.3 cm with no drainage and granulation tissue present and would bed pink. On. 6/1/17 6.5 cm by 2.5 cm with minimal serosanguineous drainage and pink wound bed. On 6/14/17 7.4 cm by 4.5 cm with minimal serosanguineous drainage, granulation tissue and pink wound bed. Review of the Skin Grid for Other Skin Impairments dated 5/3/17 revealed the lateral left foot wound identified on 12/15/16 and had the following measurements: On 5/3/17- 0.6 cm by 0.5 cm with depth 0.2 cm no drainage. On 5/10/17- 0.5 cm by 0.3 cm with depth 0.1 cm had no drainage. On 6/1/17- 1 cm by 0.5 cm with depth 0.2 cm, scant amount serous drainage and wound bed pink. On 6/14/17- 0.7 cm by 0.7 cm no depth, serous drainage and wound bed pink. Review of the Skin Grid for Other Skin Impairments dated 5/3/17 identified the right calcaneus wound identified on 1/17/17 had the following measurements: On 5/3/17 4.4 cm by 1.5 cm with 0.2 depth had moderate serous sanguineous drainage and slough and red/yellow wound bed. On 5/10/17- 4.2 by 1.3 with depth 0.1 moderate sero-sangenous drainage with granulation and pink wound bed. On. 6/1/17 4.5 cm by 1.6 cm moderate amount sero-sangenous drainage with granulation and pink wound bed. On 6/14/17 4.5 cm by 2 cm and no depth. drainage, tissue and wound bed color not assessed. Review of the Weekly Skin Sweep dated 5/3/17 to current, revealed the skin assessments completed on 5/3/17, 5/10/17, 6/1/17 and 6/14/17. The document failed to identify new skin impairment and failed to complete weekly. Review of the Wound Clinic Patient Instructions document dated 5/10/17 identified an order for [REDACTED]. Review of the Physician Clinic Sheet dated 6/14/17 indicated the order for the foot dressings must be changed daily. The Patient Instructions revealed the order for right and left heel apply Santyl and cover with white foam. The left lateral foot included apply Dakin's 0.125%. The left 3rd and 4th webspace included the order to paint with [MEDICATION NAME] daily, apply white foam between the 3rd and 4th toe and change daily. Review of the Wound Clinic Patient Instructions dated 6/21/17 included the following order for the right and left heel and left lateral foot: apply Santyl, apply Dakin 0.125% soaked gauze and then ABD dressing and roll gauze 2 times a day. Review of the TAR (Treatment Administration Record) dated 5/1/17 through 5/31/17 indicated an order to cleanse the left lateral foot and right heel with normal saline. Apply Dakin 0.125% soaked gauze, 4 by 4 and wrap with Kling 2 times a day. The TAR also identified the order to cleanse the left 3rd and 4th toe web spaces with normal saline and apply [MEDICATION NAME] 2 times a day. The treatment not documented on the following: 6:00 AM-5/20, 5/23-5/26, 5/28-5/31/17. 2:00 PM-5/12, 5/17, 5/20, 5/23, 5/24, 5/26 and 5/31/17. The TAR also identified the order to cleanse the left heel with normal saline, apply Dakin's 0.125% soaked gauze 2 times a day. (AM and hour of sleep) The treatment not documented on the following: a. AM-5/20, 5/23-5/26, 5/28-5/31/17. b. Hour of sleep-5/23, 5/26/17. The TAR dated 6/1/17 through 6/22/17 revealed the order for the left and right heel 6/8/17 through 6/22/17: cleanse with normal saline, apply Santyl then cover with foam dressing and cover with gauze, Kling and tape daily. The left lateral foot order 6/8/17 through 6/22/17 directed to cleanse with normal saline, apply Dakin, cover with gauze, Kling and tape daily. The treatment not documented completed: 6/9,6/16, 6/17, 6/18 and 6/21/17. Observation on 6/23/17 at 1:50 PM revealed Staff S, RN completed a wound treatment on the resident's pressure ulcers. The left lateral foot wound measured 1.5 cm by 3 cm. The right calcaneous measured 2 cm by 4 cm. The left lateral heel measured 8 cm by 5 cm. She cleansed the left lateral wound and left heel with normal saline. She applied Santyl with a gloved hand to the left lateral wound and used the same gloved hand to apply Santyl to the left heel. She applied a 4 by 4 inch gauze square soaked with Dakin's and ABD dressing and Kling. She cleansed the right calcaneus wound with normal saline, applied Santyl to the wound and a Dakin soaked dressing. She then applied an ABD dressing and Kerlix. She disinfected the treatment cart. On 6/23/17 at 1:30 p.m., Resident #13 was interviewed and stated the wound treatment had not been completed 2 times a day as ordered and the wound clinic wrote the facility a note about it. The dressing changes are now 1 time a day. The resident stated the dressings are not changed on Friday, Saturday or Sunday (6/16, 6/17, 6/18/17). The resident stated he could smell his/her feet and refused to get out of bed on Monday until a nurse assisted with the wounds. The resident stated the DON (Director of Nursing) did come to the room and change the dressings after he/she asked. During an interview with the Wound Clinic ARNP on 7/5/17 at 8:00 AM, he stated the resident's wound on the left calcaneous increased on size from 2.35 cm by 1.2 cm by 0.1 cm to 7.6 cm by 4.8 cm by 0.4 cm. The facility failed to follow the ordered treatment and the decline could have been potentially prevented considerably. He further stated the resident completely realizes on staff and has no family that advocates for him/her. 4. Resident #8 had a MDS with a reference date of 4/21/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 11. A score of 11 represented the resident had a moderate cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, dressing, toilet use and total dependence with transfers. The MDS identified the resident had impairments on both sides of the lower extremities. According to the MDS the resident had no risk of developing pressure ulcers and had no pressure ulcers since the last assessment. The Care Plan dated 4/11/17 directed staff to monitor/document location, size and treatment of [REDACTED]. The Care Plan also directed staff to use a pressure reduction cushion to the wheelchair and an air mattress to the bed. Staff also directed to assist the resident with repositioning frequently throughout each shift and as needed and to provide treatments per physician orders. Review of the Physician Telephone Order dated 5/30/17, directed the nurse to apply [MEDICATION NAME] and change 3 times a week and as needed every Monday, Wednesday and Friday to the left heel blister. Review of the Skin Grid for Pressure Ulcers dated 5/18/17, indicated the back left heel with 8.5 cm by 4 cm blister intact and dark purple in color. Review of the Skin Grid for Pressure Ulcers dated 5/18/17 identified the outer left heel with 9 cm by 3 cm blister intact and dark purple in color. Observation on 6/28/17 at 8:05 PM revealed Staff T, RN and Staff L, LPN completed wound care for the resident. The left heel measured 6 cm by 7.3 cm with open area of 3.6 cm by 1.1 cm. The right heel measured 3.1 cm by 2.4 cm. During an interview with the Wound Clinic ARNP on 7/5/17 at 8:00 AM, he stated the resident had family report several times the wound care not treated per physician's orders [REDACTED]. He further stated some residents did not have advocates to speak for them. 5. Resident #16 had a MDS with a reference date of 6/13/17. The MDS identified the resident had [DIAGNOSES REDACTED]. According to the MDS, the resident had a BIMs score of 15 which indicated no cognitive problems. The MDS identified the resident required limited assistance with bed mobility, transfers, dressing and toilet use. According to the MDS the resident was not assessed to have pressure ulcers. The MDS identified the resident required use of pressure reducing device for chair and bed and application of dressing to feet with or without topical medications. The Care Plan dated 6/9/14 directed staff to provide a pressure reduction surface in the bed and wheelchair. The Care Plan failed to identify skin impairment or wound care. Review of the Braden Scale dated 6/12/17 indicated the resident at low risk for the development of pressure ulcers. Review of the hospital x-ray report dated 6/1/17 indicated a soft tissue ulcer medial to the 1st metatarsal joint. There is focal osteopenia (bone loss density) and apparent mild destructive change within the 1st metatarsal head (bone behind the big toe), suggesting osteo[DIAGNOSES REDACTED]. The impression included focal osteopenia mild destruction in the 1st metatarsal head, a finding consistent with osteo[DIAGNOSES REDACTED] (bone infection). Review of the Hospital Podiatry Consult (physician orders) dated 6/2/17 identified the following wounds: Ulceration to the medial hind foot completely granular base with no acute signs of infection such as drainage, purulence, cell (TRUNCATED)

Based on record review, staff interview and review of the policy and procedures, the facility failed to assure timely assessment and intervention for residents with adverse changes of condition for 3 of 22 residents reviewed (Resident #3, #15, #17). The facility identified a census of 56 residents. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of 4/20/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The same MDS documented a Brief Interview of Mental Status score of 3. A score of 3 represented a severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The MDS identified the resident as incontinent of bowel and bladder. The Care Plan identified a problem on 11/22/15. The resident had [MEDICAL CONDITION] activity and dependent upon staff for completion of activities of daily living skills. and identified the resident had [MEDICAL CONDITION] activity and dependent upon staff for completion of activities of daily living. The Progress Notes entry competed by Staff C, registered nurse (RN), on 5/13/17 at 3:46 p.m. documented the resident had 3 episodes of dark liquid emesis. Staff C documented the nurse notified the physician and received direction to give the resident clear liquids if not vomiting and if vomiting continued to send the resident to the emergency room . The Progress Notes entry completed by Staff C on 5/13/17 at 4:30 p.m. documented the resident had another huge emesis of very dark fluid. The entry contained no assessment of the resident. The Progress Notes entry completed by Staff H, RN, on 5/13/17 at 9:15 p.m. documented the resident's medications held due to vomiting earlier in the shift. The resident's bowel tracking record documented the resident had a large loose/diarrhea stool on 5/13/17 at 9:59 PM The Progress Notes entry completed by Staff H on 5/14/17 at 5:02 AM documented the resident is pale in color, warm to touch and has increased confusion and weakness. The resident's temperature recorded at 101.4 degrees, pulse 90, blood pressure 140/40 and blood sugar 430. The resident's abdomen was firm and distended with bowel sounds sluggish and the resident complained of pain in the abdomen. Staff H notified the physician and received an order to send the resident to the emergency room by non-emergent ambulance. The resident left the facility at 5:40 AM. The After Visit Summary dated 5/22/17 documented the [DIAGNOSES REDACTED]. tissue and organs) due to pneumonia and urinary tract infection [MEDICAL CONDITION] and an ileus (lack of movement in the intestines that can lead to a build-up and potential blockage). The resident returned to the facility on [DATE]. During interview on 6/20/17 at 2:35 PM Staff C stated he did not know why he did not send the resident to the hospital after he had the order to send the resident if vomiting continued. He stated he believed he assessed the resident but acknowledged he did not document it. Staff C stated the resident had a history of [REDACTED]. During interview on 6/22/17 at 9:40 AM Staff H stated she did not know that the resident had vomited after Staff C had obtained the order to send the resident to the hospital if vomiting occurred. She did hold the resident's medications because she knew that she had vomited the day before she came on duty. Staff C told her the resident had vomited several times but did not assess the resident until right before she sent the resident to the hospital as the certified nursing assistants (CNA's) did not report anything unusual with the resident. Staff H stated she looked in on the resident while passing early morning medications and noted the s/he did not appear to be his/her usual self. The facility's Clinical Change of Condition Management policy dated 6/2015 directed the following: Overview: The Interdisciplinary team strives to identify and manage all resident/patients that are experiencing a change of condition. Daily observation and communication is important in identifying changes in a resident/patient that requires further investigation. Daily observation includes but is not limited to changes in: participation in daily routines physical assessment (i.e. cardiovascular, respiratory, mental status, neurological) behavior mobility comfort level response to medications Clinical care management includes routine assessment, evaluation, response to changes in clinical condition and communication with resident/patients and/or families/responsible parties. Procedure: 1. Assess the resident/patient clinical status when a change in condition is identified. This may include but is not limited to: vital signs lung sounds pulse oximetry (blood oxygen level) bowel sounds skin color, turgor, temperature pain 2. Review the resident/patient medical record including but not limited to: primary [DIAGNOSES REDACTED].>lab work medication changes changes in nutritional status advanced directives allergies [REDACTED]. contact the physician and provide clinical data and information about the resident/patient condition. Document notification and physician response in the resident/patient medical record. Initiate any new physician orders. 5. Document on the Change of Condition Data Collection Tool. 6. Document resident/patient condition and location on the 24 hour report. The Clinical Programs Manual Documentation policy dated 6/2015 directed the following: 1. Document all information on the Change of Condition Data Collection Tool unless otherwise indicated. 2. Complete evaluation of the resident/patient change of condition. Evaluation of conditions may include, but are not limited to: Abdominal pain, discomfort, distension to assess abdominal palpation, bowel sounds, quantity and description of vomit/diarrhea, hemocult if possible blood. The Progress Notes entry competed by Staff G, RN, on 6/1/17 at 21:19 (9:19 PM) documented the resident vomited up all medications but had no other emesis this shift. The clinical record contained no assessment of the resident by Staff G regarding the episode of vomiting. The Progress Notes entry completed by Staff dated 6/2/17 at 13:55 (1:55 PM) documented the resident had an extra-large dark coffee-ground emesis and a large soft dark stool at 4:30 AM. The resident's temperature was 99.2 degrees, pulse 96, respirations 28 and blood pressure 148/80 and the resident felt cool and sweaty and blood glucose measured 435. Staff E notified the physician and sent the resident to the hospital at 5:35 AM. the Progress Notes entry dated 6/2/17 at 8:30 PM documented the resident admitted to the intensive care unit (ICU) with the [DIAGNOSES REDACTED]. The Progress Notes entry completed by Staff O, licensed practical nurse(LPN) from a temporary staffing agency, on 6/12/17 at 12:56 PM documented the resident assessed and noted to have bowel sounds present in all 4 abdominal quadrants and no abdominal distension. The Progress Notes entry dated completed by Staff P, RN from a temporary staffing agency, on 6/15/17 at 8:41 AM documented the night nurse reported to her the resident had a coffee-ground emesis (indicative of [MEDICAL CONDITION]). Staff P held the resident's morning dose of aspirin 81 milligram (mg). Staff P assessed the resident and found the resident's heart rate elevated at 108, and the resident complained of tenderness with abdominal palpation. The physician ordered the resident to be seen in the emergency room . The Progress Notes entry completed by Staff G on 6/15/17 at 5:52 PM documented the resident readmitted to the facility for hospice care for the [DIAGNOSES REDACTED]. During an interview on 6/24/17 at 6:40 PM Staff O ( licensed practical nurse-agency) stated the resident had the coffee-ground emesis right before her shift ended on 6/15/17, but not sure what time it would have been. Staff O stated she went to the resident's room and Staff D, registered nurse, was already there so she left the facility. She did not chart anything on the resident because it was time for her to go, but reported it to Staff P (registered nurse-agency). Contact with facility staff on 6/24/17 at 7:00 PM documented Staff D on vacation and not able to be reached at this time. Review of the resident's clinical record revealed no documented assessment by Staff D or Staff P on 6/15/17 prior to transfer to the hospital. 2. Resident #17 had a MDS with a reference date of 3/25/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 15. A score of 15 represented no cognition impairment. According to the MDS, the resident required extensive assistance with bed mobility, dressing and personal hygiene and total dependence with transfers and toilet use. According to the MDS, the resident had no wounds but required the application of ointments and medications. The Care plan dated 1/10/17 directed staff to monitor residents skin daily with cares and with showers and update physician of any changes in residents skin integrity as needed. The care plan also directed staff to perform weekly skin assessments per facility policy. Review of the Physician Visit document dated 5/4/17 identified the resident had a non- healing surgical wound. Review of the Skin Grid for All Other Skin Impairments dated 4/26/17 revealed a lower right leg surgical wound had the following measurements: a. 4/26/17 - 1.4 cm by 1.0 cm by 0.3 cm had moderate drainage and yellow bed wound. b. 5/3/17 - 2.2 cm by 1.4 cm by 2.2 cm scant amount yellow drainage and yellow wound bed c. 5/10/17 - 2.0 cm by 1.2 cm by 2.2 cm scant clear drainage and yellow wound bed. d. 6/1/17 - 2.3 cm by 1.5 cm scant clear drainage with yellow wound bed. e. 6/14/17 - 2.2 cm by 1.1 cm wound. The facility failed to assess the wound on a weekly basis. Review of the Physician order [REDACTED]. a. [MEDICATION NAME] packing change daily for wound care. b. redress right ankle 2 times a day, remove idoform, prefer 1/8 inch - 1/4 inch gently pack wound, 4 by 4's, wrap with Kerlix and ace wrap until wound clinic seen. c. right lower leg use Santyl ([MEDICATION NAME] agent) ointment wrap with Kling daily. Review of the TAR dated 5/1/17 through 5/31/17 revealed the following orders not documented administered: a. [MEDICATION NAME] packing change daily for wound care: 5/20, 5/24, 5/2, and 5/30/17. b. mupirocin ointment 2% to left ankle ulcer topically daily, cover with [MEDICATION NAME] and wrap with ace wrap: 5/20, 5/24, 5/2, and 5/30/17. c. remove idoform, gently pack wound, 4 by 4's, wrap with Kerlix and ace wrap to right ankle 2 times a day: 5/13-AM, 5/20-AM & PM, 5/23-PM, 5/24-AM & PM 5/25-AM, 5/26-AM & PM and 5/27-5/29/17 PM. Review of the TAR dated 6/1/17 through 6/30/17 revealed the following orders: a. Mupirocin Ointment 2% to left ankle ulcer topical 1 time a day for left ankle wound cover with [MEDICATION NAME] and wrap with ace wrap. The treatment not documented completed on: 6/3, 6/6, 6, 6/9-6/13, 6/16, 6/17, 619 or 6/20/17. 4. Resident #15 had a MDS (minimum data set) dated 4/3/17 Resident #15 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 13. The score of 13 represented no cognitive impairments. According to the MDS, the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The MDS identified the resident had surgical wounds present and required surgical wound care and application of ointments and dressings to the feet. The Care Plan dated 5/16/17, directed staff to administer treatments per physician and/or wound clinic orders. Review of the Braden Scale dated 4/21/17 revealed the resident at low risk for the development of pressure ulcers. Review of the Hospital Visit Summary dated 5/22/17 revealed the resident admit on 5/16/17 for ulcer of the left foot incision and drainage and removal of [DEVICE] on 5/18/17 and osteo[DIAGNOSES REDACTED]. Orders include: a. right foot wound care 2 times a day: remove old dressing. Clean with 10 ml (milliliters) normal saline. Pat dry with sterile 4 by 4 gauze. Apply mupirocin ([MEDICATION NAME]) 2 % ointment. Place a non-adherent dressing. b. left post thigh every other day and as needed if dressing loosens or becomes soiled: 1) cleanse area with normal saline and pat dry. 2) cover the area with [MEDICATION NAME] foam with border. c. [MEDICATION NAME] HCL (antibiotic) 1000 mg and sodium chloride 1500 mg IV (intravenous) daily Review of the Physician Verbal Orders dated 5/23/17 revealed the order to cleanse the left and right foot wounds with normal saline, apply [MEDICATION NAME] 2% ointment, cover with non-adherent dressings and wrap with king and ace wraps daily and as needed. The Hospital facsimile dated 6/15/17 revealed the order to leave dressings intact and call office if need dressing changes. Left heel-leave dressing intact and OK to change right heel dressing. Review of the Order Summary Report dated 7/10/17 revealed the order for [MEDICATION NAME] HCL solution reconstituted use 1 gram intravenously daily for infection and meropenem solution reconstituted 1 gram intravenously every 12 hours for wounds. Review of the Telephone Orders dated 4/11/17 revealed the following orders: a. Left heel (lower leg) apply [MEDICATION NAME] soaked 4 by 4's, ABD, Kerlix and ace wrap up to the knee daily. b. Right heel ulcer apply [MEDICATION NAME] , cover with 4 by 4's, ABD, Kerlix and ace wrap up to knee daily. Review of the Physicians Order dated 5/28/17 revealed the order for Santyl to open wounds, sorbart to left heel and cover with nuprilix, change daily and as needed. Apply [MEDICATION NAME] to the right 5th toe and deep dressing on with ace wraps. Review of the Skin Grid for All Other Skin Impairments revealed the following wound measurements: a. identified 5/22/17 5th toe right foot: 5/14/17- 1 cm by 1 cm; 6/14/17- 1 cm by 1 cm. b. diabetic ulcer night great toe: 5/3/17- 0.8 cm by 0.3 cm scabbed ; 5/14/17- 0.6 cm 0.3 cm scabbed. c. lateral right foot open crater; 5/22/17- 5 cm by 5 cm depth 0.5 cm. 6/14/17-5 cm by 5 cm depth 0.5 cm. d. left lateral distal leg above ankle 5/22/17-1.8 cm by 0.8 cm,5/30/17-1.8 by 0.8 cm, 6/14/17 2.0 by 0.9 cm scabbed. c. left medial foot at great toe base debridement site: 5/22/17- 5.2 by 2.2 by 0.1 cm, 5/30/17-4.5 cm by 2.8 cm by 1 cm , 6/14/17- 3 cm by 3 cm. d. left Achilles tendon posterior heel 5/30/17- 11 cm by 4 cm, 6/14/17- 11 cm by 4 cm. e. left lateral foot: 5/22/17- 2.4 by 0.9 cm by 0.3 cm, 5/30/17- 2.4 by 0.8 cm by 0.2 cm, 6/14/17- 2.0 cm by 0.6 cm. f. right Achilles: 5/3/17- 1.0 cm by 1.0 cm, 5/30/17- 5 cm by 2 cm, 6/14/17- 4 cm by 2 cm. g. left foot bottom- 5/3/17, 12 by 11 cm by 0.2 cm, 5/21/17- 14 cm by 11 cm, 5/30/17- 15 cm by 12 cm, 6/14/17- not measured and wound covered entire bottom of foot with granulation present. Order to not remove dressings from 5/6/17 through 5/18/17. Review of the TAR dated 5/1/17 through 5/31/17 identified the following orders not documented as completed: a. right ulcer apply [MEDICATION NAME] soaked 4 by 4. Cover with Kerlix. Apply 4 inch ace to foot and 6 inch to leg up to knee daily: 5/4 & 5/5/17. b. left lower leg [MEDICATION NAME] soaked 4 by 4's, ABD, Kerlix, ace wrap to knee daily. 4 inch ace to foot and 6 inch ace to leg up to knee: 5/4 & 5/5/17. c. Wound care left post thigh every other day and as needed: cleanse area with normal saline and pat dry. Cover area with [MEDICATION NAME] foam with border: 5/24 through 5/31/17. d. Mupirocin ointment 2%. Apply to affected area topically 2 times a day: 6:00 AM- 5/23 through 5/31/17 and 2:00 PM- 5/24, 5/26 and 5/31/17. d. Rooke boots to both feet at all times every shift: 6:00 AM 5/29/17 and 5/31/17, 2:00 PM 5/26/17, 10:00 PM 5/23, 5/25, 5/27 and 5/30/17. Review of the TAR dated 6/1/17 through 6/30/17 revealed the following orders not documented completed: a. left & right heel: Santyl to open wounds. Sorbact to left heel. Cover with nuprilix daily and as needed. Wrap with Kling and cover with ace wrap: 6/1, 6/3 and 6/9/17. b. right foot, 5th digit apply [MEDICATION NAME] to toe daily: 6/1, 6/3, 6/9 and 6/17/17. c. left posterior thigh cleanse with normal saline and pat dry, cover area with [MEDICATION NAME] foam with border every other day and as needed: 6/6, 6/10, 6/12, 6/16/17. d. Mupirocin ointment 2%. Apply to affected area topical 2 times a day: 6:00 AM-6/1, 6/3 and 6/6/17. 10:00 PM- 6/1/17. to left heel. e. Continue to change right heel dressing at facility. Cleanse, apply Santyl, sorbect mesh, cover with nonadhesive [MEDICATION NAME], wrap with Kling and ace wrap daily and as needed: 6/16 and 6/17/17. Review of the Progress Notes dated 5/31/17 at 3:28 PM revealed the resident returned per facility van from the physician office with a reminder to change the foot dressings every day as his/her wound desiccating (drying and or separation of a [MEDICAL CONDITION]).

Based on record review, staff, family and physician interview, the facility failed to provide intervention for 1 of 14 residents with complaints of pain (Resident #5). Resident #5 did not receive his/her pain medication as ordered by the physician. The facility identified a census of 55 current residents. Findings include: 1. According to the clinical record, Resident #5 entered the facility on 3/25/17 and had [DIAGNOSES REDACTED]. Documentation in Resident #5's Minimum Data Set (MDS) indicated he/she scored 14 (of 15) on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The assessment for pain management identified Resident #5 received a scheduled medication and PRN (as needed) pain medication. Resident #5 frequently had pain, and the pain made it difficult to sleep. Resident #5 rated his/her worst pain at 5 (out of 10 being worst pain he/she can imagine). The assessment tool also described Resident #5 as requiring staff (one) assistance with most activities of daily living, including bed mobility, transferring, dressing, toilet use and personal hygiene. A progress note dated 3/30/17 at 5:48 a.m., revealed Resident #5 was receiving skilled therapy for strengthening. The physician's orders [REDACTED]. a. Administer [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligram) take 1 to 2 tablets by mouth every 4 hours as needed (narcotic [MEDICATION NAME]). b. Stop [MEDICATION NAME] 50 mg tablet ([MEDICATION NAME]) c. Stop [MEDICATION NAME] 325 mg tablet. Review of the Progress Notes dated 4/12/17 at 10:58 p.m. revealed the resident (re)-admitted this morning after hospital stay for post right ankle pinning. Resident #5 would receive skilled nursing level of care for rehabilitation services for strengthening for the ankle fracture. The right ankle fully dressed and no drainage visible. No signs/symptoms of neurological deficit to the right foot/toes. Denies tingling or numbness and takes [MEDICATION NAME] ([MEDICATION NAME]) for pain. Review of the facility plan of care dated 4/14/17 identified Resident #5 at risk for pain due to right ankle fracture. The care plan interventions alerted staff to monitor/record/report the resident's complaints of pain or request for pain treatment and notify physician if interventions are unsuccessful or if current complaint is a significant change from the residents past experience of pain. Progress Notes dated 4/15/17, revealed Resident #5 slept peacefully between prn (medication) up to commode at bedside (non-weight bearing to right ankle/foot due to cast). The Progress Notes dated 4/18/17, 4/19/17, 4/20/17, and 4/21/17 revealed Resident #5 slept peacefully between prn (medication) uses. Review of the April 2017 Medication Administration Record [REDACTED] a. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg give 1 tablet every 4 hours as needed for pain. b. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg give 2 tablet every 4 hours as needed for pain. c. Administer [MEDICATION NAME] 300 mg capsule three time a day. Review of April 2017 MAR indicated [REDACTED] a. From 4/12/17 to 4/16/17 Resident #5 had pain ranging from 3 to 9 (out of ten), and 2 shifts out of 15 the resident had no pain. b. On 4/17/17 at 6:00 a.m. Staff A documented Resident #5's pain rated at 8 (out of 10) c. On 4/17/17 at 2:00 p.m. Staff A documented Resident #5's pain rated at 8 (out of 10) d. On 4/17/17 at 10:00 p.m., Staff G documented Resident #5's pain rated at 6 (out of 10). The MAR indicated [REDACTED] a. Once (1) on 4/12/17 b. Tthree times (3) on 4/13/17 c. Twice (2) on: 4/14/17, 4/15/17, and 4/16/17. d. None administered ([MEDICATION NAME]-[MEDICATION NAME]) on 4/17/17. Review of the Controlled Medication Utilization Record dated 4/17/17 at 8:40 a.m. revealed [MEDICATION NAME] 50 mg administered to the resident by Staff A. (This medication was discontinued on 4/11/17). Review of the Medication Administration Record [REDACTED]. An interview with Staff A, (CMA) on 5/18/17 at 11:50 a.m. revealed she worked with Resident #5 and she did not seem uncomfortable. During an interview with Staff G, LPN on 5/18/17 at 10:40 PM she stated she did not remember administering [MEDICATION NAME] to the resident on 4/17/17. During an interview with Staff B, CMA (certified medication assistant) on 5/18/17 at 10:15 AM she stated the resident had an order for [REDACTED]. Staff borrowed pain medication from other residents. She also stated she had not been aware if the doctor had been made aware of the resident's pain. She called the pharmacy when the resident ran out and they reported they were waiting of a script from the surgeon. She further stated she did not document the call. During an interview with Resident #5's spouse on 5/19/17 at 11:26 a.m., he/she reported after surgery the resident returned to the facility. Resident #5 had an order to have [MEDICATION NAME] but the medication was not at the facility and the resident could not get [MEDICATION NAME] because he/she did not have an order. Resident #5 had a lot of pain and had no pain medication. Staff had to then go to the emergency box to get medication. (The Controlled Drug Record Ebox revealed no medication given on 4/17/17 to Resident #5.) During an interview with the Advanced Registered Nurse Practitioner on 5/23/17 at 11:30 a.m. she stated Resident #5 reported a lot of pain and had very poor pain control. Resident #5 had not been receiving his/her ordered pain medication. She further stated she would expect staff to give the pain medication as ordered. If the facility did not have the ability to give the ordered medication, she would expect staff to notify the physician to order a different medication that would be available. During an interview with the ADON on 5/18/17 at 9:30 a.m., she reported she did know there was an issue getting Resident #5 his/her medications. The ADON reported the resident did have pain.

Based on clinical record review and family and staff interviews, the facility failed to provide accurate assessment and assure timely intervention for a resident with adverse changes of condition (Resident #10). The sample consisted of 13 residents and the facility reported a census of 63 residents. Resident #10 arrived at the facility and the staff did not complete a thorough assessment and failed to implement interventions (daily weights, notification of physician of weight gain, ted hose application, incision assessments, vitals, etc.). The resident was sent to the emergency room for an unresponsive episode. The resident had abnormal laboratory tests which [MEDICAL CONDITION] from a urinary source and required admission into the Intensive Care Unit. The resident received antibiotics intravenously and oxygen therapy with [MEDICAL CONDITION]. Findings include: 1. Resident #10 had an After Visit Summary (discharge instructions from the hospital), dated 4/12/17. The form identified the resident had [DIAGNOSES REDACTED]. disease), acute kidney injury, obstructive sleep apnea (breathing issues while sleeping), acute [MEDICAL CONDITION] (a disease of the brain in which an agent effects the brain) and intertrochanteric [MEDICAL CONDITION] femur (thigh bone). The same summary documented the resident weighed 308 pounds and 10.3 ounces. Review of a consultation revealed an open reduction internal fixation of the left hip (repair of fracture) performed on 4/3/17. Review of a consultation report identified the resident had surgery for [REDACTED]. The Progress Note dated 4/17/17 at 7:28 p.m. indicated a family member called Staff H (licensed practical nurse) LPN to the resident's room due to the concern they could not awaken the resident. The staff tried several times. The nurse took vital signs and blood sugar check, called the physician and then sent the resident to the emergency room . Review of the hospital Emergency Department note dated 4/17/17 at 7:46 PM documented the resident presented for an unresponsive episode at the nursing home after being admitted to the nursing home status [REDACTED]. The note documented the resident weighed 330 pounds and 14.6 ounces. The Emergency department notes indicated the resident had bilateral decreased breath sounds, 3 plus [MEDICAL CONDITION] of both lower extremities and a large surgical wound to the left lateral hip with staples in place with surrounding [DIAGNOSES REDACTED]. Laboratory tests included a white count of 18.39 (normal is 4-10 and indicative of infection), red blood count of 3.06 (normal 4.2-6.2), hemoglobin 8.7 (normal 12-15), hematocrit 31.1 (normal 26-45 %), The differential showed an elevated [DIAGNOSES REDACTED] count of 80.9 (normal 42-74%). The lymphocytes low at 9.9 (normal 1.4-6.6). The urine specimen identified a large amount of blood with 100 milligrams of protein and a moderate amount of white blood cells and clumps present. A CT (computerized tomography) scan identified no [MEDICAL CONDITION], mass, [MEDICAL CONDITION] or acute infarct. The x-ray of the chest identified mild [MEDICAL CONDITION] vascular congestion. The physician ordered [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) intravenously [MEDICAL CONDITION] due to urinary source. The resident was placed on a Bi-PAP machine for breathing and used oxygen. The resident was transferred to the Intensive Care Unit in stable but guarded condition. Review of the After Visit Summary for Resident #10 dated 4/12/17, instructed the staff to change the dressing (on hip) with dry gauze daily and as needed for saturation. Review of the treatment administration record (TAR) dated 4/1/17-4/30/17 identified instructions for a dressing change to the right hip daily and as needed. (The resident's incision was on the left hip). The TAR documented a dressing change on 4/13/17 and 4/16/17 only. Review of the TAR (Treatment Administration Record dated 4/1/17-4/30/17, directed staff to obtain a daily weight and notify the physician if the resident gained 3 pounds in one day or 5 pounds in one week. The TAR revealed no weights recorded including on admission on 4/12/17. The TAR also directed staff to apply TED (compression hose) during the daytime (hours) and remove in the evening. The TAR documented the TED hose placed on the resident on 4/16/17 only. Review of a nursing admission data collection form dated 4/12/17 at 5:30 AM (note that the resident wasn't admitted until 4/12/17 at 1:31 p.m. per progress note) failed to document an admission weight. Per the resident's After Visit Summary dated 4/12/17 recorded a weight of 308 and the hospital emergency department note dated 4/17/17 recorded a weight of 330; the resident's weight increased by 22 pounds in 5 days. During an interview with the resident's family member on 4/19/17 at 4:05 p.m. she stated the resident felt she was full of fluid and couldn't move very well. The daughter stated she never observed TED (compression/anti-embolism) socks on the resident or that the resident had any TEDs to apply. The Progress Note dated 4/13/17 at 5:54 p.m. identified an entry by Staff F, certified medication aide (CMA) that the resident did not wear any (TED hose) so at this time no TED hose are on. On 4/20/17 at 8:47 AM, Staff F was interviewed and stated the resident did not have any TED stockings. Staff F stated the resident's legs were swollen and stiff. She stated she elevated the resident's legs on pillows but did not weigh the resident. The record did not contain an assessment of the [MEDICAL CONDITION] present except in the hospital Emergency Department note dated 4/17/17 at 7:46 PM when the resident was transported to the hospital in an unresponsive condition. During an interview with the DON (Director of Nursing) on 4/20/17 at 8:50 AM, she stated it wasn't unusual to see the resident with 3 plus [MEDICAL CONDITION]. The DON stated the staff could have notified the physician but confirmed they did not. Review of the progress notes from 4/12/17 through 4/17/17 revealed one entry related to observation of the hip dressing on 4/13/17 at 5:45 AM and recorded the dressing as clean, dry and intact. Review of a nursing admission data collection form dated 4/12/17 at 5:30 AM documented an incision to the left hip with no signs and symptoms of infection with the incision approximated well. The assessment documented different scattered bruises to the bilateral upper and lower extremities. The assessment failed to document any [MEDICAL CONDITION] or any fracture related to a fall. During an interview with the DON on 4/20/17 at 9:10 AM she stated there were no other skin sheets except the initial assessment on 4/12/17.

Based on record review and staff interview the facility failed to provide timely and complete assessment of a resident following an incident and reports of pain for 1 of 8 residents reviewed (Resident #4). The facility identified a census of 66 current residents. Findings include: According to the MDS (Minimum Data Set) dated 12/21/15 Resident #4 exhibited short and long term memory deficits and severely impaired cognitive impairment. The MDS listed concerns regarding inattention, disorganized thinking and psychomotor [MEDICAL CONDITION] for Resident #4. According to the MDS Resident #4, required extensive assistance with bed mobility, dressing and toilet use and total dependence with transfers. The MDS identified Resident was impaired on both sides of the lower extremities and required the use of a wheelchair. Resident #4 ' s [DIAGNOSES REDACTED]. The care plan revision dated 01/04/16 directed staff in the event of a fall or injury assess, provide treatment, notify physician and family and investigate cause of falls or injuries and eliminate if possible. Review of the Incident Report dated 12/30/16 at 6:30 p.m. revealed Staff K CNA (Certified Nursing Assistant) and Staff L CNA reported Resident #4 was rolled and his/her knee brushed up against the floor and an abrasion to the left knee occurred. Resident #4 unable to describe the incident. The incident report failed to contain any assessment of vital signs, range of motion or evaluation of pain to the area for Resident #4. Review of the facsimile to the Physician dated 12/30/15 at 10:00 p.m. revealed Resident #4 being turned by CNAs and Resident#4's legs brushed against the floor and an abrasion to the left knee occurred. Review of the facsimile to the Physician dated 12/31/15 at 9:54 a.m. revealed the order to send Resident#4 to the emergency room for evaluation of the left knee for pain. Review of the X-Ray Report dated 12/31/15 at 11:30 a.m. revealed Resident#4 had an oblique [MEDICAL CONDITION] left femur. Review of the Progress Notes dated 12/30/15 at 6:30 p.m. revealed staff members rolled Resident#4 and his/her knee brushed up against the floor and an abrasion to the left knee occurred. On 12/31/15 at 2:30 a.m. staff members documented Resident #4 resting quietly. Abrasion remains to the left knee. No new injuries noted. Unable to move legs well, normal range for Resident #4. No complaints of pain offered. Will continue to monitor. Vital signs 120/68, temperature 98, pulse 7- and respirations 18. On 12/31/15 at 8:30 a.m. staff members documented Resident #4 complained of right knee pain. Assessment competed, scrape noted to the lower left knee, Resident #4 hollered out in pain with repositioning. Staff members called the Physician and an order was received to send Resident #4 to the emergency room for evaluation. Staff members informed Resident #4's responsible party. On 12/31/15 at 1:50 p.m. Resident #4 returned from the emergency room visit. Resident #4 to have a follow up appointment on 1/4/16 for a reevaluation. Keep immobilizer in place and keep clean, dry and intact. [MEDICATION NAME] 5/325 mg (milligram) 1 to 2 tablets every 4 hours as needed for pain. Keep a clean bandage over small abrasion. Notify the on-call physician regarding any concerns. During an interview on 1/26/16 at 12:45 p.m. Staff H, LPN (Licensed Practical Nurse) stated that Staff K CNA and Staff L CNA reported that during a transfer Resident#4 failed to be positioned correctly and his/her legs fell off the bed. According to Staff K CNA and Staff L CNA, Resident #4s knees brushed against the floor. Staff H LPN stated she looked at Resident#4 ' s knee and he/she expressed no complaints of pain. Staff H LPN confirmed she failed to perform range of motion and that was usually done when a resident had an injury. Staff H LPN cleansed the abrasion on the left knee and placed a Band-Aid. During an interview on 1/26/16 at 12:00 p.m. Staff A CNA stated that she assisted Resident #4 with cares on 12/31/15 at approximately 3:00 a.m. to 3:30 a.m. and started to pull on the turn pad. Resident #4 screamed out with pain. Staff A CNA reported this to the nurse and the nurse stated there was an incident on the 2:00 p.m. to 10:00 p.m. shift. Staff A CNA stated she provided cares for Resident #4 again at approximately 5:00 a.m. to 5:30 a.m. Resident #4 screamed out again but only when touched or moved. Staff A CNA informed the nurse again. At 6:00 a.m. Staff A CNA assisted another CNA to get Resident #4 up for the day. Staff A knew something was wrong and went to tell the nurse. Staff A CNA stated that Resident #4 ' s not normally a noisy resident and did not scream. During an interview on 1/22/16 at 1:00 p.m. Staff C RN (Registered Nurse) stated that 2 CNAs came to tell her that there had been something wrong with Resident #4. Staff C RN went to Resident #4's room. The night nurse told her there was an incident so Staff C RN went back to get report. The DON (Director of Nursing) came in at approximately 7:00 a.m. and went to Resident #4's room and sent him/her to the hospital. According to Staff C RN Resident #4 cried out in pain when moved. The CNAs know the resident and knew something was wrong. During an interview on 1/27/16 at 9:00 a.m. Staff N CNA stated that she assisted rolling Resident #4 in bed to provide cares. Resident #4 screamed out. Staff N CNA stated she was unable to see anything wrong but knew something was not right. According to Staff N she informed the nurse and Staff C RN entered the Resident #4 ' s room prior to report. During an interview on 1/27/16 at 10:30 a.m. Staff K CNA stated she and Staff L CNA assisted Resident #4 to roll over when his/her legs and feet slipped off the bed. According to Staff K CNA she failed to see Resident #4 ' s knee or leg hit the floor or hear if the leg hit the floor. The incident happened around 4:30 p.m. on 12/30/15 per Staff K CNA. Staff K CNA noted an abrasion to the knee after the incident. Staff K CNA stated she informed Staff H LPN about the incident. During an interview on 1/27/16 11:35 a.m. Staff L CNA confirmed during a turn in bed Resident #4 ' s leg slipped off the bed. According to Staff L CNA Resident #4 ' s knee barely touched the floor. Resident #4 ' s bottom heavy according to Staff L ' s statement and the turn caught them off guard. During an interview on 1/28/15 at 5:50 a.m. Staff P RN stated that she did not complete personal cares for Resident #4. She also stated that the resident can get feisty and resists cares. At mid-shift she went to the Resident #4's room and looked at the leg. The girls turned him/her and he/she yelled out. Staff P did not believe it was anything more than his/her normal. She looked at Resident #4 ' s leg for bruising and did not see any bruising. She further stated that she moved Resident #4's leg the best she could considering the contractures. During an interview with Staff P CNA on 1/28/16 at 6:00 a.m. stated she repositioned Resident #4 on the night shift. Resident #4 cried out and she could tell that he/she was hurting. She stated that she told the nurse. The clinical record failed to contain an assessment or range of motion to the lower extremities of Resident #4 following the incident on 12/30/15.

Based on review of manufacturers recommendations for seat belts, record review and interviews with staff members and a company representative, the facility failed to protect residents against physical or environmental hazards to themselves when being transported in a vehicle and the administration failed to assume the responsibility for the overall operation of the nursing facility and have established written policies and procedures for van safety available for review (Resident #2). Resident #2 was not properly secured in the van, fell out of the wheelchair and fractured a hip. The facility did not have a policy or procedures for staff to follow for proper placement of seat lap belts. The facility transportation van could carry 2 wheelchairs and 1 staff person. The facility reported a census of 64 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 03/10/14 which identified the resident had long and short term memory problems and severely impaired skills for daily decision-making. Resident #2 required extensive assistance with activities of daily living (ADL's) skills including bed mobility, dressing, toilet use and personal hygiene, and depended upon staff for transfers. The MDS reflected the resident used a wheelchair for mobility and did not ambulate. Resident #3's [DIAGNOSES REDACTED]. The Care Plan dated 05/11/06 identified Resident #2 with right sided weakness due to a past stroke and the need for assistance with all ADL's. Resident #2 used a tilt back chair. The approaches directed the staff members that Resident #2 depended upon them for transfers to and from the bed and to the tilt back chair or bedside commode. The Care Plan dated 5/11/06 identified a problem with the resident having the potential for falling. The approaches directed staff to not leave the resident up in his/her room and unattended in the wheelchair. The resident could sit at the nurses station in the wheelchair or lay in bed The Care Plan dated 5/11/06 identified Resident #2 had a history of [REDACTED]. Resident #2 had frequent twitching and jerking movements and required medication for treatment. A Fall Risk assessment dated [DATE] documented Resident #2 scored a 15. A score of 10 and above represented the resident at high risk for falls. A Progress Note dated 06/24/14 at 8:32 a.m. documented Resident #2 received Lorazepam 0.5 mg. Staff noted Resident #2 twitching in his/her wheelchair with his/her arms slightly jerking enough to spill liquids from his/her cup. Staff removed Resident #2 from the dining room and gave the medication. At 2:15 p.m. the nurse was summoned to the (facility) van located at 36 th and Hamilton Boulevard. Upon arrival Resident #2 sat on the van floor in front of his/her wheelchair. The resident ' s left leg extended out and the right leg flexed and bent laterally to his/her right side. Resident #2 complained of pain and pointed to his/her right hip area. Resident #2's right lower extremity appeared purple and cool to touch with pedal pulses palpable. The other resident riding in the van said Resident #2 jumped around and moved around in his/her chair. Resident #2 went with paramedics to the emergency room for evaluation. An Incident Report dated 06/24/14 at 2:15 p.m. documented Resident #2 was being transported per the facility van from an appointment with the doctor. The report reflected Resident #3's wheelchair was belted into place in the van. Resident #2 went to the emergency for further evaluation and treatment. Resident #2 was admitted to the hospital with [REDACTED]. In a statement dated 06/24/14, another resident in the van at the time of the incident stated he/she sat in the van behind Resident #2 so he/she couldn't see much. The resident knew Resident #2 was buckled in properly with the floor straps and seatbelt. A Post Fall assessment dated [DATE] regarding assistive devices used, documented the wheelchair was in the upright position and not reclined. A History and Physical report dated 06/24/14 at 9:41 p.m. documented Resident #2 presented with a noticeable deformity of the right leg, with the onset of symptoms and a work up revealed a fracture of the right hip. A Physician Assistant Addendum dated 06/25/14 documented Resident #2 underwent a surgical procedure for pinning of the right hip fracture. A Progress Note dated 06/28/14 at 2:05 p.m. documented Resident #2 returned from the hospital per the facility van at 1:25 p.m. At 5:32 p.m. Resident #2 was lifted with the mechanical lift and into the wheelchair. Resident #2's right hip incisional area measured 3 inches in length, approximated with intact staples, and had scattered bruising. The area was covered with a dressing. In a statement dated 06/24/14, Staff A, the Van Driver, wrote he went to the doctor ' s office to get Resident #2. He got Resident #2 all seat belted in and got all of the floor straps on and tightened, and double checked all the straps and seat belt before leaving. On the way back with Resident #2, Staff A heard a little scream and looked back and saw Resident #2 moving around in his/her chair so he pulled over and then he saw Resident #2 sliding around and forward and then out of the chair. A note dated 06/25/14 documented the Director of Nursing (DON) observed the van driver position and secure a wheelchair in the van. The van driver was able to perform the procedure properly, including placing the seat belt on the resident and did not identify any concerns. On 08/06/14 at 3:30 p.m. the DON was interviewed and stated they send an escort in the van in addition to the van driver if a resident is at risk of getting up out of the wheelchair. The DON stated she now sends an escort with Resident #2. The DON stated she did observe Staff A put the belt on after the incident and she thought he put it from the side roof of the van through both of the wheelchair armrests, and she thought that looked okay (alright). On 08/05/14 at 12:35 p.m. Staff B, Certified Nursing Assistant/Medical Secretary, was interviewed and stated she did the van scheduling and the van driver stayed in contact with her. She stated Resident #2 had an appointment with the physician. Staff A telephoned and stated Resident #2 slid out of the chair and wanted to know if she could come and help him. She told him to pull over, put on the hazard lights and don't move (the resident). He gave directions to where he was. Staff B took Staff D Licensed Practical Nurse (LPN) to the van. When they got to the van and opened the door, Resident #2 sat on the van floor in front of his/her wheelchair with his/her right leg bent at the knee and kind of turned out and he/she tilted against the padding of the seat to his/her left. Resident #2 complained of his/her inner thigh area. They called 911. When rescue personnel arrived they moved the wheelchair so rescue personnel could lift Resident #2 into the wheelchair and then to a stretcher. Staff B checked the chair because Staff A was new, and could barely move the chair because it was tight. The seat belt was unhooked, but Staff A said he/she unhooked it. She said the wheelchair sat in the upright position, the way she had transported Resident #2, and felt the way Resident #2 should be transported; sitting upright. Staff B stated the seat belt in the position where Resident #2 sat (in the van) only went across the left shoulder to the right side waist and hooked at the floor. She stated they had no belt to go across the resident's lap. When asked how it could be safe to only use a shoulder belt for a resident in a wheelchair, Staff B stated that's all they had and that's how she was trained. During an interview on 08/05/14 at 2:36 p.m. Staff D stated she was Resident #2's nurse the day (of the incident). She got called to the scene about 1:50 p.m. She had given Resident #2 Ativan (Lorazepam) at breakfast due to twitching. Resident #2 got twitchy and jumpy, it varied, and she couldn't say how often. She said some residents needed an escort on the van, but she didn't know who. Resident #2 was alert, but confused. On 08/05/14 at 1:56 p.m., Staff A (van driver) demonstrated how he secured Resident #2's wheelchair the day Resident #2 fell in the van. Staff A then demonstrated the use of the seat belt to secure the resident. A strap hooked to the upper left side of the van was positioned over the resident's left shoulder and down to the right side waist area through the arm rest space and then attached at the floor. Staff A stated there was no belt for the resident's lap. Staff A stated he drove a van at another facility prior to working at this facility and had not worked at this facility very long when the incident occurred. He stated at the previous facility they had a lap belt, but the way he demonstrated was the way he was trained at this facility. Staff B confirmed they trained Staff A this way. Staff B looked in the van and found no instructions in securing residents in the van. A label on the shoulder strap belt identified the manufacturer as Sure Lok, part number FE 5-2, dated Feb. 2002. During an interview on 08/06/14 at 3:42 p.m. Staff C, part time van driver, stated he put the belt under the arm pits and secured to the floor on the right side from the left side of the van by the window. He had never employed any kind of a pelvic belt. He didn't recall if the previous van driver (no longer at the facility) had showed him to put the belt under both arms, but he said if he didn't it would rub on their neck and he didn't feel safe that way. During an interview on 08/05/14 at 3:36 p.m. a Sure-Lok company representative stated a shoulder belt could not be used alone to secure a resident in a wheelchair, because the shoulder strap hooked to the lap belt. When given the part number of the belt (the facility used as a shoulder belt) she said that was not a shoulder belt, it was a lap belt, and no, it should not be used as a shoulder belt/strap. A video was available online including securing the occupant. Observation on 8/5/14 at 3:36 p.m. of the online Sure-Lok Sure and Secure Training Program, identified the Doing it Right Training included: a. Pre-trip assessment, b. Sensitivity training, c. Component and assembly operation, d. Securing the wheelchair, e. Securing the occupant, f. System care and maintenance. The key points included to make sure there were 4 securement straps (for the wheelchair), a lap and a shoulder belt, and make sure an instruction sheet was available for quick reference. The instruction sheets were available from Sure-lok. The Securing the Occupant section directed that after securing the wheelchair, attach the lap belt down between the wheelchair side panel, making it firm but comfortable. The last belt is the shoulder belt, bringing it over the shoulder and attaching it to the lap belt. The information was given to Staff B. During an interview on 08/05/14 at 4:45 p.m. the Administrator stated they watched the Sure-Lok video and checked and they had all the straps in the van. The actual shoulder straps were suspended in the van. He said they previously did not realize they were there or how to use them. The van drivers watched the video and know how to use the lap and shoulder belts. During an observation on 08/06/14 at 4:08 p.m. Staff A returned (to the facility) with 2 residents in the van, using lap belts and shoulder harnesses. Staff A did have the shoulder harness over both arms and Staff B instructed him to put it under the far arm and physically showed him to do this. A Motor Vehicle and Driver Safety Program revised 02/21/12 page 1 identified the purpose included to provide a prudent, good faith effort to protect the safety of residents and employees while in transport. Page 2 included all authorized drivers were required to sign the Safety Responsibilities for Authorized Driver form. The form on page 3 documented the driver and passengers were required to wear seat belts and shoulder harnesses. Note: At the time of the investigation, the deficiency was coded at a "J", immediate and serious jeopardy. By 8/7/14, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The Administrator had developed policy/procedures for safe transporting of residents in the facility van vehicle. The facility educated staff about the proper procedure of securing straps/belts in order to keep residents safe in the facility transport van. As of the 8/18/14 exit conference, the facility needed to: ? Finish inservicing all employees regarding the proper procedure of securing straps/belts in order to keep residents safe in the facility transport van. ? Monitor to ensure the staff are compliant with the policy/procedures of securing the residents in the facility transport van and the safety belts manufacturer's recommendations are followed.

Relates to # -C: Based on clinical record review, resident and staff interviews and observations, the facility failed to maintain an environment which is respectful of each resident's dignity for 1 of 14 current residents sampled (Resident #5). The facility identified a census of 63 residents. Findings include: 1. Resident #5 had a quarterly Minimum Data Set (MDS) assessment performed with a reference date of 7/16/2010. The assessment reflected the resident had short and long term memory problems and moderately impaired with cognitive skills for daily decision making. The assessment indicated the resident usually could make self understood and had the ability to usually understand others. The assessment indicated the resident had [DIAGNOSES REDACTED]. The resident required extensive assistance of 2 staff or more for transfers and personal hygiene. The MDS indicated the resident experienced frequent incontinent episodes of the bowel and bladder. Observation on 9/21/10 at 11:53 A.M. revealed the resident was transported to the main dining room by Staff C, CNA (Certified Nursing Assistant). Staff C placed a gait belt on the resident. Staff C and Staff B, CNA then stood the resident at the wheelchair and pivoted the resident to a regular dining chair. Observation revealed the resident ' s pants heavily soiled with urine; both staff continued to place the resident at the regular dining room table. At 12:10 P.M. the resident continued to sit at the dining table with the soiled pants on. At 12:25 P.M., the resident continued to sit at the main dining room table in the chair. At 12:40 P.M. the resident continued to sit in the regular chair wearing soiled pant. At 12:48 P.M. Staff N CNA /Restorative Aid (RA) placed a gait belt on the resident. Staff B CNA and Staff N CNA/ RA stood the resident at the chair and pivoted the resident to a wheelchair. The resident's pants were visibly wet with urine in the front and back of his/her pants. At 1:00 P.M. the resident sat in the wheelchair facing the hallway. The resident's pants were visible to the resident's sitting in the area and visitors entering the building. On 9/22/2010 at 8:00 A.M. Staff B Certified Nursing Assistant was interviewed and stated she/he assisted with the transfer of the resident at the lunch table. Staff B stated had no noticed the resident's pants when transferred the resident to the regular chair, but did notice the resident had been wet when they transferred him/her back to the wheelchair. On 9/22/2010 at 10:40 a.m. the resident was interviewed and stated did not like to sit in wet briefs. The resident then began to cry. The resident stated if the staff had just taken her/him to the bathroom, then the accident would not have happened.