Every finding on record at Centerville Specialty Care

Based on observations, clinical record review, review of facility policy, and staff interviews, the facility failed to ensure nursing staff performed hand hygiene between glove changes, and changed gloves between wounds to prevent cross contamination of wounds for 2 of 2 residents observed for wound care treatment (Resident #1 and #3). The facility reported a census of 41 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #1, dated 2/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (intact cognition). The MDS documented the resident dependent on staff for Activities of Daily Living (ADLs, toileting, hygiene, bed mobility, transfers, dressing) with the exception of eating. The MDS included diagnoses congestive heart failure, diabetes, peripheral vascular disease and had 6 venous or arterial ulcers present. Review of wound assessments, titled Skin and Wound, dated 3/19/26, revealed Resident #1 had open venous ulcer wounds to the right and left lateral (outer) calf. Review of Clinical Physician Orders revealed the following orders:An order, dated 2/3/26, LT (left) heel pain paint with Betadine (type of topical wound care solution).An order, dated 3/3/26, to cleanse ulcers to BLE (bilateral lower extremities) with Vashe Wound Cleanser. Apply Triad (type of topical wound paste) to Peri-Wound for MASD (moisture associated skin damage). Place Gelling Fiber with ATB (antibiotic) Silver Dressing to Wound Bed. Apply Super Absorbent Dressing Over, and wrap with Kerlix (type of roll gauze). May use Gelling Fiber Dressing without ATB Silver if ATB Silver not Available. (apply) every other day. An order, dated 3/13/26, to apply Triad cream to ST (skin tear) on left shin daily with dressing change. On 3/24/26 at 8:04 AM, Staff C, Registered Nurse (RN), entered the resident's room with her treatment cart. Staff G, Licensed Practical Nurse (LPN), entered in shortly after to assist Staff C with wound care on the resident's left and right calf venous ulcers. Staff C and Staff G, washed their hands, gowned and gloved. Staff G set up a clean field for wound care supplies on top of the treatment cart. Staff C removed the wound dressings, including the roll gauze dressing, superabsorb pads and Silver, from the right leg and then the left leg without changing gloves between legs. The dressing from the right leg wound had a large amount of bloody drainage, and both legs had open wounds. After removing the dressing from both legs, Staff C, RN, changed her gloves without performing any type of hand hygiene (either hand washing or use of an alcohol-based hand rub). Staff G, LPN, removed her gloves, washed her hands, and donned another pair of gloves. Staff C then poured the Vashe Wound Cleanser directly over the wounds on the right leg, and used a gauze pad to wipe over the wounds after the cleanser. Staff G cleaned the left leg. The disposable pad under the resident's right leg was noted to have a large amount of bloody drainage. Staff C, RN, removed her gloves, got Triad paste out of the treatment cart and put some in a medication cup. Staff C gloved without performing hand hygiene and applied Triad paste to the right lower extremity with the gloved fingers of her left hand. Staff C, RN, and Staff G, LPN, removed their gloves, washed their hands, and donned another pair of gloves. Staff C applied the Silver dressing, superabsorb dressing and then roll gauze to the right lower leg. Staff C, RN, then picked up the medication cup with Triad paste and dropped it on the floor. Staff C picked up the medication cup off the floor with her left hand, removed the glove from her left hand, got out more Triad paste from the cart, put a new glove on her left hand without performing hand hygiene, and applied Triad paste to the left lower leg with the fingers from her left hand. Staff C then applied Betadine to the left heel. Staff C removed her gloves and donned another pair of gloves without performing hand hygiene. Staff C applied the Silver dressing, superabsorb dressing and roll gauze to the left lower leg.2. Review of the Minimum Data Set (MDS) assessment for Resident #3, dated 2/18/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (intact cognition). The MDS documented the resident dependent on staff for Activities of Daily Living (ADLs, toileting, hygiene, bed mobility, transfers, dressing) with the exception of eating. The MDS included diagnoses of diabetes and morbid obesity, had moisture associated skin damage (MASD) and received topical medicated treatment and nonsurgical wound dressings. Review of a wound assessment, titled Skin and Wound, dated 3/19/26, revealed an open MASD wound to the right iliac crest (right front pelvic area located under the resident's abdominal fold) that measured 0.25 centimeters (cm) in length, 2.09 cm in width and 0.1 cm in depth. Review of Clinical Physician Orders, dated 3/12/26, revealed an order for Triad Hydrophilic Wound Dress External Paste (wound dressings), apply to right ABD (abdominal) fold topically every day and evening shift for wound; and, revealed an order, dated 3/19/26, for Interdry (a fabric-like dressing used to moisture-related wounds) to abdominal folds, change on shower days and PRN (as needed) if soiled or missing. On 3/24/26 at 2:00 PM, during an observation, Staff C, Registered Nurse (RN), put some Triad paste into a medication cup and took the cup to Resident #3's room. Staff D, CNA, entered into the room to assist Staff C, RN. Staff C placed the medication cup on the resident's night stand. Staff C washed her hands and gloved. Staff C then pulled down the resident's incontinent brief and pulled up the resident's stomach. The resident had two open areas, one wound on the right side of the abdominal fold and one on the left side. Both wounds had a red wound bed, and the right wound was larger than the wound on the left. Staff C got a wet wash cloth with a small amount of hand soap, wiped the wounds on the right and left side two times with the wash cloth, and then patted the area dry with a hand towel. Staff C removed her gloves and donned another pair of gloves without performing hand hygiene between glove changes. Staff C applied Triad cream to both open wounds with the same fingers of her left hand. Staff C then removed her gloves and washed her hands. On 3/24/26 at 2:12 PM, during an interview, Staff C, RN, reported for wound care staff needed to wash their hands, don gloves and work from dirty (soiled) to clean. Staff C reported if she changed gloves during wound care, she should perform hand hygiene between glove changes. Staff C explained that if her hands were visibly soiled, then she needed to wash her hands; otherwise, she could either wash her hands or use an alcohol-based hand sanitizer. Staff C reported that if she was providing wound care to two different wounds, she didn't want to cross contaminate between the wounds, so she would change her gloves between wounds. Staff C explained that she should change her gloves and perform hand hygiene when going from dirty (removing soiled dressing) to clean (cleaning a wound and applying medication/dressing).On 3/24/26 at 3:39 PM, during an interview, Staff E, RN, reported when she performed wound care on a resident with more than one wound, such as Resident #1, she did wound care to one leg at a time to prevent cross contamination between wounds. Staff E reported she changed her gloves after removing the wound dressing and after cleaning the wound. She performed hand hygiene between glove changes.On 3/25/26 at 10:51 AM, during an interview, Staff G, LPN, reported when she performed wound care on Resident #1, she removed the soiled dressings from both legs, or whatever the policy is. Staff G explained she changed her gloves after removing the soiled dressings and performed hand hygiene with each glove change. Staff G reported she cleaned the wounds on one leg, changed gloves, applied the treatment on that same leg, and then changed gloves before cleaning and treating the other leg.On 3/25/26 at 2:46 PM, during an interview, the Infection Preventionist (IP) reported staff should wash their hands and don gloves prior to removing soiled wound dressings, then wash their hands and don gloves prior to cleaning wounds. After cleaning wounds, staff should wash their hands and don gloves before applying treatment. The IP reported that she would do wound treatment on one leg at a time in relation to wound care for Resident #1, and then change gloves with hand hygiene prior to moving onto the other leg.On 3/25/26 at 3:02 PM, during an interview, the Director of Nursing (DON), reported if a nurse was changing a soiled dressing on a resident with two wounds, the nurse should get new gloves before changing the soiled dressing on the second wound. Nursing staff should perform hand hygiene between glove changes. Review of the facility policy, titled Handwashing/Hand Hygiene, dated August 2019, revealed, in part, staff should perform hand hygiene before handling clean or soiled dressings, after contact with blood or bodily fluids, after handling used dressings and after removing gloves.

Based on clinical record review, policy review, and staff interviews, the facility failed to carry out assessments and interventions after high blood sugar readings for 1 of 2 residents(Resident #29) reviewed for insulin(an injectable medication used to lower blood sugar). The facility reported a census of 38 residents. Findings included: The Minimum Data Set(MDS) assessment tool, dated 10/23/25, listed diagnoses for Resident #29 which included diabetes, heart failure, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. A 6/24/22 Care Plan entry stated the resident used insulin related to diabetes.A 9/5/25 Care Plan entry directed staff to notify the provider if blood sugars exceeded 500 milligrams(mg)/deciliter(dl).The November and December 2025 Medication Administration Records(MARs) directed staff to obtain the resident's blood sugar before meals, at bedtime, and at 12:00 p.m. The MAR directed staff to notify the provider of blood sugars over 500 mg/dl.The resident's Blood Sugar Summary included the following blood sugars for 11/16/25:10:58 a.m. 547.0 mg/dl4:00 p.m. 600.0 mg/dlThe resident's Blood Sugar Summary included the following blood sugars for 12/1/25: 4:31 p.m. 538.0 mg/dlThe facility lacked documentation of provider notification of the above blood sugars and lacked documentation of any follow-up assessments or monitoring following the elevated blood sugars.The facility policy Diabetes-Clinical Protocol, revised 12/3/25, stated the physician would order desired parameters for monitoring and reporting information related to blood sugar management.On 12/3/25 at 3:20 p.m., the Director of Nursing(DON) stated orders included parameters for staff to refer to for provider notification of high blood sugars. She stated staff should follow this. On 12/4/25 at 8:28 p.m., the DON stated she could not locate any further documentation related to the resident's high blood sugars.

Based on clinical record review, policy review, and staff interview, the facility failed to carry out medication consents for residents to make informed decisions with regard to their care for 2 of 5 residents reviewed for medications(Residents #8 and #29). The facility reported a census of 38 residents.Findings included: 1. The Minimum Data Set(MDS) assessment tool, dated 11/19/25, listed diagnoses for Resident #8 which included anxiety, depression, and non-Alzheimer's dementia. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 3 out of 15, indicating severely impaired cognition. The facility policy Antipsychotic Medication Use, revised December 2016, stated the facility would obtain informed consent and document why the benefits of the medications outweighed the risks or adverse consequences.The December 2025 Medication Administration Record(MAR) listed a 12/2/25 order for Abilify(an antipsychotic medication) 2 milligram(mg) one time per day. A 12/2/25 Care Plan entry stated the resident had an order for Abilify. A 12/3/25 11:50 a.m. Nurses Note stated the facility spoke with the resident's representative regarding the reason and benefits of the medication. The facility lacked documentation of the completion of a medication consent prior to the initiation of the medication which included the risks and benefits.2. The MDS assessement tool, dated 10/23/25, listed diagnoses for Resident #29 which included diabetes, heart failure and coronary artery disease. The MDS listed the resident's BIMS score as 9 out of 15, indicating moderately impaired cognition. The December MAR listed a 12/2/25 order for Rexulti(an antipsychotic medication) 0.5 mg one time per day.A Care Plan entry, revised 12/2/25, stated the resident used antidepressant medications related to depression. The facility lacked documentation of the completion of a medication consent prior to the initiation of the medication which included the risks and benefits.On 12/4/25 at 8:28 a.m., the Director of Nursing(DON) stated staff had a conversation with the resident families regarding the initiation of the medications but stated this was not documented in the notes.

Based on observation, policy review, and staff interview, the facility failed to ensure residents on a mechanical soft and pureed diet received the correct portions for 5 of 5 residents and failed to follow the menu for 3 of 3 residents reviewed. The facility reported a census of 38 residents. Findings include:Observations on 12/03/2025 starting at 11:00 AM revealed the following:a. Staff B, [NAME] placed 2 unweighted sections of ham in the food processor and processed to a mechanical soft (ground) texture. She measured out 5 green scoops (1/3 cup) of the processed ham and stated was for the mechanical soft diets. Staff B added 1 cup of gravy to the remaining ham and processed to a pureed consistency. She measured the pureed ham as 2 cups. During the subsequent meal service, Staff B served the mechanical soft ham to 2 residents and the pureed ham to 3 residents with a 1/3 cup scoop. After serving, she measured 1 cup of mechanical soft ham and 1/3 cup of pureed ham remaining. Interview on 12/03/2025 at 1:15 PM, Staff B stated she did not measure the ham sections before processing to mechanical soft and puree. Staff B stated she estimated the portion size of ham for the number of residents on altered diets and did not weigh the portion sizes for the menu requirements of 5 ounce serving of ham for each resident with mechanical soft and puree diet. Staff B stated the mechanical soft and pureed meat serving size is always the green scoop (1/3 cup). Staff B stated did not provide rolls, per the menu, for the 3 residents with puree diets, as she forgot to puree the rolls with the ham. Facility Diet Spread Sheet for 12/3/25 revealed lunch for mechanical soft and pureed diet as 5 ounces of ham and included a roll for pureed diets. Facility's undated Pureed Food Preparation Policy directed all residents on a pureed diet shall receive the correct portions of pureed meat, fruit, starch, fat, vegetables and dessert. The policy directed staff to pureed the correct number of portions (plus 1-2 extra servings), bread as planned on the menu may be added to the mixture, determine the total volume, and determine the scoop size. Interview on 12/3/25 at 1:45 PM, the Dietary Manager (DM) stated all residents should receive the portion size per menu. The DM stated the process was to measure the meat portions, then process the meat to mechanical or puree consistency and use the chart to determine the serving size per total volume. The DM stated residents should receive all food items on the menu. the roll should have been pureed with the meat.

Based on observation, clinical record review, policy review, and resident and staff interviews, the facility failed to carry out fall interventions(the use of a gait belt) in order to prevent a fall for 1 of 4 residents reviewed for falls(Resident #5). The facility reported a census of 38 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 11/4/25, listed diagnoses for Resident #5 which included restless leg syndrome, Alzheimer's disease, and non-Alzheimer's dementia. The MDS stated the resident was dependent on staff for toilet transfers and required partial to moderate assistance for walking. The MDS listed a Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition. The facility policy Safe Lifting and Movement of Residents, revised 2017, stated the facility would incorporate resident safety, dignity, comfort, and medical conditions into the goals and decisions regarding the safe lifting and moving of residents. The facility stated staff were trained in the use of gait belts.Care Plan entries, dated 11/1/25, stated the resident was at risk for falls and required the assistance of 1-2 staff for walking and transfers. An 11/8/25 Witnessed Fall report, completed by Staff C Registered Nurse(RN), stated the resident walked to the bathroom with an assist of one. The resident stated she wanted to use the commode but the bucket was not in the commode. Staff C grabbed the commode with one hand and held onto the resident with the other hand. The resident staggered backwards and Staff C helped her land.An 11/8/25 Nurses Note, completed by Staff C, stated the resident had to use the bathroom and Staff C asked another staff member if the resident was an assist of 1 or 2 and staff reported she was an assist of 1. Staff C assisted the resident out of her chair and walked to the bathroom when the resident stated her bathroom was broken and she wanted to use the commode. The bucket was not in the commode so Staff C reached with one hand to fix the commode and her other hand was on the left arm of the resident who held onto the walker. As Staff C reached for the commode, the resident stepped backwards and fell to the floor.An 11/11/25 Encounter Note stated the resident had a fall on 11/8/25 and reported hip pain. On 12/2/25 at 9:41 a.m., Resident #5 stated she had a fall and it hurt her. On 12/2/25 at approximately 5:00 p.m., the resident walked in the hall with 2 staff members and her walker. The resident wore a gait belt that one staff held onto and another staff followed behind with a wheelchair. On 12/4/25 at 9:26 a.m., Resident #5 stated when she fell, staff did not use a gait belt but stated they typically did.On 12/4/25 at 9:57 a.m., Staff C stated the resident reported she had to use the bathroom. Staff C stated she was a travelling nurse so she asked two staff members if the resident could get up by herself and they said yes. She walked with the resident to the bathroom and when they were halfway there, the resident stated she wanted to use the commode. The commode was about 3 feet away and the bucket was not inserted. She stated they had to walk back toward the commode and the resident stepped back and fell. Staff C stated she did not have a gait belt on the resident and this was her(Staff C's) fault. Staff C stated she learned her lesson. On 12/4/25 at 10:20 a.m., the Director of Nursing(DON) stated staff should utilize a gait belt if a resident was an assist of 1 or 2. She stated staff would use the Kardex(a document containing resident information) to determine how to transfer the resident.

Based on observations, staff interviews, and policy review, the facility failed to implement the Infection Prevention and Control Program (IPCP) by staff wearing Personal Protective Equipment (PPE) in the hall after resident care and by allowing the indwelling catheter tubing to contact the floor during resident transport in a wheelchair. The facility reported a census of 38 residents. Findings include:On 12/02/25 at 9:56 AM, Staff A, Physical Therapy Assistant (PTA) transported Resident #7 in a wheelchair from his room to the shower room. Staff A was observed wearing PPE while assisting Resident #7 reposition in his wheelchair in his room. She exited Resident #7's room, did not remove the gown, and transported the resident to the shower room. The resident's indwelling catheter tubing was in contact with the floor during transport.The Minimum Data Set (MDS) dated [DATE] for Resident #7 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated completely intact cognition. It included diagnoses of atrial fibrillation (irregular heartbeat), heart failure, diabetes mellitus, thyroid disorder, arthritis, cerebrovascular accident (stroke), urinary tract infection (UTI), and acute cystitis with hematuria (bladder inflammation with blood in the urine). It also indicated the resident was dependent with all Activities of Daily Living (ADLs) and mobility. It also revealed he had an indwelling catheter upon admission.The Care Plan revised 11/18/25 included the resident's urinary (indwelling) catheter and directed staff to provide Enhanced Barrier Precautions (EBP).On 12/03/25 at 2:58 PM, Staff A stated the resident being transported in his wheelchair was not part of his therapy. She also stated the facility provided PPE education and evaluated staff appropriately putting on and removing PPE. She said she understood EBP requirements directed staff to enter the resident's room, put on PPE before touching the resident, perform hand hygiene, don gloves, and provide resident care or a transfer within the resident's room. She confirmed PPE was not required once the staff and resident were in the hallway. She admitted she kept it on because she was going to continue working with the resident in the bathroom and knew she would need another gown. She further stated she was not aware the resident's indwelling catheter bag was on the floor when she transported the resident.The EBP sign directed staff to wear gloves and a gown for the followingHigh-Contact Resident Care Activities.a. Dressingb. Bathing/Showeringc. Transferringd. Changing Linense. Providing Hygienef. Changing briefs or assisting with toiletingg. Device care or use: central line, urinary catheter, feeding tube, tracheostomyh. Wound Care: any skin opening requiring a dressingOn 12/04/25 at 8:32 AM, the Infection Preventionist stated staff should remove PPE prior to exiting residents' rooms.On 12/04/25 at 10:52 AM, the Director of Nursing (DON) stated staff should have removed the PPE before leaving the resident's room.A policy titled Catheter Care, Urinary dated [DATE] directed staff to be sure the catheter tubing and drainage bag are kept off the floor.A policy titled Enhanced Barrier Precautions revised April 28, 2024 indicated EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration. Examples: Walk to Dine Restorative program, assisting residents with feeding, transfers from w/c to stationary chair in common areas.

Based on observation, clinical record review, policy review and staff interview, the facility failed to ensure adequate kitchen sanitation and food handling for 2 of 2 visits to the kitchen. The facility reported a census of 36 residents. Findings include: The facility policy Cleaning Instructions, dated February 2016 stated (staff) would maintain all kitchen areas in a sanitary manner, free of buildup of food, grease, or other soil. The cleaning schedule directed staff to clean items such as: the dish machine, ice machine, steam table, cabinets, drawers, stove hood, and work areas. The initial kitchen tour on 10/14/24 at 10:08 a.m. revealed the following concerns: a. The Dietary Manager's (DM) front bangs protruded from her hair net from the top of her forehead to the top of her eye brows. b. An opened package of turkey breasts was dated 9/30/24. c. The spigots of the fire suppression system had dust particles hanging down from them. A kitchen observation on 10/15/24 at 11:15 a.m., revealed the following concerns: a. Dust remained on the fire suppression spigots. b. The DM picked a piece of refuse off the floor and threw it away. Without washing her hands, she went to the steam table and touched foil which covered food. c. The plastic menu holder located above the prep table was covered with dust. d. Yellow drips present on the right hand side of the steam table. e. A white shelf located directly above the steam table covered with dust and loose pieces of food hanging down over the food. The shelf was sticky to the touch. f. The DM went to the freezer to retrieve ice cream and did not wash her hands before she continued to serve meals to residents. g. The ceiling above the sink covered with multiple round dust like particles. h. A fire suppression system spigot above the spices and clean plates covered with a thick layer of dust. i. The outside of the dishwasher had a crusty white buildup. j. The floor of a drawer had crumbs covering the bottom. Measuring spoons and scoops sat in the crumbs and a black substance was present in the drawer corners. On 10/16/24 at 9:07 a.m., the ice machine had a brown buildup on the top interior wall. The outside of the machine had a white buildup on the sides. On 10/17/24 at 9:39 a.m., the Dietary Manager stated staffing had been a struggle and it was difficult to complete all the cleaning. She stated she expected cupboards, drawers, shelving, and spigots to be clean and dust free. She stated they replaced the shelf above the steam table and cleaned the ice machine yesterday. She stated if a staff person picked up something off the floor, they should then wash their hands. She stated all hair should be restrained under a hair net.

Based on observation, policy review, and staff interview, the facility failed to ensure 1 of 1 residents on a pureed diet received the correct portion and texture. The facility reported a census of 36 residents. Findings include: Observations on 10/15/24 at 11:15 a.m. revealed the following: a. The Dietary Manager (DM) placed 1 fish filet in the food processor, added broth, and processed to a pureed consistency. She measured the processed fish as 3/4 of a cup. During the subsequent meal service, the DM served the fish to the resident with a scoop. After serving, she measured 1/4 of a cup remaining. b. The DM placed a half cup of green beans into the food processor, added green bean juice, and processed to a liquid consistency. The DM stated pureed food should be pudding consistency and stated the beans were runny. The DM served the liquid-consistency beans to the resident during the subsequent meal service. On 10/17/24 at 9:39 a.m., the Dietary Manager stated residents who received a pureed diet should receive the same amount as other residents. She stated the resident at lunch should have received the entire fish filet. She stated pureed food should not be runny and it should be a pudding consistency. The undated facility policy Puree Technique directed staff to follow the menu as planned and process the correct number of portions. The policy directed staff to measure the total volume and divide by the total number of portions. The policy stated staff should puree food to a pudding consistency.

Based on clinical record review, staff interviews, and policy review the facility failed to ensure each resident was treated with respect and dignity while interacting with 1 of 3 residents reviewed. (Resident #1) The facility reported census was 40. Findings include: According to a Minimum Data Set (MDS) with a reference date of 7/11/24, Resident #1 had long and short term deficits and severely impaired cognitive abilities. Resident #1 was independent with transfers and mobility, moderate assistance with dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included Non-Alzheimer's dementia, aphasia, coronary artery disease, renal insufficiency, chronic obstructive pulmonary disease. According to Resident #1's Care Plan, he is at risk for aggression and wandering behavior with interventions to approach and speak calmly, offer food or drink, ice cream or Mountain Dew. Remind resident that his behavior is inappropriate. Offer a pleasant diversion or structured activity such as food, conversation or TV. In an interview on 8/22/24 at 8:45 a.m. Staff D, Housekeeper, stated she was unsure of the date (7/31/24), but that morning she heard Resident #1 mumbling, so she stepped out into the hall and saw Resident #1 walking down the [NAME] hall. Staff D stated this was usual behavior for Resident #1 as he liked to wander. The nurse, Staff A, headed down the hall way to redirect him. Staff A stood in front of Resident #1 with her arms outward. Staff A's voice was raised as she was telling Resident #1 he could not go in that direction. Staff D stated Resident #1 started to get physical and Staff A was escalated, so she offered to take over, but Staff A continued to interact with Resident #1, so she walked away. In an interview on 8/22/24 at 9:10 a.m. Staff E, Housekeeper, stated on Wednesday, July 31st at around 6:15 a.m. to 6:30 a.m., she and Staff D were sweeping and cleaning the outer dining room. Resident #1 was wandering as usual and he has history of exit seeking. Resident #1 was just looking around and Staff A, Licensed Practical Nurse, apparently thought he was getting too close to the front door. Staff A came over and grabbed Resident #1 by the arms as she stood behind him, saying we're not going to do this today, you need to sit down. Staff A was pushing Resident #1 away from the door, trying to redirect him. Things settled down after that and Resident #1 continued to hang around the housekeeping staff. Staff E stated she and Staff D went to the [NAME] hall shower room to clean. Resident #1 also moved into the [NAME] hall and was standing outside of room [ROOM NUMBER], looking in, when Staff A came into the hall demanding Resident #1 stay out of the room, then again grabbed his arms from behind and started redirecting him, but this time more aggressively than before. Resident #1 started hitting Staff A and at one point Staff A pushed Resident #1 so hard he stumbled and almost fell . Staff A maintained contact with Resident #1 and prevented the fall. Staff E stated she was able to intervene and get Resident #1 involved in an activity. Staff E stated she didn't believe Staff A had any malicious intent to harm Resident #1. In an interview on 8/22/24 at 10:12 a.m. Staff C, Housekeeping Supervisor, stated on the morning of Wednesday, July 31st, they (housekeeping staff) had came in early due to a power outage. At shift change (6:00 a.m.) she overheard discussion that Staff A had been assigned skin assessments and this seemed to upset her. Staff C stated she was in the outer dining room with Staff E. Resident #1 was wandering and stepped towards the front door. Staff C told Staff E to grab a magazine in an attempt to distract Resident #1 with an activity. Staff C positioned herself in front of the door. At that time Staff A walks over saying we're not doing this today, then pushes Resident #1 in the chest with open hands, away from the door. Staff C stated she stepped in encouraging Resident #1 to look at the magazine. Resident #1 responded and Staff C left the area. The facility policy dated April 2021 documented the following: 1. Abuse of any kind against residents is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. 3. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility-wide culture of compassion and caring.

S 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on clinical record review and staff interviews, the facility failed to ensure residents are appropriately assessed and provided interventions to maintain their optimal health and well being for 2 of 4 residents reviewed. (Resident #5, #6) The facility reported census was 45. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 3/28/24, Resident #5 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #5 dependent to maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #5 was coded as having a catheter and continent bowel functioning. Resident #5's diagnosis included renal insufficiency, arthritis and hip fracture. According to a progress note dated 3/24/24 at 1:15 p.m. communication with primary care physician noted blood tinged urine observed in Resident #5's catheter bag. Progress note at 10:22 p.m. indicated an order to discontinue the catheter on a trial basis was granted and Resident #5 stated he would prefer to have it removed in the morning. On 3/25/24 at 5:07 a.m. the progress note indicates the catheter was removed. A progress note written by Staff E, Licensed Practical Nurse, at 10:55 a.m. stated Resident #5 was alert and normal self with no complaints of pain or discomfort and had still not voided this shift. This is the only progress note written regarding Resident #5 by Staff E during her 6:00 a.m. to 2:00 p.m. shift. In an interview on 7/29/24 at 4:33 p.m., Staff A, Registered Nurse, stated she was working a 6:00 a.m. to 6:00 p.m. shift on 3/25/24. Staff A stated Staff E was responsible for the care of Resident #5 during her shift. Staff A stated Staff E left early that day at 1:00 p.m. and upon leaving stated Resident #5 had voided. At around 2:00 p.m. Resident #5's family voiced concern that Resident #5 indicated he had not voided since his catheter was removed early that morning. Staff A stated she questioned the aides which affirmed Resident #5 had not voided that day. Staff A stated she contacted the physician and received an order for a catheter and when inserted she got 400 milliliters returned. Resident #5 stated he felt much better afterward. In an interview on 7/31/24 at 11:34 a.m. Staff D, Certified Nurse Aide, stated she recalled the day (3/25/24) in which Resident #5 had his catheter removed. Staff D stated she remembers he was a no void that day and she informed the nurse, Staff E. According to Bladder Elimination records dated 3/25/24 at 12:21 p.m., Staff D indicated Resident #5 Did Not Void. In an interview on 7/31/24 at 12:07 p.m. Staff E, Licensed Practical Nurse, stated she remembered the morning (3/25/24) Resident #5 had his catheter removed. Staff E stated she left early (1:00 p.m.) that day, but remembers visiting with Resident #5 before she left. Staff E stated she asked Resident #5 if he had voided and he stated a little. Staff E stated she palpated his abdomen and Resident #5 denied any discomfort. 2. According to a Minimum Data Set (MDS) with a reference date of 5/3/24, Resident #6 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #6 was independent to set up assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #6 was coded as continent bowel and bladder functioning. Resident #6's diagnosis included pneumonia, diabetes mellitus and chronic obstructive pulmonary disease. According to an incident report dated 3/8/24, Resident #6 had an unwitnessed fall without injury. Facility protocol requires neurological assessments to be conducted every 15 minutes times 4, every 30 minutes times 2, every one hour times 2 and every 8 hours times 9. Neurological assessments are to include vital signs. According to the Neurological Eval's Second 8 hour check, Staff E indicated vital signs were completed at 12:30 p.m. Review of PointClickCare vital sign records for Resident #6, found no vital signs recorded at or around that time by Staff E. According to the Neurological Eval's Fifth 8 hour check, Staff E indicated vital signs were completed at 12:30 p.m. Review of PointClickCare vital sign records for Resident #6, found no vital signs recorded at or around that time by Staff E. According to the Neurological Eval's Ninth 8 hour check, Staff F indicated vital signs were completed. Review of PointClickCare vital sign records for Resident #6, found no vital signs recorded by Staff F on or around the time the Ninth 8 hour check was due.

Based on observation, policy review, resident representative interview, and staff interview, the facility failed to ensure the provision of housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 24 residents reviewed (Residents #9, #12, #39) for the environment. The facility reported a census of 51 residents. Findings include: 1. On 9/14/23 at approximately 2:00 p.m., Resident #39's toilet riser was covered with a thick layer of rust in multiple areas. The floor in front of the toilet was stained brown and multiple areas of the off-white flooring had brown discoloration present. On 9/18/23 at approximately 1:00 p.m., the carpeting down East Hall had multiple dark stains present throughout. On 9/18/23 at 1:35 p.m., the Director of Nursing (DON) stated if a resident had a rusty toilet riser, they would try to get this replaced and stated if there were stains on the floor around the toilet, ideally she would like it replaced or repaired. On 9/18/23 at 1:49 p.m., the Administrator stated she was not aware of the resident's rusty riser and stated if it could not be cleaned, they should notify her. On 9/18/23 at approximately 2:15 p.m., the Administrator stated the facility replaced the resident's toilet riser. 46513 2. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed the Brief Interview for Mental Status (BIMS) scored 15, which indicated intact cognition. On 9/11/23 at 11:00 AM, Resident #9 stated this place is dirty and always stinks Observations 09/11/23 at 09:55 AM revealed hall and room carpets were old and worn with stains included a strong odor of urine in East and [NAME] hallway during initial observations and interviews. 3. On 09/11/23 at 4:57 PM, Resident #12's Family member visited resident, stated that the housekeeping is poor and the odor is strong throughout the facility. Resident #12 sat in a recliner and had an indwelling urinary catheter. Family member reported visiting most every day to advocate for her father over the last year. Family member relayed last week, piles of towels were left on his room floor to soak up a brownish substance, the towels were just left there, and stated that they knew it was urine because of the strong urine odor. On 9/18/23 at 2:01 PM, the Family member of resident #12 elaborated on conversations with the previous administrator who reportedly, recognized the odor problem in the facility. Family member stated repeatedly reported concerns of carpet and odors to the last administrator who responded are in the process of replacing the old carpets to rid of urine odors. Prior Administrator relayed will be moving down the hall with new flooring. Family relayed only three (3) rooms are done on the other hall and felt at that rate, will be too long to wait. Family member relayed she feels that every carpet square has been stained with urine. Stated, is embarrassed when extended family visit, stated family members have gone outside because the odor is so bad especially when the humidity is up. Relayed her father did not live like this with old stained carpet that smells of urine that is prevalent throughout the entire facility. The facility policy Floors, revised December 2009, stated floors should be maintained in a clean and sanitary manner. The facility policy Work Orders, Maintenance, revised April 2010, stated maintenance work orders would be completed in order to establish a priority of maintenance service.

Based on resident interview, staff interview, record review, and policy review, the facility failed to provide bathing needs for 2 of 3 residents reviewed for Activities of Daily Living (#2, #7). The facility reported a census of 51. Findings include: 1. The Admission Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the resident had a Brief Interview for Mental Status (BIMS) scored 15, which indicated intact cognition. The MDS documented diagnoses of heart and lung disease, diabetes, renal disease and osteoporosis. The MDS documented the resident required total assistance with personal hygiene, and required extensive assistance of staff for bed mobility, transfers, and toilet use. Bathing assistance was coded as required physical help in part for bathing activity and noted resident weighed two-hundred fourteen (214) pounds. The MDS documented the resident's admitted as 8/29/23 The Care Plan revised 9/11/23 for Resident #2 indicated resident needed assistance of one person with bathing needs. The bathing record for September for Resident #2 indicated resident had physical help with bathing on 9/1/23 and documented refused on 9/5/23 and 9/8/23, no other entries for September. A Purchase order dated 8/31/23 was provided by the Administrator noted is for the extra wide shower chair. The purchase order documented in approval status. On 9/11/23 at 10:12 AM, Resident #2 reported no shower since admit to the facility. Resident #12 stated that staff did one bed bath and it didn't get me clean so, he refused and continues to wait for a shower to get clean. Resident #2 reported skin problems, which included yeast under skin folds that are not getting better because the need for water to clean and stated, not a bed bath. Resident #2 reported the nursing staff stated, I am too big and they do not have a shower chair big enough. On 9/13/23 at 2:12 PM, Director of Nurses (DON) reported that a bariatric chair was ordered a couple weeks ago. She acknowledged resident #2 has not had a shower in September as a result of not having a large shower chair. The DON confirmed awareness that the resident has wanted a shower, and confirmed Resident #2 did have a shower in the afternoon on 9/11/23 when surveyors came, by utilization of a facility wheel chair. The DON relayed the resident can transfer from one chair to another, and staff can continue to ensure showers with use of the wheel chair until the bariatric chair is delivered. On 9/14/23 at 02:40 PM, Staff #B, Certified Nursing Aide (CNA) reported it was about a month ago since the large bath chair broke. On 9/14/23 at 03:02 PM Staff #A, Licensed Practical Nurse (LPN) stated several weeks ago, the PVC cracked and the chair was thrown away (PVC refers to polyvinyl chloride material of the shower chair). On 9/14/23 at 04:30 PM, Administrator and the, Staff #E Corporate Nurse Consultant (CNC), stated the expectation was residents are to be clean. Staff E stated safety was the main concern and reason resident was not showered. The Administrator and Staff #E acknowledged alternative options for resident's shower was not presented until surveyors arrived on 9/11/23. The Facility assessment dated [DATE] outlined services offered based on residents needs included bathing, showers support and documented the facility provided bariatric equipment, which included shower chairs. On 9/18/23 at 9:10 AM Staff E, CNC stated there is no policy for bathing, staff are expected to offer at a minimum twice a week baths. 35434 2. The Minimum Data Set(MDS) assessment tool, dated 7/6/23, listed diagnoses for Resident #7 which included heart failure, quadriplegia(paralysis of all four limbs), and reduced mobility. The MDS stated the resident required extensive assistance of 1 staff for eating, depended completely on 1 staff for bathing, personal hygiene, and dressing, and depended completely on 2 staff for bed mobility and transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. 9/28/18 Care Plan entries stated the resident had the potential for skin breakdown and a self-care deficit related to quadriplegia. A 5/11/22 Care Plan entry stated the resident required assistance with bathing. An 8/21/23 Grievance/Concern Investigation Form stated the resident reported he did not have a shower in I don't know how long due to no appropriate shower chair availability. The form stated the resident had lupus (an inflammatory disease which can cause symptoms such as a rash) for [AGE] years and it caused him to be very itchy. The form stated a bariatric chair was on order and staff provided bed baths on regular shower days. On 9/12/23 at 9:20 a.m., Resident #7 stated he had not had a shower for over a month due to the shower chair being broken. He stated he received bed baths but it was not the same. He stated he kept asking the staff about it but they said it was on order. On 9/18/23 at 10:05 a.m., Staff F Certified Medication Assistant(CMA) stated the facility did not have a shower chair to fit certain residents for a few weeks. She stated the facility had to go through corporate to get approval because of the price if it is over a certain amount. On 9/18/23 at 1:07 p.m., the resident stated he still did not receive a shower. He stated the facility obtained a temporary shower chair but it did not work for him. He stated he did not like the fact that he had not had a shower.

Based on observation, staff interviews, resident interviews, record review and policy review the facility failed to follow professional standards of medication administration for 3 of 7 residents reviewed. (Resident #2, #5, #37). The facility reported a census of 51. Findings Include: On 9/12/23 at 8:50 AM, Staff #C Licensed Practical Nures (LPN) prepared two syringes of Levimer insulin. One syringe of 50 units and one syringe of 5 units. Observed Staff C gave two insulin injections to Resident #37, one syringe of 50 units, one syringe of 5 units. On 9/12/23 at 8:50 AM, Staff C reported the facility is out of stock of the large insulin syringe. Staff C state that Resicent#37 gets injected twice as a result of not having stock of the larger insulin syringe required for one injection. On 9/12/23 at 8:53 AM, Resident #37 relayed it is her understanding they have to inject her twice because they cannot use her insulin pen that she used at home that held larger amounts of insulin. Resident #37 was not aware the facility could use a larger syringe to avoid two injections. She was not aware she received two injections because the large insulin syringe stock depleted. On 09/13/23 at 07:44 AM, Staff #D, Registered Nurse (RN) prepared resident #5 medications listed on the Medication Administration record (MAR) for gastric tube administration. Staff #D attempted to expel from medication package, Sertraline 25 milligram into the medication cup. The pill dropped to the medication cart. Staff D picked up the pill with her ungloved hand and put it in the medication cup. Tablet medications that were listed on the MAR for AM (refers to morning) administration crushed together and added to the liquid Depakane solution also ordered for AM administration. Staff D proceeded to Resident #5 room, checked placement of the gastric tube by pushing air into the gastric tube while listening for placement. Staff D added water to drain in the tube via gravity, followed by the medications that were crushed together with the Depakane liquid. Medications added to the tube followed by additional water to drain via gravity. On 9/13/23 following Medication Administration for Resident #5, Nurse Staff D stated all medications can be given together. Staff D relayed two hundred (200) milliliters (ml) of total liquid was added to the gastric tube during the morning medication administration. Record review of Medication Administration Record for August 2023 for Resident #5 included specific direction to check gastric residual, flush with water between the administration of each medication. The MAR noted the following: a. Sertraline Hydrochloride (HCl) Tablet 25 MG (Sertraline HCl) Give 1 tablet b. Sertraline HCl Tablet 100 milligram (mg) Give 1 tablet c. Buspirone HCl Tablet 5 mg Give 1 tablet d. Docusate Sodium Tablet 100 mg Give 2.5 tablet via PEG-Tube one time a day, crush e. Depakene Oral Solution 250 mg/5 ml (Valproate Sodium) Give 15 ml via PEG-Tube f. Levothyroxine Sodium, 50 Microgram (mcg) Give 1 tablet via PEG-Tube (refers to gastric tube) one time a day. In addition, directed to: verify tube placement, check for gastric residual-flush with 15-30 ml of water before and after administration, flush with 5-10 Milliliter (ml) of water between the administration of each medication. g. Meloxicam Tablet 7.5 milligram (mg) Give 7.5 mg via gastric tube in the morning, verify placement, check for gastric residual-flush with 15-30 ml of water before and after administration (flush with 5-10 ml of water between the administration of each medication. On 09/13/23 at 07:57 AM, Resident #2 relayed she did not want her insulin since her blood sugar was seventy-five (75) and she did not have breakfast yet. Staff D responded, needed to check blood sugar again. Staff D took glucometer of another resident from the medication drawer and proceeded to check residents blood sugar using another resident's glucometer. 0n 9/13/23 at 08:00 AM, Staff #D acknowledged she grabbed the wrong glucometer. She acknowledged using another resident's glucometer when checked blood sugar for Resident #2. On 9/13/23 at 10:10 AM, Staff D relayed she had not given all the morning medications. She acknowledged Resident #37 had not been given her oral medication and had not been given her insulin. Staff #D acknowledged the morning medication administration should be between 7:00 and 9:00 in the morning. On 9/13/23 at 3:00 PM, Interview with the Administrator and Assistant Director of Nursing (ADON) who relayed, had ran out of the larger insulin syringe and ordered more as a result. The ADON and administrator acknowledged resident would need two injections until they receive the ordered shipment. The administrator and ADON could not explain the system for ordering before stock was depleted. On 9/14/23 at 04:30 PM, Administrator and Corporate Nurse Consultant, Staff #E relayed would expect staff to ask for help if not able to meet medication time frames for administering, expectation is staff will follow the appropriate orders and processes with medication administration. The facility policy titled Administering Medication revised April 2019 documented, medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions The facility provided a policy titled Administering Medications through an enteral tube revised November 2018 directed to administer each medication separately and flush between medications. The facility provided document relayed the time frame of 7:00 to 9:00 for morning medications.

Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to ensure residents could safely administer medications for 1 of 24 residents (Resident #1). The facility reported a census of 51 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 8/24/23, listed diagnoses for Resident #1 which included anxiety, depression, and post traumatic stress disorder. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. The facility policy, Administering Medications, revised April 2019, stated medications were administered in a safe and timely manner and stated a resident may self-administer their own medications only if the physician determined that they had the decision-making capacity to do so safely. The resident's clinical record and Care Plan lacked documentation the resident was able to self-administer her medications. On 9/14/23 at 1:05 p.m., Resident #1 laid in bed. A medication cup containing 3 pills (a blue pill, a yellow pill, and an orange and white pill) sat on the over bed table. The resident stated the nurse gave them to her. No staff were present in the resident's room. Immediately after this observation, Staff D Registered Nurse (RN) stated she gave the resident the medication and the resident was able to self-administer. Staff D stated that the resident did not feel good though so she would go down and retrieve them. Staff D went down the hall and entered the resident's room. On 9/14/23 at 2:27 p.m., the Director of Nursing(DON) stated staff should observe residents consume medications and they had no residents who requested the ability to self-administer medications.

Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to ensure call light devices were accessible for 3 of 24 residents observed for call systems (Residents #3, #27, and #37). The facility reported a census of 51 residents. Findings Include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 8/31/23, listed diagnoses for Resident #3 which included heart failure, diabetes, and abnormalities of gait and mobility. The MDS stated the resident required extensive assistance of 1 staff for bed mobility, extensive assistance of 2 staff for transfers, walking, and toilet use, completely depended on 1 staff for dressing and personal hygiene, and completely depended on 2 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 12 out of 15, which indicated moderately impaired cognition. The facility policy Answering the Call Light, revised March 2021, directed staff to ensure the call light was in easy reach of the resident if they were in bed or confined to a chair. Care Plan entries, dated 12/24/20, stated the resident was at risk for falls and directed staff to encourage the resident to utilize the call light. During an observation/interview on 9/12/23 at approximately 11:10 a.m., Resident #3 sat in her recliner in her room and yelled help several times. The resident stated her TV remote was under her chair and she could not reach it. She stated her call light was over on her bed and she could not reach it. The resident's call light laid on the resident's bed and was not in reach of the resident. The surveyor notified the MDS Coordinator that the resident needed assistance and she entered the resident's room. On 9/18/23 at 1:35 p.m., the Director of Nursing (DON) stated call lights should be in reach of the resident. 46513 2. The Annual Minimum Data Set (MDS) dated [DATE] coded Resident #27 for severe cognitive impairment, the Brief Interview of Mental Status (BIMS) was blank, not completed. The Activities of Daily Living (ADL) section documented, total dependence of staff for dressing, toilet use and personal hygiene and extensive assist of two persons for transfers. The Care Plan completed on 8/25/23 for Resident #27 did not document call light use. On 09/12/23 at 10:27 AM, Resident #27 sitting in her recliner, call light on the floor near resident's bed, out of resident's reach. 3. The Admission Minimum Data Set (MDS) dated [DATE] for Resident #37 revealed diagnoses, included diabetes, renal disease, stroke with hemiplegia or hemiparesis. The BIMS assessment score was 15 which indicated cognition intact. Assistance needed in the Activities of Daily Living (ADL) section documented total dependent for mobility on or off the unit, transfers, dressing, toilet use and personal hygiene. The Care plan completed 8/11/23 for Resident #37 documented a focus area of fall risk with intervention, to use call light for assistance. On 09/12/23 at 09:08 AM Resident #37 sat in her wheel chair, the bed was behind her and the call light was on the bed near the wall, out of residents reach On 9/12/23 at 9:09 AM Resident reported she did not have her call light, could not see it nor reach it.

Based on record review, and staff, hospital staff, physician and resident responsible party interviews, the facility failed to provide appropriate wound care, by competent nursing staff, consistent with professional standards of nursing practice, to promote healing, prevent infection and worsening of a pressure ulcer for 1 of 2 resident records reviewed with pressure ulcers (Resident #1). The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated [DATE] revealed the resident admitted to the facility [DATE] with diagnoses that included diabetes, pneumonitis due to aspiration and muscle weakness, severe cognitive impairment with symptoms of delirium present, sometimes able to make herself understood and usually able to understand others, and required extensive assistance, sometimes total dependence on staff to reposition in bed, transfer to and from bed and chair, dressing, eating, toileting, bathing and personal hygiene, non-ambulatory, always incontinent of bladder, usually incontinent of bowel, and a Stage 1 pressure sore (PS) present (defined as observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence). Physician Orders directed the following skin treatments and wound care: [DATE] Apply Calmoseptine Ointment to coccyx topically twice daily. [DATE] Fibracol to coccyx area and cover with foam dressing every 3 days, discontinued [DATE]. [DATE] Fibracol to coccyx area and cover with foam dressing daily, discontinued [DATE]. [DATE] Cleanse sacral ulcer with Dakins solution, apply Hydrofera Blue to coccyx wound, cover with foam external pad dressing daily. A Pressure related Injury to Skin Problem initiated on the Nursing Care Plan [DATE], with goal the pressure injury would show signs of healing and remain free from infection by the next review date, directed staff to: 1. Utilize pressure relieving/reducing device on bed/chair, initiated [DATE] 2. Monitor for pain related to pressure injury, initiated [DATE] 3. Monitor/document/report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length, width and depth), stage, initiated [DATE] Facility wound assessments of the sacral PS, completed by the Assistant Director of Nursing (ADON), identified as the wound nurse, revealed: [DATE], Stage 1 PS, present on admission, measured 8.6 centimeters (cm) by 5.7 cm, surrounding skin normal colored, intervention in place. [DATE], Stage 1 PS, 8.6 cm by 5.7 cm, surrounding skin normal colored, cleansed with wound cleanser, incontinence management implemented, intervention in place. [DATE], Stage 1 PS, 1.6 cm by 1.2 cm, scabbed area without drainage, surrounding skin fragile and at risk for breakdown, cleansed with soap and water, treated with Calmoseptine (a barrier cream applied to skin). [DATE], Stage 1 PS, 2.5 cm by 0.5 cm, surrounding skin fragile and at risk for breakdown, without induration or swelling, cleansed with soap and water, treated with Calmoseptine, stable. [DATE], Stage 1 PS, 10.4 cm by 0.9 cm, depth recorded as not applicable, wound bed described as granulation tissue without drainage, surrounding skin normal colored without induration or swelling, cleansed with soap and water, treated with Calmoseptine, stable. [DATE], Stage 1 PS, 2.6 cm by 1.0 cm, depth not applicable, light serosanguinous drainage (yellow-pink colored), without indication of infection, surrounding skin fragile and at risk for breakdown, without induration or swelling, cleansed with Wound Cleanser, new order for Fibracol and foam patch applied daily and as needed (PRN), stable. [DATE], Stage 1 PS, 4.8 cm by 2.1 cm, depth not applicable, slough tissue in wound bed, light serosanguinous drainage, faint odor, no indications of infection, surrounding skin normal colored, without induration or swelling, rolled wound edges, wound cleansed with Dakins,Hydroera blue applied to wound bed, cover with foam dressing, changed daily and PRN, stable. A physician progress note dated [DATE] described the resident's sacral PS as a Stage 2 PS (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.) The physician directed staff to cleanse the wound with Wound Cleanser, apply Fibracol to the wound bed, cover with a foam dressing changed every 3 days and as needed. A physician progress note dated [DATE] described the resident's sacral PS as a Stage 2 PS that measured 1 cm by 0.8 cm and 0.8 cm by 3 cm, wound bed epithelial cells and 50 percent slough tissue, and directed staff to continue cleansing wound with Wound Cleanser, apply Fibracol to the wound bed, cover with a foam dressing changed every 3 days and as needed. A facility wound photo of the resident's sacral PS, dated [DATE], revealed wound depth estimated at 1 cm based on resident anatomy in the photo, slough tissue in the wound bed, and reddened skin surrounded the wound opening and extended at least 1 cm from the wound edges that surrounded the wound opening. The wound in the photo appeared as a Stage 3 PS (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). The resident's January, 2023 Treatment Administration Records (TAR's) revealed facility Certified Medication Aides (CMA's) documented they completed the resident's sacral PS wound care and dressing changes on the following dates: [DATE] Staff D, CMA/Certified Nursing Assistant (CNA) [DATE] Staff D [DATE] Staff P, CMA/CNA [DATE] Staff E, CMA/CNA [DATE] Staff E Nursing Progress Notes revealed the following entries: [DATE] at 9:53 a.m. Patient noted to be more sleepy today, difficult to arouse. Patient will open eyes, but no verbal/mumbling noted. Skin pale, warm and dry. Two blisters to right lower extremity, calf area noted to be intact. No redness, swelling, signs or symptoms of infection noted to area, no edema noted to bilateral lower extremities. Dressing to coccyx noted to be dry and intact. Respirations even/unlabored. Lungs clear to auscultation, abdomen soft, bowel sounds present, No symptoms of pain noted. Involuntary muscle twitching to bilateral upper extremities. This RN unable to obtain vital signs after several attempts. [DATE] at 1:23 p.m. Rests in bed, no verbal response, unable to obtain vitals, fingers with some mottling, lungs diminished, bowel sounds present, no cough or dyspnea, no nausea or vomiting, TLC given, no distress noted. [DATE] at 1:39 p.m. This RN called and spoke with POA regarding change in condition. POA requesting that patient gets sent out to ER where 'people know more'. This RN attempted to provide education on assessment and status of patient but POA declined education and repeated that they wanted patient sent out to be seen by a doctor who has a 'higher level of education'. This RN verbalized understanding. The resident's record lacked any documentation of sacral pressure sore condition descriptions, type of drainage and amount, symptoms of infection present and other wound conditions as required, between [DATE] and [DATE]. Shower care documented as completed in the resident's record, completed by Staff B, Certified Nursing Assistant (CNA) who worked as a Bath Aide included: [DATE], [DATE], [DATE], [DATE] and [DATE] One other shower was documented as completed [DATE] by Staff E, CNA The facility's Certified Medication Aide (CMA) Job Duties/Job Description policy, dated effective [DATE] directed: 1. According to the description of the scope of practice pertaining to CMA's described in Iowa Chapter 58.21(6), CMA's can administer nonparenteral medications if they have taken an approved class and passed a challenge examination. (Parenteral medications are administered via routes other than the digestive tract, such as injection or infusion). 2. There are no limitations on the type of oral solid medications that can be administered. 3. Per Iowa Code 58.19(2)(a), CMA's may not administer injectable medication. The Iowa Board of Nursing regulates practices that Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) may delegate to an unlicensed assistive personnel (UAP) by: 1. Ensuring the UAP has the appropriate education and training and has demonstrated competency to perform the delegated task. 2. Ensuring the task does not require assessment, interpretation, and independent nursing judgment or nursing decision during the performance or completion of the task. 3. Verifying that, in the professional judgment of the delegating nurse, the task poses minimal risk to the patient. 4. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of the communication from the UAP. 5. Supervising the UAP and evaluating the patient outcomes of the delegated task. Results of the resident's laboratory blood work obtained in the hospitalER on [DATE] revealed: White Blood Cell (WBC) count of 18.8 K/mm3, high value, normal range 4.5 - 11.0 K/mm3. BUN (Blood Urea Nitrogen) 151 mg/dL, high value, normal range 6 to 24 mg/dL. Creatinine 8.96 mg/dL, high value, normal range 0.59 to 1.04 mg/dL. Glomerular Filtration Rate (GFR) 5 ml/min 1.73 m2, low value, normal range 90 to 120 mL/min/1.73 m2. Potassium 5.5 mMole/Liter, high value, normal range 3.6 to 5.2 mmol/L. Sodium 151 mEq/L, high value, normal range 135 to 145 mEq/L. Blood Glucose 424 mg/dL, a high value, critical result value, normal range 99 mg/dL or lower for fasting result. The results indicated the resident's septic condition (severe infection that involves the blood), severe dehydration and acute renal failure (kidney shutdown). The resident's Death Certificate, signed by the County Medical Examiner [DATE], stated the resident died [DATE] at 9:26 a.m. as a result of Sepsis from a pressure ulcer on the sacral region. The resident's responsible party/Power of Attorney (POA) interviews revealed: POA#1, interviewed [DATE] at 3:02 p.m., stated the facility notified them she had a bed sore (pressure sore), but not that there was any concern over it, that it was something minor that was being treated, and never once said it was serious, or had gotten worse, or infected. POA #2, interviewed [DATE] at 3:27 p.m., stated one day while visiting they saw the soiled dressing in the resident's trash-can in her room, there was a foul odor and what looked like pus and blood on the dressing, when they asked staff if the bedsore was infected, they wouldn't answer them. Staff interviews revealed: Staff A, Registered Nurse (RN), interviewed [DATE] at 12:45 p.m., stated she didn't care for the resident very often, had changed her PS dressing, on [DATE] she notified the physician of wound changes that included yellow-green drainage with foul odor via fax (facsimile), couldn't remember any depth to the wound, the surrounding skin was reddened but blancheable. Staff B, Certified Nursing Assistant (CNA), interviewed [DATE] at 9:50 a.m. stated she worked as a Bath Aide, she showered the resident with her dressing on her sacral area, and the nurse never came in the shower room to remove the dressing after it was saturated from the shower, or to apply a new dressing. Staff C, RN, interviewed [DATE] at 10:20 a.m., stated when she completed a dressing change, she documented that on the TAR, and no need for any other documentation unless the wound looked different, then would chart that in the progress notes. She changed the resident's dressing a couple of times. When asked to describe the wound the last time she changed the dressing ([DATE]), she stated there was about a quarter-sized dark spot, but could not provide a color or further description of the area, the dark spot hadn't opened yet, there was no drainage and no odor. When instructed that the last time she documented she changed the dressing, [DATE], was after yellow-green drainage with odor was noted and the physician informed of that on [DATE], Staff C stated she'd had a runny nose, wore a mask, couldn't smell anything, and didn't remember if the wound was opened or not. If she noticed any wound changes she would notify the physician, take a photo of the wound, and would notify family. The facility's Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN) interviewed [DATE] at 12:22 p.m., stated she was the facility wound nurse, had special training through Relias (computer based education program for health professionals) and was certified as a wound nurse through the Relias program. The ADON stated nursing should document what they see when they change a wound dressing, and document the treatment was completed in the TAR. If anything abnormal was noted staff should document that in the nursing progress notes. The last time she saw the resident's sacral pressure sore ([DATE]) there was an area that was dark, no depth to the wound but it was open, had light amount of serous drainage, a faint odor that the provider had been updated on. The provider changed the orders to cleanse it with Dakins solution, apply Hydrofera blue to the wound and cover with a foam dressing daily. The ADON stated nurses were expected to complete dressing changes, the CMA's can complete dressing changes if supervised by a nurse, whatever their company policy said. When asked what their company policy directed, the ADON stated she wasn't sure what it said. The ADON's Certificates of Attendance for wound care education revealed: 1.25 contact hours of continuing education credit for completion of Wound Care for Arterial Ulcers on [DATE] 1.0 contact hours of continuing education credit for completion of Wound Dressings: Making the Right Choice on [DATE] The facility Director of Nursing (DON), interviewed [DATE] at 12:55 p.m., stated CMA's could complete dressing changes if the nurse there delegated it to them. Both RN's and LPN's could delegate things to the CMA's if they were there. The DON stated she would have to address how the treatments were signed off on the TAR's by the CMA's and was not aware that CMA's completed pressure sore wound care. Staff D, CMA/CNA, interviewed [DATE] at 1:04 p.m., stated she had taken care of the resident, she did whatever the nurse delegated to her as far as the resident's sacral PS wound care, and when asked specifically what wound care she provided, or what actions she completed, Staff D abruptly ended the interview and stated she would call the surveyor back in 10 minutes. Staff E, CMA/CNA interviewed [DATE] at 11:48 a.m. stated she did whatever the nurse delegated to her when asked if she had provided wound care for the resident's sacral PS. Staff E was advised that was not an acceptable response, she needed to specify what activities the nurse delegated to her, what actions she had taken for the resident's wound care, then Staff E stated she didn't remember what the nurse delegated to her, but the nurse was present. When asked if she had handled the wound care supplies, or what she did with the supplies, Staff E stated she handed the supplies to the nurse when she needed them, she opened the package of Fibracol for the nurse, removed the Hydrofera blue from the package and handed it to the nurse, the nurse cut the Hydrofera blue with scissors, and helped to keep the resident positioned on her side during the care. Staff F, RN, interviewed [DATE] at 3:29 p.m. stated she hadn't seen the resident's PS as the dressing change was scheduled on the day shift, dressing changes were something the nurse should do and not appropriate for the CMA's, she would never delegate that to a CMA to do. If she thought she saw wound changes, she would communicate with the doctor immediately, document it in the progress notes, inform the wound nurse and would let the family know. Staff G, LPN, interviewed [DATE] at 2:26 p.m., stated she had not seen the resident's sacral PS until the day she was sent to the hospital ([DATE]), it was an opened area, nickel to quarter sized, depth approximately 1 cm, there was serosanguinous drainage, she couldn't tell if there was an odor, the resident was acting differently that day, she thought she was transitioning. She would report any wound changes to the doctor on call and record the changes on the skin sheets. Soiled dressings removed are supposed to go in a red bag and taken to the appropriate container in the soiled utility room, staff should not put a soiled dressing in the resident's trash in their room. Staff J, RN, agency nurse interviewed [DATE] at 12:08 p.m. stated she worked the day shift on [DATE] and [DATE] and was the nurse who sent the resident to the hospital. On [DATE] she felt the resident was transitioning and shutting down, when she assessed the resident at the request of her family she couldn't get a blood pressure reading or pulse oxymetry result, and she had not notified the physician of those findings. She provided her wound care and really couldn't recall what the wound looked like or if there was depth when she changed the dressing on [DATE] as that was so long ago. When asked if a CMA provided her wound care, Staff J stated that wasn't something a CMA could do, that was a nursing responsibility. On [DATE] she notified the resident's POA by phone that she wasn't doing well, the POA was upset and demanded that she call the doctor and send the resident to the hospital where she would get the care she needed from staff that were more knowledgeable. Staff J notified the doctor, requested an ambulance for transport, the resident was non-responsive at the time she left the facility. Staff H, hospital emergency room (ER) physician (MD), interviewed [DATE] at 10:13 a.m., stated she assessed the resident in theER on [DATE], the resident was in critical condition, septic from a wound infection of the sacral pressure sore, the sacral pressure sore was at least grapefruit sized, open, deep, infected and looked horrible. The resident had recently acquired burns on her leg, an unstageable pressure sore on her ear, she was in pain and required Morphine (a strong narcotic opiate analgesic) for pain control. Upon the Resident's presentation to the ER that included a non-responsive state, her hair was matted, very dirty and unkempt. Nursing home staff reported to ER staff that the resident had been up for breakfast and ate some, but she thought that couldn't have been possible given the resident's critical and unresponsive condition when she arrived early in the afternoon to the ER. Staff I, hospital RN, interviewed [DATE] at 2:22 p.m., stated on [DATE], the resident's sacral pressure sore measured 10 cm by 10 cm, wound bed described as black eschar, no recorded depth of the wound, scant serosanguinous drainage, surrounding skin red and indurated. The resident required Morphine administration several times for pain control before her death 3 days later on [DATE]. Her primary diagnosis was sepsis from wound infection.

Based on record review, and resident responsible party interviews and staff interviews, the facility failed to notify the resident's responsible party, both oral and in writing, of changes in Medicare provided services as required, for 1 of 5 resident records reviewed (Resident #1). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 12/31/22 revealed Resident #1 admitted to the facility from the hospital 12/19/22, at a skilled level of care with diagnoses that included intellectual disabilities with severe cognitive impairment, pneumonitis due to aspiration, respiratory failure and muscle weakness, and required extensive assistance, sometimes total dependence, on at least 1 staff to reposition in bed, transfer to and from bed and chair, dressing, eating, toileting, bathing and personal hygiene and non ambulatory. Therapy services provided and described on the MDS included 1 Speech Therapy (ST) session for 15 minutes, 5 Occupational Therapy (OT) sessions for total of 127 minutes and 3 Physical Therapy (PT) sessions for total of 36 minutes. A Notice of Medicare Non-Coverage form dated 12/28/22 revealed the resident's ST, OT and PT services would end 12/30/22 due to the resident's non-participation, staff reviewed the information over the telephone with the resident's Power of Attorney (POA), Option 3 checked which stated I don't want the care listed above. I understand that I'm not responsible for paying and I can't appeal to see if Medicare would pay. The form indicated the POA gave verbal consent via telephone, and was signed by the facility's Activity Coordinator. The resident's POA, interviewed 2/8/23 at 3:02 p.m., stated they got a call that her therapy was going to stop shortly after she got there, the facility didn't explain that they could have appealed the decision or how to do that, the family didn't understand the facility's decision as that was the primary reason the resident was admitted there so she could get stronger and return to her home, and they never received any paperwork or information on how to appeal the facility's decision and would have done that if they knew they could have. The facility's Medicare Advanced Beneficiary Notice policy, dated April, 2021, directed staff: 1. If the Admissions coordinator or business office manager believes that Medicare will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service() may not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility. 3. The Notice of Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination. During an interview 2/8/23 at 11:38 a.m., the facility's Activity Coordinator stated she was filling in for the Social Worker when she called the resident's POA on the phone, informed them that therapy under Part A Medicare was going to end. They said they didn't want to appeal the denial, if they wanted to appeal the decision she would have helped them with that, she did not send a copy of the notice to the POA, and stated she had never been instructed to do that.

Based on record reviews, resident responsible party interviews and staff interviews, the facility failed to permit residents and/or their responsible party's from participation and ongoing contribution in formulation of their care plan development, for 2 of 9 resident records reviewed (Resident's #1 and #5). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 12/31/22 revealed Resident #1 admitted to the facility from the hospital 12/19/22, at a skilled level of care with diagnoses that included diabetes, pneumonitis due to aspiration, respiratory failure, muscle weakness, intellectual disabilities, severe cognitive impairment with symptoms of delirium present, unclear speech, sometimes able to make herself understood and usually able to understand others, and required extensive assistance, sometimes total dependence, on at least 1 staff to reposition in bed, transfer to and from bed and chair, dressing, eating, toileting, bathing and personal hygiene, non ambulatory, always incontinent of bladder and usually incontinent of bowel. The MDS stated that neither the resident nor the resident's responsible party or Power of Attorney (POA) had participated in the MDS assessment, and the plan for discharge or return to the community was not addressed. POA interviews revealed: POA #1, interviewed 2/8/23 at 3:02 p.m., stated the resident was weak after she had been in the hospital for a few weeks, the physicians anticipated the resident could recover if she received therapy for strengthening at the nursing home, and the resident would be able to return to her former home if she received the therapy that she needed. Shortly after the resident was admitted to the facility they got a call that her therapy would be discontinued, the family didn't understand the facility's action, the resident had special needs due to her intellectual disabilities, and they had to demand a meeting with the facility Social Worker to address their concerns related to her care and strategies to provide the care the resident required in order to return to her home as they had planned. The facility never asked to meet with the family about the resident's care or their concerns otherwise, they only had 1 meeting on 12/29/22, and that was because the resident's POA's demanded it. POA #2 interviewed 2/8/23 at 3:27 p.m., stated the only time they ever met with the staff to discuss her care was when the 2 POA's demanded a meeting, on 12/29/22, and that was after the facility said they were going to stop her therapy, they met with the Social Worker, there were no nurses at the meeting, and they tried to address how the resident would get the therapy she required so she could return to her home as they had anticipated. Otherwise, the staff never asked for a meeting or set up anything to go over her care with either of the POA's. 2. The MDS dated [DATE] revealed Resident #5 scored 8 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment, without symptoms of delirium present, diagnoses included hypertension (high blood pressure), cerebrovascular accident (a stroke), depression, auditory hallucinations, difficulty walking, required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed and chair, ambulation, bathing, dressing, eating, toileting and personal hygiene, always continent of bladder, frequently incontinent of bowel, usually understood others and usually able to make self understood, and had highly impaired vision. The facility provided documentation that 1 of the resident's POA's participated in a care conference on 12/15/22. Documentation on 9/22/22 stated they were unable to contact the resident's POA for a care conference. During the exit conference on 2/16/23, when asked for further explanation for this, as the resident's POA's were very involved with the resident's life and spent several hours at the facility every day, the facility stated they hadn't always spent as much time at the facility, and did not address why they had not coordinated a care plan meeting with the POA's that were very actively engaged in the resident's care POA Interviews: When interviewed 2/13/23 at 2:05 p.m. the resident's POA denied they had ever participated in a care plan meeting or conference, but this Thursday, 2/16/23, they were to come to a meeting for his care, and this was the first time they have had this since the resident has been at the facility (admitted [DATE]). .

Based on record review, and resident responsible party interviews and staff interviews, the facility failed to notify the resident's responsible party of changes in the resident's condition for 2 of 9 resident records reviewed (Resident's #1 and #4). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 12/31/22 revealed Resident #1 had severe cognitive impairment with symptoms of delirium present, with diagnoses that included diabetes, pneumonitis due to aspiration, muscle weakness, intellectual disabilities, unclear speech, sometimes able to make herself understood and usually able to understand others, and required extensive assistance, sometimes total dependence, on at least 1 staff to reposition in bed, transfer to and from bed and chair, dressing, eating, toileting, bathing and personal hygiene, non ambulatory, always incontinent of bladder and usually incontinent of bowel, and a Stage 1 pressure ulcer present (defined as observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence). Nursing Progress Notes revealed the following entries: 1/22/23 at 5:17 a.m. Incident, Accident, Unusual Occurrence Note: Certified Nursing Assistant (CNA) requesting this nurse to resident room. This nurse down to room. CNA reports resident right leg is off of the bed and laying on the heat register. Resident laying on bed but air mattress has resident tilted toward register. This nurse and 2 CNA's able to move bed and bring resident leg up. Red area noted. No blisters or open areas noted at this time. Resident shakes head no when inquiring about pain. Bed repositioned away from heat register. This nurse had been in room approximately 15 minutes prior for morning medication and resident was positioned in center of bed. 1/22/2023 at 10:24 a.m. Patient noted to have a fluid filled blister to her right outer calf, dime-sized, noted redness to be around fluid filled blister that radiates up and down leg, right outer aspect of calf warm to the touch. 1/24/2023 at 2:21 p.m. Fax sent to the physician updating on coccyx open area; moderate odor today and yellow/green drainage present. Staff interviews revealed: 2/8/23 at 10:20 a.m., Staff C, registered nurse (RN), stated staff were required to notify family/resident Power of Attorney's (POA's) when there were changes in the resident's condition. Interviews with the resident's responsible party/POA's revealed: POA #1, interviewed 2/8/23 at 3:02 p.m., stated they received phone calls from the nursing home about the resident's condition, staff said she had a bedsore, but there wasn't any concern over it, they acted like it was something minor and they had a treatment for it, they never once said it was serious, they never said the sore had gotten worse, or that it was infected. Staff called, said she fell and had a scrape on her face, but they never called and said she was burned by the heater in her room, they would have remembered that. POA #2 interviewed 2/8/23 at 3:27 p.m., stated they visited the resident twice daily, on 1/22/23 when they arrived to feed the resident her lunch they saw blisters on her leg, it was obvious the resident was burned, the resident's roommate said she'd fallen out of bed the night before, ended up against the wall-mounted heater and how she was burned. They called POA #1 at the time and POA #1 didn't know anything about the burn, POA #2 asked the nurse if it was a burn and how was the resident burned, the nurse said they weren't the POA and she couldn't provide the information. One day while visiting she saw the bedsore dressing in the resident's trash-can, there was a foul odor and what looked like pus and blood on the dressing, when they asked staff if the bedsore was infected, staff wouldn't answer them. 2. Resident #4's MDS assessment dated [DATE] revealed the resident scored 3 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment, without symptoms of delirium present, had diagnoses that included hypertension (high blood pressure), malnutrition and non-Alzheimer's dementia, and required assistance of 1 staff to reposition in bed, transfer to and from bed and chair, ambulation, bathing, dressing, toileting and personal hygiene, usually understood others and usually able to make self understood. the resident received care by Hospice services. Nursing Progress Notes revealed the following entries: 2/9/2023 at 1:24 a.m. At 8:30 p.m., CNA and CMA reported resident not arousing to verbal or tactile stimuli and unable to give bedtime medications. This nurse down to assess, vital signs: temperature 97.8, pulse 52, respirations 16, blood pressure 115/58, oxygen saturation 90-92% on room air. Lungs clear to auscultation. No cough or dyspnea noted. Resident with eyes closed and not responding. Performed sternal rub, resident raised left arm and attempted to smack this nurse's hand away. Eyes remained closed. At 8:40 p.m. called Hospice nurse , she was aware. 1/27/2023 at 11:02 p.m. Vitals: temperature 98.1, blood pressure 106/68, pulse 69, respirations 18, oxygen saturation 95 % on room air. Change in Condition report. Rests in bed. Respirations unlabored. No complaint of pain. Resident continues with increased lethargy. Bedtime meds refused due to resident not wanting to open mouth. Physician updated via fax (facsimile). Blood pressure has increased since earlier today. No respiratory distress noted. Call light in reach. 1/27/2023 at 1:56 p.m. Vitals: temperature 98.3, blood pressure 75/40, pulse 53, respirations 20, oxygen saturation 99.0 % on room air. Resident appears to be more lethargic than normal, when applying the blood pressure cuff, he did not even hold his own arm up. His hospice aide was in and she thought he was more fatigued. She was going to update his hospice nurse. Resident's blood pressure was low, as was his pulse. The resident's POA was interviewed 2/13/22 at 2:56 p.m. and stated when they arrived at the facility 2/9/23 to visit staff told them something was wrong with the resident, his BP was 70/40 and they couldn't get him awake, it was like he was drunk but he never drank, staff said he had been like that since the day before. Nobody had notified the POA of this, or the resident's other family members. They questioned staff if there had been a medication error or some other reason for his condition. The Hospice nurse came to the facility, assessed the resident and thought he might have been given the wrong medications but said there was no way to prove that and the nurse denied it when they asked about it. Then his blood pressure started to come up and he started to come around. They found out almost the same thing had happened a couple weeks before (described in nursing progress notes on 1/27/23), and was not notified of that change in his condition either.

Based on record review, and staff and resident responsible party interviews, the facility failed to ensure the resident environment remained safe and free of accident hazards, and resulted in a resident's elopement from the facility undetected by staff (Resident #9), and a resident's burn when exposed to extreme heat temperature from a wall heater in the resident's room (Resident #1). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 8/4/22 revealed Resident #9 scored 10 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated minimal cognitive impairment, with symptoms of delirium present, diagnoses included diabetes, anxiety, depression, non-Alzheimer's dementia and osteoarthritis of the right knee, required staff supervision or limited assistance of 1 staff for ambulation, dressing, toileting and personal hygiene. A Wandering Evaluation (elopement risk) completed 5/19/22 revealed the resident scored 20 points, (score 10 or more points identified as high risk for elopement and Wandergard transponder bracelet required), resident scored 31 points on the next Wandering Evaluation completed 9/30/22. Treatment Administration Records (TAR's) indicated staff checked the resident for the presence and function of the Wandergard transponder every shift (3 times every day), the device last checked on 9/27/22 at 7:22 p.m. by Staff O, Licensed Practical Nurse (LPN). An Elopement Risk problem, related to a 7/26/22 elopement attempt, initiated 7/31/22 on the Nursing Care Plan directed staff: 1. Alert staff to my wandering behavior, initiated 7/31/2022 2. Approach resident positively and in calm, accepting manner, initiated 9/18/2022 3. I have a wander guard sewn into the back of my green hat, initiated 8/23/2022 4. Identify pattern of wandering. Is wandering purposeful, aimless, or escapist. Am I looking for something? Does it indicate the need for more exercise? Intervene as appropriate initiated 7/31/2022 5. If I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them 9/13/22, initiated: 09/18/2022 An entry transcribed by Staff R, Registered Nurse (RN) in the Nursing Progress Notes on 9/27/22 at 11:23 p.m. stated: At 10:10 p.m., Staff M called facility and alerted this nurse that resident was outside in gravel. This nurse, other nurse and 2 Certified Nursing Assistants (CNA's) out to assess resident. Noted resident sitting on bottom in gravel. Resident stating wanting to go home. Range of Motion (ROM) to all extremities per normal. Resident uncooperative with assessment. Resident not wanting to come back into facility. Did get resident back into facility. Staff K, CNA sent into facility to assess door and opened East hall door since resident so close to door. Noted door alarm on East hall door sounded at this time. Did not note alarm going off at time of resident exit. Staff M, CNA, stated rounds were completed at approximately 9:40 p.m. Other LPN on staff noted she had just left resident's room after his treatment. During that time, no door alarms noted going off. Once inside building, resident with comments like I might as well just die. Resident also made threatening statements. Other nurse did note some scrapes to arm, resident still uncooperative with assessment. Call to physician at 10:30 p.m., orders to send to the hospital emergency room (ER) for evaluation. Called for ambulance at 10:45 p.m., arrived at 11:00 p.m. and took the resident to the ER. Did check residents Wandergard in hat before leaving, appeared to work, but Wandergard alarm did not sound when exited front door with ambulance. A written statement transcribed by the facility Administrator on 9/28/22 at approximately 8:00 a.m., obtained during a telephone interview with Staff O, LPN, (Staff O worked the evening shift on 9/27/22) stated: Saw the resident on the ground on buttocks, walker still upright. Helped him inside, then checked all alarms. Resident was not in pain, scratch on arm. Front door alarm was canceled before Paramedic took resident out. Resident had his green hat on with the Wandergard sewn in the back. All other alarms sounded. Resident just wanted to go somewhere besides here. The facility's self-reported incident described the resident found outside near east hall exit door 9/27/22 at approximately 10:10 p.m., the time of the resident's exit unknown but estimated between 10:00 p.m. and 10:10 p.m. based on facility's investigation, that also revealed no door alarms sounded, including Wandergard alarmed exit doors. The facility hypothesized the resident exited through 1 of the 2 Kitchen service doors from the Dining Room, the doors swollen, did not close and latch completely, and could have been opened without the required security pass-code. From the Kitchen, the resident could have entered the service hall and exited through the service hall exit door without sounding any alarms. A Nursing Note transcribed by a hospital RN in the resident's ER record on 9/28/22 at 1:08 p.m. stated: Administrator from Care Center present to look for patient's Wandergard. Patient very irritated, stated get your hands off my stuff. Patient kept stating he didn't know what box she was talking about. After Administrator left the room, patient stated Ya, I know what box she's talking about, they used to keep it right here on my wrist. I threw that away a long time ago. Found trauma shears in patient's pants pocket from the Care Center. Asked patient what he was doing with the scissors, patient stated that's his business. Staff Interviews revealed: Staff K, CNA interviewed 2/7/23 at 5:51 p.m., stated when he worked the night shift (10 p.m to 6 a.m.) on 9/27/22 they were at the Nurse's Station getting report per usual, probably between 9:55 p.m. and 10:05 p.m., while there he didn't see the resident, several staff were there for report and nobody saw him up by the Nurse's station or in the Dining Room area. Staff K stated he did not hear any alarms while at the Nurse's Station for report, then Staff M found him outside as she left after she worked 2nd shift (2 p.m. to 10 p.m.). Staff K thought the resident went out the East hall exit door, the door was supposed to alarm when opened, but didn't that night. Staff K stated nobody had seen the resident walking around in the area, and didn't think the resident could walk from his room (near the end of the East hall) to the kitchen and out the service entrance, then walk all the way back to the area outside by the East door where he was found. The resident said he hated it there and wanted to leave. Staff L, CNA, interviewed 2/7/23 at 6:07 p.m. stated she worked the night shift on 9/27/22, was at the Nurse's Station for report with her coworker Staff K, they didn't hear any door alarms go off, and she had not seen the resident up and around at anytime while at the Nurse's Station. Staff M called into the building from her phone about 10:10 p.m. - 10:15 p.m. and said the resident was outside and needed help to get him up. Both nurses went out and they brought the resident in through the front door, sat him at a table until the ambulance came and took him to the hospital. The resident could walk independently with his walker. Staff M, Certified Medication Aide (CMA) and CNA, interviewed 2/13/22 at 6:12 p.m. stated she punched out and left after she worked the evening shift on 9/27/22, she talked to a coworker by their car for a few minutes, then went to her car that was located towards the east end in the parking area in front of the facility and thought she heard someone say help me. It was dark so she moved her car in a way that the headlights shone in that direction and could tell someone was on the ground at the east end of the building, went there and found the resident seated on the ground, his walker was upright, he had a hold of his cane and the remote control for his television, he said he was leaving and just needed help getting back up on his feet. She believed he came out the East door, as she didn't think he could have navigated the back gravel parking lot, full of pot-holes in the dark with his walker, and made it all the way around the building to the East door where he was seated near. She called the facility for help with her cell phone, 2 nurses and 1 of the aides came out, checked him over, he wasn't hurt, they got him up and walked him back into the building through the front door. The resident didn't have a Wandergard on his wrist, he had a habit of removing them. As a CMA she'd checked for the function and placement of Wandergard's on all residents that had them, they did that every shift. The resident didn't like it there and frequently said that, usually ambulated with a walker. Staff M stated sometimes the East hall exit door would stick, wouldn't go all the way shut, and if it wasn't latched you could open it without the alarm going off and thought that's how the resident eloped without sounding an alarm. Staff M stated she had not heard any door alarms going off before she left work that night, between 10:00 p.m. and 10:05 p.m. The facility Administrator, interviewed 2/13/22 at 3:08 p.m., stated the resident exited through 1 of the 2 kitchen doors from the Dining Room (both with pass code required), at the time of the elopement both of the dietary doors were swollen so didn't close completely unless forced, if unlatched the resident could have pushed the door open without the pass code, no alarm would have sounded and how the resident was able to leave undetected. Once in the Kitchen, the resident could have entered the service hall and exited through the service hall exit door. An employee found him outside at the East end of the building when she left work after 10 p.m. The employee used her cell phone and called into the building for help. The resident had his Wandergard on him, but no door alarms had sounded. Both nurses responded and assessed the resident, there were no injuries, he was assisted back into the building, they sat him in the front room/living room area while they called the physician, Director of Nursing (DON) and herself. It must have been while he sat there that he got dressing scissors from a treatment cart and cut his Wandergard bracelet off. He was sent to the hospital by ambulance within a half hour of the elopement. Since then, both of the Kitchen doors were sanded down the day after the elopement so they latched easily, and a second alarm was added to each Kitchen door located near the top of the door. They added a pass-code key pad to enter the service hall from the Kitchen exit door, and an alarm was added to the service hall exit door that alarmed whenever the door was opened. All door alarms were checked at the time of the elopement and all worked, if the Kitchen doors were latched they alarmed. All staff were re-educated on procedures for elopement. Staff P, CNA, interviewed 2/13/23 at 1:28 p.m. stated the resident always said he wanted to get out of there, he'd pack his things up in his room and would say he's leaving. She was not surprised to hear he eloped, he ambulated independently. Staff Q, CNA, interviewed 2/14/23 at 8:18 a.m., stated she never heard the resident say he wanted to leave but heard he said that to other staff, he missed his home and just wanted to go back to it. He had a Wandergard bracelet on but he got it off. When he came back from the hospital after he eloped they had to check him every 15 minutes for his whereabouts. 2. The Minimum Data Set (MDS) Assessment tool dated 12/31/22 revealed Resident #1 had severe cognitive impairment with symptoms of delirium present, with diagnoses that included diabetes, pneumonitis due to aspiration, muscle weakness, intellectual disabilities, unclear speech, sometimes able to make herself understood and usually able to understand others, and required extensive assistance, sometimes total dependence, on at least 1 staff to reposition in bed, transfer to and from bed and chair, dressing, eating, toileting, bathing and personal hygiene, non ambulatory, always incontinent of bladder and usually incontinent of bowel, A skin-impairment related to blister problem initiated on the nursing care plan 1/22/23 directed staff: 1. Educate resident, family, and caregivers of causative factors and measures to prevent skin injury. 2. Monitor for and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection to physician. 3. Resident bed was moved away from the heater on 1/22/23. 4. Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudate, and any other notable changes or observations. Nursing Progress Notes revealed the following entries: 1/22/23 at 5:17 a.m. Incident, Accident, Unusual Occurrence Note: Certified Nursing Assistant (CNA) requesting this nurse to resident room. This nurse down to room. CNA reports resident right leg is off of the bed and laying on the heat register. Resident laying on bed but air mattress has resident tilted toward register. This nurse and 2 CNA's able to move bed and bring resident leg up. Red area noted. No blisters or open areas noted at this time. Resident shakes head no when inquiring about pain. Bed repositioned away from heat register. This nurse had been in room approximately 15 minutes prior for morning medication and resident was positioned in center of bed. 1/22/2023 at 10:24 a.m. Patient noted to have a fluid filled blister to her right outer calf, dime-sized, noted redness to be around fluid filled blister that radiates up and down leg, right outer aspect of calf warm to the touch. The facility Skin/Wound assessment forms stated: 1/22/23 at 9:16 p.m., Staff F, RN, described a 2.3 centimeter (cm) by 0.7 cm blister on the resident's right calf. 1/23/23 at 10:59 a.m., the Assistant Director of Nursing (ADON) and facility wound nurse described a 1.6 cm by 1.4 cm blister on the right thigh. A physician Progress Note related to the physician's assessment on 1/23/22 stated: A new blister wound on right lateral calf first noted 1/22/23 measured 4 cm by 1.8 cm, and directed staff to continue cleansing blistered areas to right lower extremity with wound cleanser, apply xeroform gauze, cover with non adherent gauze pad, wrap with rolled gauze daily and as needed (PRN). Monitor for signs or symptoms of infection. Physician orders directed staff: 1/5/23 - May have bed against the wall. 1/26/23 - Apply Xeroform Petrolatum Patch to right leg topically daily (a treatment for burns). Iowa Chapter 58 Administrative Code regulation 58.35(4)j specifically directs: Beds shall not be placed in such a manner that the side of the bed is against the radiator or in close proximity to it unless it is covered so as to protect the resident from contact with it or from excessive heat. Staff interviews revealed: Staff K, CNA interviewed 2/7/23 at 5:51 p.m. stated he worked the night shift, on 1/22/23 the resident started to slide out of bed and when he found her she was between the bed and the heater on the wall (her bed was up against the wall). The nurse had been in her room around 5 a.m. to give her medication, and when he found her it was between 5:15 and 5:20 a.m. and he called out for help. The 2 other staff on duty responded, they had to work together to get the resident back in bed. The resident had not really fallen, her leg was hanging off the side of the bed and it was up against the heater, her skin was red but there wasn't a blister. The nurse knew it and had looked at it. Staff L, CNA interviewed 2/7/23 at 6:07 p.m., stated she worked the night shift on 1/22/23 when the resident slid off the side of the bed, they had just put an air mattress on top of her bed, she didn't really fall, but the mattress had started to slide off the right side of the bed, where the legs would be, her bed was up against the wall so the resident's right leg was between the bed and the wall, and up against the heater but it was wrapped in her sheet, her bottom and the rest of her were still on top of the bed. It took the 3 staff on duty to get the resident's bed moved away from the wall and the resident positioned back in the bed. Her leg was red but she didn't see any blister at the time. Staff F, RN, interviewed 2/8/23 at 3:29 p.m. stated she worked night shift , on 1/22/23 she gave the resident her thyroid pill at 5 a.m., the resident was in her bed per usual. Around 5:15 a.m. Staff K found her leg over the side of the bed and she went in to help him and the other CNA on duty to get the resident back on the bed and the bed moved away from the wall. The resident had not fallen, the air mattress was sort of tilted off the edge of the bed and her right leg was between the bed and the wall, against the heater. She checked her for injuries, the leg was red where it had been against the heater, warm, but there was no open areas or blistering, she filled out an incident report and notified the oncoming nurse and the Director of Nursing (DON). They had her bed up against the wall because of her attempts to get up on her own, that she frequently did after she woke her up for her 5 a.m. medication. Staff H, physician (MD), interviewed 2/14/23 at 10:13 a.m., stated the resident had recently acquired burns on her leg when she assessed her 1/29/22. (Staff H was the physician on duty in the hospital emergency roiagnom on [DATE].) Resident responsible party/Power of Attorney (POA) interview revealed: 2/8/23 at 3:27 p.m., the resident's POA stated on 1/22/23, when they arrived at the facility to feed the resident lunch they saw blisters on her leg and could tell the resident was burned. The resident's roommate told them she'd fallen out of bed the night before, was up against the wall-mounted heater and how she was burned. When they asked the nurse if it was a burn and how the resident was burned, the nurse said she couldn't tell them that.

Based on record review, interviews, and facility policy review, the facility failed to notify the physician of changes in condition and/or the need to alter treatment for two (Resident #311 and Resident #209) of six residents reviewed for medication administration. Specifically, the facility failed to notify the physician when Resident #311 tested positive for COVID-19, which resulted in a delay in obtaining treatment orders for the resident, who subsequently expired; Resident #311's blood sugars were out of prescribed parameters; Resident #311's medications were unavailable for administration and Resident #209 did not receive medications as ordered. The facility identified a census of 53 current residents. Findings include: 1. A review of an Admission Record revealed Resident #311 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the admission record revealed the resident expired at the facility on [DATE]. A review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #311 scored 12 on a Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident required limited to extensive assistance of two people for activities of daily living (ADLs). The MDS indicated the resident received insulin injections on six out of seven days during the lookback period. A review of a care plan, dated as initiated on [DATE], revealed Resident #311's goal was to transition back to the community. The facility developed an intervention for the resident to transition home with goals met. 1. a) A review of the facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], indicated, The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. When test results are report to the facility, a nurse will first review the results. The policy also indicated the following: - A nurse will identity the urgency of communicating with the attending physician based on the physician's request, the seriousness of any abnormality, and the individual's current condition. - A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. [et cetera]. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of a facility policy titled, COVID-19 Testing Policy, revised [DATE], revealed, Documentation of Testing. Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. A review of Progress Notes revealed a COVID-19 Testing note was entered on [DATE] at 5:55 PM, which indicated Resident #311 had a positive COVID-19 test. The note did not indicate the physician was notified of the positive results. A review of Progress Notes dated [DATE] at 12:21 AM and [DATE] at 12:47 PM, revealed Resident #311 had no signs or symptoms of COVID-19 after testing positive. A review of Progress Notes dated [DATE] at 12:24 AM, revealed Resident #311's oxygen saturation was 86% on room air. Oxygen was applied, and the resident's oxygen saturation came up to 91% with the oxygen at 2 liters per minute via nasal cannula. There was no indication the physician was notified. A review of a focused evaluation Progress Note, dated [DATE] at 12:30 AM, indicated Resident #311 had an occasional non-productive cough with oxygen in place. The note indicated the resident had no other signs and symptoms and remained in isolation for a recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Doctor's Orders and Progress Notes, dated [DATE] at 12:30 PM, revealed, Apparently, [Resident #311] tested positive for COVID-19 on Friday night [[DATE]]. No provider was notified. Labs and medications were ordered at this time. A review of a Social Service Note, dated [DATE] at 12:59 PM, indicated Resident #311 expired that morning. A review of the Death Record, dated [DATE], indicated Resident #311's time of death was [DATE] at 7:28 AM, and the cause of death was COVID-19 pneumonia. During an interview on [DATE] at 2:32 PM, Staff T, Nurse Practitioner (NP), stated she was the primary provider for Resident #311. She stated Resident #311 tested positive for COVID-19 on a Friday and she was not notified until she came into the facility to do rounds on the following Tuesday ([DATE]). She stated the night shift nurse had left a note in her folder requesting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was going to see the resident, and that was when she was told the resident was on the COVID unit. She stated the resident went five days before any COVID treatment was ordered, then died the next day. On [DATE] at 8:42 AM, the surveyor attempted to call Staff U, the nurse caring for Resident #311 on [DATE] when the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff U did not respond by the end of the survey. During an interview on [DATE] at 2:37 PM, Staff H, a Licensed Practical Nurse (LPN), stated whenever a resident tested positive for COVID-19, they were put into quarantine and notifications were made to the physician and families and should be documented in the progress notes. She stated the facility did not have standing orders for how to treat COVID-19. After reviewing Resident #311's record, Staff H stated she was unable to find documentation of the provider being notified when the resident tested positive for COVID-19. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated whenever a positive COVID-19 test result was obtained, the facility would put the resident in isolation and notify the physician, family, state, and medical director. She stated those notifications should be documented in the progress notes. She stated the facility did not have standing orders for positive COVID-19 residents, but the physician should be updated, and they would provide orders as needed. The DON stated she could not recall the details of Resident #311's death. During an interview on [DATE] at 4:53 PM, the Administrator, she stated when a positive COVID-19 case was identified the resident was moved to the isolation area and the physician and family should be notified. She stated it should be documented in a progress note. 1. b) A review of the facility's policy titled, Diabetes, revised [DATE], indicated, The physician and staff will establish notification parameters related to diabetes monitoring. Based on individualized notification parameters, the staff will inform the practitioner about the status of each patient's glucose control, depending on the situation, goals, and other associated symptoms or conditions. A review of Resident #311's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the facility was required to contact the resident's primary care provider (PCP) if Resident #311's blood sugar was over 300 or less than 70. A review of the February 2022 MAR revealed Resident #311's blood sugar was greater than 300 on 58 occasions out of the 112 times it was checked. On fourteen of those occasions, it was greater than 400; on sixteen occasions, it was greater than 500; and on one occasion, it was greater than 600. A review of Resident #311's Progress Notes for February 2022 revealed the resident's PCP was notified on five of the 58 occasions that the resident's blood sugar was greater than 300. On [DATE] at 8:42 AM, the surveyor attempted to contact Staff T, Resident #311's PCP, for an interview regarding Resident #311's blood sugars. The surveyor left a message requesting a callback. Staff T did not respond by the end of the survey. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated the licensed nurses dealt with residents' blood sugars and notifying the physician if the results were out of parameters. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated the physician should always be notified as ordered if a resident's blood sugar was out of parameters, because the physician may want to make changes to the resident's medications. During an interview on [DATE] at 2:37 AM, Staff H, a Licensed Practical Nurse (LPN), stated staff should document in a progress note or in the MAR notes when a resident's blood sugar was out of physician-ordered parameters and the provider was notified. After reviewing Resident #311's record, she was not able to find documentation that the resident's blood sugars were reported to the physician as ordered, but she stated they should have been. She stated it was important to let the provider know, because they may adjust the resident's medications or diet. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated any resident with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated notifying the physician when a resident's blood sugar was not within physician-ordered parameters was important, so the physician could make changes if needed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a resident's blood sugars were out of physician-ordered parameters, the physician and DON should be notified, and it should be documented in a progress note. 1. c) A review of the facility's policy Pharmacy and Therapeutics Oversight, revised [DATE], revealed Medications will be ordered, administered, and monitored appropriately and safely. According to the policy, The medical director will advise the facility on prescribing, handling, dispensing, storing, prescribing, and monitoring medications, including the following: a. Appropriate indications, selection, and prescribing of medications for the facility's resident/patient population. b. Safe procurement, storage, distribution, use and disposal of drugs and biologicals . d. Contents of emergency and interim medication kits . i. Monitoring for, identifying, correcting, and preventing medication-related problems including adverse consequences. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (used of urinary incontinence) 0.4 milligrams (mg) give one tablet by mouth one time a day. - [MEDICATION(S)] (used for yeast infections) 50 mg give one tablet by mouth one time a day every three days. - [MEDICATION(S)] (used for chest pain) 1,000 mg give one tablet by mouth two times a day. - [MEDICATION(S)] (used for chest pain) 50 mg give 50 mg by mouth two times a day. - [MEDICATION(S)] (used for [CONDITION(S)]) 20 mg give three tablets by mouth one time a day. - [MEDICATION(S)] (used for restless leg syndrome) 2 mg give one tablet by mouth one time a day. Further review of the February 2022 MAR revealed the resident did not receive the following medications due to not being available from the pharmacy for administration: - [MEDICATION(S)] 0.4 mg on [DATE], [DATE], [DATE], and [DATE] - [MEDICATION(S)] 50 mg on [DATE], [DATE], and [DATE] - [MEDICATION(S)] 60 mg on [DATE], [DATE], and [DATE] - [MEDICATION(S)] 1,000 mg on [DATE], [DATE], [DATE], [DATE] AM and PM dose, [DATE] AM and PM dose, and [DATE] AM and PM dose - [MEDICATION(S)] 50 mg on [DATE], [DATE], [DATE], and [DATE] - [MEDICATION(S)] 2 mg on [DATE] and [DATE] A review of the Orders-Administration Notes for the above medications indicated the medications were either not available or were on order. A review of Resident #311's record revealed no documentation that the primary care provider (PCP) was notified of the resident not receiving the above medications. During an interview on [DATE] at 2:32 PM with Staff T, Nurse Practitioner (NP), she stated she could not recall if the facility had notified her of Resident #311 missing medications. She stated she expected to be notified whenever the nurse held a medication so that if the resident ended up having an adverse reaction to not getting the medications, then she would know the reason and it would affect how she would treat the resident. She stated having the staff fail to notify her when a medication was being held or not given had been an issue in the past. During an interview on [DATE] at 9:05 AM with Staff V, Certified Medication Aide (CMA), she stated if a medication was not available during the medication pass, then she would tell the nurse and document that it was not available. She stated she was unsure if the physician was notified but thought the nurse did that. During an interview on [DATE] at 10:33 AM with Staff W, CMA, she stated if a medication was not available, she would tell the charge nurse and document it was not available. She stated the charge nurse should notify the physician. During an interview on [DATE] at 2:37 PM with Staff H, Licensed Practical Nurse (LPN), she stated if a medication was not available during the medication pass, the physician was notified by fax but admitted it was not done every time. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated if a medication was not available during the medication pass, the physician should be notified sometime during the day, and depending on the type of medication, maybe sooner. She stated if a medication was unavailable for multiple days, the physician, pharmacy, and DON should be notified. The DON stated the physician should be contacted for clarification whenever a medication was not available to see how the physician wanted to proceed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a medication was not available during the medication pass, the pharmacy and physician should be contacted along with the DON. 2. A review of Resident #209's Admission Record, revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #209's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognitive skills. A review of Resident #209's Order Summary Report revealed the resident was admitted with orders for [MEDICATION(S)] tablet 0.25 milligram (mg). The order was to give one tablet by mouth twice a day related to [CONDITION(S)] disease. The order start date was the day of admission, [DATE]. A review of the pharmacy receipt revealed Resident #209's [MEDICATION(S)] tablets were delivered to the facility on [DATE]. A review of the resident's [DATE] and [DATE] Medication Administration Record [MAR] revealed the [MEDICATION(S)] tablet 0.25 mg was not administered the evening of [DATE] or the mornings of [DATE], [DATE], or [DATE]. A review of the resident's Progress Notes, dated [DATE], [DATE], [DATE], and [DATE] revealed the medication was not available for morning administration and no note indicated the physician was called regarding the missing medication. During a telephone interview with Staff R, a Certified Medication Assistant (CMA), on [DATE] at 1:33 PM, she stated she was able to pass medications as of [DATE] and had worked at the facility for four years as a CNA. She stated if the medication was in stock it was administered. She stated if the medication was not available, she would inform the charge nurse and they would see what was going on. If a medication was not given, it should be documented on the MAR and in a nursing note. She stated she could not find the Parkinson medication for Resident #209 the morning of [DATE]. She stated the medication cards were not in the cart that morning and she notified Staff F, a Licensed Practical Nurse (LPN) and charge nurse, who double checked and could not find the medication card either. An interview with Staff F on [DATE] at 2:28 PM revealed if a medication needed to be given but was not available, she would call the pharmacy to see when it could be delivered. She stated the pharmacy for the facility could be very slow when delivering medications. She stated she was not passing medications on [DATE] and did not recall getting any reports from the CMAs about missing medications. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, she stated ideally if the medication was not available the nurse would call the pharmacy and check the E-kit (emergency kit; emergency medication box). If the medication was determined to not be sent from the pharmacy, it should be reordered. She stated the physician should be notified the same day when a medication was not available for administration and kept up to date about when the medication could be given. She stated if the medication had not arrived in a few days, the nurses should be following up with pharmacy. She stated there was a card issue with Resident #209's medication and the doses not given in the morning should have been reported to the physician. During an interview on [DATE] at 2:37 PM with Staff H, a Licensed Practical Nurse, she stated she was not sure if the physician was notified that Resident #209's medications were not given. During an interview with the Administrator on [DATE] at 4:04 PM, she stated the physician, the pharmacy, and the DON should be notified if a medication was not available at medication pass time. She stated the CMAs should report to the nurse if medications were not available.

Based on observations, record review, and interview, the facility failed to ensure three (Resident #311, Resident #29, and Resident #209) of six sampled residents reviewed for medication administration received care and treatment in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #311's physician was notified of a positive COVID-19 test on [DATE]. Once the provider was aware the resident had COVID-19 on [DATE], the facility failed to ensure physician-ordered medications were provided and tests were obtained as ordered on [DATE]. In addition, the facility failed to monitor Resident #311's vital signs for approximately 23 hours prior to the resident's death. Resident #311 expired on [DATE] due to COVID-19 pneumonia; failed to notify the physician when blood sugar levels were out of parameters (too high and/or too low) and failed to conduct and document follow-up blood sugar results and assessments after obtaining abnormal blood sugars for Resident #311 and Resident #29; and failed to administer medications as ordered and/or inform the physician when medications were missed or unavailable for Resident #29 and Resident #209. The facility identified a census of 53 current residents. Findings include: 1. A review of an Admission Record revealed Resident #311 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the admission record revealed the resident expired at the facility on [DATE]. A review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #311 scored 12 on a Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident required limited to extensive assistance of two people for activities of daily living (ADLs). The MDS indicated the resident received insulin injections on six out of seven days during the lookback period. A review of a care plan, dated as initiated on [DATE], revealed Resident #311's goal was to transition back to the community. The facility developed an intervention for the resident to transition home with goals met. 1. a) A review of the facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], indicated, The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. When test results are report to the facility, a nurse will first review the results. The policy also indicated the following: - A nurse will identity the urgency of communicating with the attending physician based on the physician's request, the seriousness of any abnormality, and the individual's current condition. - A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. [et cetera]. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of a facility policy titled, COVID-19 Testing Policy, revised [DATE], revealed, Documentation of Testing. Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. A review of Progress Notes revealed a COVID-19 Testing note was entered on [DATE] at 5:55 PM, which indicated Resident #311 had a positive COVID-19 test. The note did not indicate whether the physician was notified of the positive results. A review of Progress Notes dated [DATE] at 12:21 AM and [DATE] at 12:47 PM, revealed Resident #311 had no signs or symptoms of COVID-19 after testing positive. A review of Progress Notes dated [DATE] at 12:24 AM, revealed Resident #311's oxygen saturation was 86% on room air. Oxygen was applied, and the resident's oxygen saturation came up to 91% with the oxygen at 2 liters per minute via nasal cannula. A review of a focused evaluation Progress Note, dated [DATE] at 12:30 AM, indicated Resident #311 had an occasional non-productive cough with oxygen in place. The note indicated the resident had no other signs and symptoms and remained in isolation for a recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Doctor's Orders and Progress Notes, dated [DATE] at 12:30 PM, indicated Resident #311 tested positive for COVID-19 on [DATE] and no provider was notified. Further review revealed the provider ordered a Z-pak (antibiotic), [MEDICATION(S)] (a steroid medication) six milligrams (mg) by mouth daily for 10 days, [MEDICATION(S)] pearls (for cough) 200 mg one by mouth four times a day for 72 hours and then as needed (PRN), Robitussin DM 2 teaspoons every six hours as needed for cough, and oxygen to keep saturations greater than 90%. The provider also ordered a chest x-ray, a complete blood count (or CBC, a laboratory test to detect [CONDITION(S)] and/or infection), a basic metabolic profile (BMP, a blood test to check for hydration and kidney function), and a d-dimer (test used to rule out blood clots). The ordered labs were to be completed today [[DATE]]. There was also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes also indicated the facility would be contacted to set up a monoclonal antibody infusion (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a Social Service Note, dated [DATE] at 12:59 PM, indicated Resident #311 expired that morning. A review of Resident #311's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #311's Progress Notes, dated [DATE] at 2:08 PM, indicated the resident had a non-productive cough but the lungs were clear to auscultation, and respirations were even and unlabored. The note indicated the resident's oxygen saturation was 96% on room air on [DATE] at 6:11 AM, approximately eight hours earlier. According to the notes, Resident #311's other vital signs, including temperature (98.5 degrees Fahrenheit), blood pressure (,d+[DATE] millimeters of mercury), pulse (71 beats per minute), and respirations (16 breaths per minute) were also obtained at 6:11 AM, approximately eight hours earlier. A review of Progress Notes, dated [DATE] at 4:16 AM, indicated Resident #311 did not show any signs or symptoms of COVID-19. The resident's lungs were clear to auscultation and respirations were even and unlabored. Further review of the note revealed the same vital signs obtained on [DATE] at 6:11 AM (the previous day) were also documented on the [DATE] note, oxygen saturation-96%, temperature-98.5 degrees Fahrenheit, blood pressure-,d+[DATE] millimeters of mercury, pulse-71 beats per minutes, and respirations-16 breaths per minute. There were no current vital signs documented. A review of Resident #311's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Death Record, dated [DATE], indicated Resident #311's time of death was [DATE] at 7:28 AM, and the cause of death was COVID-19 pneumonia. Continued review of Resident #311's Progress Notes revealed no documentation of the circumstances surrounding the death of Resident #311 and no documented evidence the facility checked the resident's vital signs, including the oxygen saturation level, for approximately 23 hours before the resident's death. During an interview on [DATE] at 2:32 PM, Staff T, Nurse Practitioner (NP), stated she was the primary provider for Resident #311. She stated Resident #311 tested positive for COVID-19 on a Friday and she was not notified until she came into the facility to do rounds on the following Tuesday ([DATE]). She stated the night shift nurse had left a note in her folder requesting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was going to see the resident, and that was when she was told the resident was on the COVID unit. She stated the resident went five days before any COVID treatment was ordered, then died the next day. On [DATE] at 8:42 AM, the surveyor attempted to call Staff U, the nurse caring for Resident #311 on [DATE] when the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff U did not respond by the end of the survey. On [DATE] at 11:28 AM, the surveyor attempted to contact Staff C, the nurse who input the orders on [DATE] after the resident expired. Staff C did not answer, and the surveyor left a message. Staff C did not respond by the end of the survey. During an interview on [DATE] at 2:37 PM, Staff H, a Licensed Practical Nurse (LPN), stated whenever a resident tested positive for COVID-19, they were put into quarantine and notifications were made to the physician and families and should be documented in the progress notes. She stated the facility did not have standing orders for how to treat COVID-19. After reviewing Resident #311's record, Staff H stated she was unable to find documentation of the provider being notified when the resident tested positive for COVID-19. She stated when a physician did rounds, they would provide the progress notes at the time of the visit and then the note should go into the resident's chart. Staff H stated the provider would write any new orders on the progress note. She stated she was unable to say why Resident #311's orders were not put into place the day they were ordered. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated whenever a positive COVID-19 test result was obtained, the facility would put the resident in isolation and notify the physician, family, state, and medical director. She stated those notifications should be documented in the progress notes. She stated the facility did not have standing orders for positive COVID-19 residents, but the physician should be updated, and they would provide orders as needed. She stated when a provider completed a visit at the facility, the progress notes would be put in the resident's file to be uploaded into the computer. She stated the providers would write any new orders on the progress notes. She stated she expected the orders to be put into the computer right away. After reviewing Resident #311's provider progress note dated [DATE], she stated the orders should have been put in right away and initiated. The DON stated she could not recall the details of Resident #311's death. During an interview on [DATE] at 4:53 PM, the Administrator, she stated when a positive COVID-19 case was identified the resident was moved to the isolation area and the physician and family should be notified. She stated it should be documented in a progress note. The Administrator stated when a physician did a visit and wrote orders, the staff should be putting those orders in when they were received and followed. The Administrator stated Resident #311's orders should have been put in the same day and started and did not know why there was a delay. 1.b) A review of the facility's policy titled, Diabetes, revised [DATE], indicated, The physician and staff will establish notification parameters related to diabetes monitoring. Based on individualized notification parameters, the staff will inform the practitioner about the status of each patient's glucose control, depending on the situation, goals, and other associated symptoms or conditions. A review of Resident #311's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the facility was required to contact the resident's Primary Care Provider (PCP) if Resident #311's blood sugar was over 300 or less than 70. A review of the February 2022 MAR revealed Resident #311's blood sugar was greater than 300 on 58 occasions out of the 112 times it was checked. On fourteen of those occasions, it was greater than 400; on sixteen occasions, it was greater than 500; and on one occasion, it was greater than 600. A review of Resident #311's Progress Notes for February 2022 revealed documentation that the resident's PCP was notified on five of the 58 occasions that the resident's blood sugar was greater than 300. On [DATE] at 8:42 AM, the surveyor attempted to contact Staff T, Resident #311's PCP, for an interview regarding Resident #311's blood sugars. The surveyor left a message requesting a callback. Staff T did not respond by the end of the survey. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated the licensed nurses dealt with residents' blood sugars and notifying the physician if the results were out of parameters. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated the physician should always be notified as ordered if a resident's blood sugar was out of parameters, because the physician may want to make changes to the resident's medications. During an interview on [DATE] at 2:37 AM, Staff H, a Licensed Practical Nurse (LPN), stated staff should document in a progress note or in the MAR notes when a resident's blood sugar was out of physician-ordered parameters and the provider was notified. After reviewing Resident #311's record, she was not able to find documentation that the resident's blood sugars were reported to the physician as ordered, but she stated they should have been. She stated it was important to let the provider know, because they may adjust the resident's medications or diet. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated any resident with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated notifying the physician when a resident's blood sugar was not within physician-ordered parameters was important, so the physician could make changes if needed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a resident's blood sugars were out of physician-ordered parameters, the physician and DON should be notified, and it should be documented in a progress note. 2. A review of the Admission Record indicated Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the quarterly Minimum Data Set (MDS) indicated Resident #29 had moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 12. The resident required extensive to total assistance of two people for activities of daily living (ADLs). The MDS indicated the resident received insulin injections seven out of seven days during the look back period. 2. a) A review of the facility's policy titled, Diabetes, revised [DATE] indicated, The physician and staff will establish notification parameters related to diabetes monitoring. Based on individualized notification parameters, the staff will inform the practitioner about the status of each patient's glucose control, depending on the situation, goals, and other associated symptoms or conditions. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The directions were to inject one mg subcutaneously as needed and update the PCP if the resident's blood sugar was over 300 or less than 70. A review of the [DATE] MAR revealed Resident #29 had a blood sugar below 70 on eleven occasions, with three blood sugar results below 60. There was no documentation the PCP was notified, no documentation that [MEDICATION(S)] was administered, nor of any follow-up assessments/checks of the resident's blood sugar. A review of the [DATE] MAR revealed nine occasions when the resident's blood sugars were below 70, two of which were less than 60. Further review revealed Resident #29's blood sugar was above 300 on occasions. There was no documented evidence the resident's PCP was notified. In addition, there was no documentation that [MEDICATION(S)] was administered when the resident's blood sugar was below 70, nor of any follow-up/assessments of the resident's blood sugar. A review of all progress notes dated from [DATE] through [DATE] revealed no documentation Resident #311's PCP was notified as ordered when Resident #29's blood sugars were out of physician-ordered parameters (below 70 or greater than 300). There was also no documentation of the low blood sugars being treated or monitored. On [DATE] at 8:42 AM, the surveyor attempted to contact Staff T, Resident #29's primary care provider, for an interview regarding the resident's blood sugars. The surveyor left a message requesting a return call. Staff T did not respond by the end of the survey. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated the nurses dealt with residents' blood sugars and physician notification if results were out of parameters. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated the physician should always be notified if blood sugars were out of physician-ordered parameters, because the physician may want to make changes to the resident's medications. During an interview on [DATE] at 2:37 AM, Staff H, a Licensed Practical Nurse (LPN), stated staff should document in a progress note or on the MAR notes when a resident's blood sugar was out of physician-ordered parameters and the provider was notified. After reviewing Resident #311's record, she was not able to find documentation that the resident's blood sugars were reported to the physician as ordered, but she stated they should have been. She stated it was important to let the provider know, because they may adjust the resident's medications or diet. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated any resident with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated notifying the physician when a resident's blood sugar was not within physician-ordered parameters was important, so the physician could make changes if needed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a resident's blood sugars were out of physician-ordered parameters, the physician and DON should be notified, and it should be documented in a progress note. 2.b) A review of the facility's policy Pharmacy and Therapeutics Oversight, revised [DATE], revealed Medications will be ordered, administered, and monitored appropriately and safely. According to the policy, The medical director will advise the facility on prescribing, handling, dispensing, storing, prescribing, and monitoring medications, including the following: a. Appropriate indications, selection, and prescribing of medications for the facility's resident/patient population. b. Safe procurement, storage, distribution, use and disposal of drugs and biologicals . d. Contents of emergency and interim medication kits . i. Monitoring for, identifying, correcting, and preventing medication-related problems including adverse consequences. A review of Progress Notes, dated [DATE], indicated Resident #29 was congested and tested positive for COVID-19 twice. The note indicated the provider was notified and new orders were obtained. A review of Resident #29's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #29's [DATE] Medication Administration Record (MAR) revealed on [DATE] and [DATE], [MEDICATION(S)] was coded 9, indicating to see the progress notes. A review of Progress Notes, dated [DATE] at 3:08 PM and [DATE] at 7:59 AM, revealed the [MEDICATION(S)] was not available to be administered. The [DATE] note indicated the medication was ordered. Further review of the MAR revealed [MEDICATION(S)] was only administered for five days, [DATE] through [DATE], instead of the physician-ordered seven days. A review of the Ekit (Emergency medication kit) Contents indicated twelve [MEDICATION(S)] one mg tablets were available in the e-kit. During an interview on [DATE] at 2:32 PM, Staff T, the Physician Assistant who was Resident #29's primary care provider, stated she expected to be notified if a medication was held. She stated she needed to be aware in case the resident had an adverse reaction due to not receiving the medication. She stated not being notified by facility staff when a medication was held or not given had been an issue in the past. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated if a medication was not available during the medication pass, she would notify the nurse and document that it was not available. She stated she was unsure if the physician was notified. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated if a medication was not available, she would tell the charge nurse and document it was not available. She stated the charge nurse should notify the physician. She stated if the medication was available in the e-kit, then it should be given. She stated she was unsure why [MEDICATION(S)] for Resident #29 was not pulled out of the e-kit. She stated the medication should have been given as ordered for seven days, even if it was not available the first two days. During an interview on [DATE] at 2:37 PM, Staff H, a Licensed Practical Nurse (LPN), stated if a medication was not available during medication pass, the nurse or CMA should check the e-kit to see if it was available there. She stated if the medication was available at the same dose but was with medications ordered at a different time, it could be pulled from those medications and the pharmacy should be notified so the dose could be replaced. She stated if a medication was not available at all, staff should notify the pharmacy. She stated the physician should be notified by fax, but admitted it was not done every time. After reviewing Resident #29's record, she stated the [MEDICATION(S)] should have been pulled from the e-kit the first two days until it was provided by the pharmacy. Staff H stated Resident #29's [MEDICATION(S)] should have been given for the full seven days as ordered. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated if a medication was not available during the medication pass, the cart and the medication room should be double-checked and then the e-kit should be checked to see if the medication was available. The DON stated the pharmacy needed to be called to find out when it was sent and when it would be available. She stated sometimes they could get the pharmacy to deliver medications the same day, even though the pharmacy was hours away. The DON stated the physician should be notified that day, and depending on the type of medication, maybe sooner. She stated if a medication was unavailable for multiple days, the physician, pharmacy, and DON should be notified. She stated [MEDICATION(S)] was available in the e-kit and could have been used. The DON stated the physician should be contacted for clarification whenever a medication was not available, to see how the physician wanted to proceed. During an interview on [DATE] at 4:53 PM, the Administrator, stated if a medication was not available, the pharmacy, physician, and DON should be contacted. 3. A review of Resident #209's Admission Record, dated [DATE], revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS, dated [DATE], revealed the resident scored 3 on a BIMS, which indicated the resident had severely impaired cognitive skills. A review of the computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The directions were to give one tablet by mouth twice a day related to [CONDITION(S)] disease. A review of a pharmacy receipt revealed Resident #209's [MEDICATION(S)] tablets were delivered to the facility on [DATE]. A review of the [DATE] and [DATE] Medication Administration Records (MARs) revealed the [MEDICATION(S)] tablet was not administered the evening of [DATE], nor the mornings of [DATE], [DATE], and [DATE]. During a telephone interview on [DATE] at 1:33 PM, Staff R, a Certified Medication Assistant (CMA), stated she was able to pass medications as of [DATE] and had worked at the facility for four years as a Certified Nursing Assistant (CNA). She stated she had passed medications twice on her own. She stated if the medication was in stock, then it was administered. She stated if a medication was not available, she would inform the charge nurse and the charge nurse would see what was going on. If a medication was not given, that information should be documented on the MAR and in a nursing note. She stated she could not find the [MEDICATION(S)] for Resident #209 the morning of [DATE]. She stated the medication cards (pharmacy provided the facility's medications on blister cards) were not in the cart that morning, and she notified Staff F, Licensed Practical Nurse (LPN) charge nurse, who double-checked and could not find the morning medication card either. She stated the medication was available the previous two evenings ([DATE] and [DATE]) and she administered it. During an interview on [DATE] at 2:28 PM, Staff F revealed if a medication needed to be given but was not available, she would call the pharmacy to see when it could be delivered. She stated the pharmacy for the facility could be slow when delivering medications. She stated she was not covering the medication cart on [DATE] and did not recall getting any reports from the CMAs about medications missing. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, she stated, ideally, if a medication was not available, the nurse would call the pharmacy and check the emergency-medication-kit. If the medication was determined to not be sent from the pharmacy, it should be reordered. She stated the physician should be notified the same day when a medication was not available for administration and kept up to date about when the medication could be given. She stated if the medication had not arrived in a few days, the nurses should be following up with the pharmacy. She stated there was a card issue with Resident #209's medication, and the doses not given in the morning should have been reported to the physician. During an interview on [DATE] at 2:37 PM, Staff H, Licensed Practical Nurse, revealed she was not sure if the physician was notified that Resident #209's medication was not given as ordered. During an interview with the Administrator on [DATE] at 4:04 PM, she stated the physician, the pharmacy, and DON should be notified if a medication was not available at medication pass time. She stated the medication assistants should report to the nurse if medications were not available. She stated staff members should have been administering the medication from the medication cards regardless of whether they were AM or PM medication cards.

Based on record review and staff interviews, the facility failed to provide adequate supervision and assistance devices to prevent falls for 2 of 4 sampled (Residents #1 and #2). The staff failed to secure a safety strap around Resident #1 in the shower chair. Resident #1 fell out of the chair, which resulted in a right femur fracture requiring surgical repair. The staff failed to use a footboard on the wheelchair as directed by the plan of care. Resident #2 tipped the wheelchair and struck her head on the floor sustaining cervical fracture. The facility reported a census of 52. Findings include: 1. The Minimum Data Set (MDS) assessment dated of 1/23/20 documented Resident #1 had short and long-term memory deficits and severely impaired cognitive skills for daily decision-making. Resident #1 required total staff assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 had [DIAGNOSES REDACTED]. The Care Plan initiated 10/11/19 revealed Resident #1 at risk for falls and required the following safety devices: a. Floor mat at bedside. b. Scooped/winged mattress. c. Specialty call light. d. Positioning devices in bed, body pillow. f. Seat belt resident when in shower chair immediately. The Incident Report dated 10/7/19 at 9:40 a.m. documented Resident #1 sitting in shower chair and the Nurse Aide turned to grab another resident's glasses. The Nurse Aide turned back and noticed Resident #1 sliding off the shower chair. Resident #1 hit her forehead on the shower chair. During an interview on 2/4/20 at 11:05 a.m., Staff A (Nurse Aide) reported Staff B assisted to transfer Resident #1 from the wheelchair to the shower chair with a total mechanical lift. Staff A confirmed she failed to secure Resident #1 in the shower chair with the safety belt per protocol. Staff A assisted Resident #1 with removing her clothing. Staff B escorted another resident out of the Shower Room. Staff B asked Staff B if she left the resident's glasses on a shelf next to Staff [NAME] Staff A turned her back to Resident #1 and retrieved the glasses. As Staff A turned back around, Resident #1 fell , striking her face on the floor. Staff B yelled for assistance while Staff A supported Resident #1 on the floor. Staff C (Licensed Practical Nurse) responded and assessed Resident #1. Staff A and Staff C lifted Resident #1 from the floor back into the shower chair. Staff A stated it was common practice to use the safety belt while residents are in the shower chair. During an interview on 2/4/20 at 4:30 p.m., Staff B (Nurse Aide) reported she assisted Staff A to transfer Resident #1 from her wheelchair into the shower chair. Staff B stated another resident was in the shower room at the same time. Staff A proceeded to assist the other resident. Staff B stated she escorted the other resident to the door when she noticed she needed her glasses. Within seconds, Staff B heard Staff A gasp. Staff B turned and observed Resident #1 lying face down on the floor. Staff B yelled for the nurse, who promptly arrived. Staff B exited the room with the other resident. During an interview on 2/4/20 at 10:41 a.m., Staff C (Licensed Practical Nurse) heard Staff B yell for help. Staff C responded and found Resident #1 sitting on the floor, leaning next to the shower chair. Resident #1 yelled, Get me up several times. Staff C assessed Resident #1 and completed range of motion on all extremities. Resident #1 voiced no pain. Staff C and Staff A lifted Resident #1 off the floor and back into the shower chair and buckled the safety belt. Staff C stated she noticed an abrasion on the right side of Resident #1's forehead. The Staff B initiated neurological checks and Resident #1 showered without further incident. Staff C stated it was common practice to secure the safety belt when a resident sat in the shower chair. During an interview on 2/5/20 at 9:30 a.m., Staff D (Licensed Practical Nurse) reported she had Resident #1's section, but was busy at the time of the fall. Staff C completed the initial assessment. Staff B noticed Resident #1 making unusual noised during follow up assessments. Staff D reported Resident #1 non-verbal. Staff d performed range of motion and Resident #1 had no signs of pain. At lunch, a Nurse Aide reported Resident #1 yelled out when the staff touched her right leg. Staff D contacted Resident #1's physician and received an order to transfer Resident #1 to the Emergency Department for evaluation. According to the History and Physical final report dated 10/7/19, Resident #1 had a fall from a shower chair 3.5 hours ago and hit her head. The staff denied a change in level of consciousness. Resident #1 guarded her right thigh. Radiology findings note a right femur fracture and Resident #1 sent to a higher level of care facility to have surgical repair of right femur. In an interview on 2/4/20 at 11:40 a.m., the Director of Nursing (DON) stated an expectation of all staff to utilize the safety belt on the shower chair when occupied by a resident. The DON stated following the incident involving Resident #1's fall in the shower room, all staff were re-educated on the required use of the shower chair seat belt when showering residents. During an interview on 2/4/20 at 11:35 a.m., the Administrator stated an expectation of staff to utilize safety devices. The Administrator stated following Resident #1's fall in the shower room, all staff were re-educated on the required use of the shower chair belt when providing showers. The Administrator stated the staff received a reprimand for not utilizing the safety belt on the shower chair. 2. The MDS assessment dated [DATE] Resident #2 had short and long-term memory deficits and severely impaired cognitive skills for daily decision-making. Resident #2 required extensive assistance for transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2 had [DIAGNOSES REDACTED]. The Care Plan revealed Resident #2 had 30 falls in the last year. The Care Plan directed the staff to utilize the following safety interventions: a. Floor mat/mattress at bedside. b. Anti-slid mat to recliner. c. Anti-thrust cushion to wheelchair. d. Baby monitor placed in bedroom. e. Encourage resident to nap in bed verses recliner. f. Encourage to use the call light. g. Foot board on wheelchair at all times. (12/10/19) h. Allow to sit in recliner in dining room in the evenings. i. High back/reclining wheelchair and anti-tip front and back. (1/7/20) j. Anti-slip strips in bathroom. k. Keep walker in reach at all times. l. Place bells on the walker. m. Remove wheelchair pedals when sitting at table. According to the Incident Report dated 12/10/19 at 3:15 p.m., Resident #2 had two unwitnessed falls. At 3:15 p.m., the staff discovered Resident #2 on the floor in the outer dining room. The staff noticed the wheelchair near Resident #2. Resident #2 had an abrasion near her left eye with bruising and swelling. Resident #2 transferred to the Emergency Department for evaluation. Resident #2 returned to the facility and at 8:30 p.m. The staff assisted Resident #2 to bed. Later, staff found Resident #2 sitting on her floor mat beside the bed. Resident #2 had no injuries. During an interview on 2/4/20 at 2:50 p.m., Staff [NAME] (Licensed Practical Nurse) reported she worked at the time of the falls. After the first fall, Staff [NAME] placed a footboard across the wheelchair pedals to keep Resident #2 from leaning forward in her wheelchair. Staff [NAME] stated she added the intervention onto Resident #2's care plan and therapy assisted her with getting the footboard. Staff [NAME] stated the Nurse Aides view the Care Plan updates on the Kardex. During an interview on 2/5/20 at 9:20 a.m., Staff F (Therapy Supervisor) reported Staff [NAME] consulted her for interventions for Resident #1 while in her wheelchair. Staff F stated Resident #2 had a tilt in space wheelchair, which allowed seating to tilt backward for pressure relief and positioning. Staff F stated they changed wheelchair to a high back reclining chair on 1/7/20 to provide better comfort and added a footboard on 12/10/19 to prevent Resident #2's legs from dangling and better supported Resident #2 in her wheelchair and from leaning forward. Staff F stated they also transferred the anti-thrust cushion from one chair to the other. The anti-thrust cushion prevents the resident from pushing back into the chair and causing her to slide According to the Incident Report dated 1/7/20 at 10:40 a.m., the Nurses heard a crash, looked up and observed Resident #2 lying face down on the floor in outer dining room. Resident #2 tipped her wheelchair forward and fell out, hitting her forehead on the floor. Resident #2 sustained two lacerations to forehead with a moderate amount of bleeding. The staff implemented neurological assessments, cleansed the [MEDICAL CONDITION], applied pressure and transferred Resident #2 sent to the Emergency Department for evaluation.\ During an interview on 2/5/20 at 10:49 a.m., Staff G (Licensed Practical Nurse) stated she heard a loud thud as Resident #2's head hit the floor. Staff G jumped up and ran over to Resident #2, who was lying face down with the wheelchair tilted forward. The foot pedals had Resident #2's legs pinned. Resident #2 had two indents on her forehead and two lacerations. The Director of Nurses provided cervical support as Staff G yelled for another staff to call an ambulance. Staff G stated Resident #2's legs caught behind her foot pedals and she fell forward. Staff G had no knowledge Resident #2 had a Care Plan intervention for a footboard. During an interview on 2/5/20 at 10:39 a.m., the Director of Nursing (DON), stated she was in her office and heard Resident #2 fall. The DON responded with Staff G and Staff H and provided care and support. The DON supported Resident #2's head until the ambulance arrived. The DON could not recall any of the specifics related to the wheelchair or interventions, as she focused on caring for the resident. During an interview on 2/5/20 at 11:40 a.m., Staff I (Nurse Aide) recalled Resident #2 had a footboard but at some point, it disappeared. Staff I stated after that they started tilting the wheelchair to prevent her from leaning forward. During an interview on 2/5/20 at 11:23 a.m., Staff J (Nurse Aide) had no knowledge Resident #2 had a footboard. Staff J did not see a footboard in Resident #2's room the day of the fall. Staff J stated Resident #2 really needed a footboard because she always stood up unassisted. During an interview on 2/5/20 at 11:55 a.m., Staff K (Nurse Aide) stated she consistently worked Resident #2's hall and had no knowledge she had a footboard. During an interview on 2/6/20 at 1:10 p.m., the Director of Nursing (DON), stated she spoke with staff following Resident #2's fall. The DON reported Resident #2 had ongoing behaviors and falls. The DON had no knowledge Resident #2's Care Plan directed the staff to utilize a foot board. The DON had no knowledge if the footboard was in place at the time of the fall. The DON stated Resident #2's mobility status declined since returning from the hospital and now had hospice services. The DON reported the staff did not receive education for failing to ensure Care Plan interventions were in place. During an interview on 2/5/20 at 12:26 p.m., the Advanced Registered Nurse Practitioner (ARNP) stated Resident #2 stopped communicating and lost her gag reflex after the fall. Resident #2 started hospice services. The ARNP noted Resident #2 had an odontoid fracture (cervical 2 vertebrae), but otherwise no overt indications of intracranial trauma. The ARNP stated Resident #2 failed to recover from the fall and hitting her head. According to the Discharge Summary dated 1/9/20, Resident #2 sustained a C2 cervical fracture related to her fall on 1/7/20. Resident #2 presented to the hospital post fall with an altered mental status. Resident is non-verbal during exam, but does localize to pain and will spontaneously open her eyes. There was no evidence of a hemorrhagic nor non-hemorrhagic contusion. Swallow study noted inability to swallow and resident placed on strict nothing by mouth. Family discussed plan to provide comfort measures only. According to the Progress Note dated 1/9/20 at 10:42 a.m., Resident #2 readmitted to facility. Resident #2 remained in bed and non-responsive to verbal or tactile stimuli. Resident #2 received comfort care and passed away on 1/10/20 at 6:27 p.m.

Based on record review and staff interviews, the facility failed to plan and direct the nursing care and services, provide assessments and timely interventions to prevent the development of a pressure ulcer on the right heel for 1 of 4 residents reviewed (Resident #3). The facility reported a census of 53 residents. The facility identified Resident #3 had a high risk for pressure ulcers and wore a left heel suspension boot due to a pressure ulcer following repair of the right hip. On 2/7/2011 the staff identified a Stage 2 pressure ulcer located on the right heel. The facility did not assess or provide interventions to prevent the development of the right heel ulcer. The resident developed infection (MRSA) in the wound and required debridement of the pressure ulcer. Findings include: 1. A 30 day Minimum Data Set (MDS) assessment completed on 2/14/11 revealed Resident #3 as severely cognitively impaired, required limited assistance of two staff for bed mobility, extensive assistance of two for transfers and toileting and as non-ambulatory. The MDS further indicated the resident as totally dependent on staff for bathing and had impaired range of motion to the right lower extremity. The MDS revealed the resident as frequently incontinent of bladder and occasionally incontinent of bowel. According to the assessment, the resident had [DIAGNOSES REDACTED]. The MDS identified the resident at risk for developing pressure sores and that he/she currently had a Stage 1 and Stage 2 pressure ulcer. The Resident Assessment-Data Collection Form/Initial Care Plan dated 1/17/11 at 1:40 p.m. revealed the resident had a 0.5 cm (centimeter) by 0.5 cm red, non-open area on his/her left heel and that the resident wore a left heel suspension boot. The assessment indicated the resident had been admitted to the facility from the hospital status [REDACTED]. The Braden Scale-For Predicting Pressure Sore Risk dated 1/17/11, 1/24/11, 1/31/11, 2/7/11 and 2/11/11 documented the resident's score for each assessment to equal 12 (each total score of 12 or less represented high risk for pressure ulcer development). The facility provided the surveyor with a copy of "The Prevention of Pressure Ulcers" dated March 2007 Edition which directed staff to: observe all pressure points at a minimum of twice daily with AM and PM care, use elbow/or heel foot protectors if needed, and document preventive measures used. Record review failed to reveal documentation staff observed the resident's pressure points every AM and PM during the resident's stay. The care plan dated 2/3/11 indicated the resident had been admitted with a Stage I pressure sore to his/her left achilles, and at risk for further skin breakdown due to impaired mobility (secondary to recent right [MEDICAL CONDITION]), poor appetite, frequent incontinence, and an inability to voice needs to staff. Care plan interventions included an air pressure relieving mattress (to the bed), turning and repositioning per a turning wheel schedule, a left heel suspension boot, and the administration of a multivitamin and Prostat (high protein supplement). On 2/7/11, staff documented the resident had a new, Stage II (partial thickness skin loss involving epidermis, dermis or both and can present as an abrasion, blister or shallow crater) pressure ulcer, on his/her right heel; on 2/9/11, staff added interventions for the resident to wear bilateral heel suspension boots at all times, and to leave shoes off due to skin breakdown. The nurses' notes dated 2/7/11 revealed staff had discovered a pressure area to the resident's right heel during the resident's shower at 6:00 p.m. on 2/7/11. A facsimile (fax) communication dated 2/7/11 revealed the facility notified the resident's physician that staff had noted a 5 cm round, non-open, fluid-filled blister to the resident's right heel to which staff had applied a [MEDICATION NAME] (semi-permeable dressing) dressing, and had floated the resident's heel off the bed. The notification indicated staff would follow the facility pressure area protocol and change the [MEDICATION NAME] every 7 days and PRN (as needed) until healed. A fax communication dated 2/8/11 to the physician asked for permission to initiate a daily multivitamin and Prostat 30 cubic centimeters (cc) daily to promote healing, to which the physician replied "no." The Pressure Ulcer Healing Record dated 2/7/11 revealed the resident had a right heel, Stage II, non-open blister measuring 5 cm round with no odor, no drainage, normal skin color, and wound edges normal for skin. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This intervention to reduce pressure to right heel occurred approximately 48 hours after the ulcer had been reported to the charge nurse. The Pressure Ulcer Healing Record dated 2/10/11 revealed the resident's right heel pressure sore had increased in size measuring 9 cm by 5.3 cm with no odor, no drainage, white/gray pallor skin color, and wound edges normal for skin. The documentation indicated staff would continue with the heel suspension boots, air mattress, and turning wheel program. A fax to the physician dated 2/10/11 asked for permission to administer Prostat 30 cc twice a day, increase Hormel 2.0 supplement to 4 ounces (oz) twice a day as well as a request to change the dressing to a [MEDICATION NAME] dressing covered with Kerlix; the physician responded "yes" to the requests. The Pressure Ulcer Healing Record dated 2/17/11 revealed the resident's right heel ulcer as now unstageable (unable to visualize wound bed due to eschar or necrotic tissue covering the wound), measuring 7.5 cm by 5.3 cm, with a slight odor, no drainage. A nurses' note dated 2/17/11 at 6:10 a.m. noted the resident's right heel area had an odor and staff would update the physician later that morning regarding a new treatment order. The nurses' notes dated 2/17/11 (no time noted), indicated staff had spoken with the physician's nurse and received new orders about the resident's right heel. On 2/17/11 at 3:15 p.m., the nurse's notes indicated staff had swabbed the resident's right heel and sent the specimen to the laboratory. On 2/19/11 at1:40 p.m., the nurses' notes documented the resident's daughter was in the facility and thought her parent's face appeared swollen and hot. The note documented the resident's temperature to be 101.5 (degrees). The daughter requested the resident be sent to the hospital and the facility made arrangements. On 2/19/11 at 5:00 p.m., the facility documented the resident had been admitted to the hospital. During an interview on 3/16/11 at 5:30 p.m., the physician who examined the resident in the emergency roiagnom on [DATE] stated he/she was not sure when the resident's ulcer had developed, but stated it needed to be debrided so he/she admitted the resident for treatment. The physician stated that when she/he peeled the dressing off the resident's heel, a foul odor, black necrotic tissue and drainage from the ulcer was noted. The physician indicated the ulcer covered a large area of the resident ' s heel and it had redness surround the ulcer and was warm to touch. The physician stated the ulcer had been infected [MEDICAL CONDITIONS] and the surgeon had surgically debrided (removed) the necrotic tissue from the ulcer. A laboratory report dated 2/19/11 confirmed the swabbed specimen collected from the resident's right heel on 2/17/11 as positive [MEDICAL CONDITION]. A statement from the resident ' s primary care physician dated 3/18/11 documented the resident had the following Diagnoses: [REDACTED]. The physician documented the following statement: "My impression is that (Resident #3) would have difficulty repositioning self and likely he/she sustained his/her ulcer from prolonged contact with the bed mattress. Likely his/her dementia impaired his/her ability to perceive or process his/her heel pain and reposition even if able. I feel his/her general poor conditioning and refusal to eat limits his/her nutritional support and slows tissue repair and healing. I don't think his/[MEDICAL CONDITION] caused the ulcer, but may have been contributing to the delayed healing." During an interview on 4/18/10 at 11:15 a.m., Staff A, L.P.N., the facility's wound nurse indicated the resident had an air mattress on his/her bed that had a special area that floated the resident's heels. Staff A also stated facility staff used a turning wheel schedule that directed the Certified Nurses' Aides (CNAs) when and in what direction to reposition residents so the staff didn't have to document when they repositioned residents. Staff A also stated they didn't place the resident's right foot in a suspension boot because his/her right heel was pink, firm, and healthy. Several nurses' notes dated after the resident developed his/her right heel ulcer indicated the resident was not compliant with the turning wheel schedule; the notes indicated the resident preferred to lay on his/her back. The dates and times of those notes were: 2/10/11 at 8:30 a.m. 2/12/11 at 10:30 p.m. 2/17/11 at 10:00 p.m.