Every finding on record at Chapters Living of Council Bluffs

Based on clinical record review, observations, provider interviews, resident interviews, staff interviews, family interviews and policy review the facility failed to ensure staff provided skin assessments, failed to notify the provider of deterioration timely and failed to implement interventions to prevent and treat the development and worsening of pressure ulcers for 7 of 8 residents reviewed (Resident #29, #2, #9, #30, #22, #23, and #21). The facility failure to assess a Stage II pressure ulcer from 12/16/25 through 1/3/26 resulted in Resident #29's wound to deteriorate to an unstageable ulcer due to necrosis (dead tissue) with infection that required debridement of the wound and then hospitalization. Significant debridement required with the wound base extending down into ligamentous structures running along the posterior sacrum and there was exposed bone. The facility reported a census of 28 residents.The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of January 2, 2026 on January 14, 2026 at 4:00 p.m. The facility staff removed the immediacy of the IJ on January 14, 2026, and decreased the scope to E through the following actions:In-service/education/training for pressure ulcer prevention and wound care - policy and practice update.a. All full time and part time clinical staff to complete the mandatory education/training before their next scheduled shift. All as needed (PRN) clinical staff to complete before their next scheduled shift.b. Audits to begin 1/15/26: completed weekly x 12 weeks.This was implemented due to an Immediate Jeopardy and focused on required practices to protect residents from avoidable skin breakdown and wound deterioration.Education Topics Covered:a. Review of updated Pressure Ulcer Prevention Policyb. Weekly wound assessment completion and weekly skin assessment completion.c. Weekly Wound Care Rounds every Friday (mandatory participation & documentation)New skin concerns evaluated by Interdisciplinary Team (IDT) for Director of Nursing (DON) / Assistant Director of Nursing (ADON) notification, pressure relief interventions, proper Medical Doctor (MD) notification and order entry.d. Mandatory notification to DON and ADON of any skin or wound changes.e. Mandatory MD notification for any wound decline, worsening, or lack of improvement.Resident repositioning at least every 2 hours to be audited by charge nurse or leadership team member each shift every 2 hours.f. Repositioning residents at least every 2 hours - importance, frequency, and documentation. Daily shower/bath completion form to be implemented beginning 1/15/26 that included a section for new skin concerns, nurse notification and DON/ADON notification. Nurse to sign stating they documented a progress note regarding the new findingsg. Nurse aides must immediately notify the nurse on duty of any skin changes noted during bathing/showering. Findings include:The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3, or stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 1. The MDS dated [DATE] documented Resident #29 had a BIMS of 15 indicating no cognitive impairment. The MDS documented Resident #29 had one or more unhealed pressure ulcers. The MDS documented a Stage 2 pressure ulcer present. The MDS documented Resident #29 had an admission date of 11/11/25. Review of Resident #29's (Electronic Health Record) EHR dated 11/26/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 16 that indicated Resident #29 was at risk for development of a pressure ulcer. Review of Resident #29 TAR documented a physician's order with a start date of 11/28/25 and end date of 12/16/25 to cleanse the sacral wound with wound cleanser, pat dry and apply Plurogel and foam patch daily until healed. A physician's order with a start date of 12/16/25 and discontinued date of 1/2/26 to cleanse the sacral wound with wound cleanser, pat dry and apply Santyl and foam patch every other day. Review of Resident #29's EHR dated 11/11/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 20 that indicated Resident #29 was not at risk for development of a pressure ulcer. Review of Resident #29's EHR, titled Skin Check documented the following: On 11/12/25 completed by Staff M, LPN documented no concerns. On 11/29/25 open area on coccyx with no measurements or description. On 12/6/25 open area on coccyx with no measurements or description. On 12/6/25 slit above sacrum with current treatment in place with no measurements. Review of Resident #29's EHR titled, Wound Evaluation documented the following: On 11/28/25 at 7:37 AM entered by Staff MM, a minutes old in-house acquired Stage 2 pressure ulcer on the sacrum that had an area of 1.63 cm2, length of 3.24 cm, and width of 0.94 cm. On 12/6/25 at 9:29 PM entered by Staff MM, an in-house acquired Stage 2 pressure ulcer on the sacrum that had an area of 2.5 cm2, length of 4.17 cm, and width of 0.98 cm. Wound Evaluation documented additional care of cushion, incontinence management, and nutrition / dietary supplementation. Notes reported area stalled treatment changed and encouraged to allow staff to reposition. On 12/16/25 at 10:43 AM entered by Staff P, an in-house acquired stage 2 pressure ulcer on the sacrum that had no measurements. Wound Evaluation documented stage 2 pressure ulcer with no evidence of infection and additional care of cushion, nutrition / dietary supplementation and turning / reposition program. Review of Resident #29's EHR dated 12/16/25 titled, Skin and Wound Evaluation documented an in-house acquired stage 2 pressure ulcer with no measurements, superficial loss of tissue and no odor. Review of Resident #29's EHR, titled Skin Check documented the following: On 12/18/25 a pressure injury on coccyx and sacrum with no measurements or description. On 12/25/25 a pressure injury on sacrum with no measurements or description. On 1/1/25 a pressure injury on sacrum with no measurements or description. Review of Resident #29's EHR dated 12/23/25 titled Progress Notes documented wound condition reported to nurse practitioner order for wound care appointment. Review of Resident #29's EHR dated 12/25/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 9 that indicated Resident #29 was at a very high risk for development of a pressure ulcer. Review of Resident #29 TAR documented a physician's order with a start date of 12/29/25 for Cephalexin 500mg, give one tablet by mouth every 12 hours for buttocks ulcer infection for 5 days. Review of Resident #29's EHR dated 12/31/25 titled, Progress Notes documented Nurse Practitioner in facility to review chart and see resident. New orders for air mattress to bed. Review of Resident #29's EHR documented no skin assessments completed between 12/16/25 and 1/3/26. Interventions for wound management were not changed until 1/2/26 when seen at a wound clinic. Review of Resident #29's EHR titled Infection Documentation dated 1/1/26 through 1/5/26 documented sacral ulcer infection with odor, no measurements, no description of wound and no medical doctor notification. On 1/3/26 at 9:54 AM entered by Staff J, an in-house acquired unstageable pressure ulcer on the sacrum that had an area of 14.6 cm2, length of 6.63 cm, and width of 3.72 cm. Wound Evaluation documented unstageable pressure ulcer due to slough and / or eschar with a light amount of serous drainage and a strong odor. Wound Evaluation documented additional care of air flow pad, incontinence management, positioning wedge, repositioning devices, and turning / repositioning program. On 1/5/26 at 9:43 AM entered by Staff P, an in-house acquired stage 2 pressure ulcer on the sacrum that had an area of 15.78 cm2, length of 6.57 cm, and width of 4.36 cm. Wound Evaluation documented stage 2 pressure ulcer with moderate amount of serous drainage and no odor. Wound Evaluation documented additional care of cushion, incontinence management, mattress with pump, nutrition / dietary supplementation and turning / reposition program. Review of Resident #29's EHR dated 1/5/26 titled, Skin and Wound Evaluation documented an unstageable pressure ulcer with slough and/or eschar that had an area of 15.8 cm2, length of 6.6 cm, and width of 4.4 cm with no physician notification. Review of Resident #29's EHR titled, Care Plan documented a focus for potential for pressure injury development related to assist needed initiated on 11/11/25 with a in house stage 2 pressure ulcer on sacrum initiated 11/28/25. No new interventions in place for in-house acquired a stage 2 pressure ulcer that was found from 11/28/25. The care plan does not reflect any new interventions since returning from the hospital with a surgically debrided stage 4 pressure ulcer that requires a wound vacuum. Review of Resident #29's document dated 1/6/26 at 5:06 PM titled, Operative Report documented Resident #29 had a known sacral decubitus pressure ulcer for the last 2 months, who presented to the hospital with fevers and concern for sepsis from her sacral decubitus wound. She has undergone some minimal debridement of this in the wound care clinic already. Her wound had a foul smell and significant necrotic tissue, warranting urgent debridement in the operating room. Debridement of all of the nonviable completely necrotic tissue which had a foul odor. The base of the wound was down onto the ligamentous structures running along the posterior sacrum and there was exposed bone. A bone biopsy which was sent separately. Area was debrided, removal of the necrotic soft tissue down to the bone centrally, and then to the bilateral gluteal muscles. The total debrided area was 6 cm x 5.5 cm. Review of Resident #29's document dated 1/12/26 titled, Discharge Summary documented Resident #29 entered the Emergency Department (ED) at 4:40 PM with chief complaint of sacral wound ulcer. Resident #29 had a temperature of 101.3, a pulse of 116 and was found to be positive for influenza A. During review Resident #29 reported she underwent debridement though the wound care clinic on 1/2/26, at that time it was determined she may need a more aggressive surgical debridement and had been referred to the surgical clinic for debridement. Sacral dressing was removed to inspect the ulcer. Documented ulcer measured approximately 5cm x 5cm in surface area with significant soft tissue loss. There is a large necrotic area centrally, the ulcer itself was unstageable as the base was not able to be visualized. Foul smell from the wound consistent with tissue necrosis. Suspect the ulcer was down to at least muscle gluteal region, possibly down to the posterior aspect of the sacrum itself. Review of Resident #29's document dated 1/12/26 titled, Hospital Progress Notes documented Resident #29 was concerned about returning to the facility because she did not get repositioned. Document explained Resident #29 acknowledged she had never had an ulcer ever before entering the facility in November. Discharge plan for return to facility repositioning every 2 hours. On 1/12/26 at 1:09 PM the DON stated Resident #29 had an unstageable pressure ulcer on her sacrum. The DON explained Resident #29 had entered the facility on 11/11/25 and the wound must have been facility acquired. The DON acknowledged Resident #29's wound was not on the admission. The DON explained the first photograph of the wound was taken on 11/28/25. The DON stated the area on Resident #29 was on the gluteal fold or sacral area. The DON acknowledged the wound on Resident #29's sacral area had declined. The DON acknowledged the facility did not complete assessments with pictures, measurements, or description of the wound from 12/16/25 - 1/3/26. The DON acknowledged Resident #29's wound had deteriorated. On 1/12/26 at 7:43 PM entered by Staff J, a stage 4 pressure ulcer on the sacrum that was present on admission that had an area of 22.4 cm2, length of 6.98 cm, and width of 4.6 cm. Wound Evaluation documented stage 4 pressure ulcer with light amount of serosanguineous drainage and no odor. Wound Evaluation documented additional care of incontinence management, positioning wedge, repositioning device and turning / reposition program. On 1/13/25 at 11:29 AM the Nurse Practitioner stated she was not notified that Resident #29 had returned and currently had strict orders for 2 hour repositioning. The Nurse Practitioner stated just seen Resident #29 and the CNA had told her Resident #29 was not adequately turned last night. The Nurse Practitioner stated she was shown the picture of the wound on 12/16/25. The Nurse Practitioner stated she did not hear anything again until the week of Christmas. The Nurse Practitioner stated she received a text from Staff MM reporting the wound was looking worse and requested a wound care visit. The Nurse Practitioner stated she gave an order for Resident #29 to be seen at wound care. The Nurse Practitioner explained she never received a report as to what wound care said. The Nurse Practitioner stated Resident #29 was sent to the ED on 12/5/25 with fever and concerns with vitals. The Nurse Practitioner explained she had seen an updated picture. The Nurse Practitioner stated the wound looked awful. The Nurse Practitioner stated she did not know it was unstageable or was no longer a stage 2. The Nurse Practitioner stated with the changes in the wound she would have expected to be notified. The Nurse Practitioner explained Resident #29's wound was debrided all the way to the bone. The Nurse Practitioner stated she would have expected an update if the wound had deteriorated. The Nurse Practitioner stated the wound did appear to be preventable and should have never gotten to where it was at currently. On 1/13/26 at 2:00 PM Staff R, CNA stated she talked to the nurse about Resident #29 not being repositioned or changed appropriately last night. Staff R stated she spoke to Staff A, RN about it that morning. Staff R stated Resident #29 reported she had not been repositioned or changed the way she should have been last night. Staff R explained Resident #29s' care plan specified every 2 hours. On 1/13/26 at 2:50 PM Staff A, RN acknowledged that Staff R had told her Resident #29 had reported she had not been repositioned the night prior. Staff R stated Resident #29 had been soaked through the pad, the sheet to the bed when Staff R provided care that morning. Staff A stated the overnight nurse reported off to her that he repositioned her every 2 hours. Staff A acknowledged there was a dark ring around Resident #29 on the bed pad that appeared to be indicative of not checking or changing but, did know if Resident #29 was repositioned. Staff A stated she assisted Staff R with repositioning Resident #29 that morning. On 1/14/26 at 7:39 AM Staff M, Licensed Practical Nurse (LPN) acknowledged she was the nurse that sent Resident #29 to the hospital the day she went out. Staff M stated when she came in on her shift at 2:00 PM that afternoon, Staff M explained Resident #29 had an elevated temperature and pulse. Staff M stated she was going to be seen by the surgeon on 1/5/26 or 1/6/26 and the surgeon canceled the appointment till 1/9/26. Staff M stated Resident #29 had just finished her course of antibiotic and requested to send Resident #29 to the hospital. Staff M stated Resident #29 had been seen by the wound clinic and they were going to schedule her consult for a surgical debridement of her wound. Staff M stated the wound clinic did a debridement in the office then scheduled her to see a surgeon. Staff M stated she had cared for Resident #29's wound a few days before when it was evaluated by the nurse practitioner. Staff M explained Resident #29's sacral wound had deteriorated. Staff M stated Staff MM said she did not know what had happened to the wound but it looked like it was worse overnight. Staff M explained she had been off a couple days during the holiday. Staff M stated the wound had eschar at the time and initially it was just a slit in the sacral area. Staff M stated the nurses are expected to notify the physician with any changes in the wound and if the wound is not improving or deteriorating. Staff M stated if a wound became open then she felt that was a change in condition of the wound and would prompt a call to the physician. On 1/14/26 at 1:51 PM MM, RN acknowledged she cared for Resident #29. Staff MM stated she notified Staff P of the change in condition of the wound. Staff MM stated she notified the nurse practitioner of the change of condition for Resident #29's wound on her buttocks. Staff MM stated she was off for a while and 12/23/25 was her first day back. Staff MM stated the wound had gotten larger and was open. Staff MM stated this was noticed and she notified Staff P wound nurse / interim DON. Staff MM stated the wound was still a stage 2 at that time but was larger. Staff MM stated there was no eschar present at that time. Staff MM stated the wound had worsened but was not showing signs of infection. Staff MM stated the treatment did not change at that time. Staff MM stated Staff P was supposed to take the picture that day. Staff MM stated she notified the nurse practitioner as well about the change in condition. Staff MM stated Resident #30 had a deterioration in the wound. On 1/14/26 at 2:45 PM Staff P acknowledged there was no assessment for Resident #29 and unclear of what actually was notified to the physician as far as the wound description. Staff P stated she was informed about the wound from Staff MM and does not know why an assessment with measurement, description and photo was not completed. Staff P acknowledged she had worked that day and she did not look at the wound either. Staff P stated Staff MM said the wound looked worse. Staff P said it was concerning there was no assessment completed, no documentation of what exactly the physician was notified of and no photo of the area taken when the area was found on Resident #29. Staff P acknowledged there had not been any change in Resident #29's orders from 12/16/25 till seen at the wound clinic on 1/2/26. Staff P stated the physician should have been notified of Resident #29's worsening condition to the wound, assessments should have been documented to ensure appropriate treatment and physician update. On 1/14/26 at 3:00 PM the DON stated her expectation was with all wounds an assessment would be completed weekly with measurements and description of the wound. The DON stated her expectation was to notify the physician if there was any deterioration or lack of improvement to ensure the appropriate treatment was being completed. The DON stated documentation of the physician notification would be documented in the resident's electronic health records. The DON stated her expectation was that all changes in wounds worsening, lack of improvement or deterioration would also be reported to her or the ADON. The DON acknowledged Resident #29 skin assessments lacked an accurate assessment from 12/16/25 - 1/3/26 with measurements, a description of the wound or a photo. The DON acknowledged Resident #29's wound did not go from a stage 2 wound to that size of an unstageable pressure overnight and should have been documented with a physician notification before 1/3/26. On 1/15/26 at 1:30 PM Resident #29 stated she had to set an alarm on her phone to ensure the staff come to turn her every 2 hours or the staff will not reposition her. Resident #29 stated her doctor wants her repositioned every 2 hours. Resident #29 stated prior to going to the hospital the staff were not repositioning her every 2 hours and some overnight shifts the staff would only come in at 3:00 AM or 4:00 AM to reposition her in bed. Resident #29 stated she had multiple sclerosis and was not able to reposition herself in bed. Resident #29 stated she required the assistance of staff for repositioning. Resident #29 stated she had reported not being repositioned by the overnight staff several times to staff. Resident #29 stated when she entered the facility, she did not have any wounds on her bottom. On 1/21/26 at 1:51 PM Staff J, RN acknowledged he worked with Resident #29 prior to having the wound on her buttocks. Staff J stated he felt the deterioration of the wound on Residents #29 buttocks could have been prevented. Staff J stated Resident #29 was not being repositioned appropriately prior to the wounds appearing. Staff J stated some CNA's had reported the wound was not getting better and requested the nurse to look at it. Staff J explained the CNA was told to put some cream on it and did not assess the area. Staff J stated Resident #29 had an alarm to remind staff to reposition her since she had returned. Staff J stated he knew Resident #29 had issues brought up about overnight CNAs not being in her room. Staff J acknowledged if those aides are working, she told him she will set the alarm every 2 hours. On 1/22/26 at 11:29 AM Resident #29 stated last night Staff EE, Certified Nurse Assistant refused to change her brief and stated she was out of briefs. Resident #29 stated she had not had a BM. Resident #29 stated she was wet and nobody changed her at all last night. Resident #29 stated Staff EE only repositioned her at night but never changed her. Resident #29 stated she has had problems with Staff EE from the get go. Resident #29 stated Staff EE was not supposed to be caring for her because she had voiced concerns about how she cared for her in the past. Resident #29 stated she had told Staff R, CNA the concerns she had with Staff EE. Resident #29 said she thought Staff R told Staff P about the concerns with Staff EE. On 1/22/26 at 12:58 PM Staff EE, CNA stated she has very little interaction with Resident #29. Staff EE stated she was not supposed to have contact with Resident #29 but the facility kept putting her on that side. Staff EE stated she does work with Resident #29 and had worked with her last night. Staff EE stated she did have contact with Resident #29 last night. Staff EE acknowledged Resident #29 was on a 2 hour reposition schedule. Staff EE stated she repositioned her. Staff EE explained she did not toilet Resident #29 at night. Staff EE explained Resident #29 would turn on her call light at night asking for a brief change. Staff EE stated Resident #29 turned her call light on last night to be repositioned. Staff EE stated she took Staff Y when she was there but she left early but did not know what time. Staff EE stated she provided peri care to freshen her up down there but did not have to change her brief. Staff EE stated Resident #29 had not requested for her brief to be changed at any time overnight the night before. Staff EE stated Resident #29 had thought that she had a BM and wiped her up to show her that she had not had a BM. Staff EE stated she had Staff Y in the room with her at that time. Staff EE stated Resident #29 told her that she was a 3XL in brief size. Staff EE stated she did not change her brief because it was changed prior to her going in the room. Staff EE stated Resident #29 never asked her to change the brief. Staff EE stated if she was doing peri care and the brief is dirty, she changed the brief but she told her that she had not had a BM then she said she would just wear the same brief. On 1/22/26 at 2:06 PM Staff R stated when she came in at 6:00 AM on 1/22/26 and Resident #29 stated she had asked to be changed because she had some urine incontinence on the overnight shift. Staff R stated Resident #29 explained Staff EE said there was no brief to change her with. Staff R stated Resident #29 told her that she told Staff EE that she was a 3XL brief. Staff R reported Resident #29 said Staff EE told her that she would not get her another brief, reapplied the brief in the front, walked out of the room and did not return the rest of the night. Staff R said Resident #29 told her Staff EE refused to change her. Staff R reported Resident #29's brief was saturated when she provided care that morning. Staff R stated she reported the concern to Staff J, RN. On 1/22/26 at 2:10 PM Staff J, RN stated Staff R had informed him Resident #29 reported she had not been changed on the overnight shift. Staff J reported Staff R stated Resident #29 stated she had asked to be changed because she had incontinence. Staff J stated Resident #29 stated Staff EE said there was no brief to change her with. Staff J stated Resident #29 told Staff EE that she was a 3xl brief. Staff J stated Resident #29 said Staff EE told her that she would not get her another brief, reapplied the brief in the front, walked out of the room and did not return the rest of the night. Staff J said Resident #29 told her Staff EE refused to change her brief. On 1/23/26 at 2:00 PM Staff Y, CNA stated she had assisted Staff EE with care on Resident #29. Staff Y stated she assisted Staff EE with repositioning Resident #29. Staff Y stated Resident #29 stated she had a bowel movement. Staff Y stated Staff EE checked Resident #29's brief, it was dry and there was no bowel movement. Staff Y stated Resident #29 does not always void at night. Staff Y stated Resident #29 was cognitive of when she needs to use the bathroom. Staff Y stated Resident #29 did not have incontinence. Staff Y stated she did not notify the nurse because Resident #29 had not urinated that shift. Staff Y stated Resident #29 told the staff that she did not need her briefs changed if it was not soiled. Staff Y stated she did not go back in Resident #29's room after that time. Staff Y stated typically during personal care she would change the brief but she let Resident #29 exercise her rights and her wishes. Staff Y stated Resident #29 was not soiled, the 2 of them just freshened her up. Staff Y stated Resident #29 was dishonest and a troublemaker. Staff Y stated she did not know if there were briefs because she was only the second person. Staff Y stated Resident #29 had never said anything about her brief size. Staff Y stated Staff EE did not have a conversation about not having any briefs available. Staff Y stated she minds her own business. On 1/26/26 at 2:43 PM Staff J, RN stated the CNA's have never notified him of a stage 1 or any discoloration. Staff J stated he does not know if CNA's know what pressure injuries are or when to notify the nurse. On 1/26/26 at 3:26 PM the DON stated she had heard CNA's report they had told the nurse and there was no documentation. The DON stated Resident #29 did not want Staff E in their room. The DON stated there were a lot of balls that were dropped when it comes to wound care in the facility. 2. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented Resident #2 was at risk for developing pressure ulcers/injuries and Moisture Associated Skin Damage (MASD) present. The MDS documented admission date for Resident #2 of 11/28/25. It also documented treatments for skin injury included pressure reducing device for chair, pressure reducing device for bed, nutrition hydration intervention to manage skin problems. Review of Resident #2's Care Plan documented a focus initiated on 11/28/25 that Resident #2 had potential for pressure injury development. The Care Plan lacked any other skin issues and lacked the interventions identified on the MDS. It identified Resident #2 required the assistance of 1 staff for bed mobility and required the assistance of 1 staff for personal hygiene. Review of Resident #2's EHR dated 11/28/25 titled, Discharge Summary documented a Braden scale score of 17 with a reposition schedule at least every 2 hours. The Discharge Summary documented a wound undiagnosed gluteal cleft mid right. Review of Resident #2's Treatment Administration Record (TAR) documented a physician's order with a start date of 11/28/25 to cleanse buttocks with soap and water, pat dry, apply Z guard every shift until healed. A physician's order with a start date of 11/28/25 to evaluate buttocks wound / peri wound for complications including symptoms of infection. A physician's order with a start date of 1/15/26 to cleanse sacral stage 2 pressure ulcer with wound cleanser, pat dry, apply a foam dressing and change every 3 days and as needed (PRN). A physician's order with a start date of 1/15/26 to evaluate stage 2 pressure wound/peri-wound for complications including symptoms of infection. Review of Resident #2's EHR documented the following: On 11/28/25 at 2:50 PM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis that was present on admission on the buttocks that had an area of 1.42 cm2, length of 3.42 cm, and width of 0.61 cm. On 12/5/25 at 8:03 PM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis that was present on admission on the buttocks that had an area of 19.8 cm2, length of 8.86 cm, and width of 5.66 cm. On 12/12/25 at 8:29 AM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that did not have any measurements with the assessment. On 12/23/25 at 10:14 AM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that had an area of 1.4 cm2, length of 2.57 cm, and width of 1.29 cm. On 12/30/25 at 6:48 AM entered by Staff J, RN titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that had an area of <0.1 cm2, length of 0.25 cm, and width of 0.21 cm. On 1/6/26 at 7:21 PM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that had an area of 15.65 cm2, length of 7.01 cm, and width of 3.06 cm. Observation of the photo on EHR dated 1/6/26 at 7:21 PM entered by Staff P titled, Wound Evaluation revealed 2 areas of stage 2 present on sacrum / coccyx area at that time that were undocumented. Review of Resident #2's EHR dated 1/15/26 at 10:18 AM entered by Staff J titled, Wound Evaluation documented Stage 2 pressure ulcer on the sacrum that was in-house acquired that h

Based on clinical record review, policy review, resident interviews, family interviews, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care. The facility also failed to complete revisions to care plans when there was a change in the residents care to 10 of 20 residents reviewed (Resident #23, #11, #7, #8, #21 #2, #3, #9, #29, and #30). The facility reported a census of 28 residents.Findings include:1.According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 10/24/2025, Resident #23 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS documented the following diagnoses for Resident #23: Alzheimer's disease, hip fracture, anxiety, depression, muscle weakness and diabetes mellitus. The MDS documented an admission date of 2/7/2025. Record review revealed a document titled Baseline Care Plan Summary with an effective date of 12/17/2024. The resident's Power of Attorney (POA) signed and dated on 1/9/2025. Record review revealed no care conference attendance sheets or documents. On 1/20/2026 at 11:28 AM Resident #23's emergency contact #1 stated since the new company has taken over, the family has not been a part of her care plan meetings. The previous owners were holding meetings quarterly with family present but that has not happened since January 2025. On 1/23/2025 at 10:39 AM via email communication the Administrator acknowledged facility was unable to locate Resident #23's care plan attendance sheets. 2. Review of Resident #11's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. The MDS further revealed that Resident #11 was dependent on staff for chair/bed to chair transfers, transferring to the toilet, and tub/shower transfer. The MDS then revealed a diagnosis of unspecified fracture of the lower end of the right femur, muscle weakness, and difficulty in walking. Interview 1/20/26 at 10:43 AM with Resident #11 revealed that the staff utilize a whole body mechanical lift when transferring him with a sling. Resident #11 then revealed that sometimes there will only be one staff when transferring him with the lift, and sometimes there will be two staff. Review of Resident #11's Care Plan with a created date of 12/9/25 revealed Resident #11 requires staff assistance of one staff member for toilet transfer, and toileting with a gait belt. The Care Plan further revealed that Resident #11 was a stand pivot assist with one staff member and a gait belt. Interview 1/21/26 at 12:20 PM with Staff G Occupational Therapist Assistant revealed Resident #11 was a whole body mechanical lift transfer. Staff G then revealed on 12/17/25 she documented Resident #11 was a whole body mechanical transfer. Staff G further revealed when the physical therapy does the evaluation physical therapy will inform the nursing staff of how the resident transfers. Staff G then revealed Resident #11 was non-weight bearing on the right leg because of a right hip fracture that was on 12/3/25. Interview 1/21/26 at 2:10 PM with the DON revealed that care plans should be updated accordingly. Interview 1/21/26 at 2:14 PM with Staff H LPN revealed that she did not get the update on the whole body mechanical lift from OT/PT and would expect them to update the care plan accordingly. 3. Resident #7's MDS dated [DATE] revealed a BIMS score of 11/15 indicating moderate cognitive deficit. The resident utilized a wheelchair (w/c) with partial/moderate assistance. The document disclosed diagnoses including chronic kidney disease, nonrheumatic aortic valve stenosis, unspecified osteoarthritis. The resident's Care Plan dated 1/7/25 contained 19 focus areas with goals/target dates and interventions. All 19 focus areas reflected goals that were revised on 1/7/25 with a target date of 4/8/25. 18/19 focus areas contained interventions for staff to follow that had not been changed since 4/23/24. The facility failed to revise Resident #7's Care Plan to reflect current needs, goals and target dates. The facility failed to reflect discontinuation of restorative nursing services as the facility does not offer this. Review of the Electronic Medical Record (EMR) on 1/21/26 identified no documentation in the Progress Notes or scanned documents indicating Care Conferences were held or updates were made to the Care Plan. On 1/22/26 at 1:40 PM Staff H, Licensed Practical Nurse (LPN)/MDS Coordinator/Infection Preventionist, stated the resident's Care Plan should have been revised when reviewed with the Director of Nursing (DON) and should be dated to reflect the updates. Staff H stated she did not schedule Care Plan Conferences. On 1/22/26 at 1:49 PM Staff N, Interim Director of Social Services, stated she had been in the position since 5/25. The staff stated Care Plans were reviewed quarterly. When asked about Care Conferences the staff stated she would have to locate the documents indicating the conferences were held with the resident representative. On 1/26/26 at 8:44 AM Staff N provided documents from Social Services indicating Care Plans were reviewed with the resident's representative on 6/16/25, 9/5/25 and 11/26/25. On 1/26/26 at 8:58 AM Staff N stated invitations for Care Conferences would go out to the resident/resident representative and interdisciplinary team (IDT) and a note should be placed in the Progress Notes. The staff acknowledged there were no entries in the Progress Notes for Care Conference invitations. The staff stated notices for conferences should go out 2-3 weeks in advance. At this time the Progress Notes revealed late entries dated 6/13/25 (time stamp 1/22/26 3:18 PM), 9/5/25 (time stamp 1/22/26 3:20 PM) and 11/26 (time stamp 1/22/26 3:21 PM) phone meetings were held for Care Plans. Staff N acknowledged she entered the Progress Notes following the interview on 1/22/26 at 1:49 PM. The staff stated the documents provided were completed by herself, but she could involve other IDT members. Staff N acknowledged Care Conference Notes should be in the Progress Notes and documentation should be put in the EMR at the time of the occurrence. The staff stated she had not been uploading documents into the EMR as part of the assessment/meeting process. On 1/26/26 at 11:51 AM resident representative stated she had not been invited to or taken part in a Care Plan Conference since the facility transition to new ownership the previous year. 4. Resident #8's MDS dated [DATE] revealed a BIMS score of 8/15 indicating moderate cognitive impairment. The document provided that the resident required partial/moderate assistance for upper and lower body dressing and required supervision/touching assistance for transfers and ambulation up to 50'. The document disclosed resident diagnoses of diabetes mellitus, cognitive communication deficit and obstructive sleep apnea. The resident's Care Plan reviewed on 1/20/26 at 3:50 PM revealed a focus of assistance with ADLs revised 4/8/24 with staff interventions of stand pivot transfer with assistance of 1 using a wheeled walker and ambulation with wheeled walker and assistance of 1 revised 4/8/24; walking with a device revised 9/23/25 and walking with assistance of 1 with a gait belt initiated 9/23/25. At the time of the review the facility failed to update the Care Plan to reflect a change in transfer status to the need for a dependent full body mechanical lift and the resident's diagnosis of Influenza A requiring personal protective equipment (PPE). The resident's Care Plan showed an intervention entered on 1/21/26 for the use of a Hoyer lift (dependent full body mechanical lift) with assistance of 2. The After Visit Summary dated 1/17/26 revealed the resident was transferred to the hospital following a fall and was discharged back to the facility with a diagnosis of the flu on the same date. On 1/20/26 at 11:35 AM observed signs posted outside of Resident #8's room for Enhanced Barrier Precautions (EBP) and Droplet Precautions. On 1/20/26 at 1:54 PM Resident #8 stated he had fallen recently, went to the hospital and got the flu. The resident stated he hasn't been able to stand up and transfer since getting sick. Observed a Hoyer lift in the resident's room during the interview. On 1/21/26 at 8:20 AM Staff C, CNA, stated when she worked on 1/16/26 the resident required standby assistance of 1 with a walker and was completing tasks for himself. The staff stated since getting Influenza A the resident had required significantly more assistance with care and transfers. On 1/22/26 at 12:27 PM Staff D, Certified Medication Aide (CMA), stated staff would look at the Electronic Medical Record/the Kardex for information on the resident's needs. On 1/22/26 at 1:40 PM Staff H, stated if she was aware of changes in a resident status she would put it on the Care Plan. The staff stated she was she was unaware of Resident #8 had a change in transfer ability. The staff stated any nurse could revise the Care Plan to change a resident's status. The staff acknowledged the resident did have a change in respiratory status with the diagnosis of Influenza A and the need for precautions. 5. Resident #21's MDS dated [DATE] Significant Change export ready revealed a BIMS score of 8/15 indicating moderate cognitive impairment. The document disclosed the resident did not have a catheter, was incontinent of bowel and bladder, and dependent for bed mobility and transfers. The document indicated the resident's diagnoses included heart failure, atrial fibrillation (A-fib) and impaired brain function. The MDS revealed the resident had (1) Stage 2 pressure ulcer, partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, at the time of admission. The EMR Clinical Physician Orders revealed the following orders: Urinary catheter: output every shift; start date 12/23/25 and discontinued 12/24/25. Urinary catheter: output every shift; start date 12/23/25 and discontinued 12/24/25. Urinary catheter: change urinary catheter 16f 10cc bulb; start date 12/23/25 and discontinued 12/24/25. Urinary catheter: catheter diagnosis: urinary retention; revision date 12/24/25 and discontinued 12/24/25. Urinary catheter: provide urinary catheter care every shift; start date 12/23/25 and discontinued 12/24/25. The EMR Progress Note entry on 12/24/25 disclosed staff observed the resident had removed her catheter with the balloon still inflated. The nurse obtained a physician order to discontinue the catheter use due to placing the resident at risk; the resident's daughter was present at the time and updated. The resident's Care Plan dated 12/30/25 revealed a focus area for indwelling catheter initiated on 12/23/25 and revised on 12/30/25. The interventions for staff included Enhanced Barrier Precautions (EBP) (initiated 12/24/25), monitor/record report signs/symptoms of urinary tract infection (UTI) (initiated 12/23/25), keep per area clean, position catheter bag and tubing below the level of the bladder, provide catheter care daily and as needed, record output every shift all dated 12/30/25. A focus area related to a pressure injury revised 12/30/25 included an intervention for use of EBP related to the wound and catheter. The facility failed to revise the Care Plan to reflect the discontinuation of the indwelling catheter per physician order on 12/24/25 and revise an intervention related to EBP needs on a pressure injury focus area. On 1/22/26 at 1:40 PM when asked about Resident #21's catheter, Staff H stated the resident did have a catheter. When asked about the Significant Change MDS dated [DATE] revealing the resident did not have a catheter and was incontinent of bowel and bladder, the staff responded the resident had a significant change related to hospice services being initiated. When provided with knowledge the catheter was discontinued on 12/24/25, Staff H acknowledged the Care Plan should have been updated to reflect that change in status. The staff stated any nurse could revise the Care Plan to reflect a change in a resident's status. On 1/26/26 at 8:58 AM Staff N stated Care Conferences were held quarterly and IDT members have their own components to complete. The staff stated the MDS Coordinator updates the Care Plan; however there may be sections in the Care Plan that were updated by whoever was assigned and the MDS Coordinator oversees the Care Plan to ensure all sections were completed. On 1/26/26 at 2:39 PM Staff J, Registered Nurse (RN), stated he did not update Care Plans. The staff stated when the residents were admitted as part of the admission process an initial Care Plan was started. The staff stated the MDS Coordinator and Social Services complete the Care Plans. On 1/26/26 at 10:12 AM the DON and the Administrator discussed Care Plans and Care Plan Conferences. The Administrator stated that in normal circumstances he would expect the IDT to be in attendance at the Care Plan Conferences. Neither the Administrator nor the DON could answer to the frequency of Care Plan Conferences. The Administrator stated he was not aware the Care Plan Conferences were not being held with IDT members present. The Administrator acknowledged there was not a corporate liaison for the facility regarding skilled care social services. The DON stated she started to notice the previous week there might be a problem as she thought a Care Plan Conference should be held regarding a resident's change in needs. The DON expected Care Plans to be revised as needed, including the goals and target dates. The DON and Administrator concurred that the Care Plans and Kardex needed to be current regarding the resident's needs to allow for pulled staff and/or contract staff to meet the needs of the residents. 6. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. MDS documented Resident #2 was at risk for developing pressure ulcers/injuries and Moisture Associated Skin Damage (MASD) present. Review of Resident #2's MAR-TAR documented a physician's order with a start date of 1/11/26 and discontinued 1/12/26 to paint right heel deep tissue injury (DTI) daily with betadine and cover with dry dressing. A physician's order with a start date of 1/12/26 and discontinued 1/14/26 for the right heel to be cleansed, dry, painted with betadine and covered with mepilex foam once a day related to DTI. A physician's order with start date of 1/14/26 for wound on the right heel to be cleansed with wound cleanser, pat dry, apply Triple Antibiotic Ointment (TAO) and cover with foam dressing one time a day. A physician's order with a start date of 1/11/26 to evaluate right heel wound / peri-wound for complications including symptoms of infection. A physician's order with a start date of 11/28/25 to cleanse buttocks with soap and water, pat dry, apply Z guard every shift until healed. A physician's order with a start date of 11/28/25 to evaluate buttocks wound / peri wound for complications including symptoms of infection. A physician's order with a start date of 1/15/26 to cleanse sacral stage 2 pressure ulcer with wound cleanser, pat dry, apply a foam dressing and change every 3 days and as needed (PRN). A physician's order with a start date of 1/15/26 to evaluate stage 2 pressure wound/peri-wound for complications including symptoms of infection. Resident #2's MDS dated [DATE] documented treatments for skin injury included pressure reducing device for chair, pressure reducing device for bed, nutrition hydration intervention to manage skin problems. Resident #2's EHR titled, Care Plan documented a focus initiated on 11/28/25 that Resident #2 had potential for pressure injury development. Resident #2's care plan did not have MASD documented or intervention in place. Resident #2's care plan did not have treatments for skin injury including pressure reducing device for chair or bed, nutrition hydration interventions to manage skin problems documented. Resident #2's care plan identified Resident #2 required the assistance of 1 staff for bed mobility and required the assistance of 1 staff for personal hygiene. On 1/12/26 at 11:20 am an observation of Resident #2 lying on a scoop mattress. Review of Resident #2's EHR dated 1/11/26 at 7:53 AM entered by Staff P, RN, ADON, Assistant Director of Health and Wellness, and Wound Nurse titled, Wound Evaluation documented a DTI to the right heel minutes old that was in-house acquired that had an area of 1.25 cm2, length of 2.42 cm, and width of 1.1 cm. Review of Resident #2's EHR dated 1/6/26 at 7:41 PM titled, Skin Check documented no injury to right or left heel. Review of Resident #2's EHR dated 1/11/26 at 9:54 PM titled, Progress Notes documented reported on the am shift Resident #2 had an open area to the right heel. The exam showed suspected DTI. The area was cleansed, painted with betadine and protective dressing applied. Review of Resident #2's EHR dated 11/28/25 at 2:50 PM entered by Staff P titled, Wound Evaluation documented incontinence associated dermatitis that was present on admission on the buttocks that had an area of 1.42 cm2, length of 3.42 cm, and width of 0.61 cm. Review of Resident #2's EHR titled, Care Plan documented a focus initiated on 11/28/25 that Resident #2 had potential for pressure injury development. Resident #2's care plan did not have MASD or DTI on the right heel documented or intervention in place. Resident #2's care plan did not have treatments for skin injury including pressure reducing device for chair or bed, nutrition hydration interventions to manage skin problems documented. Resident #2's care plan identified Resident #2 required the assistance of 1 staff for bed mobility and required the assistance of 1 staff for personal hygiene. On 1/13/26 at 1:59 PM Resident #2, stated with Staff A present in the room, that her left foot heel protecting boot was applied 1/12/26. Resident #2 stated she had not been assisted with repositioning the whole day. Resident #2 stated it was hard for her to turn to the right because she had a left sided stroke. Resident #2 stated the triangle wedges helped her to stay on her side when staff use them. Resident #2 stated it feels good because then she is off her back. On 1/13/26 at 1:59 PM an observation revealed no triangle wedges present in Resident #2's room. On 1/13/26 at 2:00 PM Staff R, CNA stated the facility was supposed to get Resident #2 an air mattress. On 1/21/26 at 1:51 PM Staff J, RN explained frequently on the long term side of the facility the positioning wedges were not utilized appropriately. Staff J acknowledged Resident #2 had a scoop mattress in her bed and that was not appropriate for pressure relief. Staff J stated the scoop mattress prevented Resident #2 from turning in bed. Staff J stated Resident #2 did not have any interventions in place that were being utilized when the MASD was present on her buttocks. Staff J stated the wedges in Resident #2's room were not being utilized. Staff J explained he assessed Resident #2's MASD the area had turned into a stage 2. Staff J stated that was when the pressure relief wedge was being utilized. On 1/26/26 at 11:35 AM Staff H, Licensed Practical Nurse / MDS Coordinator / Infection Preventionist stated she was familiar with Resident #2. Staff H stated she was not aware of any MASD on Resident #2's buttocks. Staff H stated the MASD should have been addressed on the care plan but everybody should be updating the care plan. Staff H stated she would not expect any other interventions in place besides creams for MASD on Resident #2 for pressure ulcer prevention. On 1/26/26 at 3:13 PM the DON explained the scoop mattress that Resident #2 had in her room was not appropriate for pressure relief. 7. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. On 1/12/26 at 10:49 am Resident #3 stated she had not been invited to any care conferences. On 1/13/26 at 4:11 PM Resident #3's son stated he had not been contacted every 3 months to discuss his mothers care at the facility. Resident #3's son stated he had not been invited to a care conference for his mother since she had been at the facility. Review of Resident #3's EHR titled, Progress Notes documented no family invitation or Care Conference meetings held with resident or family. Review of Resident #3's EHR documented admission to the facility on 4/9/25. On 1/26/26 at 9:00 AM Staff N, Interim Social Services Director stated she would enter resident and resident family invites to care conferences in resident's EHR titled, Progress Notes. Staff N stated she could complete the Social Services Comprehensive Quarterly assessment by herself without any IDT but she invites the IDT. Staff N stated there was a base care plan meeting, then one at 30 days and then there was a care conference completed quarterly (every 3 months). Staff N explained things were dropped a little on her part. Staff N acknowledged a lot of the care conferences were not completed. Staff N stated she could not find any care conference meetings for Resident #3. Staff N stated the assessment should include who was present for the meeting. Staff N acknowledged the family and residents had not been a part of the quarterly assessments or the Social Services Comprehensive Quarterly assessment. Staff N stated the family, resident and team members should be identified in the comments sentence. Staff N stated she had discussed concerns with care conferences not being completed appropriately with the previous Administrator and then brought it to the current Administrator. Staff N stated she spoke to the Administrator about the concern when he started. Staff N stated the Administrator would work on getting more resources to help her get caught up to help things move smoothly and would reach out to corporate to ask if there was someone she could talk to about things she was unsure of. Staff N explained the corporation did not have anybody to help but to reach out to somebody that might have that knowledge because they do not have any other skilled facilities. Staff N stated she had reached out to a previous Social Services Director at the facility. Staff N explained during the care conference meeting the IDT should be invited and a part of development. Staff N stated the family and resident should be a part if they can. Staff N explained family and residents should be invited and the care conference meeting should be completed quarterly. On 1/26/26 at 10:08 AM the DON stated she expected nursing to be part of a care conference meeting. The DON explained the MDS Coordinator was a nurse and would represent both the nurse department and MDS. The DON stated care conferences should be completed when there was a significant change or if the resident had reached a plateau. The DON stated social services set the care conferences up. The DON stated residents and or family should be invited to the care conferences. 8. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #9 was at risk for developing pressure ulcers/injuries and one or more unhealed pressure injuries. On 1/20/26 at 11:31 AM Resident #9 stated the area on her buttocks started as a bed sore. Resident #9 explained the area got better then got worse. Resident #9 stated she did not remember if she was wearing heel protectors or not when she was in bed before she had the area on her right heel. Resident #9 stated she did not have the area on her right heel when she entered the facility. Review of Resident #9's MAR-TAR documented a physician's order with a start date of 12/9/25 and discontinued date of 12/30/25 to cleanse right heel DTI with soap and water, pat dry, and apply skin prep twice a day. A physician's order with a start date of 12/30/25 and a discontinued date of 1/16/26 to cleanse right heel DTI with soap and water, pat dry, apply betadine, an ABD dressing and secure with roll gauze every 3 days until healed. A physician's order with a start date of 12/9/25 and discontinued date of 1/7/26 to cleanse left inferior buttocks stage 2 pressure ulcer with wound cleanser, pat dry, apply Z guard every shift until healed. A physician's order with a start date of 12/9/25 and a discontinued date of 12/23/25 to cleanse left superior buttocks stage 2 pressure ulcer with wound cleanser, pat dry, apply Z guard every shift until healed. Review of Resident #9's EHR documented Resident #9 entered the facility on 12/4/25 with no documentation of pressure injury or DTI. Review of Resident #9's EHR dated 12/4/25 at 3:03 PM titled, admission / readmission Screener documented no injury to buttocks, right or left heel. Review of Resident #9's EHR dated 12/4/25 at 3:37 PM titled, Braden Scale for Predicting Pressure Sore Risk documented Resident #9 had a Braden score of 18 that indicated Resident #9 was at risk for development of a pressure sore. Review of Resident #9's EHR dated 12/8/25 at 2:37 PM entered by Staff P titled, Wound Evaluation documented an in-house acquired stage 2 pressure ulcer that was minutes old on the left superior gluteus that had an area of 6.35 cm2, length of 8.73 cm, and width of 1.98 cm. Review of Resident #9's EHR dated 12/9/25 at 10:01 AM entered by Staff P titled, Wound Evaluation documented an in-house acquired stage 2 pressure ulcer that was minutes old on the left inferior gluteus that had an area of 3.65 cm2, length of 2.54 cm, and width of 1.98 cm. Review of Resident #9's EHR dated 12/9/25 at 10:04 AM entered by Staff MM, Licensed Practical Nurse (LPN) titled, Wound Evaluation documented a minutes old in-house acquired DTI on the right heel that had no measurements but was present in the photo of the area. Review of Resident #9 EHR titled, Care Plan documented no focus, goals or interventions on prevention of a pressure sore. Pressure injury stage 2 left buttocks and DTI to right heel documented as initiated on 12/15/25 after pressure injuries had occurred. Review of Resident #9 EHR titled, Care Plan documented no focus, goals or interventions on prevention of a pressure sore. Pressure injury stage 2 left buttocks and DTI to right heel documented as initiated on 12/15/25 after pressure injuries had occurred. 9. The Minimum Data Set (MDS) dated [DATE] documented Resident #29 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #29 had one or more unhealed pressure ulcers. The MDS documented a Stage 2 pressure ulcer present. The MDS documented Resident #29 had an admission date of 11/11/25. Review of Resident #29 MAR-TAR documented a physician's order with a start date of 11/28/25 and end date of 12/16/25 to cleanse the sacral wound with wound cleanser, pat dry and apply Plurogel and foam patch daily until healed. A physician's order with a start date of 12/29/25 for Cephalexin 500mg, give one tablet by mouth every 12 hours for buttocks ulcer infection for 5 days. A physician's order with a start date of 12/16/25 and discontinued date of 1/2/26 to cleanse the sacral wound with wound cleanser, pat dry and apply Santyl and foam patch every other day. Review of Resident #29's document dated 1/12/26 titled, Hospital Progress Notes documented Resident #29 was concerned about returning to the facility because she did not get repositioned. Document explained Resident #29 acknowledged she had never had an ulcer ever before entering the facility in November. Discharge plan for return to facility repositioning every 2 hours and placement of wound vacuum. Review of Resident #29's document dated 1/6/26 at 5:06 PM titled, Operative Report documented Resident #29 had a known sacral decubitus pressure ulcer for the last 2 months, who presented to the hospital with fevers and concern for sepsis from her sacral decubitus wound. She has undergone some minimal debridement of this in the wound care clinic already. Her wound had a foul smell and significant necrotic tissue, warranting urgent debridement in the operating room. Debridement of all of the nonviable completely necrotic tissue which had a foul odor. The base of the wound was down onto the ligamentous structures running along the posterior sacrum and there was exposed bone. A bone biopsy which was sent separately. Area was debrided, removal of the necrotic soft tissue down to the bone centrally, and then to the bilateral gluteal muscles. The total debrided area was 6 cm x 5.5 cm. Review of Resident #29's EHR titled, Care Plan documented a focus for potential for pressure injury development related to assist needed initiated on 11/11/25 with a in house stage 2 pressure ulcer on sacrum initiated 11/28/25. No new interventions in place for in-house acquired a stage 2 pressure ulcer that was found from 11/28/25. The care plan does not reflect any new interventions since returning from the hospital with a surgically debrided stage 4 pressure ulcer that requires a wound vacuum. 10. The MDS dated [DATE] documented Resident #30 had a BIMS of 13 indicating no cognitive impairment. The MDS documented Resident #30 was at risk for development of pressure ulcers. The MDS documented no pressure ulcers. The MDS documented Resident #30 had an admission date of 12/2/25. Review of Resident #30 EHR titled, Care Plan documented no care plan update or intervention with unstageable skin found 12/23/25. On 1/26/26 at 11:35 AM Staff H, MDS Coordinator stated she was familiar with Resident #30. Staff H acknowledged there was no care plan update with unstageable skin found 12/23/25 and would have updated interventions as well. On 1/26/26 2:43 PM Staff J, RN stated he does not update care plans. Staff J stated Staff H, updated care plans. Staff J stated he does not think floor nurses updated the care plans or develop the interventions on the care plans. On 1/27/26 at 11:03 AM the DON stated there should be non-pharmaceutical interventions in place right away with any pressure ulcers like off loading and those interventions should be on the residents care plan. The DON explained Staff H builds the baseline care plan. The DON stated Staff H completed all the care plan updates. The DON stated a charge nurse sh

Based on the facility assessment, Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 4 2025 ([DATE] - [DATE]) review, facility staffing reports review, policy review and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 28 residents.Findings include: The PBJ Staffing Data Report run date [DATE] for quarter 4 2025 triggered for failing to submit data for the quarter and one star staffing rating.Review of weekend staffing schedules for months of July, August, September, October, November, December and January revealed on [DATE] 10:00 PM - 6:00 AM 1 nurse and 1 Certified Nurse Assistant (CNA), [DATE] 6:00 AM - 2:00 PM 2 CNA, [DATE] 6:00 AM - 2:00 PM 2 CNA 2:00 PM - 10:00 PM 2 CNA, [DATE] 2:00 PM - 10:00 PM 1 nurse, [DATE] 6:00 AM - 2:00 PM 1 nurse, [DATE] 6:00 AM - 2:00 PM 1 nurse 2:00 PM - 10:00 PM 1 nurse 10:00 PM - 6:00 AM 1 nurse and 1 CNA, [DATE] 6:00 AM - 2:00 PM 1 nurse, [DATE] 6:00 AM - 2:00 PM 1 nurse and 2 CNA 2:00 PM - 10:00 PM 1 nurse and 3 CNA 10:00 PM - 6:00 AM 1 nurse and 1 CNA.Review of schedules Monday - Friday for months of July, August, September, October, November, December and January revealed on [DATE] 2:00 PM - 10:00 PM 1 nurse and 2 CNA, [DATE] 10:00 pm - 6:00 AM 1 nurse and 1 CNA, [DATE] 2:00 PM - 10:00 PM 1 nurse and 2 CNA, [DATE] 6:00 AM - 2:00 PM 1 nurse and 3 CNA, 2:00 PM - 10:00 PM 1 nurse and 3 CNA, 10:00 PM - 6:00 AM 1 nurse and 1 CNA, [DATE] 6:00 AM - 2:00 PM 1 nurse and 2 CNA 2:00 PM - 10:00 PM 1 nurse and 2 CNA, [DATE] 2:00 PM - 10:00 PM 1 nurse, [DATE] 10:00 pm - 6:00 AM 1 nurse and 1 CNA, [DATE] 2:00 PM - 10:00 PM 1 nurse and 3 CNA, [DATE] 6:00 AM - 2:00 PM 1 nurse and 3 CNA 2:00 PM - 10:00 PM 1 nurse 10:00 PM - 6:00 AM 1 CNA.On [DATE] at 10:50 PM Staff O, Certified Medication Assistant (CMA) / Certified Nurse Assistant (CNA) / Scheduler stated had worked as the scheduler for the facility since September of 2025. Staff O stated when developing a schedule she needs to make sure there is a CNA in every section GP1, GP2 and GP3. Staff O stated nurses on GP1 and GP2. Staff O stated on am shift and pm shifts. Staff O stated overnight shift there is only 1 nurse and 2 CNAs. Staff O acknowledged those assignments have not happened every day since she had taken over. Staff O stated there were days that the facility was a CNA short on the am shift. Staff O explained the facility had been short a nurse on am or pm because of call outs. Staff O stated there had not been a full shift where there had not been enough staff. Staff O explained she had very little training prior to entering into the position. Staff O stated she had asked the Administrator and Staff P, Registered nurse 9RN) / Assistant Director of Nursing (ADON) / Previous Interim Director of Nursing (DON) for any help on how she was doing. Staff O stated she was not aware of any RN coverage requirements for daily hours or 7 days a week. Staff O stated she was not aware of any CPR coverage in the building. Staff O stated she does not develop a schedule to have RN coverage. Staff O stated when she developed a schedule she was unaware any CPR coverage was required. Staff O stated the facility did not have a CPR certification list prior to survey team request. Staff O stated Staff P was the interim DON from September until current DON at the very end of December. Staff O stated Staff P worked Monday - Friday at least 8 hours. Staff O stated Staff P only comes into the facility on the weekends if needed for an IV flush. Staff O explained Staff P never worked 8 consecutive hours on the weekends.On [DATE] at 10:15 AM Staff J, RN stated Staff P usually worked Monday through Friday for 8 hours. Staff J explained Staff P does not work on weekends. Staff J stated he became a RN on [DATE]. Staff J stated the facility did not always have a RN. Staff J explained there would be no RN on Saturdays at times. Staff J stated there were times where there was no RN coverage on Saturday and Sunday. Staff J stated on [DATE] a nurse called in and he was the only nurse in the whole building. Staff J stated the DON did not answer the phone or respond. Staff J stated he called 3 different times and called the ADON once also no answer. Staff J explained Staff O was the on-call and had not been trained to pass medications. Staff J stated the facility was supposed to have 2 nurses or 1 nurse with 1 CMA and 3 CNAs on day shift. Staff J stated the pm shift was supposed to be the same as the am shift for staffing. Staff O stated the overnight shift was supposed to have one nurse and 2 CNAs. On [DATE] at 10:35 AM Staff Q, CNA stated staffing on the am shift was supposed to have 2 nurses and 3 CNAs on day shift. Staff Q stated there had been only 2 CNAs on the floor more than twice since she had been working at the facility. Staff Q explained there had been 1 nurse on the floor several times on days and evenings. On [DATE] at 11:23 AM Staff P acknowledged she had worked 8 hours a day for RN coverage. Staff P stated she works Monday through Friday usually at least 8 hours. Staff P stated she did not feel the schedule was an accurate representation of her shifts or hours worked because she is on every schedule. Staff P explained she felt her name just carried over every day. Staff P acknowledged her days off were not represented appropriately. Staff P stated in the nursing department there would be a minimum 2 nurses and 3 CNA's on am shift and pm shift. Staff P stated if the facility census was below 20 there are 2 CNAs and a bath aide. Staff P stated the pm shift required 2 nurses and 3 CNAs. Staff P stated the overnight shift required 1 nurse and 2 CNAs. Staff P stated she knew there had been a time or 2 where the nurse had not shown up for a while and the staff usually called and someone came into the facility. Staff P stated they have never made one nurse without a medication aide passing their medications that she could remember. Staff P stated she could not remember just one nurse on 2 - 10 shifts ever. Staff P stated she knew in the last 6 months there had been a couple days when the census was less than 20. Staff P acknowledged there were several weekends there was no RN coverage. On [DATE] at 10:45 AM the DON stated a minimum of 2 day nurses or nurse and a medication aide and 3 CNAs. The DON stated the pm shift should have the same staffing as am shift and the overnight shift was staffed with 1 nurse and 2 CNA's. The DON acknowledged the Facility assessment did not accurately reflect the amount of RN required on pm shift.On [DATE] at 8:53 AM the Administrator acknowledged the PBJ was not being submitted correctly by the corporation the facility utilized because the data that was being pulled reflected the wrong employees in the wrong area of the building. The Administrator stated staff in Assisted Living (AL) and memory care were being recorded on the Skilled Nursing Facility (SNF) side and some of the SNF staff were being recorded on the AL and memory care side. The Administrator stated that it was noticed in October. The Administrator stated during that quarter they definitely had nurse coverage and believed there was RN coverage. The Administrator stated they utilized agency for a bit as well. On [DATE] at 12:23 PM the Administrator stated the Facility Assessment for staffing was just an approximate number for staffing. The Administrator stated the Facility Assessment was not a minimum. The Administrator acknowledged the RN on the evening shift was not required but only a possible need. Review of document titled, Facility Assessment documented direct care staff hours per resident day (HPRD) or total hours per discipline on day shift 0.33 for RN, 0.33 for Licensed Practical Nurse (LPN), and 0.67 for CNA. Direct care staff hours per resident day (HPRD) or total hours per discipline on evening shift was 0.33 for RN, 0.33 for LPN, and 0.67 for CNA. Direct care staff hours per resident day (HPRD) or total hours per discipline on night shift was 0 for RN, 0.33 for LPN, and 0.67 for CNA.Review of undated policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal) documented Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Beginning with the fiscal quarter of 2016 (beginning [DATE]), direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees. Providers who are employed by the facility (including physicians) are included in direct-care staffing information; providers who bill Medicare directly are not included. For auditing purposes, reported staffing information is based on payroll records, or other verifiable information. Information may be uploaded to the PBJ system manually, or through a payroll time and attendance system, or a combination of both. The PBJ system is accessed through the QIES. Manual entries are made only by designated personnel with training on the PBJ user interface.

Based on facility assessment, clinical record review, staff interviews, and facility plan review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies in 11 areas over the last year and development of performance improvement plans (PIPs) for monitoring and tracking for effectiveness. The facility reported a census of 28 residents.Findings include:Review of CMS Form 2567 with a date the survey was completed as 11/12/25 documented F-880 infection prevention and control. One repeated deficiencies identified during the current survey.Review of CMS Form 2567 with a date the survey was completed as 6/13/25 documented F-584 safe/clean/comfortable/homelike environment, F-657 care plan revision, F-684 Quality Care, F-686 treatment of pressure ulcer, F-725 sufficient nursing staff and F-842 resident records. Six repeated deficiencies identified during the current survey.Review of CMS Form 2567 with a date the survey was completed as 1/9/25 documented F-550 resident rights/exercise of rights, F-641 accuracy of assessments, F-684 Quality Care, F-812 food procurement, store/prepare/serve-sanitary and F-880 infection prevention and control. Five repeated deficiencies identified during the current survey.Review of a document titled, Provider History Report Standard Health Survey Deficiency Comparison documented F-684 quality of care and F-812 food procurement, store/prepare/serve-sanitary identified as a repeat deficiency on 3 of the last 4 standard health surveys also identified during the current standard survey. F-550 resident rights/exercise of rights, F-689 free of accidents and hazards and F-725 sufficient nursing staff identified as a repeat deficiency on 2 of the last 4 standard health surveys also identified during the current standard survey. F-584 safe/clean/comfortable/homelike environment, F-625 notice of bed hold policy and F-641 accuracy of assessments as concerns identified on one of the last 4 standard health surveys also identified during the current standard survey. Clinical record review completed on 1/29/26 at 12:20 PM revealed no QAPI policy in place with a description of how the facility would identify, report, track, investigate and analyze adverse events or problem-prone concerns, a description as to how the facility obtains and uses any feedback from resident representatives to identify high-risk or problem prone issues, and how the facility monitored the effectiveness of its performance improvement activities to ensure improvements are sustained established. On 1/29/26 at 12:23 PM the Administrator stated the QAPI committee reviewed the deficiencies and had not been very good at developing Performance Improvement Plans (PIPs) around the concerns. The Administrator stated he had reached out to the corporate office for help and they do not have a long term care skilled consultant for assistance. The Administrator stated the facility had been building their own policies as they go. The Administrator acknowledged the facility currently does not have a QAPI policy. The Administrator explained the facility does not have any PIPs developed currently. The Administrator acknowledged he had not developed any PIPs since being employed at the facility. The Administrator stated the QAPI committee did not feel any of the audits were not working but there probably could have been adjustments to be more helpful. The Administrator explained he felt training or performance was causing the repeated concerns. Review of document titled, Facility Assessment evaluation of infection prevention and control program risk assessment documented the facility must conduct a facility based and community based risk assessment. Gaps and issues should be identified and adapted to QAPI programs.

Based on facility assessment, clinical record review and staff interview the facility failed to properly establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan and properly monitor and measure its success and track performance to ensure that improvements are realized and sustained for the QAPI plan. The facility reported a census of 28 residents.Findings include:Clinical record review completed on 1/29/26 at 12:20 PM revealed no QAPI policy in place with a description of how the facility would identify, report, track, investigate and analyze adverse events or problem-prone concerns, a description as to how the facility obtains and uses any feedback from resident representatives to identify high-risk or problem prone issues, and how the facility monitored the effectiveness of its performance improvement activities to ensure improvements are sustained established. Clinical record review also revealed no Performance Improvement Plans (PIPs) developed to track or ensure improvements.On 1/29/26 at 12:23 PM the Administrator stated the facility reviewed the deficient practices from state surveys and had not been very good at developing Performance Improvement Plans (PIP) around the concerns. The Administrator stated he had reached out to the corporate office for help and they do not have a long term care skilled consultant for assistance. The Administrator acknowledged they have been building their own policies as they go. The Administrator stated the facility does not currently have a QAPI policy. The Administrator acknowledged the facility does not have any PIPs currently. The Administrator stated the facility had not developed any PIPs since he had been employed at the facility. Review of document titled, Facility Assessment evaluation of infection prevention and control program risk assessment documented the facility must conduct a facility based and community based risk assessment. Gaps and issues should be identified and adapted to QAPI programs. The Facility Assessment also documented under policies and procedures for provision of care some considerations were to describe how the facility would evaluate what policies and procedures may be required in the provision of care, and how you ensure those meet current professional standards of practice. Include, for example, your process to determine if new or updated policies are needed, and how they are developed or updated. Examples of policies and procedures include pain management, IV therapy, fall prevention, skin and wound care, restorative nursing, specialized respiratory care for tracheostomy or ventilator, storage of medications and biologicals and transportation. Process for updating and rolling out new/updated policies documented policies and procedures are evaluated annually or more often as needed. The Administrator evaluates any potential revisions or changes to the policies and procedures.

Based on document review and staff interview the facility failed to have the minimum members of the quality assessment and assurance committee meet quarterly. The facility reported a census of 28 residents.Findings include: Review of document dated 4/17/25 titled, QAPI Attendance documented no Infection Preventionist (IP) present at the meeting. Review of document dated 7/17/25 titled, QAPI Attendance documented no Medical Director present at the meeting.Review of document dated 8/28/25 titled, QAPI Attendance documented no Medical Director or Infection Preventionist present at the meeting.Review of document dated 10/23/25 titled, QAPI Attendance documented no Director of Nursing (DON) or Assistant Director of Nursing (ADON) present at the meeting.Clinical record review completed on 1/29/26 at 12:20 PM revealed no QAPI policy in place with a description of how the facility would identify, report, track, investigate and analyze adverse events or problem-prone concerns, a description as to how the facility obtains and uses any feedback from resident representatives to identify high-risk or problem prone issues, and how the facility monitored the effectiveness of its performance improvement activities to ensure improvements are sustained established. On 1/29/26 at 12:23 PM the Administrator stated QAPI should meet a minimum of quarterly. The Administrator stated the Medical Director, Pharmacy Consultant, DON, MDS Coordinator, Social Services, Life enrichment, IP, Business Office and Kitchen is invited. The Administrator acknowledged there were 1 or 2 meetings that did not have all the required staff present. Stated he felt that the medical director missed a quarter. The Administrator acknowledged the DON or ADON was not available to make it to the meeting a quarter as well. The Administrator explained the facility did not currently have a QAPI policy.

Based on staff interviews, facility assessment review and facility policy review the facility failed to develop and implement a facility wide system to monitor protocols and the use of antibiotics prescribed to residents. The facility reported a census of 28 residents.Findings include:During an interview on 1/29/26 at 9:51 AM, Staff H, Infection Preventionist (IP) / MDS Coordinator stated she had been in the IP position since June 2025. Staff H explained the facility does not have currently have Antibiotic Stewardship Program. Staff H stated she is familiar with an Antibiotic Stewardship Program and the requirements. Staff H stated a review of antibiotic use for residents prescribed by the physicians was occurring. Staff H stated for the quarterly Quality Assurance and Performance Improvement (QAPI) meetings she does keep track of the residents that were prescribed antibiotics for the quarter, but nothing further. Staff H explained management talked about the results of lab cultures in the morning meetings daily but she does not track antibiotic use, or infection trends. During an interview on 1/29/26 at 10:27 AM, the Director of Nursing (DON) stated she would expect that the corporate office would provide the facility with updated policies for infection control and antibiotic stewardship. The DON explained the policies should be according to the federal regulation. The DON stated she was familiar with Antibiotic Stewardship, and the facility did not currently have tracking for infections, or trends. The DON acknowledged if the facility could not find trends if there was no tracking at the facility. The DON stated the facility should review antibiotics prescribed for residents for effectiveness and need with the physician. Review of the document titled, Facility Assessment, dated July 14, 2025, revealed participants included an Infection Preventionist, The Assessment list of Common Diagnoses/Conditions included Infectious Diseases, with the common diagnoses of Skin and Soft Tissue infections, Respiratory infections, Tuberculosis, Urinary Tract Infections, Infections with Multi-Drug Resistant Organisms, Septicemia, Viral Hepatitis, Clostridium difficile (commonly called c-diff which is bacterial infection often antibiotic-associated diarrhea and colon inflammation), Influenza, Scabies and Legionella's listed. The General Care section of the Assessment listed Infection Prevention and Control which listed specific care or practices, in part as Identification and containment of infections. The Evaluation of Infection Prevention and Control Program section indicated The facility has a qualified Infection Preventionist who leads the facility in providing training on prevention, identification, reporting, investigating, and controlling any infections or communicable diseases throughout the facility. Review of the undated facility policy titled, Infection Prevention and Control Program included a Policy Statement which declared An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Policy Interpretation and Implementation section directed, in part: Elements in of the IPCP4. Antibiotic Stewardshipa. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities.b. Medical criteria and standardized definitions of infections are used to help recognize and manage infections.c. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews.

Based on staff interviews, employee record review, and facility policy review, the facility failed to offer COVID 19 vaccinations and education regarding the benefits of vaccination to facility employees. The facility reported a census of 28 residents.Findings include: During an interview on 1/28/26 at 4:28 PM, Staff J, Registered Nurse (RN) stated he had not been offered a COVID 19 vaccine at the facility this last year. Staff J stated the facility did not inquire if he had received the recent Covid 19 vaccination. During an interview on 1/28/26 at 4:28 PM, Staff L, Certified Nursing Assistant (CNA) stated she had not been offered a COVID 19 vaccine at the facility this last year. Staff L stated the facility did not inquire if she had received the recent Covid 19 vaccination or her vaccination status. During an interview on 1/29/26 at 9:51 AM, Staff H, Infection Preventionist (IP) / MDS Coordinator stated she had been in the IP position since June 2025. Staff H stated the facility had never offered COVID 19 vaccines to the staff at the facility. Staff H stated there was an annual competency fair in which the facility provided mask fitting for COVID 19 but the staff are not educated outside of the competency fair about COVID 19. Staff H stated the fair occurred in February or April of 2025. Staff H stated the facility did not have a policy for employee's Covid 19 vaccine administration, documentation or education. Staff H acknowledged there were no documents to review for staff Covid vaccine administration, screening, education or current COVID-19 vaccination status.Review of facility employee files completed on 1/29/26 revealed no record of offering education or vaccinations to employees. During an interview on 1/29/26 at 10:27 AM, the Director of Nursing (DON) stated she did not know if staff screening, education, vaccine offered, and current COVID 19 vaccination status is required. The DON explained she would expect that the corporate office would provide the facility with an updated policy for employee vaccinations. Review of an undated facility policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures revealed a Policy Statement which declared This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility.The Policy Interpretation and Implementation section directed, in part:a. The infection prevention and control measures that are implemented to address SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include:Encouraging staff, residents and visitors to remain up to date with all COVID -19 vaccine doses;Providing resources and counseling about the importance of receiving the COVID-19 vaccine

Based on Resident Council Meeting, observations, clinical record review, resident interviews, staff interviews and policy review the facility failed to provide dignity and respect. Staff refused to wear gloves, a staff was reported to have gone through a resident's personal belongings, pushing a resident partially exposed in a wheelchair (w/c), residents reporting being spoken to rudely, residents stating care was denied or length of time to provide care, and fear of retaliation from staff to 6 of 12 residents reviewed (Resident #7, #17, #33, #16, #15 and #29 ). The facility reported a census of 28 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive deficit. The document provided the resident utilized a manual w/c and required partial/moderate assistance. The document disclosed the resident had diagnoses of chronic kidney disease, nonrheumatic aortic valve stenosis, and unspecified arthritis. The resident's Care Plan dated 1/7/25 revealed a focus area related to Activities of Daily Living (ADLs) dated 4/23/24 with staff interventions of manual w/c mobility with assistance of 1, dressing tasks with maximal assistance of 1 and bathing requires assistance of 1 staff (revised 4/23/24). On 1/21/26 at 7:10 AM observed Staff I, Certified Nursing Assistant (CNA), push Resident #7 partially exposed down 2 hallways from the resident's bedroom until stopped at Staff H's (Licensed Practical Nurse (LPN)/MDS Coordinator/Infection Preventionist) office. Staff H directed Staff I that she had past the shower room and needed to go back the other direction. Staff A, Registered Nurse (RN), was also present at Staff H's office. Staff A followed Resident #7 and Staff I down the hallways to the shower room. The total distance the resident traveled through the facility was 240' or ¾ the length of a football field. On 1/21/26 at 7:48 AM Staff H stated residents must be covered when being transported to the shower room. On 1/22/26 at 12:27 PM Staff Staff D, Certified Medication Aide (CMA), stated residents must be fully covered when being pushed in a w/c. On 1/26/26 at 2:39 PM Staff J, Registered Nurse (RN), expected that residents would be covered when being transported to the shower room whether in a w/c or shower chair. On 1/27/26 at 11:01 AM the Director of Nursing (DON) stated she expected residents to be fully covered when being transported to the shower room. The DON stated if a resident was wearing a hospital gown, the resident needed to be cocooned in 2 blankets, 1 for the front and 1 for the back to ensure complete coverage. On 1/28/26 at 11:14 PM when asked about a resident being partially exposed going to the shower room, the Administrator stated he expected residents to be covered with blankets. 2. Resident #17's MDS dated [DATE] revealed a BIMS score of 12/15 indicating moderate cognitive deficit (intact cognition 13-15). The self care area of eating revealed the resident was independent. The document disclosed the resident's diagnoses of atrial fibrillation (A-fib), heart failure, Non-Alzheimer's Dementia and Chronic Obstructive Pulmonary Disease (COPD). The MDS did not reveal any behaviors exhibited by Resident #17. The resident's Care Plan dated 1/20/26 revealed a focus area for assistance with ADL's dated 1/5/26 with an intervention of independence with eating. Focus areas related to antipsychotic medication and antidepressant medications revised 1/6/25 contained staff interventions of monitoring for anxiety/nervousness, irritability with over stimulation and crying/sadness. The Care Plan did not contain behaviors related to making false statements or refusing care. On 1/20/26 at 10:33 AM Resident #17 stated when she has voiced concerns about her care regarding her oxygen or needing assistance with her care, staff have responded with calm down, we are going to get you, you are a smart ass. The resident stated these responses by unidentified staff make her feel horrible and that she was voicing concerns, not trying to be hard to get along with. The resident further revealed that when asking her cold food to be reheated was told to be grateful she got food and that the food was not reheated. On 1/22/26 at 12:27 PM Staff D stated Resident #17 had not voiced concerns to her regarding any specific staff or concerns with her care. The staff stated residents should not be called names. On 1/26/26 at 2:39 PM Staff J stated residents should not be called names and assistance should be given when requested. On 1/27/26 at 11:01 AM the DON stated residents' needs should be addressed when requested and staff should not be calling residents names. On 1/28/26 at 11:14 AM the Administrator stated calling residents names was not acceptable. 3. Resident #33's Export Ready MDS dated [DATE] revealed a BIMS score of 14/15 indicating normal cognition. The document provided the resident required partial/moderate assistance for rolling, sitting to/from lying positions, transfers, toilet hygiene and dressing. The document provided the resident had continence of urine and frequent incontinence of bowel. The document disclosed resident diagnoses including heart failure, renal insufficiency, benign prostatic hyperplasia (BPH), diabetes mellitus, Parkinson's, and complete traumatic amputation of unspecified great toe. The Resident's Care Plan dated 1/24/26 revealed an assistance with ADL's focus area dated 1/17/26 with staff interventions of toileting assistance of 1 with a gait belt, transfer with walker and w/c mobility with assistance of 1. On 1/26/26 at 12:24 PM the resident's family reported that overnight staff had been extremely rude to the resident. The family stated examples included staff stating they couldn't help the resident and shutting his door despite the resident request for his door to remain open. The family further reported when assisting the resident with toileting the resident had urinated on clothing with the staff wiping the resident's pants and putting him back in bed without changing the garment. The family stated the tone and attitude of staff towards the resident was demeaning and undignified. On 1/27/26 at 10:25 AM during the Resident Council meeting the residents stated they were unaware of having rights, did not know if Resident Rights were posted in the facility, and did not know who to talk to about their rights. On 1/27/26 at 11:01 the DON stated the resident's needs should be addressed when requested. 4. According to the quarterly MDS assessment tool with a reference date of 1/2/2026 documented Resident #16 had a BIMS score of 11. A BIMS score of 11 suggested mild cognitive impairment. The MDS documented Resident #16 was independent with meals. The following diagnosis were listed for the resident: dementia. On 1/20/2026 at 11:52 AM revealed a sign outside of the dining room with the following meal times:a. Breakfast 7:30 AM-9:00 AMb. Lunch 12:00 PM-12:30 PMc. Supper 5:30 PM-6:00 PM On 1/21/2026 at 11:31 AM Resident #16 sat in the dining room at a table, by herself; no residents or staff present. Resident #16 hollered help, where is my food. At 12:29 PM a food cart was brought in to the dining room. On 1/22/2026 at 11:28 AM Resident #16 sat in the dining room at a table, alone in the room. Resident #16 yelled help, help me. On 1/27/2026 at 11:25 AM Resident #16 sat in the dining at the table, alone with a drink in front of her. On 1/28/2026 at 11:29 AM Resident #16 sat in the dining at the table, alone with a boost drink and clear cup in front of her. On 1/27/2026 at 11:02 AM the Director of Nursing (DON) stated she was not sure why Resident #16 would be in the dining room alone that early before the meal is served. Would hope the resident would have asked to go to the dining room, at least she would assume that is the case. She acknowledged lunch is to start between 12:00 PM and 12:30 PM. The facility provided a document titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 5. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of Resident #15's Medication Administration Records - Treatment Administration Records documented an order with start date of 1/19/26 for Enhanced Barrier Precaution related to wounds with gown and gloves required for high contact resident care activities. On 1/20/26 at 11:49 AM Resident #15 stated on 1/12/26 she sat in soiled urine and feces from 3:00 AM - 6:00 AM. Resident #15 explained she was told she could not get out of bed on her own. Resident #15 stated she had turned her call light on several times during that night. Resident #15 stated the staff do not take her to the bathroom on the overnight shift. Resident #15 stated she had talked to everyone about the concern, especially Staff P Registered Nurse (RN) / Assistant Director of Nursing (ADON). Resident #15 stated Staff EE, Certified Nurse Assistant (CNA) was working with Staff Y, CNA and Staff Y refused to wear gloves to clean her up after she used the toilet . Resident #15 stated that Staff Y was going through her bag of personal belongings. Resident #15 stated she told Staff J about the incident. On 1/21/26 at 7:43 AM Staff J, RN stated Resident #15 had voiced concerns to him. Staff J stated Resident #15 briefly mentioned staff going through her personal belongings. Staff J stated she knows there are certain people Resident #15 was hesitant to allow going into her room. Staff J stated those people are the girls on the overnight staff. Staff J stated Resident #15 had not mentioned that the overnight staff would not take her to the bathroom. Staff J stated he did not write a grievance for Resident #15 because they found the pants. Staff J stated he talked to Resident #15 about discussing with the overnight nurse about staff going through her stuff. Staff J stated staff going through Resident #15's stuff had been brought up to management. On 1/21/26 at 7:52 AM Staff R, CNA stated Resident #15 had voiced concerns to her about Staff Y, CNA rummaging through her stuff about a week ago on overnights. Staff R stated Resident #15 told her the reason she had laid in the bed with feces that morning was because Staff EE, CNA came into her room and was talking about recipes and Staff Y, CNA was going through her stuff. Staff R stated she told that to the Staff EE, CNA that was working overnights. Staff R stated she told Staff EE that she needed to stop bringing Staff Y, CNA in Resident #15's room because she was going through Resident #15 stuff. Staff R stated she told Staff J and Staff GG, LPN about the incident. Staff R stated Resident #15 told Staff Y that she needed to wear gloves when she was providing the cares and Staff Y told her she told her no and then Resident #15 refused the care. Staff R stated she did not inform any of the management of the incident. On 1/21/26 at 7:26 AM Staff P stated Resident #15 did not report any missing items but did say something was missing from her shoe. Staff P stated Resident #15 had never reported any staff going through her personal belongings. On 1/26/26 at 10:08 AM the DON stated she thought that the resident filled out the grievance with the Social Services Director. The DON stated the Social Services Director had spoken to Resident #15 and she did not want to fill out a grievance. The DON stated if a resident voiced concerns the staff should still fill out a grievance for that resident. On 1/27/26 at 11:03 AM the DON stated she expected grievances would be completed when residents reported any concerns and that was not being completed appropriately at the facility. She also stated she would have expected gown and gloves to be worn with Resident #15 when completing personal care because she is on EBP even if you are assisting with care. 6. The MDS dated [DATE] documented Resident #29 had a BIMS of 15 indicating no cognitive impairment. The MDS indicated Resident #29 required partial/moderate assistance for toileting hygiene. On 1/15/26 at 1:30 PM Resident #29 stated she had to set an alarm on her phone to ensure the staff come to turn her every 2 hours or the overnight staff will not reposition her. Resident #29 stated her doctor wants her repositioned every 2 hours. Resident #29 stated prior to going to the hospital the staff were not repositioning her every 2 hours some nights overnight staff would only come in at 3:00 AM or 4:00 AM to reposition her in bed. Resident #29 stated she had Multiple Sclerosis and was not able to reposition herself in bed. Resident #29 stated she required the assistance of staff for repositioning. Resident #29 stated she had reported not being repositioned by the overnight staff several times to staff. On 1/22/26 at 11:29 AM Resident #29 stated Staff EE, Certified Nurse Assistant (CNA) refused to change her brief last night. Resident #29 stated she was out of briefs and Staff EE refused to change her last night. Resident #29 stated she had not had a bowel movement but was incontinent of urine and nobody changed her at all last night. Resident #29 stated the Staff EE only repositioned her at night but never changed her. Resident #29 stated she has had problems with Staff EE from the get go. Resident #29 stated Staff EE was not supposed to be caring for her because she had voiced concerns about how she cared for her in the past. Resident #29 stated Staff EE treated her undignified. Resident #29 stated she did not feel like Staff EE had provided her with the appropriate dignity or respect when requesting to be cleaned up and change her brief. Resident #29 stated she had told Staff R, CNA the concerns she had with Staff EE. Resident #29 said she thought Staff EE told Staff P, Assistant Director of Nursing (ADON) about the concerns with Staff EE. On 1/26/26 at 1:00 PM Resident #29 stated Staff EE entered her room the night before and had spoken under her breath about that resident turning her into the state surveyors about not changing her on overnight shift. Resident #29 stated she was not afraid of the staff and felt there were plenty of rules that would keep her safe. Resident #29 stated she felt safe at the facility currently. Resident #29 stated Staff EE was not supposed to provide her care anyways so she was not afraid of care not being provided. Resident #29 stated she did feel like there was a lack of dignity with Staff EE coming into the room to confront her about what she had supposedly said to the state survey team. On 1/26/26 at 12:24 PM Resident #33's daughter stated there was a resident at the facility who did not want to speak up. Resident #33's daughter stated the resident next door Resident #29 was confronted by Staff EE as to what the resident had shared with the survey team. Resident #33's daughter stated she did not know how Staff EE found out about Resident #29 talking to the survey team but Staff EE approached the resident about it. Resident #33's daughter stated she had talked to the DON about all the concerns. On 1/12/26 at 12:49 PM Staff P, Assistant Director of Health and Wellness / Assistant Director of Nursing (ADON) / Registered Nurse (RN) stated there had not been any staff or residents that had reported staff were rough with resident care or short with residents. Staff P stated there had been staff that had been asked not to go in certain resident rooms. Staff P stated Resident #29 did not want Staff EE or Staff RR in her room because they were talking about their own lives and another resident down the hall while in her room. Staff PP stated Resident #29 thought it was disrespectful for them to talk about other residents in her room. On 1/12/26 at 1:09 PM the Director of Nursing (DON) stated there are several staff that really need to be let go. The DON stated because of the lack of DON presence prior to her starting in the position at the building there was not enough of a documentation trail to let the staff go. The DON stated 95% of the complaints are staff to staff complaints. The DON stated she was not aware of any staff that could not go into any resident's room. On 1/13/26 at 2:00 PM Staff R stated she talked to Staff A, Registered Nurse (RN) about Resident #29 not being repositioned appropriately last night. Staff R stated she spoke to Staff A about it that morning. Staff R stated Resident #29 reported she had not been repositioned or had her brief changed with incontinence the way she should have last night. On 1/13/26 at 2:50 PM Staff A acknowledged that Staff R had told her Resident #29 had not been repositioned on the overnight shift. Staff A stated Resident #29 had been noted to be soaked through the pad, the sheet to the bed when Staff R entered the room. Staff A stated the overnight nurse reported to her that he repositioned Resident #29 every 2 hours. Staff A stated there was a dark ring around Resident #29's bed pad that appeared to be indicative of not checking or changing but did know Resident #29 had been repositioned. Staff A stated she assisted Staff R with repositioning Resident #29 that morning. On 1/22/26 at 2:06 PM Staff R stated when she came in at 6:00 AM on 1/22/26 and Resident #29 stated she had asked to be changed because she had some urine incontinence on the overnight shift. Staff R stated Resident #29 explained Staff EE said there was no brief to change her with. Staff R stated Resident #29 told her that she told Staff EE that she was a 3XL brief. Staff R reported Resident #29 said Staff EE told her that she would not get her another brief, reapplied the brief in the front, walked out of the room and did not return the rest of the night. Staff R said Resident #29 told her Staff EE refused to change her. Staff R reported Resident #29's brief was saturated when she provided care that morning. Staff R stated she reported the concern to Staff J. On 1/22/26 at 2:10 PM Staff J, RN stated Staff R had informed him Resident #29 reported she had not been changed on the overnight shift. Staff J reported Staff R stated Resident #29 stated she had asked to be changed because she had incontinence. Staff J stated Resident #29 stated Staff EE said there was no brief to change her with. Staff J stated Resident #29 told Staff EE that she was a 3xl brief. Staff J stated Resident #29 said Staff EE told her that she would not get her another brief, reapplied the brief in the front, walked out of the room and did not return the rest of the night. Staff J said Resident #29 told her Staff EE refused to change her brief. On 1/22/26 at 12:58 PM Staff EE, CNA stated she did provide care for Resident #15. Staff EE stated Resident #15 had not voiced any concerns with her about other staff at the facility. Stated Resident #15 will say things that are not true. Staff EE stated she usually works with Staff Y and she would go into the resident room with her. Staff EE stated she had not worked with a staff that refused to wear gloves with Resident #15. Staff EE stated Resident #15 was making a fuss about a coworker who went into the room and was helping her out. Staff EE stated they usually work in pairs on the overnight shift. Staff EE stated the co-worker was Staff Y. Staff EE stated Resident #15 told Staff Y to wear gloves. Staff EE stated Staff Y was getting an ice pitcher not providing care. Staff EE stated the overnight staff do the rounds at night at 10:00 PM, 12:00 AM, 2:00 AM, 4:00 AM and 6:00 AM. Staff EE stated Staff Y asked Resident #15 why she wanted her to wear gloves. Staff EE stated Staff Y told Resident #15 I'm just holding your cup. Staff EE stated Resident #15 then said okay. Staff EE stated Staff Y did not apply gloves at that time. Staff EE stated after that everything was already done. Staff EE stated Resident #15 had not mentioned any concerns about staff going through her stuff. Staff EE stated she could not remember what staff had said staff were stealing her stuff. Staff EE stated maybe she or another overnight girl had stolen some stuff. Staff EE stated the conversation occurred a couple of days ago. Staff EE stated she had never stolen anything from Resident #15. Staff EE stated she had never gone through Resident #15's personal items. Staff EE stated Staff Y had not gone through her stuff or stolen anything. Staff EE stated Staff R does not want her to be on the skilled side of the building. Staff EE, CNA stated she has very little interaction with Resident #29. Staff EE stated if she was not supposed to have contact with Resident #29 but the facility kept putting her on that side. Staff EE stated she does work with Resident #29 and had worked with her last night. Staff EE stated she did have contact with Resident #29 last night. Staff EE acknowledged Resident #29 was on a 2 hour reposition schedule. Staff EE stated she repositioned her. Staff EE explained she did not toilet Resident #29 at night. Staff EE explained Resident #29 would turn on her call light at night asking for a brief change. Staff EE stated Resident #29 turned her call light on last night to be repositioned. Staff EE stated she took Staff Y when she was there but she left early but did not know what time. Staff EE stated she provided peri care to freshen her up down there but did not have to change her brief. Staff EE stated Resident #29 had not requested for her brief to be changed at any time overnight the night before. Staff EE stated Resident #29 had thought that she had a BM and wiped her up to show her that she had not had a BM. Staff EE stated she had Staff Y in the room with her at that time. Staff EE stated Resident #29 told her that she was a 3XL in brief size. Staff EE stated she did not change her brief because it was changed prior to her going in the room. Staff EE stated Resident #29 never asked her to change the brief. Staff EE stated if she was doing peri care and the brief is dirty she changed the brief but she told her that she had not had a BM then she said she would just wear the same brief. On 1/23/26 at 2:00 PM Staff Y, CNA stated she typically worked overnights. Staff Y stated she only assisted on that skilled side. Staff Y stated she assisted by lifting a gown up when Staff EE completed peri care on Resident #15. Staff Y stated there are false accusations flying around the facility. Staff Y stated Staff EE was banned from the room and she went into the room to help Resident #29 because if there are 2 sets of eyes then the truth will come out. Staff Y stated she is in fear of reporting what she is supposed to report and they had not had a DON in a long time. Staff Y stated she did not need to wear gloves while holding a gown up while another staff completed peri care on Resident #15. Staff Y stated she had assisted Staff EE with care on Resident #29. Staff Y stated she assisted Staff EE with repositioning Resident #29. Staff Y stated Resident #29 stated she had a bowel movement. Staff Y stated Staff EE checked Resident #29's brief, it was dry and there was no bowel movement. Staff Y stated Resident #29 does not always void at night. Staff Y stated Resident #29 was cognitive of when she needs to use the bathroom. Staff Y stated Resident #29 did not have incontinence. Staff Y stated she did not notify the nurse because Resident #29 had not urinated that shift. Staff Y stated Resident #29 told the staff that she did not need her briefs changed if it was not soiled. Staff Y stated she did not go back in Resident #29's room after that time. Staff Y stated typically during personal care she would change the brief but she let Resident #29 exercise her rights and her wishes. Staff Y stated Resident #29 was not soiled, the 2 of them just freshened her up. Staff Y stated Resident #29 was dishonest and a troublemaker. Staff Y stated she did not know if there were briefs because she was only the second person. Staff Y stated Resident #29 had never said anything about her brief size. Staff Y stated Staff EE did not have a conversation about not having any briefs available. Staff Y stated she minds her own business. Staff Y acknowledged she had worked with Resident #15 but only went into Resident #15's room one time to help Staff EE. Staff Y stated the night before she had exchanged words with Staff R. Staff Y stated Staff R accused her of stealing for Resident #15. On 1/26/26 at 3:26 PM the DON stated Resident #33 family had overheard Staff EE in Resident #29's room and lectured the resident as to why she had talked about her to state. The DON stated she told Staff EE on Thursday or Friday that she was not supposed to be working on that side. The DON explained any staff who are not supposed to be caring for a resident should not be caring for that resident. The DON stated she had not spoken with Resident #29 about the concern that was reported to her. Stated she still needed to talk to Resident #29 but felt Resident #29 probably felt intimidated and scared. The DON stated Resident #15 and Resident #29 do not want Staff EE in their rooms. On 1/27/26 at 11:03 AM the DON stated she would expect all the residents be treated with dignity and respect. The DON stated she would not expect staff to approach Resident #29 about any concerns reported to management or the state survey team. Review of undated policy titled, Resident Rights documented Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include a dignified existence; be treated with respect, kindness, and dignity; be free from abuse, neglect, misappropriation of property, and exploitation; self-determination; be informed about their rights and responsibilities; privacy and confidentiality; voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal and have the facility respond to their grievances.

Based on resident interviews, staff interviews, facility document review and policy review the facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that is understandable to them. The facility had a census of 28.Findings include:On 1/27/26 at 10:25 AM during the Resident Council meeting, the residents present indicated they were unaware of having rights, knowing what the Resident Rights were or if they were posted within the facility for their knowledge.Review of Resident Council Minutes for 11/25, 12/25 and 1/26 revealed a variety of facility leadership in attendance at the meetings with no education provided to the residents on Resident Rights. During the Resident Council meeting on 1/27/26 Staff K, Life Enrichment Director, stated she normally assisted with leading the Resident Council, but if she was not available an Activity Coordinator filled her position. Staff K acknowledged the staff had not been reviewing/educating residents on Resident Rights during Resident Council meetings. The Director of Nursing, DON, during the Resident Council meeting on 1/27/26 stated the residents were provided the Resident Rights as part of their admission packets, but concurred the Resident Rights needed to be reviewed with the residents on an ongoing basis. Neither Staff K nor the DON could confirm the Resident Rights were posted and readily available for the residents. The facility's Resident Rights Policy, undated, revealed the residents had the right to be supported by the facility in exercising their rights, be informed about their rights and the resident rights were to be posted throughout the facility.

Based on observations, resident interviews, staff interviews, and facility document reviews the facility failed to provide residents and/or their representatives accessible reports related to surveys, certifications and complaint investigations for the facility during the 3 preceding years and any plan of correction with respect to the facility. The facility had a census of 28. Findings include: On 1/21/26 at 9:20 AM the Survey Binder did not have 3 years of surveys/complaints. On 1/22/26 at 8:00 AM the Survey Binder did not have 3 years of surveys/complaints. On 1/27/26 at 10:25 AM during the Resident Council meeting the residents present did not know about having recent State Inspection documents and plans of correction available for their review. The residents did not know where those documents would be kept for their knowledge. Staff K, Life Enrichment Director, present during the Resident Council meeting on 1/27/26 could not provide additional information regarding the availability of the State Inspections for residents and/or their representatives. On 1/27/26 during the Resident Council meeting the Director of Nursing (DON) could not provide additional information regarding the State Inspections for residents. Observation on 1/21/2026 at 11:47 AM revealed the survey results book on a table to the right of the Long-Term Care (LTC) entrance. The survey results book only contained one Centers of Medicare and Medicaid Services (CMS) form 2567 with a survey end date of 6/13/2025. Review of the Iowa Department of Inspections, Appeals, and Licensing website revealed the following surveys were completed at the facility: a) Survey end date of 1/26/2023 for an incident investigation with one deficiency cited,b) Survey end date of 1/10/2024 for their recertification and complaint/incident investigations with three deficiencies cited,c) Survey end date of 1/9/2025 for their recertification and complaint investigation with eight deficiencies cited,d) Survey end date of 6/13/2025 for an incident investigation with 11 deficiencies cited,e) Survey end date of 11/12/2025 for complaint investigation with three deficiencies cited. On 1/27/2026 at 11:02 AM the Director of Nursing (DON) indicated she did not know who was in charge keeping the survey results book up to date. She was unsure if the Administrator would do this, she did not know. The facility was unable to produce a policy related to having survey results readily available.

Based on clinical record review, resident interview, staff interviews, family interview, provider interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) and physician for change in condition when a resident had a head injury and residents had a new or worsening wound for 4 of 4 residents (Residents #2, #15, #29, #30 and #23) reviewed. The facility reported a census of 28 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #2 was at risk for developing pressure ulcers/injuries and Moisture Associated Skin Damage (MASD) present. The MDS documented admission date for Resident #2 of 11/28/25 Review of Resident #2's (Electronic Health Record) EHR dated 11/28/25 titled, Discharge Summary documented a Braden scale score of 17 with a reposition schedule at least every 2 hours. The Discharge Summary documented a wound undiagnosed gluteal cleft mid right. Review of Resident #2's EHR documented on 11/28/25 a rash on buttocks upon entry. Review of Resident #2's Treatment Administration Record (TAR) documented a physician's order with a start date of 1/11/26 and discontinued 1/12/26 to paint right heel deep tissue injury (DTI) daily with betadine and cover with dry dressing. A physician's order with a start date of 1/12/26 and discontinued 1/14/26 for the right heel to be cleansed, dry, painted with betadine and covered with mepilex foam once a day related to DTI. A physician's order with start date of 1/14/26 for wound on the right heel to be cleansed with wound cleanser, pat dry, apply Triple Antibiotic Ointment (TAO) and cover with foam dressing one time a day. A physician's order with a start date of 1/11/26 to evaluate right heel wound / peri-wound for complications including symptoms of infection. A physician's order with a start date of 11/28/25 to cleanse buttocks with soap and water, pat dry, apply Z guard every shift until healed. A physician's order with a start date of 11/28/25 to evaluate buttocks wound / peri wound for complications including symptoms of infection. A physician's order with a start date of 1/15/26 to cleanse sacral stage 2 pressure ulcer with wound cleanser, pat dry, apply a foam dressing and change every 3 days and as needed (PRN). A physician's order with a start date of 1/15/26 to evaluate stage 2 pressure wound/peri-wound for complications including symptoms of infection. Review of Resident #2's EHR dated 1/6/26 at 7:41 PM titled, Skin Check documented no injury to right or left heel. Review of Resident #2's EHR dated 1/11/26 at 7:53 AM entered by Staff P, RN, ADON, Assistant Director of Health and Wellness, and Wound Nurse titled, Wound Evaluation documented a DTI to the right heel minutes old that was in-house acquired that had an area of 1.25 cm2, length of 2.42 cm, and width of 1.1 cm. Review of Resident #2's EHR dated 1/11/26 at 9:54 PM titled, Progress Notes documented reported on the am shift Resident #2 had an open area to the right heel. The exam showed suspected DTI. The area was cleansed, painted with betadine and protective dressing applied. Review of Resident #2's EHR titled Wound Evaluation documented the following: On 11/28/25 at 2:50 PM entered by Staff P titled, Wound Evaluation documented incontinence associated dermatitis that was present on admission on the buttocks that had an area of 1.42 cm2, length of 3.42 cm, and width of 0.61 cm. On 12/5/25 at 8:03 PM entered by Staff P titled, Wound Evaluation documented incontinence associated dermatitis that was present on admission on the buttocks that had an area of 19.8 cm2, length of 8.86 cm, and width of 5.66 cm. On 12/12/25 at 8:29 AM entered by Staff P titled, Wound Evaluation documented incontinence associated dermatitis on the buttocks that was present on admission that did not have any measurements with the assessment. On 12/23/25 at 10:14 AM entered by Staff P titled, Wound Evaluation documented incontinence associated dermatitis on the buttocks that was present on admission that had an area of 1.4 cm2, length of 2.57 cm, and width of 1.29 cm. On 12/30/25 at 6:48 AM entered by Staff J, RN titled, Wound Evaluation documented incontinence associated dermatitis on the buttocks that was present on admission that had an area of <0.1 cm2, length of 0.25 cm, and width of 0.21 cm. On 1/6/26 at 7:21 PM entered by Staff P titled, Wound Evaluation documented incontinence associated dermatitis on the buttocks that was present on admission that had an area of 15.65 cm2, length of 7.01 cm, and width of 3.06 cm. Observation of the photo on EHR dated 1/6/26 at 7:21 PM entered by Staff P titled, Wound Evaluation revealed 2 areas of stage 2 present on sacrum / coccyx area at that time that were undocumented. Review of Resident #2's EHR dated 1/15/26 at 10:18 AM entered by Staff J titled, Wound Evaluation documented Stage 2 pressure ulcer on the sacrum that was in-house acquired that had an area of 1.67 cm2, length of 1.81 cm, and width of 1.19 cm. Review of Resident #2's MDS dated [DATE] documented treatments for skin injury included pressure reducing device for chair, pressure reducing device for bed, nutrition hydration intervention to manage skin problems. Review of Resident #2's EHR titled, Progress Notes documented on 1/15/26 Resident #2 was seen for right heel and buttocks at the facility by physician new orders for wound care. Resident #2's Progress Notes documented on 1/11/26 the physician was notified of the area on Resident #2's right heel. Resident #2's Progress Notes did not document physician notification of worsening wound on sacrum on 1/6/26. On 1/12/26 at 11:21 AM Resident #2 stated the area on her right heel started on 1/8/26. Resident #2 explained there was not a heel protecting boot available until 1/11/26. Resident #2 stated she spoke to Staff R, Certified Nurse Assistant (CNA) on 1/8/26 and Staff R told the nurse that was working. Resident #2 stated it was reported on the overnight shift. Resident #2 stated the area was now open and when she reported it was not open. Resident #2 stated there was a treatment started 1/11/26 to paint the area with betadine and apply a dressing. On 1/13/26 at 2:00 PM Staff R, CNA stated the area on Resident #2's heel was because she was not getting up out of the bed. Staff R stated she reported the heel weeks ago to several nurses. Staff R explained Resident #2 did have an open area on her buttocks. Staff R stated she had notified the nurses about the open area. Staff R stated Resident #2 wants to lay in bed all day. On 1/13/26 at 2:37 PM Resident #2 stated her right heel was very red on 1/8/26 and worsened 1/10/26. Resident #2 explained that the nurse said she was going to paint the area and got her the heel protecting boot. On 1/26/26 at 3:13 PM the DON stated while reviewing Resident #2's Wound Evaluation documents that the sacral wound was a stage 1 on 12/23/25 and was a stage 2 on 1/6/26. The DON explained MASD assessment should have been closed and Stage 1 Pressure ulcer assessment should have been opened on 12/23/25. The DON stated the stage 2 was taken on 1/14/26 and added to the MASD photo. The DON stated Staff P, ADON educated the nurse to open the wound assessment as a stage 2. The DON acknowledged the facility received new orders for Resident #2's sacral wound on 1/15/26. The DON explained the physician should have been notified of the stage 1 pressure ulcer on the 1/23/26. The DON explained she felt the deterioration of the wound would have been preventable with change in treatment or appropriate identification of the wound change and deterioration. The DON explained all the facility had for a treatment on Resident #2's buttocks was a cream that was not working because the area became a stage 2. The DON explained Resident #2's heel wound would not have been evaluated till 1/18/26 but if the wound was open or there was a change in condition she would have expected physician notification. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/20/26 at 11:49 AM Resident #15 stated she told Staff P RN / Assistant Director of Nursing (ADON) about the sore on her foot and she did nothing about it. Resident #15 stated Staff J, RN was the nurse that finally did something about it. Review of Resident #15's TAR documented a physician's order with a start date of 1/15/26 to cleanse 2nd toe on left foot with wound cleanser, pat dry, apply Triple Antibiotic Ointment (TAO) and cover with band aid daily. Review of Resident #15's EHR dated 1/5/26 titled, Progress Note admission readmission Progress Note documented at 2:48 PM Resident #15 had an admission date of 1/5/26. The Progress Note documented reason for admission weakness post hospitalization for acute and chronic renal failure. The Progress Note documented no impaired skin integrity, no bruise, burn, deep tissue injury, diabetic ulcer, incontinence associated dermatitis, moisture associated skin damage, open areas, wound, rash, redness, skin tear or surgical incisions. Review of Resident #15's EHR dated 1/15/26 at 10:05 AM entered by Staff J, RN titled, Wound Evaluation documented a diabetic ulcer on left foot second digit that was present on admission that had an area of 0.33 cm2, length of 0.98 cm, and width of 0.5 cm. The wound note described area red with slough and Physician notified. Review of Resident #15's EHR dated 1/16/26 at 4:57 PM entered by Staff J, RN titled, Wound Evaluation documented a diabetic ulcer on left foot second digit that was present on admission that had an area of 0.33 cm2, length of 0.98 cm, and width of 0.5 cm. Review of Resident #15's EHR dated 1/23/26 at 5:27 PM entered by Staff J, RN titled, Wound Evaluation documented a diabetic ulcer on left foot second digit that was present on admission that had an area of 0.11 cm2, length of 0.62 cm, and width of 0.28 cm. Review of EHR documented no physician notification or treatment completed for Resident #15's wound since admission on [DATE] until 1/15/26 when Staff J RN addressed the area. On 1/26/26 at 3:26 PM the DON stated her concern was the initial admission skin assessment for Resident #15 was completed by Staff A, RN. The DON explained Staff A completed the assessment and left without documenting the assessment. The DON stated the evening nurse went in and completed the assessment again. The DON stated she did not think Staff A made an observation of her foot / toe. The DON explained Staff J documented the area as not facility acquired because Resident #15 stated she had the area before entering the facility. The DON stated Resident #15 was a good historian. The DON stated there were a lot of balls that were dropped when it comes to wound care in the facility. The DON stated the area should have been noticed on the admission skin assessment, the physician should have been notified then and a treatment started if the physician thought it warranted. The DON acknowledged Resident #15 was at the facility for a week and the wound was not assessed and not treated. The DON stated the CNA's should have noticed the wound when cleaning Resident #15's feet. 3. The MDS dated [DATE] documented Resident #29 had a BIMS of 15 indicating no cognitive impairment. The MDS documented Resident #29 had one or more unhealed pressure ulcers. The MDS documented a Stage 2 pressure ulcer present. The MDS documented Resident #29 had an admission date of 11/11/25. Review of Resident #29 TAR documented a physician's order with a start date of 11/28/25 and end date of 12/16/25 to cleanse the sacral wound with wound cleanser, pat dry and apply Plurogel and foam patch daily until healed. A physician's order with a start date of 12/29/25 for Cephalexin 500mg, give one tablet by mouth every 12 hours for buttocks ulcer infection for 5 days. A physician's order with a start date of 12/16/25 and discontinued date of 1/2/26 to cleanse the sacral wound with wound cleanser, pat dry and apply Santyl and foam patch every other day. Review of Resident #29's EHR dated 11/11/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 20 that indicated Resident #29 was not at risk for development of a pressure ulcer. Review of assessment completed by Staff M, LPN on 11/12/25 titled, CHI Skin Check documented no concerns. Review of Resident #29's EHR dated 11/26/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 16 that indicated Resident #29 was at risk for development of a pressure ulcer. Review of Resident #29's EHR dated 11/29/25 titled, Skin Check documented open area on coccyx with no measurements or description. Review of Resident #29's EHR dated 12/6/25 titled, Skin Check documented open area on coccyx with no measurements or description. Review of Resident #29's EHR dated 12/16/25 titled, Skin and Wound Evaluation documented an in-house acquired stage 2 pressure ulcer with no measurements, superficial loss of tissue and no odor. Review of Resident #29's EHR dated 12/25/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 9 that indicated Resident #29 was at a very high risk for development of a pressure ulcer. Review of Resident #29's EHR dated 1/5/26 titled, Skin and Wound Evaluation documented an unstageable pressure ulcer with slough and/or eschar that had an area of 15.8 cm2, length of 6.6 cm, and width of 4.4 cm with no physician notification. Review of Resident #29's EHR documented no skin assessments completed between 12/16/25 and 1/3/26. Interventions for wound management were not changed until 1/2/26 when seen at a wound clinic. On 1/21/26 at 1:51 PM Staff J, RN acknowledged he worked with Resident #29 prior to having the wound on her buttocks. Staff J stated he felt the deterioration of the wound on Residents #29 buttocks could have been prevented. Staff J stated Resident #29 was not being repositioned appropriately prior to the wounds appearance. Staff J stated some CNA's had reported the wound was not getting better and requested the nurse to look at it. Staff J explained the CNA was told to put some cream on it and did not assess the area. Staff J stated Resident #29 had an alarm to remind staff to reposition her since she had returned. Staff J stated he knew Resident #29 had issues brought up about overnight CNAs not being in her room. Staff J acknowledged if those CNA's are working she told him she will set the alarm every 2 hours. On 1/26/26 at 2:43 PM Staff J, RN stated the CNA's have never notified him of stage 1 or discoloration. Staff J stated he does not know if CNA's know what pressure injuries are or when to notify the nurse. On 1/26/26 at 3:26 PM the DON stated she had heard CNA's report they had told the nurse and there was no documentation. The DON stated Resident #29 did not want Staff E in their room. The DON stated there were a lot of balls that were dropped when it comes to wound care in the facility. On 1/14/26 at 2:45 PM Staff P acknowledged there was no assessment for Resident #29 and unclear of what actually was notified to the physician as far as the wound description. Staff P stated she was informed about the wound from Staff MM and does not know why an assessment with measurement, description and photo was not completed. Staff P acknowledged she had worked that day and she did not look at the wound either. Staff P stated Staff MM said the wound looked worse. Staff P said it was concerning there was no assessment completed, no documentation of what exactly the physician was notified of and no photo of the area taken when the area was found on Resident #29. Staff P acknowledged there had not been any change in Resident #29's orders from 12/16/25 till seen at the wound clinic on 1/2/26. Staff P stated the physician should have been notified of Resident #29's worsening condition to the wound, assessments should have been documented to ensure appropriate treatment and physician update. On 1/14/26 at 3:00 PM the DON stated her expectation was with all wounds an assessment would be completed weekly with measurements and description of the wound. The DON stated her expectation was to notify the physician if there was any deterioration or lack of improvement to ensure the appropriate treatment was being completed. The DON stated documentation of the physician notification would be documented in the resident's electronic health records. The DON stated her expectation was that all changes in wounds worsening, lack of improvement or deterioration would also be reported to her or the ADON. The DON acknowledged Resident #29 skin assessments lacked an accurate assessment from 12/16/25 - 1/3/26 with measurements, a description of the wound or a photo. The DON acknowledged Resident #29's wound did not go from a stage 2 wound to that size of an unstageable pressure overnight and should have been documented with a physician notification before 1/3/26. 4. The MDS dated [DATE] documented Resident #30 had a BIMS of 13 indicating no cognitive impairment. The MDS documented Resident #30 was at risk for development of pressure ulcers. The MDS documented no pressure ulcers. The MDS documented Resident #30 had an admission date of 12/2/25. Review of Resident #30's EHR dated 12/22/25 titled, Skin Check documented no skin issues. Review of Resident #30's EHR dated 12/23/25 titled, Braden Scale for Predicting Pressure Sore Risk documented a Braden Score of 11 that indicated Resident #30 was at a high risk for development of a pressure ulcer. Review of Resident #30's EHR dated 12/23/25 at 1:22 PM entered by Staff P titled, Wound Evaluation documented a minutes old in-house acquired unstageable pressure ulcer on the sacrum that had an area of 1.88 cm2, length of 1.91 cm, and width of 1.31 cm. Review of fax dated 12/23/25 at 3:50 PM from nurse practitioner documented an order for high calorie protein supplement for wound twice a day to promote wound healing, an order to cleanse right buttocks with wound cleanser, pat dry apply Santyl ointment daily until healed for wound care, an order to cleanse left buttocks with wound cleanser, pat dry apply Santyl ointment daily until healed for wound care and consult wound care. Review of Resident #30's EHR dated 12/29/25 titled, Skin Check documented a pressure injury on sacrum and coccyx with no measurements or description. On 1/21/26 at 1:51 PM J, RN stated he had provided care to Resident #30 primarily Staff MM worked with Resident #30 but he worked on Resident #30 on Staff MM's days off. Staff J acknowledged the skin assessment for the UDA with admissions and discharges they are left over due at times. Staff J stated next thing you know there are 40 assessments needed to be completed. Staff J stated then you are in a hurry to complete them. Staff J stated during those times he might have just taken the report from the CNA that the wound had not changed. Staff J stated the wound was probably present on 12/22/25 when he completed the skin check. Staff J stated the wound on Resident #30 did not appear to be new on the 12/23/25 assessment. Staff J acknowledged the area should have been discovered prior to becoming an unstageable pressure ulcer. On 1/26/26 at 11:35 AM Staff H, MDS Coordinator stated she was familiar with Resident #30. Staff H acknowledged there was no care plan update with unstageable skin found 12/23/25 and would have updated interventions as well. Staff H stated the skin assessment completed for Resident #30 on 12/22/25 does not indicate there are any skin concerns. Staff H stated the wound found on 12/23/25 on Resident #30 was very unlikely to have developed overnight. Staff H stated there would have had to have been a breakdown in several areas of resident care for that to have developed on Resident #30 overnight. On 1/14/26 at 7:39 AM Staff M, Licensed Practical Nurse (LPN) stated she had cared for Resident #30. Staff M stated she had reported an injury of unknown origin, a bruise to the forehead. Staff M stated 1/4/26 she went into Resident #30's room at 7:00 AM or 7:30 AM. Staff M stated Resident #30 had a scratch on the right side of her forehead. Staff M explained Resident #30 reported she had hit the table and also said she did not know what had happened. Staff M stated that afternoon when she was going to document that the injury and Resident #30's daughter came to the nursing desk. Staff M stated the area on Resident #30 had become a hematoma. Staff M acknowledged she started neuro checks and notified the doctor at that time. Staff M stated Resident #30's daughter notified a CNA and the CNA told her that Resident #30's daughter would like to talk to her. Staff M stated she entered Resident #30's room and the area was no longer a red mark. Staff M stated the area on the right side of her forehead was swollen. Staff M stated it looked like a goose egg and had started bruising. Staff M stated she called the on call provider at that time and he asked if the neuro had been started and if there was any altered mental status. Staff M reported Resident #30 was at her baseline. Staff M stated the daughter was at the facility late morning. Staff M stated she was going to call Resident #30's daughter and the physician but had not at that time. Staff M stated Resident #30 initially reported she hit her head on the table and then said she had fallen in her bathroom and daughter assisted her in getting to her bed. Staff M stated Resident #30's daughter said she did not assist Resident #30 to get up. Staff M reported it did not look like Resident #30 had hit her head there was no induration or swelling. Staff M stated Resident #30 was a poor historian. Staff M stated they did do an initial set of vitals when the red mark was found. Staff M explained she did an assessment at the same time when she was completing her daily assessment. Staff M stated the red area was documented in the daily assessment. Staff M stated she did not know if there was a procedure for injury of unknown origin. Staff M stated she was not aware of any procedure for injury of unknown origins with injury to the head or witness / unwitnessed head injury. Staff M stated Resident #30 was wearing pants and it was difficult for her to get up and would often get agitated if the staff tried to move her. Staff M stated she did not remove Resident #30's clothes. Staff M explained she pulled Resident #30's pant legs up but did not assess the hips or buttocks. Staff M stated Resident #30 was being transferred to the ER the next day and the daughter wanted her to be seen the next day based on the general decline of the resident. Staff M acknowledged she did not initiate neuro assessments when the injury was found on the head that morning. On 1/20/26 at 1:05 PM Resident #30's Daughter / Power of Attorney (POA) stated she walked into the facility around 12:30 PM or 1:00 PM on 1/4/26. Resident #30's Daughter / POA stated she found Resident #30 with a bruise on her knee and a wound on the right side of her head. Resident #30's Daughter / POA stated her mother said she fell in the bathroom that morning. Resident #30's Daughter / POA stated the staff said her mother told them she leaned forward toward the table and hit her head. Resident #30's Daughter / POA stated she was told the staff had used a full body mechanical lift on her and possibly bumped her head. Resident #30's Daughter / POA stated she was then told her mother was combative on Saturday night and might have bumped her head. Resident #30's Daughter / POA stated she asked where the knee bruise came from. Resident #30's Daughter / POA stated she came to the facility the next day and told the DON she wanted her mother sent to the hospital. Resident #30's Daughter / POA once at the hospital there was a huge bruise noticed on Resident #30 right hip and sent a picture to the DON. Resident #30's Daughter / POA was told they would have to look into the bruise. Resident #30's Daughter / POA stated Resident #30's right shoulder blade had a huge bruise on it as well when she was rolled over in the Emergency Department (ED) where both bruises were noted. Resident #30's Daughter / POA stated the goose egg was very large on the right side of Resident #30 head. Resident #30's Daughter / POA stated the bruising was not brought to her attention at all until seen in the ED. Resident #30's Daughter / POA stated the DON stated the bruising could have happened when transferred to hospital. On 1/14/26 at 1:51 PM MM, RN acknowledged she cared for Resident #29. Staff MM stated she notified Staff P of the change in condition of the wound. Staff MM stated she notified the nurse practitioner of the change of condition for Resident #29's wound on her buttocks. Staff MM stated she was off for a while and 12/23/25 was her first day back. Staff MM stated the wound had gotten larger and was open. Staff MM stated this was noticed and she notified Staff P wound nurse / interim DON. Staff MM stated the wound was still a stage 2 at that time but was larger. Staff MM stated there was no eschar present at that time. Staff MM stated the wound had worsened but was not showing signs of infection. Staff MM stated the treatment did not change at that time. Staff MM stated Staff P was supposed to take the picture that day. Staff MM stated she notified the nurse practitioner as well about the change in condition. Staff MM stated Resident #30 had a deterioration in the wound. On 1/12/26 at 1:09 PM the DON stated Resident #29 had an unstageable pressure ulcer on her sacrum. The DON explained Resident #29 had entered the facility on 11/11/25 and the wound must have been facility acquired. The DON acknowledged Resident #29's wound was not on the admission. The DON explained the first photograph of the wound was taken on 11/28/25. The DON stated the area on Resident #29 was on the gluteal fold or sacral area. The DON acknowledged the wound on Resident #29's sacral area had declined. The DON acknowledged the facility did not complete assessments with pictures, measurements, or description of the wound from 12/16/25 - 1/3/26. The DON acknowledged Resident #29's wound had deteriorated. The DON stated Resident #30 went to the hospital on 1/5/26. Resident #30 stated Resident #30 did have a wound. The DON explained Resident #30's wound was also on her buttocks. The DON stated the area was a facility acquired. On1/20/26 at 4:32 PM the DON stated there was an injury of unknown origins that had happened to Resident #30. The DON explained the facility had completed an investigation and determined the injury was no longer of unknown origins. The DON stated that Resident #30 had a red area on the right side of her forehead at approximately 7:30 AM on 1/4/26. The DON explained Staff M notified her, an assessment was completed, and the physician was notified. The DON stated she asked Staff M if Resident #30 was on a blood thinner and Staff M told her no. The DON explained she would have only started neuro assessments if the resident was on a blood thinner and had an injury to the head of unknown origins or a change in cognition. The DON explained a neuro assessment was also completed. The DON stated Resident #30's daughter was notified. The DON stated Resident #30's daughter had come to the facility later in the afternoon and asked about the area on Resident #30 forehead as it was now a raised area. The DON stated Resident #30's daughter must have forgotten about the earlier notification. The DON stated the raised area was only there for about a day and had decreased and was almost gone the next day. The DON stated there was no other injuries to Resident #30 from the incident. The DON stated she completed an investigation and interviewed the staff. The DON explained the staff had stated Resident #30 did have a shower the day prior but had not fallen. The DON stated Resident #30 was aggressive and combative the night prior. The DON explained Resident #30 had kicked an employee in the groin and hit an employee. The DON stated Resident #30 stated she had hit her head on the bedside table on the morning of 1/4/26. The DON stated Resident #30's cognition was enough that she felt that is where the injury had come from. The DON explained the injury probably occurred from the aggression and combativeness of the evening before. The DON explained the staff had not notified the physician or family appropriately and some writes came from that incident. The DON stated she would have expected the staff would have notified the DON at 7:30 AM on the day the injury was found when the injury was found and the staff did not. The DON stated she expected the nurse would have notified the physician of the area on the head at 7:30 AM when it was found as well and that was not completed. The DON stated she would have expected the family of Resident #30 would have been notified of the injury as well at 7:30 when the injury was noticed. The DON stated neuro assessments should have been initiated when the area was found on Resident #30 forehead at 7:30 AM and the neuro assessments were not imitated. Review of Resident #30's EHR dated 1/4/26 titled, Neurological Assessment Flow Sheet documented neurological assessments were not started at 6:00 PM on 1/4/26. Review of Resident #30's EHR dated 1/4/26 at 7:49 PM titled, Skilled Note entered by Staff M documented Resident #30 had a hematoma to the right side of the forehead. On call provider made aware, DON made aware, Resident #30's daughter in and aware. Review of Resident #30's document dated 1/4/26 at 7:27 PM titled Fax documented physician notification that Resident #30 had a 3 cm x 2.5 cm hematoma to the right forehead of unknown origin. On 1/4/26 evening propranolol was held due to b/p 102/50 and pulse of 53. Called to inform the on call provider with no return call at this time. On 1/13/25 at 11:29 AM the Nurse Practitioner stated she was not notified that Resident #29 had returned and currently had strict orders for 2 hour repositioning. The Nurse Practitioner stated just seen Resident #29 and the CNA had told her Resident #29 was not adequately turned last night. The Nurse Practitioner stated she was shown the picture of the wound on 12/16/25. The Nurse Practitioner stated she did not hear anything again until the week of Christmas. The Nurse Practitioner stated she received a text from Staff MM reporting the

Based on clinical record review, observations, resident interviews, and staff interviews the facility failed to provide the residents with a comfortable / clean homelike environment by resident rooms found with various debris on the floor and failed to ensure resident's personal property was protected from loss or theft no personal inventory sheet was completed upon entry to the facility for 4 of 12 residents reviewed (Resident #15, #30, #38 and #11). The facility reported a census of 28 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/20/26 at 11:49 AM Resident #15 stated that Staff Y, Certified Nurse Assistant (CNA) was going through her bag of personal belongings with Staff EE, CNA present in the room. Resident #15 stated she told Staff J about the incident. On 1/20/26 at 11:52 AM Resident #15 stated she had 4 pairs of pants that were $25 or $30 apiece and only had 2 left. Resident #15 explained she was missing several shirts as well. Resident #15 stated she had told everyone that would listen. On 1/20/26 at 12:04 PM Resident #15 stated she had only had her bathroom cleaned twice since she had been at the facility. Resident #15 stated that she was the only person who had ever cleaned the bathroom. Resident #15 stated there was a bandage on the floor and the toilet had feces all over it. Resident #15 stated she had told several staff about the bathroom and the bathroom still had not been cleaned. Resident #15 stated he had not seen anyone come into her room, clean or sweep the floor. Resident #15 stated that debris on the floor was popcorn and had been on the floor since last week. On 1/20/26 at 12:08 PM an observation in Resident #15's room revealed a bandage on the floor, toilet had brown splatter all over the riser and white debris on the floor under the bedside table. On 1/21/26 at 8:32 AM an observation in Resident #15's room revealed a bandage on the floor, toilet had brown splatter all over the riser and white debris on the floor under the bedside table. Observation revealed the same concerns as 1/20/26. Review of Resident #15's (Electronic Health Record) EHR revealed no personal property list. Review of Resident #15's EHR dated 1/5/26 documented by Staff A, Registered Nurse (RN) at 2:48 PM documented an inventory list was completed and there were personal items present. On 1/21/26 at 7:43 AM Staff J, RN stated Resident #15 had voiced concerns to him. Staff J stated Resident #15 told him yesterday that she was missing a couple pairs of pants and some shirts. Staff J stated Resident #15 got all the pants back yesterday and is currently missing a shirt. Staff J stated Resident #15 briefly mentioned staff going through her personal belongings. Staff J acknowledged there are certain people Resident #15 is hesitant in allowing to go in her room. Staff J stated those people are the girls on the overnight. Staff J stated he discussed with Resident #15 about discussing with the overnight nurse about staff going through her personal belongings right away. Staff J stated staff going through Resident #15's stuff had been brought up to management. On 1/21/26 7:52 AM Staff R, CNA stated Resident #15 had voiced concerns to her about Staff Y, CNA rummaging through her stuff about a week ago on overnights. Staff R stated she told that to the Staff EE, CNA that was working overnights. Staff R stated she told Staff EE that she needed to stop bringing Staff Y, CNA in Resident #15's room because she was going through Resident #15 stuff. Staff R stated she told Staff J and Staff GG, LPN about the incident. Staff R stated she did not inform any of the management of the incident. Staff R stated Resident #15 told her that she was missing a shirt and pants. Staff R stated laundry came and she had not heard anything else about the incident. On 1/21/26 at 10:45 AM Staff NN, Laundry stated if a missing item is reported she takes down what they are missing and she tells Staff OO, Laundry. Staff NN stated if she can not find the missing item she will pass the concern onto Staff OO because she is the staff that delivers the clothing to the residents. Staff NN stated she used to fill out resident grievance forms but since the new company had taken over she had not filled out any grievances for the residents that report missing items. Staff NN stated she does not know what the process was for the current facility owners. Staff NN stated she had not been in-serviced on what the procedure was. Staff NN stated she had not been notified of where a resident grievance form was because she does not know. Staff NN stated if she was supposed to have the forms the laundry department does not have them for sure. Staff NN stated sometimes missing items never make it to her department because the nurses and CNA's don't tell them. Staff NN stated when the laundry was delivered that was when the resident told them. On 1/22/26 at 7:50 AM Staff OO stated she had residents complain about missing items. Staff OO stated there was a problem that many clothes come without names to the laundry department. Staff OO stated it was difficult to know who the clothes belonged to. Staff OO stated when she gets time she will take the rack around to find out if the clothes are the residents that reported missing clothes. Staff OO stated the residents' family will make complaints and ask for missing items of clothing. Staff OO stated there is a section for lost and found. Staff OO stated the residents will report to the CNA's the items are missing but the CNA's do not pass it on to the laundry. Staff OO stated she frequently finds out the CNA's have been notified but never told them. Staff OO stated when a resident comes into the facility she does not know who is supposed to label the clothes. Staff OO stated when residents leave she will bring the missing clothes to the social services staff. Staff OO stated she was not aware of what a resident grievance form was. Staff OO stated she was not informed of any form to fill out for missing items or resident concerns. Staff OO stated Resident #15 had mentioned she was still missing a shirt. On 1/21/26 at 7:26 AM Staff P, Assistant Director of Nursing stated Resident #15 did not report any missing items but did say something was missing from her shoe. Staff P stated Resident #15 had never reported anyone going through her personal belongings. On 1/27/26 at 11:03 AM the DON stated she expected grievances would be completed when residents reported any concerns and that was not being completed appropriately at the facility. The DON acknowledged she did not know if a grievance had been filled out for Resident #15's missing shirt yet. The DON explained she did not know what the process was, if the missing items would be replaced and how many days that would take. On 1/21/26 at 4:45 PM the DON acknowledged there was no personal property list for Resident #15. The DON stated she expected a personal property list would be completed upon admission and updated with any items that were brought to the facility and not on the list already. 2. The MDS dated [DATE] documented Resident #30 had a BIMS of 13 indicating no cognitive impairment. On 1/20/26 at 1:05 PM the daughter of Resident #30 stated she did not know if housekeeping did any cleaning in her mother's room. The daughter of Resident #30 stated the room would look the same for several days with the stuff left that should have been thrown away. Review of Resident #30's document dated 12/29/25 titled, Grievance Form documented Resident #30's daughter stated the floor was dirty, no trash can liners, no paper towels in the bathroom and house keeping needed to do better. The investigation was on 12/29/25 Staff N, Interim Director of Social Services had a conversation with daughter about the housekeeping issues. The daughter let Staff N know that the floor had been dirty, there were no trash can liners and no paper towels. The findings describing the concerns were reviewed with the housekeeping supervisor. Staff Z, Housekeeping Supervisor said he would get a hold of the housekeeper to go double check. Actions taken were to complete a daily check on the room to make sure everything is cleaned and stocked. Review of Resident #30's document dated 1/5/26 titled, Grievance Form documented Resident #30's daughter stated there was a lack of communication, housekeeping issues and nursing issues. Resident #30's daughter stated there was a lack of communication to the family. Resident #30's daughter requested all medical records and reported housekeeping issues. Findings indicated Staff N spoke with ADON and CEO, obtained all medical records, made a staff plan, talked to Staff Z about lack of hand towels. Staff Z let Staff N know he would check on it. Actions that were taken indicated daily checks on room to make sure it was clean, staff education, all medical records given to Resident #30's daughter. 3. The MDS dated [DATE] documented Resident #38 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #38's EHR documented Resident #38 resided in room [ROOM NUMBER]. On 1/20/26 at 12:49 PM observation of copious amounts of white debris on the floor between the bed and recliner. On 1/21/26 at 8:31 AM observation of copious amounts of white debris on the floor between the bed and recliner similar debris as yesterday. On 1/21/26 at 7:52 AM Staff R, CNA stated she had spoken to the housekeeper about cleaning room number #7 and it never gets done. Staff R stated Resident #38's room was a mess and still looks the same today. Staff R stated that Resident #38's room has been looking like that since the previous weekend. Staff R stated housekeeping does not clean the rooms daily and does not know what the schedule is. Staff R stated these rooms on the skilled hall definitely had not been cleaned since before the weekend. On 1/21/26 at 12:00 PM Staff AA, CNA stated the facility needed better housekeeping. Staff AA stated the residents' rooms are gross and had never seen them swept or cleaned. On 1/21/26 at 10:29 AM Staff PP, Housekeeping stated she worked every other weekend opposite Staff QQ, Housekeeping. Staff PP stated housekeeping were expected to clean the residents' rooms every day. Staff PP stated high contact areas are cleaned every day. Staff PP stated bathrooms are swept every day and toilets are cleaned every day. Staff PP stated during the week the two of them work together. Staff PP stated she felt there was enough staff to complete all the tasks. Staff PP stated the housekeeping staff have enough time that at times the housekeeping staff are still looking for stuff to do once they have completed their tasks. Staff PP stated housekeeping staff work at 7:00 AM and clean the rooms only once a day. Staff PP stated at times when she comes in the morning she wonders what happened because the room is dirty again. On 1/21/26 at 10:29 AM Staff QQ stated she worked every other weekend opposite Staff PP. Staff QQ stated housekeeping staff did the deep cleans last weekend. Staff QQ stated she did a couple of the resident rooms this last weekend. Staff QQ stated the housekeeping staff are expected to clean the residents' rooms every day. Staff QQ stated high contact areas are cleaned every day. Staff QQ stated bathrooms are swept every day and toilets are cleaned every day. Staff QQ stated during the week the two of them work together. Staff QQ stated she felt there was enough staff to complete all the tasks. Staff QQ stated they have enough time to complete all the tasks and at times they are still looking for stuff to do once they have completed their tasks. Staff QQ acknowledged the residents' rooms are not cleaned daily. On 1/21/26 at 10:20 AM the Assistant Director of Nursing (ADON) stated staff had brought concerns about not replacing garbage can liners and such to her attention but had not heard any concerns about the rooms being dirty. On 1/21/26 at 10:15 AM the Director of Nursing (DON) stated she expected resident rooms would be cleaned daily. The DON stated housekeeping staff were not available on the weekends but expected light housekeeping would be completed by CNA's when time allowed. On 1/29/26 at 8:11 AM the Administrator sent an email that documented no policy for environmental cleanliness. 4. Review of Resident #11's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview 1/20/26 at 10:37 AM with Resident #11 revealed his reading glasses went missing, and nobody can find them. Resident #11 further revealed they had been missing a week now. Resident #11 then revealed that he reported this to the nurse. Follow up interview 1/21/26 at 4:23 PM with Resident #11 revealed that he did have glasses, and that he reported this to the DON. Review of the inventory list revealed there was no inventory list of personal items to review. Interview 1/21/26 at 4:45 PM with the DON revealed that the facility staff had not found the inventory list, and that she did not recall Resident #11 telling her that his glasses were gone. The DON then revealed that glasses would definitely be on the inventory list. Interview 1/21/26 at 4:45 PM with the Administrator revealed glasses would be part of the personal items list.

Based on resident council meeting, resident interview, staff interviews, document review and policy review the facility failed to document grievances when residents voiced concerns, educated staff on where grievance forms could be found and when to fill grievance forms out, make prompt efforts to resolve grievances the resident may have and have grievance forms available for staff, residents and resident family members to complete for 2 of 2 residents reviewed (Resident #15 and #29). The facility reported a census of 28 residents.Findings include: On 1/27/26 at 10:25 AM at the Resident Council meeting, the residents present stated they were unaware of what grievances were, where to locate a grievance form, how to file a grievance and if the facility responded to grievances. 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/20/26 at 11:49 AM Resident #15 stated on 1/12/26 she sat in soiled urine and feces from 3:00 AM - 6:00 AM. Resident #15 explained she was told she could not get out of bed on her own. Resident #15 stated she had turned her call light on several times during that night. Resident #15 stated the staff do not take her to the bathroom on the overnight shift. Resident #15 stated she had talked to everyone about the concern, especially Staff P Registered Nurse (RN) / Assistant Director of Nursing (ADON). Resident #15 stated she told Staff P about the sore on her foot and she did nothing about it. Resident #15 stated Staff J, RN was the nurse that finally did something about it. Resident #15 stated Staff EE, Certified Nurse Assistant (CNA) was working with Staff Y, CNA and Staff Y refused to wear gloves to clean her up after she used the toilet . Resident #15 stated that Staff Y was going through her bag of personal belongings. Resident #15 stated she told Staff J about the incident. On 1/20/26 at 11:52 AM Resident #15 stated she had 4 pairs of pants that were $25 or $30 apiece and only had 2 left. Resident #15 stated she was also missing several shirts. Resident #15 stated she had told everyone that would listen about the missing items. Review of resident grievances provided by the facility documented no grievances from Resident #15. On 1/21/26 at 7:26 AM Staff P stated Resident #15 did not report any missing items but did say something was missing from her shoe. Staff P stated Resident #15 had never reported any staff going through her personal belongings. On 1/21/26 at 7:43 AM Staff J, RN stated Resident #15 had voiced concerns to him. Staff J stated Resident #15 told him yesterday that she was missing a couple pairs of pants and some shirts. Staff J stated Resident #15 got all the pants back yesterday and was currently missing a shirt. Staff J stated Resident #15 briefly mentioned staff going through her personal belongings. Staff J stated she knows there are certain people Resident #15 was hesitant to allow going into her room. Staff J stated those people are the girls on the overnight staff. Staff J stated Resident #15 had not mentioned that the overnight staff would not take her to the bathroom. Staff J stated he did not write a grievance for Resident #15 because they found the pants. Staff J stated he talked to Resident #15 about discussing with the overnight nurse about staff going through her stuff. Staff J stated staff going through Resident #15's stuff had been brought up to management. On 1/21/26 at 7:52 AM Staff R, CNA stated Resident #15 had voiced concerns to her about Staff Y, CNA rummaging through her stuff about a week ago on overnights. Staff R stated Resident #15 told her the reason she had laid in the bed with feces that morning was because Staff EE, CNA came into her room and was talking about recipes and Staff Y, CNA was going through her stuff. Staff R stated she told that to the Staff EE, CNA that was working overnights. Staff R stated she told Staff EE that she needed to stop bringing Staff Y, CNA in Resident #15's room because she was going through Resident #15 stuff. Staff R stated she told Staff J and Staff GG, LPN about the incident. Staff R stated Resident #15 told Staff Y that she needed to wear gloves when she was providing the cares and Staff Y told her she told her no and then Resident #15 refused the care. Staff R stated she did not inform any of the management of the incident. Staff R stated Resident #15 told her that she was missing a shirt and pants. Staff R stated laundry came and she had not heard anything else about the incident. On 1/21/26 at 10:45 AM Staff NN, Laundry stated if a missing item is reported she takes down what they are missing and she tells Staff OO, Laundry. Staff NN stated if she can not find the missing item she will pass the concern onto Staff OO because she is the staff that delivers the clothing to the residents. Staff NN stated she used to fill out resident grievance forms but since the new company had taken over she had not filled out any grievances for the residents that report missing items. Staff NN stated she does not know what the process was for the current facility owners. Staff NN stated she had not been in-serviced on what the procedure was. Staff NN stated she had not been notified of where a resident grievance form was because she does not know. Staff NN stated if she was supposed to have the forms the laundry department does not have them for sure. Staff NN stated sometimes missing items never make it to her department because the nurses and CNA's don't tell them. Staff NN stated when the laundry was delivered that was when the resident told them. On 1/22/26 at 7:50 AM Staff OO stated she had residents complain about missing items. Staff OO stated there was a problem that many clothes come without names to the laundry department. Staff OO stated it was difficult to know who the clothes were. Staff OO stated when she gets time she will take the rack around to find out if the clothes are the residents that reported missing clothes. Staff OO stated the residents' family will make complaints and ask for missing items of clothing. Staff OO stated there is a section for lost and found. Staff OO stated the residents will report to the CNA's the items are missing but the CNA's do not pass it on to the laundry. Staff OO stated she frequently finds out the CNA's have been notified but never told them. Staff OO stated when a resident comes into the facility she does not know who is supposed to label the clothes. Staff OO stated when residents leave she will bring the missing clothes to the social services staff. Staff OO stated she was not aware of what a resident grievance form was. Staff OO stated she was not informed of any form to fill out for missing items or resident concerns. Staff OO stated Resident #15 had mentioned she was still missing a shirt. On 1/26/26 at 10:08 AM the DON stated she thought that the resident filled out the grievance with the Social Services Director. The DON stated the Social Services Director had spoken to Resident #15 and she did not want to fill out a grievance. The DON stated if a resident voiced concerns the staff should still fill out a grievance for that resident. On 1/27/26 at 11:03 AM the DON stated she expected grievances would be completed when residents reported any concerns and that was not being completed appropriately at the facility. The DON acknowledged she did not know if a grievance had been filled out for Resident #15's missing shirt yet. The DON explained she did not know what the process was, if the missing items would be replaced and how many days that would take. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #29 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/15/26 at 1:30 PM Resident #29 stated she had to set an alarm on her phone to ensure the staff come to turn her every 2 hours or the overnight staff will not reposition her. Resident #29 stated her doctor wants her repositioned every 2 hours. Resident #29 stated prior to going to the hospital the staff were not repositioning her every 2 hours some nights overnight staff would only come in at 3:00 AM or 4:00 AM to reposition her in bed. Resident #29 stated she had Multiple Sclerosis and was not able to reposition herself in bed. Resident #29 stated she required the assistance of staff for repositioning. Resident #29 stated she had reported not being repositioned by the overnight staff several times to staff. On 1/22/26 at 11:29 AM Resident #29 stated she was told last night by Staff EE, Certified Nurse Assistant (CNA) refused to change her brief. Resident #29 stated she was out of briefs and Staff EE refused to change her last night. Resident #29 stated she had not had a bowel movement but was incontinent of urine and nobody changed her at all last night. Resident #29 stated the Staff EE only repositioned her at night but never changed her. Resident #29 stated she has had problems with Staff EE from the get go. Resident #29 stated Staff EE was not supposed to be caring for her because she had voiced concerns about how she cared for her in the past. Resident #29 stated Staff EE treated her undignified. Resident #29 stated she did not feel like Staff EE had provided her with the appropriate dignity or respect when requesting to be cleaned up and change her brief. Resident #29 stated she had told Staff R, CNA the concerns she had with Staff EE. Resident #29 said she thought Staff EE told Staff P, Assistant Director of Nursing (ADON) about the concerns with Staff EE. Review of resident grievances provided by the facility documented no grievances from Resident #29. On 1/12/26 at 12:49 PM Staff P, Assistant Director of Health and Wellness / Assistant Director of Nursing (ADON) / Registered Nurse (RN) stated there had not been any staff or residents that had reported staff were rough with resident care or short with residents. Staff P stated there had been staff that had been asked not to go in certain resident rooms. Staff P stated Resident #29 did not want Staff EE or Staff RR in her room because they were talking about their own lives and another resident down the hall while in her room. Staff PP stated Resident #29 thought it was disrespectful for them to talk about other residents in her room. On 1/12/26 at 1:09 PM the Director of Nursing (DON) stated there are several staff that really need to be let go. The DON stated because of the lack of DON presence prior to her starting in the position at the building there was not enough of a documentation trail to let the staff go. The DON stated 95% of the complaints are staff to staff complaints. The DON stated she was not aware of any staff that could not go into any resident's room. On 1/13/26 at 2:00 PM Staff R stated she talked to Staff A, Registered Nurse (RN) about Resident #29 not being repositioned appropriately last night. Staff R stated she spoke to Staff A about it that morning. Staff R stated Resident #29 reported she had not been repositioned or had her brief changed with incontinence the way she should have last night. On 1/13/26 at 2:50 PM Staff A acknowledged that Staff R had told her Resident #29 had not been repositioned on the overnight shift. Staff A stated Resident #29 had been noted to be soaked through the pad, the sheet to the bed when Staff R entered the room. Staff A stated the overnight nurse reported to her that he repositioned Resident #29 every 2 hours. Staff A stated there was a dark ring around Resident #29's bed pad that appeared to be indicative of not checking or changing but did know Resident #29 had been repositioned. Staff A stated she assisted Staff R with repositioning Resident #29 that morning. On 1/22/26 at 2:06 PM Staff R stated when she came in at 6:00 AM on 1/22/26 and Resident #29 stated she had asked to be changed because she had some urine incontinence on the overnight shift. Staff R stated Resident #29 explained Staff EE said there was no brief to change her with. Staff R stated Resident #29 told her that she told Staff EE that she was a 3XL brief. Staff R reported Resident #29 said Staff EE told her that she would not get her another brief, reapplied the brief in the front, walked out of the room and did not return the rest of the night. Staff R said Resident #29 told her Staff EE refused to change her. Staff R reported Resident #29's brief was saturated when she provided care that morning. Staff R stated she reported the concern to Staff J, RN. On 1/22/26 at 2:10 PM Staff J stated Staff R had informed him Resident #29 reported she had not been changed on the overnight shift. Staff R stated Resident #29 stated she had asked to be changed because she had incontinence. Staff J stated Resident #29 stated Staff EE said there was no brief to change her with. Staff J stated Resident #29 told Staff EE that she was a 3xl brief. Staff J stated Resident #29 said Staff EE told her that she would not get her another brief, reapplied the brief in the front, walked out of the room and did not return the rest of the night. Staff J said Resident #29 told her Staff EE refused to change her brief. On 1/21/26 at 10:48 AM an observation of a sign on a table near the entrance of the facility that documented the facility grievance policy with the previous DON's phone number and email address also documenting grievance forms can be found at each nursing desk and at the front entrance. No grievances forms available at that table. On 1/21/26 at 10:53 AM Staff A, RN stated she does not know where to find any grievance forms if a resident had any concerns. On 1/21/26 at 10:57 AM Staff R, CNA stated she does not know where resident grievance forms would be located. Staff R stated she could find out though. On 1/21/26 at 10:57 AM Staff J, RN stated if a resident had a grievance he would direct the resident to the social services office. Staff J stated he would fill the grievance form out for the resident after getting the form social services. Staff J stated he thought there were grievance forms in a drawer at the nursing station. Staff J searched for grievance forms. Staff J explained there were no grievance forms available at the nursing desk. On 1/21/26 at 10:59 AM Staff H, Licensed Practical Nurse (LPN) / MDS Coordinator / Infection Preventionist (IP) stated if a resident had a grievance she would direct the resident to the social services office. Staff H stated she would fill the grievance form out for the resident after getting the form social services. On 1/21/26 at 11:40 AM the Director of Nursing (DON) stated she would ask the social worker where the grievance forms were and thought they were in her office but did not know where else the residents or residents family could find the forms. On 1/21/26 at 11:45AM the Assistant Director of Nursing (ADON) stated she would ask the social worker where the grievance forms were and thought they were in her office but did not know where else the residents or residents family could find the forms. On 1/21/26 at 11:48 AM an observation of a sign on a table near the entrance of the facility that documented the facility grievance policy with the previous DON's phone number and email address also documenting grievance forms can be found at each nursing desk and at the front entrance. No grievances forms available at that table. On 1/21/26 at 11:50 AM the Administrator stated he was not sure where the grievance forms were available for the residents or the resident family members. The Administrator stated he would assume they would be located on the other side of the building where the residents were but was unaware of where the grievance forms were located. The Administrator acknowledged the sign documented grievance forms available at the front entrance and at each nursing desk. The Administrator acknowledged grievance forms were not available. Review of undated policy titled, Grievances / Complaints, Recording and Investigation documented all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations. The department director(s) of any named employee(s) will be notified of the nature of the complaint and that an investigation is underway. The investigation and report will include, as applicable: The date and time of the alleged incident. The circumstances surrounding the alleged incident. The location of the alleged incident. The names of any witnesses and their accounts of the alleged incident. The resident's account of the alleged incident. The employee's account of the alleged incident. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and Recommendations for corrective action. The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: the date the grievance/complaint was received. The name and room number of the resident filing the grievance/complaint (if available); the name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); the date the alleged incident took place. The name of the person(s) investigating the incident. The date the resident, or interested party, was informed of the findings; and the disposition of the grievance (i.e., resolved, dispute, etc.). The Resident Grievance/Complaint Investigation Report Form will be filed with the Administrator within five (5) working days of the incident. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten business days of the filing of the grievance or complaint. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. Review of undated policy titled, Resident Rights documented Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to retain and use personal possessions to the maximum extent space and safety permits; privacy and confidentiality; voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal and have the facility respond to their grievances.

Based on personnel file review, staff interviews and policy review the facility failed to perform further background checks clearing an employee for hire that was on probation for exploitation. The facility reported a census of 28 residents. Findings include:Review of Staff A's Registered Nurse (RN) employee file revealed the following:Hired date of 9/8/2025;Single Contact License and Background Check completed on 9/4/2025 at 2:36 PM;Background Check showed further research under the criminal history section;QuickConfirm License Verification Report dated 9/4/2025 at 2:53 PM showed her RN license was on probation-RN privilege adverse action by Nebraska;QuickConfirm License Verification Report documented on 10/30/2024 action was taken against Staff's Nebraska nursing license; against privilege to practice-yesQuickConfirm License Verification Report documented Staff A was on probation from 4/18/2025-4/18/2027 in Iowa for error in prescribing, dispensing or administrating medication or sedation, against privilege to practice-noStaff A's employee file did not contain further research documentation to confirm whether or not she could work at the facility.On 1/30/2026 at 8:05 AM the Administrator stated after speaking with corporate office, they learned the background check company can only go back 30 days after a background check has been completed. In order to resubmit for it to be completed again they would need Staff A to complete the paperwork and she is no longer employed at the facility. The facility provided a document titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on personnel file review, policy review, document review, and staff interviews the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility also failed to implement their abuse policies when staff reported concerns about a staff member and complete further research when Staff A's background check suggested one be completed. The facility reported a census of 28 residents.Findings include:Review of Staff A's Registered Nurse (RN) employee file revealed the following: a) hired date of [DATE]; b) Single Contact License and Background Check completed on [DATE] at 2:36 PM; c) Background Check showed further research under the criminal history section; d) QuickConfirm License Verification Report dated [DATE] at 2:53 PM showed her RN license was on probation-RN privilege adverse action by Nebraska; e) QuickConfrim License Verification Report documented on [DATE] action was taken against Staff's Nebraska nursing license; against privilege to practice-yes f) QuickConfrim License Verification Report documented Staff A was on probation from [DATE]-[DATE] in Iowa for error in prescribing, dispensing or administrating medication or sedation, against privilege to practice-no. Staff A's employee file did not contain further research documentation to confirm whether or not she could work at the facility. On [DATE] at 8:05 AM the Administrator stated after speaking with corporate office, they learned the background check company can only go back 30 days after a background check has been completed. In order to resubmit for it the be completed again they would need Staff A to complete the paperwork and she is no longer employed at the facility. On [DATE] at 12:27 PM Staff D Certified Medication Aide (CMA) stated there was an issue about a month ago when Resident #3 had her call light on and asked for something for pain. Staff D saw she got something 30 minutes prior and let her know she already had something for pain. Resident #3 denied receiving any pain medications with her morning medications. Staff D stated when Resident #3 has pain, she will ask her what she wants. Resident #3 will request Tylenol. Staff D stated Staff A is the only staff member that signs out Resident #3's oxycodone as given. Staff D stated Resident #3 would be reliable, could rate her pain on the pain scale and would be able to tell staff which pain medication she wants. She believed Resident #3 would be a good historian. Staff D stated about two weeks prior to the surveyors coming in to the building, she had passed medications on both Long-Term Care and Skilled residents. Staff A approached her wanting the keys for the medication room on the skilled side. Staff A did labs and just assumed that's why she was asking for the medication room key. Staff D needed to start her medication pass so she went to the medication room, knocked on the door to get her keys back. She saw Staff A had the skilled side tool box that had narcotics in it. Staff A stated Resident #20 wanted something for pain. She had pulled oxycodone from the box. She reported this to the ADON the day it happened, [DATE]. She also wrote a statement about this issue and put it in the Administrator's office and now the Director of Nursing (DON) has the statement. These kinds of concerns had been reported so many times. There were suspicions of Staff A being the only nursing signing out Resident #1's PRN oxycodone, back dating the time when she would sign out narcotics on days she came in late. She would sign out the narcotics when she was not even in the building at that time. On [DATE] at 12:47 PM Staff J RN stated on the first day he trained Staff A she was to start at 6:00 AM but she did not show up until about 6:45 AM. He asked what she was comfortable with and she stated she worked on the Skilled side a few times but she knew how to use their Electronic Health Record (EHR). They decided she could pass medication on Long-Term Care Hall and he would help the other staff and her when they needed help. He stated there was a 15-minute window when he was not around her while she passed medications. Staff A started with Resident #3 but he was not sure if it was the day they changed her wound vac or not. Staff A signed out in the narcotic book that she had administered Resident #3's oxycodone but she never got in the drawer in the medication cart to get the medication out. From that point he did not leave her alone. He watched her whole medication pass and any time there was a schedule medication given other than a narcotic, Staff A would get in the narcotic drawer but when it was a PRN oxycodone, she did not get in the narcotic drawer. When asked if she said anything to her, he stated he did not, it was not his place. He felt this was to be handled by management. He stated he let the on-call person know his concerns via text. On [DATE] at 7:40 AM he sent a text to the Staff O Scheduler/CNA/CMA who was on call. He sent, I don't know about this nurse. Staff O replied, I know. Staff J then sent, like I'm watching her like a hawk and there's some questionable things happening. I won't let her out of my sight so she can't lie, but someone needs to come double check that I am not crazy so she can't say I set her up. Staff O said, I understand completely. Staff J then sent, it's nothing on you, I just feel like I can't leave her to do anything alone. He stated no one from management talked to him about his concerns. Later that day, he noticed Staff A had back charted when she gave residents their oxycodone. She did not get in to work until about 6:45 AM that day and she was signing out medications as being given at 6:15 AM. On [DATE] at 8:55 AM the Scheduler stated when she received that text on [DATE] she stated staff are always saying stuff about new staff when they first start. She felt it was a personnel issue, did not think too much of it. On [DATE] at 11:02 AM the ADON acknowledged she did not look in to the concerns about Staff A further when Staff D came to her. On [DATE] at 12:10 PM the DON stated in regards to the concerns brought to the ADON's attention from Staff D, she was informed they investigated the time the medication was signed out but nothing further. When the resident stated she did not receive the medication that Staff A pulled, but was later found on the medication cart next to her cup; this should have been looked in to further as well. She indicated she was just informed that Staff J had notified the Scheduler via text message his concerns with Staff A during her training shifts. She acknowledged this should have been looked into further. The DON indicated she was not aware of the note Staff DD had sent to the HR department. When the DON completed the self report in regards to Staff A signing out Resident #3's oxycodone as given but the resident denied receiving the medication, she only interviewed Resident #3. The other residents where they found concerns on their count sheets were not interviewed based on their low BIMs scores, were deceased , or discharged . She felt someone from the State Agency would be here to complete an investigation. She denied interviewing staff members as well. While completing a narcotic check they noted Resident #32 was missing 3 milliliters (mL) of hydromorphone after Staff A had signed it out as being given. She denied an investigation was completed. Review of document dated [DATE] titled, Single Contact License and Background Check documented Staff Y, Certified Nurse Assistant (CNA) had her background check completed on [DATE]. Review of undated document titled, List of New Hires Since Last Annual Survey documented Staff Y had a start date of [DATE]. Review of document dated [DATE] titled, Single Contact License and Background Check documented Staff A, Registered Nurse (RN) had her background check completed on [DATE]. Review of undated document titled, List of New Hires Since Last Annual Survey documented Staff A had a start date of [DATE]. Review of Staff R, CNA Personnel file revealed no Mandatory Reporter / Dependent Adult Abuse training or Single Contact License and Background Check completed. Review of undated document titled, List of New Hires Since Last Annual Survey documented Staff R had a start date of [DATE]. An email sent by the Administrator at 1:48 PM on [DATE] documented he was unable to locate the Mandatory Reporter / Dependent Adult Abuse training or Single Contact License and Background Check for Staff R. Review of staff personnel files for Staff F, Dietary Aide, Staff S, Cook, Staff U, Cook, Staff V, Dietary Staff, Staff W, Dietary Staff and Staff X, [NAME] did not have any Single Contact License and Background Check completed. Review of undated document titled, List of New Hires Since Last Annual Survey documented a hire date for Staff F of [DATE], Staff S of [DATE], Staff U of [DATE], Staff V of [DATE], Staff W of [DATE] and Staff X of [DATE]. On [DATE] at 11:03 AM the DON stated she would like the background checks on all the staff that would be in contact with residents on file at the facility including the kitchen staff. On [DATE] at 8:53 AM the Administrator stated the kitchen staff are employed by a contract company. The Administrator stated the employees in the kitchen were supposed to have their background check completed by the company that employed them but the company sent an email that explained the staff were all hired from the previous facility's owner. The Administrator acknowledged the facility did not have background checks completed on a significant amount of the kitchen staff at the facility. The Administrator stated the contract company was rerunning the background checks currently. Review of undated policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program documented Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to conduct employee background checks and not knowingly employ or otherwise engage any individual who has; been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on clinical record review, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to complete a thorough investigation when it was reported Staff A signed out Resident #3's oxycodone but failed to administer the medication. The facility also failed to investigate concerns brought to them from staff members related to Staff A in September and December. The facility reported a census of 28 residents.Findings include: 1.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 11 suggested mild cognitive impairment. Resident #3 did not receive a scheduled pain medication regimen; she did receive as needed (PRN) pain medications or was offered and declined. During the pain assessment Resident #3 did have pain at any time in the last 5 days occasionally. Resident #3 indicated the pain rarely the pain made it hard for her to sleep nor did it limit her day-to-day activities. The MDS documented Resident #3 rated her pain at a 4 out of 10 (zero being no pain and ten as the worst pain you can imagine). The MDS documented Resident #3 had received an opioid. The MDS documented the following diagnoses for Resident #3: stage 4 pressure ulcer of sacral region, renal failure, stroke, stage 4 pressure ulcer of right and left buttock.The Care Plan Focus Area with a revision date of [DATE] documented Resident #3 was on an analgesic medication therapy related to pain. The Care Plan directed staff to administer medications as ordered and monitor of adverse effects and monitor the effectiveness of medication. A second Care Plan Focus Area with a revision date of [DATE] documented Resident #3 had complaints of pain. The Care Plan directed staff to administer medications as ordered and monitor for adverse effects. Staff were directed to ask residents what non-medication pain relief methods have helped in the past and attempt to utilize these strategies and to notify the physician if pain management interventions are unsuccessful.Review of Resident #3's [DATE] Medication Administration Review (MAR) revealed the following orders:-Oxycodone (narcotic pain medication) oral tablet 10 milligrams (mg). Give one tablet by mouth every 6 hours needed (PRN) for pain. The medication was signed out being given by Staff A Registered Nurse (RN) on: a) [DATE] at 11:09 AM for a pain rating of 5;b) [DATE] at 9:40 AM for a pain rating of 5;c) [DATE] at 10:20 AM for pain rating of 7;d) [DATE] at 11:45 AM for a pain rating of 7.Review of Staff A's timecard for the [DATE] revealed on [DATE] Staff A closed out for lunch from 9:53 AM until 10:23 AM.Review of Resident #3's [DATE] MAR from 1/2 revealed the following orders:-Oxycodone (opioid to treat severe pain) oral tablet 10mg. Give one tablet by mouth every 6 hours PRN for pain. The medication was signed out has being given by Staff A on: a) [DATE] at 9:00 AM for a pain rating of 5, b) [DATE] at 10:00 AM for a pain rating of 6, c) [DATE] at 12:36 PM for a pain rating of 7, d) [DATE] at 7:27 PM for a pain rating of 6, e) [DATE] at 8:45 AM for a pain rating of 7, f) [DATE] at 9:48 AM and 9:07 PM for a pain 7 both times, g) [DATE] at 8:10 AM for a pain rating of 6 and at 8:01 PM for a pain rating of 7, h) [DATE] at 10:15 AM and 8:15 PM for a pain rating of 7, i) [DATE] at 8:50 PM for a pain rating of 7, j) [DATE] at 9:35 AM for a pain rating of 7, k) [DATE] at 8:40 AM and 8:39 PM with a pain rating of 7, l) [DATE] at 8:15 AM for a pain rating of 7, m) [DATE] at 9:50 AM and 8:50 PM with a pain rating of 7, and n) [DATE] at 8:49 AM for a pain rating of 7. Review of Staff A's timecard for [DATE] revealed the following:[DATE] she clocked out for lunch from 9:50 AM until 10:20 AM;[DATE] she clocked out for lunch from 9:48 AM until 10:18 AM;[DATE] she clocked out for lunch from 10:00 AM until 10:30 AM;[DATE] she clocked out for lunch from 9:50 AM until 10:20 AM.Record review revealed the following Progress Note: on [DATE] at 9:00 AM PRN oxycodone was given by Staff A for anticipatory pain related to a wound care clinic appointment. On [DATE] at 9:26 AM Resident #3 stated she has not requested a PRN pain medication for a long time. She stated staff will ask if she wants a PRN pain medication but she will tell them no. She added she felt staff would not give a PRN pain medication unless she asks for it. Resident #3 stated she is used to how her body feels and denied requesting PRN pain medication very often. Resident #3 stated her pain was under a 5 at the time of the interview. When asked if she requested a PRN medication this morning, she denied doing so and stated she would know if the nurse gave her any extra medications. On [DATE] at 9:59 AM Staff A stated she has had interactions with Resident #3 today and had voiced concerns of pain to her this morning. Resident #3 had rated her pain at a 7 and that was when Staff A stated she asked if she wanted any pain medication this morning. Staff A stated whenever a resident has a pain level of 6 to 10, she offers a pain medication. Staff A stated she does not talk to Resident #3 a lot but she seemed okay and cognitively aware. 2. According to the admission MDS assessment tool with a reference date of [DATE], documented Resident #11 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. Resident #11 received a scheduled pain medication regimen and received a PRN pain medication or was offered and declined. The MDS documented Resident #11 had occasional pain any time in the last 5 days. Resident #11 reported he rarely had pain that made it hard for him to sleep at night and occasionally had pain that limited his participation in therapy sessions and his day-to-day activities. The MDS listed the following diagnoses for Resident #11: right femur fracture and malignant neoplasm of prostate. The Care Plan Focus Area with an initiated date of [DATE] documented Resident #11 complained of plan. The Care Plan directed staff to administer medications as ordered and monitor for adverse effects and notify the physician if pain management interventions are unsuccessful.Review of Resident #11's [DATE] MAR revealed the following order: hydrocodone-acetaminophen (treatment of pain) oral tablet 5-325mg, give one tablet by mouth every 8 hours PRN for severe pain. The order had a start date of [DATE] at 10:59 AM. The order was signed out as being given by Staff A on: a) [DATE] at 8:14 AM for a pain rating of 6, at 7:20 PM for a pain rating of 6;b) [DATE] at 8:40 PM for a pain rating of 7; c) [DATE] at 11:07 AM for a pain rating of 7 and at 7:35 PM for a pain rating of 8; d) [DATE] at 8:00 PM for a pain rating of 7; e) [DATE] at 8:00 A for a pain rating of 7; f) [DATE] at 9:19 AM for a pain rating of 6 and at 8:22 PM for a pain rating 7; g) [DATE] at 8:38 AM for a pain rating of 7.On [DATE] at 9:29 AM Resident #11 was lying in bed, watching TV. He stated he has pain and its all over, it's there all the time. When he has pain, he will ask for Tylenol first but every once in a while, he will ask for something strong. When asked what that stronger medication was, he stated tramadol. Since they got the order for hydrocodone a few weeks ago, he has asked for it once but they never brought it for him. When asked if Staff A, the nurse with a boot on her foot, has ever asked if needed the hydrocodone or brought one in for him, he denied seeing her with that medication for him. He again stated he has only asked for it once but he never got it. He indicated he knows what medications he takes and would know if they put it with other medications. 3. According to the admission MDS assessment tool with a reference date of [DATE] documented Resident #32 had a BIMS score of 12. A BIMS score of 12 suggested mild cognitive impairment. The MDS documented she did not have a scheduled pain medication regimen; she did receive a PRN medication or was offered and declined it. Resident #32 reported pain occasional pain over the last 5 days. Resident #32 reported she rarely had pain that made it hard for her to sleep at night, limited her participation in therapy seasons, and did not limit her day-to-day activities. The MDS documented she rated her pain a 6 on a scale from 0-10. The MDS documented the following diagnoses for Resident #32: acute respiratory failure with hypoxia, atrial fibrillation, heart failure, and renal failure.The Care Plan does not address pain management.Review of Resident #32's [DATE] MAR reviewed the following order: hydromorphone (treatment of severe pain), give 0.25 milliliters (mL) by mouth every 1 hour as needed (PRN) for pain/shortness of breath; with a start date of [DATE]. Review of the order revealed Staff A signed out the medication as given on [DATE] at 8:32 AM for a pain rating of 6.Review of Resident #32's chart revealed a document titled Controlled Drug Report/Record/Disposition Form. The form was for Resident #32's hydromorphone 0.25mL order. It documented when the medication was delivered on [DATE] there was 15mL in the bottle. On [DATE] at 8:30 AM Staff A signed out she gave 0.25 mL with 14.75 mL remaining in the bottle. On [DATE] at 1:00 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) documented there was 11.75mL remaining in the bottle; 3mL missing.Review of the facility's investigative file revealed it lacked staff and resident interviews.On [DATE] at 12:27 PM Staff D Certified Medication Aide (CMA) stated there was an issue about a month ago when Resident #3 had her call light on and asked for something for pain. Staff D saw she got something 30 minutes prior and let her know she already had something for pain. Resident #3 denied receiving any pain medications with her morning medications. Staff D stated when Resident #3 has pain, she will ask her what she wants. Resident #3 will request Tylenol. Staff D stated Staff A is the only staff member that signs out Resident #3's oxycodone as given. Staff D stated Resident #3 would be reliable, could rate her pain on the pain scale and would be able to tell staff which pain medication she wants. She believed Resident #3 would be a good historian. Staff D stated about two weeks prior to the surveyors coming in to the building, she had passed medications on both Long-Term Care and Skilled residents. Staff A approached her wanting the keys for the medication room on the skilled side. Staff A did labs and just assumed that's why she was asking for the medication room key. Staff D needed to start her medication pass so she went to the medication room, knocked on the door to get her keys back. She saw Staff A had the skilled side tool box that had narcotics in it. Staff A stated Resident #20 wanted something for pain. She had pulled oxycodone from the box. These kinds of concerns had been reported so many times. There were suspicions of Staff A being the only nursing signing out Resident #1's PRN oxycodone, back dating the time when she would sign out narcotics on days she came in late. She would sign out the narcotics when she was not even in the building at that time. On [DATE] at 2:00 PM Staff Y Certified Nursing Assistant (CNA) stated in December she heard Resident #3 had asked for a pain pill and Staff A stated she was not eligible for one. The resident told her she had not had a pain pill all day. Staff Y stated she heard Resident #20 had requested a pain medication and it was signed out by Staff A as given. But the resident denied receiving the pain medication. Staff A then found the pain pill in a medication cup by her drinking cup. The ADON was made aware of this and told Staff A to give Resident #20 her pain medication.On [DATE] at 10:45 AM Staff H Licensed Practical Nurse (LPN) stated she has never given Resident #3 a PRN for pain. When she does her pain assessments, Resident #3 would say no. If she did have pain, she would rate it 5 of 6. She denied ever giving Resident #3 a oxycodone for pain. She added, she would never go with that medication first because she would be unsure how she would react to it. She would start with her Tylenol PRN. When she started to complain of left shoulder pain, they got orders for a PRN cream/gel but would always start with Tylenol when she needed/requested something for pain.On [DATE] at 12:47 PM Staff J RN stated on the first day he trained Staff A, she was passing medications on the Long-Term Care side of the building. When she went to pass Resident #3 her morning medications and Staff A signed out her oxycodone. He was not sure if it was the same day they did her wound vac change but she never took oxycodone. Resident #3 always said Tylenol was enough. That morning Staff A signed out the medication in the narcotic book but never got in the drawer on the medication cart to retrieve the medication. From that point on he did not leave her alone while passing medications. The same thing happened with Resident #1; Staff A signed out the oxycodone medication but did not see her give the medication to the resident nor did he see her get in the drawer to get the medication out. He noticed any other medication that required to be signed out in the narcotic book, she obtained the medication and administered it to the resident, except the oxycodone. Staff J stated Resident #1 was [AGE] years old and with the amount of oxycodone Staff A had signed out as being given to her, one would think that resident would be sedated but when you would assess her, she was awake and fine.On [DATE] at 10:05 AM Staff DD LPN laughed when asked if Resident #3 experienced a lot of pain. She stated no, every once in a while, but not all the time. She would usually give her Tylenol or her PRN gel if she did have pain and when she would follow up for effectiveness it would help. When she did have pain, she would report pain to her left shoulder or her neck and back some times; rating it between 3 and 6. Staff DD stated Resident #3 had not asked for anything stronger and she would always offer Tylenol first. She indicated when she would come in for her 2:00 PM-10:00 PM shift after Staff A worked, Resident #3 would ask for a Tylenol, Staff DD stated Resident #11 has scheduled Tylenol. This morning, he rated his pain at a 3 and asked him to let her know if he would need anything for pain. She denied ever giving him his hydrocodone. She has noted his pain is more when he is in bed, which is rare because he sits in his recliner a lot. There was one time when the narcotic count was off. She had Staff A call Staff P Assistant Director of Nursing (ADON) to figure it out before Staff A left the building. Staff A had them document the correct count on the narcotic count sheet. Staff DD indicated Staff A would always complain about picking up extra hours and hurting. Staff DD stated there was a letter sent to the Human Resource Staff in December.On [DATE] at 10:21 AM Staff DD shared the document she provided to the Human Resource Staff in December. It documented staff had noticed that narcotics are being given to residents multiple times a day to residents who never ask for pain medications. There have been multiple count corrections and there have never been issues with narcotics prior to their new employee.On [DATE] at 8:55 AM the Scheduler stated when she received that text on [DATE] she stated staff are always saying stuff about new staff when they first start. She felt it was a personnel issue, did not think too much of it.On [DATE] at 11:02 AM the ADON stated they noticed around November-ish that Staff A was giving Resident #1 and Resident #3 their PRN pain medications a lot. She did talk with Staff A about this; with her history, heard of her not giving those medications after signing them out. Staff A told her she is the only one that cared about the residents, when she assessed them and asked for pain medication should it give it to them. The ADON stated she believed her and she regrets it after looking at the issues deeper. While completing spot checks she would talk to Resident #3. The resident stated she would not receive a PRN all the time but acknowledged she asked a couple of times for something for pain. The ADON did not specifically ask what she requested. She just asked if she was in pain and if she received something for it; she answered yes to both questions. The ADON also spoke with Resident #1 and would ask if she was hurting. Resident #1 would say yes or no but would not recall if she received anything or not. She was looking at the narcotic book once a week and did notice Staff A gave a lot pain medication. She noticed this around November. The ADON acknowledged she did not look in to things further. She believed Staff A was giving the medications she signed out and should have looked further in to things. When asked about the concerns brought to her from Staff D she felt the concern was falsifying the time but was able to get that figured out after looking at the handwriting closer. The ADON stated she did see the medication in the medication cup that Staff A found on the medication cart next to her water bottle. She did acknowledge they are not to have medications left on the medication cart, but she watched Staff A administer the medication that was requested by the resident. It was a red flag to her that Staff A walked right passed the resident's room with the medication to set it on the medication cart. She questioned why she did not administer the medication as walked passed the resident's room, Staff A said she had to go to the bathroom. She did not look further in to this either, she took it as it was. She believed they could have handled the accusations better. On [DATE] at 12:10 PM the DON stated she started at the facility on [DATE]. The DON stated she was just alerted of Staff D's concern about pulling a pill out of the narcotic box in the medication room on the skilled hall. The DON said her understanding was they have a medication aide passing medications, so why was Staff A doing that. When she went in there Staff D did not think anything of it because Staff A would draw blood and that's where the supplies were located. When Staff D knocked on the door to get the medication cart keys back, she saw Staff A pulling a medication out of the box. The ADON pulled the keys and went to talk to the resident the medication was for. The resident stated she did not receive the pill, so she went to Staff A about this. Staff A stated it was in the medication cart, she had set the pill in a medication cup and put it in the cart drawer. When they opened the drawer on the medication cart there was no cup with a pill in it. Staff A then found the medication cup with the pill in it on top of the medication cart next to her water bottle. She immediately took the pill to the resident. After this happened, they did not let allow Staff A to hold the narcotic keys. She was told she would need to ask the other nurse or CMA if she needed to give a narcotic. Staff A came in to her office bawling, told her it was embarrassing that she did not have her narcotic keys. The DON stated in regards to the concerns brought to the ADON's attention from Staff D, she was informed they investigated the time the medication was signed out but nothing further. When the resident stated she did not receive the medication that Staff A pulled, but was later found on the medication cart next to her cup; this should have been looked in to further as well. At that time the DON stated she did not know about Staff A's previous issue with taking narcotics at her two previous jobs. The Administrator told her to keep an eye on Staff A, so they allowed her to have the keys back. The DON was not aware of the note that Staff DD typed up. The DON was asked to discuss the missing hydromorphone. Staff A had signed in the medication as received it at the facility. Hospice had ordered the medication for the Resident #32. Staff A had signed out the medication as being given on [DATE]; 0.25mL given. That was the only person that signed out the medication. The liquid medication came as 15mL in a bottle. There should have been 14.75mL after Staff A documented she administered 0.25mL. Staff A documented 14.75mL remained but when they did a check on all narcotics on [DATE], they noticed there was 11.75mL left; noting 3mL was missing from the bottle. The DON stated since Staff A has been out of the building Resident #3 has only been getting Tylenol for pain and has been fine. She indicated she was just informed that Staff J had notified the Scheduler via text message his concerns with Staff A during her training shifts. She acknowledged this should have been looked into further. The DON indicated she was not aware of the note Staff DD had sent to the HR department. When the DON completed the self-report in regards to Staff A signing out Resident #3's oxycodone as given but the resident denied receiving the medication, she only interviewed Resident #3. The other residents where they found concerns on their count sheets were not interviewed based on their low BIMs scores, were deceased , or discharged . She felt someone from the State Agency would be here to complete an investigation. She denied interviewing staff members as well. While completing a narcotic check they noted Resident #32 was missing 3 milliliters (mL) of hydromorphone after Staff A had signed it out as being given. She denied an investigation was completed.On [DATE] at 1:12 AM during the exit conference with the facility, the Administrator stated he was unaware of the text that was sent from Staff J to the Scheduler in September. He also stated he was unaware of the letter Staff DD sent to the Human Resource Staff. On [DATE] at 1:57 PM Staff A stated on the day she was asked to leave the facility Resident #3 told Staff D CMA that she needed something for pain on [DATE]. When she was told Resident #3 denied asking for and receiving a pain pill on [DATE] she stated the resident was confused because she asked her for a pain pill. When asked if Resident #11 ever asked for a pain medication when she worked, she stated he definitely did get pains pills when he asked for them. Staff A was asked to talk about Resident #3's pain and relief regimen. She stated the resident's pain was always moderate to severe in her shoulders or back, basically her full body; just hurt everywhere. They would try a gel to her shoulders but the resident would still complaint of pain. When asked why Tylenol was not tried first, Staff A stated if the resident's pain was rated at a 7 or above, she would give her oxycodone. Anything below that she would give Tylenol. Staff A added it got to the point where she was routinely giving Resident #3 her oxycodone. When asked what that meant, Staff A stated she would pretty much give it to her without asking. She would give pain medications prophylactically. When asked about Resident #11's pain and relief regimen she stated he had right hip and knee pain that he would rate between a 6 and 7. She indicated he received routine Tylenol was not working so she would give him his hydrocodone and it was somewhat effective. Staff A was shown the MARS for Resident #3 and #11, with her consistently signing out the medication. She acknowledged she could see that it would be concerning. Then stated the other nurses at the facility are hesitant to give the narcotics. But with her trauma background, they always gave pain medications. She again stated she gave the pain medications prophylactically, even if the residents did not ask for it. She then stated she did not do this all the time. Staff A was informed the other nurses at the facility reported Resident #3 and #11 not having enough pain for them to give them a narcotic routinely. Staff A stated everyone was getting those medications prior to her starting. Staff A was also informed Resident #3 and #11 have not been receiving them since she was terminated. She stated when she worked at the trauma unit at the hospital, they always gave people pain medications. Staff A stated Resident #3 and #11 asked for their pain medications, when she was told these residents both denied asking for their pain medications as frequently as they were signed out as being given. Staff A was also informed that Resident #3 was interviewed on [DATE] roughly 40 minutes after she signed out her oxycodone as being given. Resident #3 denied asking for her oxycodone, as well as stating she never received a pain medication that morning. Staff A stated she asked for a pain pill, she gave it then the resident asked 10 minutes later for something for pain. She was confused that day and is at time. Staff A denied ever signing out a resident's narcotic medication and taking it for herself. She indicated she would never take pain medications from a patient in need.The facility provided a document titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The policy statement included: residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:facility staff;

Based on observations, record review, staff and family interviews, and facility policy review. The facility failed to provide oral cares for 5 of 5 residents (Resident #22, #2, #3, #29, and #30) reviewed and also failed to provide toileting and repositioning for Resident #29. The facility reported a census of 28 residents. Findings include:1.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 10/31/2025 documented Resident #22 had a Brief Mental Status (BIMS) score of 4. A BIMS score of 4 suggested severe cognitive impairment. The MDS documented the resident required substantial/maximal assistance with oral hygiene. Resident #22 had the following diagnoses listed: multiple sclerosis, neurogenic bladder, dementia and depression. The Care Plan Focus Area with a revision date of 11/18/2020 documented Resident #22 had activities of daily living (ADL) self-care performance deficit due to her multiple sclerosis diagnoses and required the assistance of one staff for daily grooming (personal hygiene and oral care). On 1/20/2026 at 10:30 AM observed a sign on top of her heating/cooling unit. A hand written note was present that stated please brush Resident #22's teeth every day. On 1/20/2026 at 11:15 AM Resident #22's emergency contact #1 stated sometimes her teeth are not brushed much. She has noticed this a lot when she visits. When asked if Resident #22 would refuse her teeth be brushed, she indicated the resident would allow staff to complete oral cares on her. On 1/22/2026 at 8:25 AM Resident #22 was asked if staff brushed her teeth this morning, she stated not today. On 1/27/2026 at 11:02 AM the Director of Nursing (DON) was informed of the sign in Resident #22's room informing staff to brush her teeth every day. She stated that has not been brought to her attention and she has not been in her room. She indicated oral cares should be completed at least twice a day. When asked who is to complete this task, she indicated ideally the Certified Nurses Assistants (CNA) but nurses or anyone on the clinical team could complete oral cares. She added if the resident is receiving occupational therapy (OT) oral care can be completed with them as well. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS indicated Resident #2 required supervision or touching assistance from staff for oral hygiene. Review of Resident #2's EHR documented no documentation of oral care provided. On 1/12/26 at 11:21 AM Resident #2 stated she does have a toothbrush in her bathroom. Resident #2 stated it does depend on the staff if oral care was provided. Resident #2 stated her husband came to the facility in the evenings and would help her with brushing her teeth. Resident #2 stated in the morning if she was going to therapy she would be in the wheelchair and would go to the bathroom. Resident #2 stated Occupational Therapy used to help her but she no longer saw OT. Resident #2 stated occasionally a Certified Nurse Assistant (CNA) would assist her with oral care. Review of Resident #2's Electronic Health Record (EHR) titled, Care Plan with initiation date of 12/5/25 documented Resident #2 required an assist of 1 staff for oral care. 3. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS indicated Resident #3 required partial / moderate assistance with oral hygiene. On 1/13/26 at 4:11 PM Resident #3's son stated his mother would require staff to complete oral care for her because she can not get out of bed by herself. Review of Resident #3's EHR titled, Care Plan with initiation date of 4/12/25 documented Resident #3 required an assist of 1 staff for oral care. Review of Resident #3's EHR documented no documentation of oral care provided. On 1/12/26 at 10:49 AM an observation revealed no toothbrush in Resident #3's room. On 12/26/26 at 1:00 PM an observation of Staff P, Assistant Director of Health and Wellness / Assistant Director of Nursing (ADON) entered Resident #3's room, looked for a sponge dental swab or a toothbrush. On 12/26/26 at 1:05 PM Staff P acknowledged there was no equipment in Resident #3's room to provide oral care. On 1/12/26 at 12:17 PM Staff C, CNA stated the staff provide oral care to the residents. Staff C stated she completed oral care with Resident #3 that morning. Staff C stated she gets Resident #3 a new toothbrush everyday because she does not know what happened to the toothbrush the day prior. Staff C stated she offers Resident #3 a basin and toothbrush and Resident #3 did her own brushing. Staff C stated she Resident #3 only required set-up only according to the care plan. 4. The Minimum Data Set (MDS) dated [DATE] documented Resident #29 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. MDS documented Resident #29 required supervision or touching assistance for oral hygiene. Review of Resident #29's EHR titled, Care Plan documented an intervention / task for oral care dated 11/19/25 that Resident #29 required an assistance of one for oral care. Review of Resident #29's EHR documented no documentation of oral care provided. On 1/15/26 at 1:30 PM Resident #29 stated she had to set an alarm on her phone to ensure the staff come to turn her every 2 hours or the staff will not reposition her. Resident #29 stated her doctor wants her repositioned every 2 hours. Resident #29 stated prior to going to the hospital the staff were not repositioning her every 2 hours some overnight shifts the staff would only come in at 3:00 AM or 4:00 AM to reposition her in bed. Resident #29 stated she had multiple sclerosis and was not able to reposition herself in bed. Resident #29 stated she required the assistance of staff for repositioning. Resident #29 stated the staff rarely provided oral care to her. Resident #29 stated she would like oral care but felt like she should be able to do it on her own but she could not even sit up in bed on her own. Resident #29 stated she would appreciate staff assisting with oral care. On 1/22/26 at 11:29 AM Resident #29 stated she was told last night by Staff EE, Certified Nurse Assistant (CNA) refused to change her brief. Resident #29 stated she was out of briefs and Staff EE refused to change her last night. Resident #29 stated she had not had a bowel movement but was incontinent of urine and nobody changed her at all last night. Resident #29 stated the Staff EE only repositioned her at night but never changed her. Resident #29 stated she has had problems with Staff EE from the get go. Resident #29 stated Staff EE was not supposed to be caring for her because she had voiced concerns about how she cared for her in the past. Resident #29 stated Staff EE treated her undignified. Resident #29 stated she did not feel like Staff EE had provided her with the appropriate dignity or respect when requesting to be cleaned up and change her brief. Resident #29 stated she had told Staff R, CNA the concerns she had with Staff EE. Resident #29 said she thought Staff EE told Staff P, Assistant Director of Nursing (ADON) about the concerns with Staff EE. 5. The MDS dated [DATE] documented Resident #30 had a BIMS of 13 indicating no cognitive impairment. The MDS documented Resident #30 required substantial / maximal assistance for oral hygiene. Review of Resident #30's EHR titled, Care Plan documented an intervention / task for oral care dated 12/3/25 that Resident #30 required an assistance of one for oral care. Review of Resident #30's EHR documented no documentation of oral care provided. On 1/20/26 at 1:05 PM Resident #30's daughter stated frequently she would come to the facility at random times and would have food on her mother's face and mouth. Resident #30's daughter stated it looked as though her mother's teeth had not been brushed. On 1/12/26 at 12:49 PM Staff P stated Resident #29 did not want Staff EE or RR in her room because they were talking about their own lives and another resident down the hall. Staff P stated Resident #29 thought it was disrespectful for them to talk about other residents in her room. Staff P stated it was an expectation that all residents receive oral care even if the resident does not have teeth. Staff P stated if the resident had dentures they should be cleaned or soaked overnight. On 1/12/26 on 1:09 PM the DON stated oral care should be completed or offered and documented if refused. The DON explained assistance the resident required should be on their care plan as well. On 1/21/26 at 8:11 AM Staff R, CNA stated if the resident is cognitive she would ask if the resident wanted their teeth brushed before or after the meal. Staff R stated if the resident was not cognitively aware she would complete the oral cares before breakfast. Staff R stated she frequently found residents with food on residents faces and hands not cleaned from dinner. Staff R stated she had brought it up to the management at the facility. On 1/27/26 at 11:03 AM the DON stated oral care should be completed twice a day ideally by CNA or the nurses if the CNA's are too busy. Review of undated policy titled, Oral Care documented the purposes of the procedure was to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. Review the resident's care plan to assess any special needs of the resident. Assemble the equipment and supplies as needed. The following information should be recorded in the resident's medical record: The date and time the mouth care was provided. The name and title of the individual(s) who provided the mouth care. All assessment data obtained concerning the resident's mouth. The certified nursing assistant should report to the licensed nurse to record in the medical record. Complaints of pain or discomfort of mouth. The certified nursing assistant should report to the licensed nurse to record in the medical record. If the resident refused the treatment, the reason(s) why and the intervention taken. The signature and title of the person recording the data.

Based on facility document review, Facility Assessment review and staff interviews the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff on duty at the facility trained in cardiopulmonary resuscitation (CPR) at all times. The facility reported a census of 28 residents.Findings include: On [DATE] at 11:03 AM the DON stated there was nothing available for CPR certification on any staff at the facility. The DON explained there was no list for CPR certified staff and no way Staff O planned 24 hour CPR coverage at the facility. The DON stated Staff O thought as long as a nurse was present that nurse was CPR certified. The DON stated she expected the facility would have a list of CPR certified staff to ensure appropriate coverage. On [DATE] at 11:11 AM Staff P stated the facility did not have any CPR list when she was the interim DON from [DATE] - [DATE]. Staff P stated there was no list for CPR certified staff when she was the interim DON and CPR coverage was not being assessed 24 hours a day at the facility. Review of facility staff schedules for [DATE] - [DATE] revealed no CPR coverage for 283 shifts.On [DATE] at 10:50 PM Staff O, Certified Medication Assistant (CMA) / Certified Nurse Assistant (CNA) / Scheduler stated had worked as the scheduler for the facility since September of 2025. Staff O explained she had very little training prior to entering into the position. Staff O stated she was not aware of any required CPR coverage in the building. Staff O stated she does not develop a schedule to have RN coverage. Staff O stated when she developed a schedule she was unaware any CPR coverage was required. Staff O stated the facility did not have a CPR certification list prior to survey team request. On [DATE] at 10:15 AM Staff J, RN stated the facility had not asked for his CPR certification until [DATE].Review of document titled, Facility Assessment documented staff training/education and competencies considerations to describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. List (or refer to or provide a link to) all staff training and competencies needed by type of staff. Consider if it would be helpful to indicate which competencies are reviewed at the time the staff member is hired, and how often they are reviewed after that. Staff competency review competency-based evaluations of staff knowledge and skills required to maintain or improve residents' physical, functional, mental, and psychosocial well-being. Evaluate competency levels among employees, contract staff, and volunteers to meet professional standards of practice. Training programs that evaluate the facility's training program to ensure alignment with needs identified in resident assessments and regulatory standards. Assess training adequacy for new and existing staff, managers, nursing, and direct care staff, contractors, and volunteers.

Based on observation, clinical record review, interviews and policy review the facility failed to protect residents from possible accidents and injuries for 4 of 12 residents (Residents #7, #41, #2 and #3) reviewed. The facility failed to protect residents when dependently pushed in manual wheelchairs (w/c's) without the use of footrests and using only 1 staff member with the use of dependent non-weight bearing mechanical lifts. Additionally the facility failed to protect the residents from possible scalding injuries with water temperatures above the recommended temperature range for burn prevention. The facility reported a census of 28 residents. Findings include:1. Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive deficit. The resident utilized a manual w/c with partial/moderate assistance. The document disclosed diagnoses including chronic kidney disease, nonrheumatic aortic valve stenosis, unspecified osteoarthritis. The resident's Care Plan dated 1/7/26 disclosed a focus area of requiring assistance with activities of daily living (ADLs) revised 4/23/24. Interventions for staff included manual w/c for mobility with assistance of 1, transfers with a sit to stand lift with staff assistance of 2 and dressing and bathing with maximal assistance of 1. On 1/21/26 at 7:10 AM observed Staff I, Certified Nursing Assistant (CNA), push Resident #7 without w/c foot pedals down 2 hallways from the resident's bedroom until stopped at Staff H's, Licensed Practical Nurse (LPN)/MDS Coordinator/Infection Preventionist office. Staff H directed Staff I that she had passed the shower room and needed to go back the other direction. Staff A, Registered Nurse (RN), was also present at Staff H's office. Staff A followed Resident #7 and Staff I down the hallways to the shower room. The total distance the resident traveled through the facility was 240' or ¾ of a football field. The facility failed to stop the transport of Resident #7 in a w/c without footrests. On 1/21/26 at 7:48 AM Staff H stated she hadn't noticed Resident #7 did not have footrests on her w/c. The staff stated residents must have footrests on the w/c prior to being pushed. 2. Resident #41's MDS dated [DATE] revealed a BIMS score of 3/15 indicating severe cognitive impairment. The document disclosed the resident was dependent on staff for the use of a manual w/c. The document provided the resident had diagnoses including acute kidney failure, high blood pressure, and diabetes mellitus. The resident's Care Plan dated 1/20/26 provided a focus area for ADL assistance revised on 1/10/26 with staff interventions for use of manual w/c with assistance of 1 and transfers with assistance of 1 using a gait belt dated 1/12/26. On 1/20/26 at 1:04 PM observed Staff E, CNA, push Resident #41 from the dining room to the living room meeting 1 unidentified staff member in the hallway. Observed the resident's feet to be dragging on the floor during the dependent mobility. The distance traveled was approximately 75'. The facility failed to ensure the resident's feet were on footrests while being transported in a w/c. On 1/21/26 at 2:22 PM Staff J, Registered Nurse (RN), stated a resident must have footplates prior to being pushed in a w/c. On 1/22/26 at 12:27 PM Staff D, Certified Medication Aide (CMA), stated residents' feet must be on the foot pedals prior to pushing them in their w/c's. On 1/27/26 at 9:28 AM Staff G, Certified Occupational Therapy Assistant (COTA), stated residents should have their feet on footrests prior to being pushed. On 1/27/26 at 11:01 AM the Director of Nursing (DON) stated she expected that residents have their feet on footrests, dignity bags if necessary, clean appearance, dressed and/or covered prior to being pushed in a w/c. The DON stated she would expect any staff, especially a Charge Nurse or someone on the Leadership Team, to step in to stop w/c dependent mobility if the resident's feet were not on footrests. On 1/28/26 at 11:14 AM during an interview with the Administrator and DON, the Administrator acknowledged footrests should be in place prior to pushing a resident in a w/c. The DON stated during the Nurse Meeting on the previous day she started training on a w/c policy. On 1/29/26 at 11:13 AM the Administrator provided the facility did not have a policy related to w/c safety and use. On 1/29/26 at 11:50 AM when asked for clarification about the w/c policy that was referenced by the DON that was being trained, the Administrator stated he had not reviewed that policy and wanted to read through it first. 3. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #2 was dependent on staff for the chair to bed transfer and required the staff to do all of the effort. Resident #2 does none of the effort to complete the activity or the assistance of 2 or more staff is required for the resident to complete the activity. Review of Resident #2's EHR documented Resident #2 required a full body mechanical lift with the assistance of 2 staff. On 1/12/26 at 11:21 AM Resident #2 stated she was required to use a full body mechanical lift for transfers. Resident #2 stated it depended on the staff as to how the full body mechanical lift was utilized. Resident #2 stated some staff use 1 staff but most staff use 2 when they transfer her. Resident #2 stated she has been a nurse for 30 years and knows there should be 2 staff when a resident was transferred in a full body mechanical lift. Resident #2 stated she would tell the staff to get a second staff for the full body mechanical lift and the staff asked her if she didn't trust the staff. Resident #2 stated she told the staff it was not that she did not trust them but what if the sling breaks? Resident #2 explained she was worried she would end up on the floor. Resident #2 stated it did worry her when she was being transferred. 4. The MDS dated [DATE] documented Resident #3 had a Brief BIMS of 11 indicating moderate cognitive impairment. The MDS documented Resident #3 was dependent on staff for the chair to bed transfer and required the staff to do all of the effort. Resident #3 does none of the effort to complete the activity or the assistance of 2 or more staff is required for the resident to complete the activity. On 1/12/26 at 10:49 am Resident #3 stated she does not like to use the full body mechanical lift. Resident #3 stated she grabs the staff around the neck and the staff place her in the wheelchair. Resident #3 stated she did not remember when the staff last used a full body mechanical lift to transfer her. Resident #3 stated the staff will wheel the full body mechanical lift into her room but they decide not to use it. On 1/8/26 at 5:22 PM Staff BB stated when he was trained the staff told him that the lift was based on the manufacturer's recommendations and they were able to utilize the full body mechanical lift with only one person. Staff BB stated he reported the incident to Staff MM, Licensed Practical Nurse (LPN) and did not think anything became of it. On 1/12/26 at 12:37 PM Staff A, Registered Nurse (RN) stated occasionally she will be asked to help with full body mechanical lift transfers but not very often. Staff A stated she had seen staff transfer residents that required a full body mechanical lift with only one staff. Staff A stated she always reeducated the staff to request help and she would be able to help. Staff A stated all the staff do it all the time. Staff A stated she frequently saw Staff RR, Certified Nurse Assistant (CNA) and Staff JJ, CNA transfer residents that required a full body mechanical lift with only one staff. On 1/12/26 at 1:09 PM the DON stated every mechanical lift at the facility required 2 staff to utilize for resident transfers. On 1/14/26 at 1:51 PM Staff MM, RN stated there were a couple staff that she had to remind they needed 2 people to transfer residents with a full body mechanical lift. Staff MM stated there were reports from other staff that so and so was in the room transferring by themselves with a full body mechanical lift. Staff MM stated Staff BB came to her about a complaint that staff were not helping him with full body mechanical lift transfers. On 1/21/26 at 7:52 AM Staff R, CNA stated staff are not supposed to transfer residents with full body mechanical lifts alone but when a nurse will not help she has to transfer with only one staff. On 1/28/26 at 2:04 AM a review of a document titled, Water Temperature logs documented on 1/27/25 water temperature in resident room on a-hall 122, b-hall 121, rehab hall 122 and laundry 145. On 2/26/25 water temperature in resident rooms on a-hall 121, b-hall 121, rehab hall 122 and no water temperatures taken in laundry. On 3/25/26 water temperature in resident rooms on a-hall 122, b-hall 122, rehab hall 122 and no water temperatures taken in laundry. On 4/22/25 water temperature in resident rooms on a-hall 121, b-hall 122, rehab hall 122 and no water temperatures taken in laundry. On 5/20/25 water temperature in resident rooms on a-hall 122, b-hall 122, rehab hall 119 and no water temperatures taken in laundry. 6/18/25 water temperature in resident rooms on a-hall 121, b-hall 120, rehab hall 120 and no water temperatures taken in laundry. On 7/18/25 water temperature in resident rooms on a-hall 122.4, b-hall 121.9, rehab hall 122.3 and laundry 140.1. On 8/22/25 water temperature in resident rooms on a-hall 122, b-hall 121.4, rehab hall 122.3 and laundry 139.7. 9/26/25 water temperature in resident rooms on a-hall 121.9, b-hall 122.1, rehab hall 122 and laundry 143. On 10/21/25 water temperature in resident rooms on a-hall 122.3, b-hall 121.4, rehab hall 120.7 and laundry 120.2. On 11/14/25 water temperature in resident rooms on a-hall 122.4, b-hall 122.6, rehab hall 123.2 and laundry 144.5. No water temperatures obtained since 11/4/25. On 1/28/26 at 2:04 PM Staff Z, Director of Plant Operations explained it was probably his job to review the temperatures every month but he did not. Staff Z acknowledged he did not know what water temperature was too hot for resident rooms or for resident showers. Staff Z explained he was unaware of appropriate water temperature for the facility high or low. On 1/29/26 at 10:27 AM the DON said 124 degrees for resident room water temperatures was a little too hot. The DON explained she was not sure what the temperature should be to prevent burns or the timeframe as to when a burn would occur. On 1/28/26 at 2:56 PM the Administrator stated he was not a temperature expert and could not speak to the appropriate temperature of water for the shower or resident rooms off the top of his head. The Administrator stated it would be good if Staff Z was trained in the appropriate water temperatures for resident use but was not sure if Staff Z had ever been trained in the appropriate water temperatures for resident use. No policies presented for appropriate water temperatures for resident rooms and shower rooms, full body mechanical lift use or transportation of residents in wheelchairs.

Based on observations, clinical and facility record review, and staff and Climatologist interviews, the facility failed to provide adequate nursing supervision and assistive devices to mitigate a resident's risk for elopement (when a cognitively impaired resident leaves the facility without staff awareness or permission) for 1 of 2 residents reviewed (Resident #2). On 12/1/22, sometime between 1:30 and 1:40 PM, Resident #2 exited the building wearing a long sleeve shirt, long pants, and gripper socks (no shoes). The resident demonstrated severe cognitive impairment with a history of wandering and prior elopement attempts. Staff reported the exit doors did not alarm and they were not aware Resident #2 had left the building until a staff member observed the resident standing outside an exit. Although the resident wore a wanderguard bracelet, she had successfully exited through a push-activated emergency exit door that did not alarm. The staff immediately escorted the resident back inside with no injury noted. The temperature was 46 Fahrenheit (F) with a 38 degree wind chill and no precipitation. This failure put the resident at risk of harm or severe injury due to cold weather, no shoes or coat, and a history of falls. The facility was notified on 1/19/23 that Resident #2's elopement on 12/01/22 was considered an Immediate Jeopardy (IJ) situation. However, the facility provided sufficient evidence to show that they had removed the IJ situation later that day (12/1/22) by re-educating staff regarding door alarms and elopement, ordering a lock box for the door deactivation key, limiting key access to 1 management staff person per day until the box arrived, and implementing more frequent door alarm audits. Since the facility corrected the IJ prior to the Department's survey entrance, this incident was considered an IJ past non-compliance incident. Thus, the facility was found in substantial compliance at the conclusion of the investigation. The facility reported a census of 28 residents at the time of the survey. Findings include: The Minimum Data Set (MDS) assessment tool dated 10/14/22, documented Resident #2 did not speak and was rarely/never understood. The MDS documented the resident displayed severely impaired cognitive skills for daily decision making, exhibited physical behaviors and engaged in wandering. The MDS revealed she required extensive assist of 1 staff for dressing, toilet use and personal hygiene, minimum assist of one staff for bed mobility and transfers, required supervision of one person when walking. The MDS identified she had diagnoses that included peripheral vascular disease, dementia, diaphragmatic hernia, and pulmonary hypertension. The MDS also identified she experienced 1 fall since the last MDS assessment and a wander/elopement alarm used daily. The Care Plan dated 11/15/21 documented Resident #2 showed a self-care deficit related to confusion and dementia. The Care Plan documented Resident #2 transferred and walked with her walker independently but forgot her walker at times. The Care Plan directed staff to provide cues if the resident did not use her walker. The care plan dated 11/17/21 documented the resident as at risk for falls and elopement due to wandering, with an actual elopement which occurred on 12/1/22. The care plan directs staff to provide the following interventions: -Check wanderguard battery function and placement every shift and as needed (PRN) and redirect the resident when wandering or exit seeking. -Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and/or book. -Monitor for fatigue and weight loss. -Offer food or snacks. -Offer to take to a scheduled or planned activity. The Elopement Prevention facility policy dated 2/19/21 included the following information: Key Term: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any unnecessary supervision to do so. Procedure: - Door locks or alarms will not be considered a replacement for necessary supervision and associates must be vigilant in responding to alarms in a timely manner. - All associates will ensure that exit alarms are responded to immediately. - If for any reason door alarms must be turned off, the associates will continually monitor the door(s) until the door alarm is fully functioning again. - If door alarms, an investigation is needed to determine who triggered the door alarm, at what time, and for what reason. An Elopement Risk Assessment form dated 10/8/22 documented Resident #2 as at high risk for elopement. Observation on 1/17/23 at 12:55 PM revealed doors GP16 and GP24 alarms activated. Both doors' alarms sounded and alerted staff. Further observation revealed a small black box on the wall next to door GP24 with a keypad on it. The Director of Nursing (DON) identified it as the lockbox they purchased after the 12/1/22 elopement to house the key to re-alarm the doors. She stated if a resident exits the building and sets off the door alarms, the nurse needs a key to reset them by calling the on-call manager to obtain the code to open the box and use the key to reset the door alarm. She added that the door code is then reset and nobody has the key except select management personnel. Observation on 1/17/23 at 1:10 PM revealed the facility sat approximately 50 yards from country side with many steep hills and a busy highway with a 55 mile per hour speed limit to the north, approximately 100 yards away. On 1/18/23 at 12:38 PM the DON stated the resident exited the facility on the day shift 12/1/22 right after lunch. She stated the door did not alarm so staff did not know she left until Staff B in maintenance saw her outside; he escorted the resident into the building and alerted staff. The DON reported she interviewed all staff and found that an aide had cared for her right before that, so the resident was not out for very long. She stated she checked all the door alarms and they were all sounding except for door GP24 - the hall where Resident #2 resides. She stated during her investigation she determined the last time the doors had been activated was the day before on 11/30/22 when a resident tried to get out. She added Staff A was the nurse on duty and she told her she re-activated the door alarms. The DON speculated Staff A did not activate them and that is how Resident #2 exited undetected on 12/1/22. She stated when the doors are opened they have to be re-set with a key. The facility purchased a lockbox for the key and placed it on the wall next to door GP24 - the door where the residents that wander reside. The DON reported when the doors are activated, the door alarm will now sound until they are reactivated. She said the nurse has to call the manager on-call and they will give them the code to open the lock box and reset the door alarm. She stated the managers are to stay on the phone and listen for a double chirp and that sound means the door is reset. She added management then resets the lockbox code. On 1/18/23 at 1:56 PM the Staff B stated on 12/1/22 at around 1:40 PM he was walking up Grace Point (GP) hall and when he got halfway up the hall he noticed Resident #2 outside door 16 with her walker and yelled for the nurse for help. He said he then got his keys out to deactivate the door and noticed the door was not alarmed so he held it open for the nurse to bring the resident in. He stated she was not injured as far as he could tell, just confused and that she came in without any problems. He continued that he checked the other doors and door 24 was not activated either, which meant anyone could have pushed the bar and walked out of the facility. He stated he does not know why the doors were not alarmed because both of them are to be alarmed at all times, and someone would have had to use a key to turn off the door alarms. He reported when you hear a quick couple of beeps, you know the door is reset. Staff B added that prior to this time, med aides and charge nurses were the only ones to have a key prior to this. After the elopement, the facility purchased a locked key box and it has solved the problem. The key is now only kept in the lockbox, and once the doors are activated the alarm will sound until the nurse calls, gets the code for the lockbox, and resets the doors. On 1/18/23 at 2:26 PM the aide, Staff C, stated after lunch on 12/1/22 she assisted Resident #2 to the bathroom, changed her brief and put her to bed. She stated four to five minutes later the resident was found outside the opposite door 16. The aide stated no alarms were sounding and usually they will hear alarms if a resident tries to go outside or gets outside. She stated the doors weren't alarmed and the last she knew management was trying to find out who didn't lock them last. The aide stated the resident is a frequent wanderer and sets the door alarms off daily or sometimes twice a day. She stated Resident #25 also wanders, lives on that hall, and set off the alarms. In an interview, the State Climatologist reported that, on 12/1/22 at 1:40 PM in Council Bluffs, Iowa, the temperature was 46 degrees with relative humidity at 25 percent and no precipitation, with a south wind at 21 miles per hour gusting to 31 miles per hour, and a 38 degree wind chill. The Facility Investigation documented the resident wore a long sleeve shirt, long pants, and gripper socks at the times of the elopement. Observation on 1/19/23 at 2:10 PM revealed Resident #2 resting in the living room with her walker in front of her, wander guard on her left ankle, wearing gripper socks. On 1/23/23 at 2:40 PM, the Staff A stated she does not remember whether or not the doors were activated on 11/30/22 as it was a while ago. She stated if that is what she told the DON, then that is what happened. Staff A reported before the new lock box arrived, they had to keep re-arming the doors a lot because the facility had residents that approached the doors and pushed on them when they wandered. They would set off the alarms when they pushed on them, then would normally just walk away and not try to exit through the door. Staff A said she did not work the day Resident #2 exited, but heard about it when she returned. She reported the key to unlock or lock and reset the door used to be kept at the nurse's station or in the medication cart, but now is located in the lock box on the wall. If a resident activated the door alarm, staff had to call a supervisor to get the code to open the box and reset the door. She stated the supervisor stays on the phone and when they hear two quick beeps, the alarm resets and the light turns green. Staff A reported the supervisor will then change the code needed to open the box.

I. Based on documents review and interviews, the facility did not monitor and assess the deteriorating health condition to include analysis and evaluation of pertinent factors (low trending intakes and low outputs, diuretic therapy, and the progressive decline in level of consciousness) in order to implement timely measures to alleviate or prevent the illness from getting worse for 1 of 4 residents (Resident # 28) in the sample reviewed for hospitalization . The facility reported a census of 47 residents at the time of the survey. Findings include: Resident # 28's Minimum Data Set (MDS) assessment for significant change in status dated 9/9/22, showed impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4. The MDS listed Resident # 28's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed that Resident # 28 received antidiuretics. The MDS indicated use of a urinary catheter, and needed assistance of the assistance of 2 persons for toilet use. The MDS also indicated the need for the assistance of 1 person for eating. Resident # 28's care plan showed focus areas to include the following: 1. Catheter use related to [CONDITION(S)]. The Care plan directed staff to record intake and output; monitor and report signs and symptoms of urinary tract infection ([CONDITION(S)]) such as no output, foul-smelling-urine, change in behavior, and change in eating patterns; 2. Potential nutritional problem related to [CONDITION(S)] and weakness. The care plan directed staff to monitor intake and record every meal. 3. Self-care performance deficit for Activities of Daily Living (ADL). The care plan directed staff to cue for set-up and assist with feeding. 4. Diuretic therapy. The care plan directed staff to administer medications as ordered and to monitor for adverse consequences and side effects. Resident # 28's intake record (fluids, meals, and snacks) from 10/26/22 to 10/29/22, showed low trending consumption and multiple times of long periods between intakes, as recorded: - On 10/26/22 at 5:25 PM (evening meal) - 360 milliliters (ml) of fluid, 26% to 50% of food, and no bedtime snacks. - On 10/27/22 at 8:41 AM (breakfast) - 240 ml of fluid, and 76% to 100% of food. This meal was after 15 hours without intake. - On 10/27/22 at 12:51 PM (lunch) - 240 ml of fluid, and 26% to 50% of food. There lacked record of evening meal and bedtime snack on this date. - On 10/28/22 at 9:07 AM (breakfast) - 480 ml of fluid, and 76% to 100% of food. This meal was after 21 hours without recorded intake - On 10/28/22 at 12:52 PM (lunch) - 120 ml of fluid, and no food intake (refused). - On 10/28/22 at 9:30 PM (night meal) - 0 ml of fluid , 0% to 25% of food, and 0% to 25% of snack. This night meal was after 8.5 hours of no intake. - On 10/29/22 at 8:23 AM (breakfast) - 240 ml of fluid, and 26% to 50% of food. This meal was after 11 hours without intake. - On 10/29/22 at 12:30 PM (lunch) - 240 ml of fluid, 0% to 25% of food. - On 10/29/22 at 5:30 PM (evening meal) - 120 ml of fluid, 0% to 25% of food. - On 10/29/22 at 9:30 PM (night time drink) - 120 ml of fluid. Resident # 28's catheter output record from 10/26/22 at 4:57 AM to 10/30/22 at 4:35 AM, also showed multiple shifts that recorded very low urine output, as follows: - On 10/26/22 from 4:57 AM to 5:26 PM (12 hours), the output was 120 ml or 10 ml/hour. - On 10/26/22 at 5:26 PM to 10/27/22 at 5:59 AM (13 hours), the output was 50 ml or 3.8 ml/hr. There was no bedtime snack during this night (see intakes above). - On 10/27/22 at 1:59 PM to 10/28/22 at 5:32 AM (15 hours), the output was 300 ml or 20 ml/hr. There was no evening meal or bedtime snack for this night (see intakes above). - On 10/29/22 at 9:59 PM to 10/30/22 at 4:35 AM (6.5 hours), the output was 150 ml or 23 ml/hr. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] # 28 had low intakes and outputs as noted above (10/26/22 to 10/29/22). The progress notes indicated Resident # 28's declining medical condition, as follows: - On 10/17/22, Resident # 28 was sent to the hospital for symptoms as noted, shakes, lethargic, unable to answer, noted resident using accessory muscles to breathe . Resident # 28 returned to the facility with report from hospital that Resident # 28 had severe [CONDITION(S)] and awaiting for results of culture before starting antibiotics. - On 10/20/22, Resident # 28 started on antibiotics as ordered, [MEDICATION(S)] 100 milligrams (mg) PO (per orem) twice a day for 7 days. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - On 10/24/22 at 12:43 PM, the notes described Resident # 28's urine output as cloudy and with strong odor. The notes also indicated Resident # 28 was more sleepy and slow to follow commands. Resident # 28's symptoms were reported to physician, who ordered to discontinue [MEDICATION(S)] and start a different antibiotics as ordered, [MEDICATION(S)] 250 mg PO daily for 7 days. - On 10/27/22, Resident # 28 continued on [MEDICATION(S)], with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - On 10/30/22 at 3:01 AM, the note described Resident # 28's urinary output as noted, 100 at HS [hours of sleep], yellow, slightly cloudy with some odor present. - On 10/30/22 at 8:47 AM, Resident # 28 refused morning meal and medications. The staff notified the on-call physician, who ordered to send Resident # 28 to the hospital. - On 10/30/22 at 4:37 PM, an update regarding Resident # 28 showed admission for [CONDITION(S)] (high Sodium level in the blood), acute kidney injuries, [CONDITION(S)] (high potassium level in the blood), and altered mental status. The notes indicated that Resident # 28 continued to be non-verbal. On 11/1/22 at 4:37 PM, Family Member (FM) verified Resident # 28's hospitalization , and said that the hospital staff notified about admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . FM also said she/he found out that Resident # 28 had been unresponsive since 4:00 PM on Saturday and was sent to the hospital the following morning [Sunday]. FM reported that prior to hospital admission, Resident # 28 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the progress notes showed that prior to the day of Resident # 28's hospital admission, the last entry related to Resident # 28's [CONDITION(S)] was on 10/28/22 at 4:04 AM. The progress notes showed that for 48 hours or from 10/28/22 (early morning Friday) through 10/30/22 (early Sunday morning), there were no entries related to assessment/monitoring signs and symptoms of Resident # 28's [CONDITION(S)], including her declining health condition such as change in her mental status or level of consciousness. The Orders Summary Report showed ST evaluation and treat ordered on 10/20/22. However, the Administrator sent an email on 11/2/22 and verified that the order was not carried out because of Resident # 28's hospitalization on [DATE], as written, [Resident # 28] was hospitalized prior to speech being able to get in. II. Based on clinical record review, staff interview and facility policy review, facility staff failed to perform neurological assessments following a fall for one of 16 current residents reviewed (Resident #21). The facility reported a census of 47 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #21 had a Brief Interview of Mental Status Score (BIMS) of 8 which indicated moderately impaired memory and cognition. The assessment recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21 required the assistance of one with transfers and toilet use and experienced frequent bladder incontinence. The Incident Report dated 10/07/22 at 3:27 PM documented Resident #21 had an unwitnessed fall in his bathroom. Assessment revealed no injuries at the time and the resident denied hitting his head. Review of the resident's progress notes and assessment information contained within his clinical record revealed staff did not conduct neurological checks following his unwitnessed fall. The facility's Fall Prevention policy with a revision date of 10/18/13 directed that neurological checks will be done per protocol on any resident who has had an unwitnessed fall or has hit his/her head and documented in the clinical record. During interview on 10/25/22 at 11:02 AM, the Director of Nursing (DON) reported that there were no neurological assessments in the resident's clinical record for his fall on 10/07/22. The DON stated that facility policy would be to initiate neurological assessments with unwitnessed falls.

Based on documents review, interviews, and observation, the facility failed to ensure development and implementation of interventions based on corresponding assessment data in order to prevent fall incidents, and minimize complications resulting from falls for 3 of 5 (#2, #9, #12) residents reviewed for accidents. The facility reported a census of 47 residents at the time of the survey. Findings include: 1. Resident # 3's electronic medical records showed an admitted [DATE] after hospitalization related to right femur fracture. The records also showed that Resident # 3 had 2 incidents of fall since admission, as follows: Fall on 4/15/22 at 1:15 PM. On 10/20/22 at 9:38 AM, when followed up regarding her wound treatments, Resident # 3 replied, They keep saying it's getting better, I don't know. I want to be able to walk again but I had a bad fall. Resident # 3 said she called for help to use the bathroom and a staff came in to help. Resident # 3 said not knowing what happened but that she was just on the floor with my foot behind the toilet. Resident # 3 said, They did nothing! Resident # 3 further said they did not send her to the hospital after the fall, that X-ray was called in here and found out I had broken bone in my leg. Resident # 4 also said after that she had more pain and then the wound to her right heel. The clinical/medical records show details of Resident # 3's fall on 4/15/22 as follows: A. The documents that indicated Resident # 3's status and need for physical assistance during transfers prior to the fall, include the following: i) Resident # 3's Admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS showed Resident # 3's active diagnoses including diabetes mellitus, depression, and fractures. The MDS also indicated Resident # 3 required physical assistance of 2 persons for transfers, dressing, and toilet use. ii) Resident # 3's care plan, which was downloaded from facility's electronic medical records system on 10/19/22, showed the care plan initiation date as 2/17/22, indicating the required assistance for Resident # 3's Activities of Daily Living (ADL) as 2-person physical assistance for dressing, personal hygiene, transfers, and toilet use. iii) The PT [Physical Therapy] - Therapist Progress & Updated Plan of Care dated 3/29/22, showed assessments on 3/3/22 (prior level) and on 3/29/22 (current level) related to Toilet transfer showed, Not attempted due to medical condition or safety concerns. However, that on the same day (3/29/22) that the current level assessment for toilet transfer was not attempted, the corresponding STG (short term goal) for Toilet transfer was upgraded, as noted, The [Resident # 3] is able to safely complete STS [sit to stand] transfers requiring min [minimum] assist [25% assist] verbal, tactile and visual instructions/cues. The document further noted that Resident # 3 required continued training in transfers to improve safety in SPT [stand pivot transfer]and STS [sit to stand]. iv) The OT [Occupational Therapy] Daily Treatment Note showed Resident # 3's level of tolerance for standing, need for maximum assistance for transfer and the use of transfer devices, on the following dates: - On 3/28/22, Resident # 3 went for an ortho appt [orthopedic appointment] where physician discontinued immobilizer on RLE (right lower extremity) and weight bearing status to WBAT (weight bearing as tolerated). The notes indicated maximum assist for STS [sit to stand] and for static standing balance at FWW [four-wheel-walker] and tolerating stand for approx [approximately] 30 seconds x 3 trials with SPT [stand pivot transfer] with max [maximum] assist on third trial. The notes also indicated that Resident # 3 had well tolerated the use of standing frame when tried. The notes further indicated upgrade of transfer status in PCC (point click care) and communicated with Staff Q, Certified Nurse Assistant (CNA). - On 3/29/22, Resident # 3 participated in group therapy. The specific focus for Resident # 3's treatment noted, Deficits in standing tolerance, UE [upper body] strength, and functional endurance in order to improve independence with functional sit to stand, and ADL pivot transfers. v) The OT - Therapist Progress & Updated Plan of Care dated 3/29/22, showed updated short term goal related to toilet transfer for Resident # 3 to safely transfer to toilet/commode with minimal assistance (25%). The document noted upgraded challenges to STS performance, standing tolerance, SPT (stand pivot transfer) including toilet transfer with increase in WBAT (weight bearing as tolerated) status, and staff education to use standing frame for all functional transfers with Resident # 3. The document indicated staff education as written, Staff educated in increase in RLE WB [right lower extremity weight bearing] status and upgrade from Hoyer lift to use of standing frame for all functional transfers. The document also noted, Patient continues to have deficits in standing tolerance, transfer performance, UB [upper body] strength, and functional activity tolerance which limit to safely perform functional transfers . and the document further noted, Due to safety reasons, the patient requires continued use of standing lift with facility staff to minimize fall risk during transfers at this time. vi) Resident # 3's electronic medical records showed that on 3/29/22, Resident # 3's care plan was revised as noted, The resident requires sit/stand lift for all transfers. In addition, the care plan showed revisions related to Resident # 3's ADL that indicated 1-2 persons physical assistance for dressing and personal hygiene. The records further showed that the care plan initiated on 2/9/22 (prior to the fall) and through the next care plan 5/23/22 (after the fall), Resident # 3's required need for 2 staff/persons assistance for toileting remained in place. vii) Resident # 3's 5-day Medicare MDS assessment dated [DATE] and signed on 4/6/22 (the most recent MDS assessment immediately preceding the fall), indicated need for physical assistance of 2 persons for transfers, dressing, and toilet use. viii) The Skilled Notes from 3/30/22 through 4/14/22 at 9:15 PM (prior to fall), showed 16 inconsistent skilled nursing notes entered for Resident # 3 regarding assistance for toileting and transfers, where 10 of 16 indicated that Resident # 3 required 2-person assistance and use of mechanical device for transfers, 2 out 16 indicated 1 staff assistance for ADLs and transfers, and 4 of 16 did not indicate transfers and assistance needed for ADL, as follows: - On 3/30/22 at 3:30 PM - 2 person assist with sit to stand lift. - On 3/30/22 at 9:28 PM - 2 person assist with sit to stand lift - On 4/2/22 at 3:14 PM - transfers sit to stand and assist of 1 - On 4/3/22 at 3:44 PM - using sit to stand for transfers - On 4/4/22 at 3:44 PM - assist of 2, and use of sit to stand mechanical lift for transfers - On 4/6/22 at 11:44 AM - no notes about transfers; - On 4/7/22 at 11:44 AM - no notes about transfers; - On 4/8/22 at 11:44 AM - no notes about transfers; - On 4/9/22 at 11:44 AM - no notes about transfers; - On 4/10/22 at 3:15 PM - Resident [#3] requires assist of one [1] with ADLs. Requires sit-to-stand mechanical lift with all transfers. The document further noted, Education with resident on using mechanical lift with nursing staff, and standing with FWW and gaitbelt with therapy only at this time, until determined safe. Understanding demonstrated by reiteration. - On 4/11/22 at 2:15 PM - Requires sit-to-stand mechanical lift with all transfers. - On 4/12/22 at 9:15 AM - Requires sit-to-stand mechanical lift with all transfers. - On 4/13/22 at 9:15 AM - 1 assist with adls and transfers. - On 4/13/22 at 9:15 PM - Transfers with hoyer lift. requires assist with ADLs. - On 4/14/22 at 9:15 AM - Transfers with hoyer lift, requires assist with ADLs. - On 4/14/22 at 9:15 PM - Transfers with hoyer lift, requires assist with ADLs. ix) The PT - Therapist Progress & Discharge Summary dated 4/14/22, showed an assessment of current level that indicated when therapy ended on 4/14/22, toilet transfer was not attempted due to Resident # 3's medical condition or safety concerns. The document noted Resident # 3's current level for transfers from sit to stand as Substantial/maximal assistance where helper does more than half the effort. The document also noted that physical therapy goals including standing balance, strength, and transfers were not met on 4/14/22 because of unexpected therapy discharge. The document further showed discharge plans and instructions indicating Resident # 3's need for ongoing therapy as noted, Remain in LTC [Long Term Care] and continue therapy services under Medicare part B[.] x) The OT - Therapist Progress & Discharge Summary dated 4/14/22, showed that STGs (short term goals) related to activity tolerance for standing and toilet transfers were not met (STGs noted in v above). The document also noted, [Resident # 3] was progressing with OT POC [plan of care] steadily but slowly progressing towards all goals. However, [Resident # 3 was discharged ] from skills OT services prior to all goals met due to Insurance cut and lost appeal this date. The discharge plans and instructions noted, Recommend continued OT services as able to continue functional progression for maximal safe level of independence in ADLs. B. The documents revealed Resident # 3's call for assistance, and fall during toilet transfer by 1 person that resulted to increased discomfort/pain, include the following: i) The call light log indicated that on 4/15/22, Resident # 3's call light was on from 1:05 PM and off at 1:32 PM for a total response time of 27 minutes. ii) The progress notes on 4/15/22 showed Staff P's entry that read, Approximately 1315 [1:15 PM] this nurse was asked by resident to get help to go to the bathroom. This nurse used gaitbelt and had resident stand. Wheelchair was locked. Resident's legs became week and started lowering. This nurse lowered resident to the floor. iii) The progress notes showed Resident # 3's complaints of right leg pain and received as needed (PRN) pain medication or [MEDICATION(S)] (HCl) tablet 50 milligram (MG) 0.5-1 tablet on 4/15/22 at 10:22 PM, 4/17/22 at 1:05 AM and Resident # 3 was quoted as saying, My right leg is really hurting. and on 4/17/22 at 11:03 PM. iv) The Medication Administration Record (MAR) for the month of 4/22, indicated Resident # 3 had increased discomfort after the fall starting on 4/15/22, where her PRN pain medication ([MEDICATION(S)]) and PRN medication for muscle spasms ([MEDICATION(S)]) were administered at a more frequent interval than the preceding days, as follows: - On 4/13/22 - no PRN pain medications - On 4/14/22 - no PRN pain medications - On 4/15/22 at 10:22 PM, [MEDICATION(S)] 50 milligrams (mg) on - On 4/17/22 at 01:05 AM and at 11:03 PM - [MEDICATION(S)] 50 mg; - On 4/18/22 at 11:32 PM - [MEDICATION(S)] 50 mg and [MEDICATION(S)] 2 mg; - On 4/19/22 at 07:48 PM - [MEDICATION(S)] 50 mg; - On 4/20/22 at 05:16 AM - [MEDICATION(S)] 50 mg; at 09:53 PM - [MEDICATION(S)] 50 mg and [MEDICATION(S)] 2 mg; - On 4/21/22 at 3:03 PM - [MEDICATION(S)] 25 mg; at 10:25 PM - [MEDICATION(S)] 50 mg and [MEDICATION(S)] 2 mg; - On 4/22/22 at 05:36 AM - [MEDICATION(S)] 50 mg; at 01:13 PM - [MEDICATION(S)] 25 mg; at 6:24 PM - [MEDICATION(S)] 2 mg; - On 4/22/22 starting at 10:00 PM - [MEDICATION(S)] 50 mg and was then scheduled every 8 hours thereafter. C. The documents revealed facility's actions following Resident # 3's fall (4/15/22), including: i) The MAR dated 4/22 and medication administration notes in the progress notes, showed staff members have been giving Resident # 3's PRN medications in attempt to relieve Resident # 3's right leg pain; ii) The progress notes entered on 4/20/22 at 10:06 AM, showed that on 4/18/22 (3 days post fall), the Nurse Practitioner (NP) visited and Resident # 3 reported no complaints of pain to NP related to fall, and no [CONDITION(S)] on bilateral legs. The NP noted, Fall without injury and the plan was to continue with medications and treatments. iii) The Order Summary Report showed orders for Physical Therapy and Occupational Therapy to evaluate and treat starting on 4/21/22. iv) Therapy documents showed Resident # 3 started assessment for therapy services on 4/21/22, still with complaints of right leg pain, as noted: - The Occupational Therapy Plan of Care dated 4/21/22, showed Resident # 3 reported pain of 8/10 in right anterior knee. - The Physical Therapy Plan of Care dated 4/21/22, noted, [Resident # 3] reports right [NAME] [lower extremity] pain, nursing aware and [Resident # 3] received Tylenol. v) The progress notes indicated Resident # 3's complaints of pain, and then discovery of fractured tibia and fibula on right leg, as noted: - On 4/21/22 at 5:48 PM, showed that Resident # 3 complained of right front lower leg pain, where pain medications had been given throughout the day with some relief. The notes indicated that Resident # 3's complaints had been reported to the NP, and that the NP to see tomorrow on rounds and to continue pain medications as needed. - On 4/21/22 at 11:22 PM, Resident # 3 complained of right lower leg pain and leg is swollen and bruised. Pain medication was given and an x-ray ordered due to increased pain and swelling. - On 4/22/22 at 5:49 AM, showed, Resident [#3] continues to complain regarding her right leg. Pain pill given at this time. Ordered x-ray last night stat [as soon as possible] and at this time they still haven't shown up to perform the xray. - On 4/22/22 at 8:45 AM, the x-ray results on Resident # 3's right lower extremity showed tibula/fibula fracture. Resident # 3 was sent to the emergency room (ER) for evaluation and treatment. - On 4/22/22 at 6:35 PM, Resident # 3 returned from the hospital with orders for non-weight bearing and to follow up with physician for orders. D. The documents confirmed Resident # 3's statement regarding more pain and pressure ulcer development on right heel following the fall, as follows: i) The progress notes on 5/6/2022, indicated Resident # 3's continued pain on right leg with increased anxiety, and new orders for [MEDICATION(S)] 0.5 milligrams (mg) 2X a day for anti-anxiety and [MEDICATION(S)] 5/325 mg every 8 hours as needed for breakthrough pain. ii) The progress notes indicated the presence of pressure ulcer on right heel on 6/13/22, with treatment order noted, xeroform gauze to open area R heel, cover with [MEDICATION(S)], change [every] 3 days or PRN [MEDICATION(S)] to intact skin on r heel and cover with [MEDICATION(S)] every 72 hours for pressure area [right] heel iii) The care plan identified a pressure wound on Resident # 3's right heel was identified on 6/27/22. Staff interviews related to the fall on 4/15/22, are as follows: On 10/26/22 at 10:59 AM, the Nurse Practitioner (NP) said that on 4/14/22, staff reported to her about Resident # 3's fall when staff lowered her to the floor, and that assessments did not show injury nor pain, and no concerns reported. The NP said she does not know or review residents' transfer status and how many staff needed to assist, and that she will go by what staff members report. The NP further said that Resident # 3 was so inconsistent with what she was saying regarding her pain because when she (NP) personally went to ask, Resident # 3 reported no pain but then I get a call that she is in pain. The NP said she would go by her own assessment because it was difficult to know with Resident # 3's inconsistencies and the NP added, Of course there is pain after a fall, it could be anything, could be a residual discomfort, musculoskeletal twisting. The NP verified ordering x-ray on 4/22/22, the 7th day after the fall when Resident # 3's pain was not being relieved and there was swelling. On 10/26/22 at 12:40 PM,the Director of Nursing (DON) and Administrator verbalized their understanding that on 3/29/22, Resident # 3's requirement for transfer of sit to stand lift meant assist of 1-2 staff members and can be with the use of a gait belt. The Administrator said that based on therapy recommendations, Resident # 3 can be assisted for transfers by 1 staff person using a gait belt and that was what happened when a nurse (that DON identified Staff P, a nurse manager) lowered Resident # 3 to the floor during transfer. The Administrator said that Staff P correctly followed the care plan. The DON said that Resident # 3 was discharged from therapy on 4/14/22 and the fall happened on 4/15/22, and so there was no time to revise the care plan but also reiterated that Staff P followed the care plan of sit/stand lift by using a gait belt by herself to assist Resident # 3. On 10/28/22 at 5:23 PM, Staff L, Physical Therapist (PT) verified having previously worked with residents at the facility. Staff L explained that if functional deficits that have not been attempted during the assessment period, such as toilet transfer, it was because of safety concerns for the patient. Staff L also clarified that a standing lift and a standing frame are machines (devices) used for patient transfers. Staff L said that a stand lift or EZ stand is used by nursing to transfer patients from one seated surface to another and a standing frame is used by therapy. Staff L said that for these to be used, it would not be safe even for one therapist to use because there needs another person to put a sling safely under the patient's armpits. Staff L further clarified that a stand lift or EZ stand is not the same as assist of one person using a gait belt to help a patient stand. Staff L said that recommendations of upgrading assistance when therapy goals were not met at discharge is case by case basis, that is why there is need for re-evaluation at discharge for whatever is safer for the patient. Staff L also stated assumption that if she noted a recommendation for a patient to remain in LTC (long term care) and continue services, it is because the patient needs more therapy. Staff P, the former nurse manager who lowered Resident # 3 to the floor did not return 3 attempted calls for interview on different days and time, despite voice messages left on phone. Fall on 8/9/22 at 4:30 AM. The Quarterly MDS assessment dated [DATE], indicated Resident # 3's frequent urinary and bowel incontinence. The MDS also showed Resident # 3 required the assistance of 2 staff members for bed mobility and toilet use. The care plan, which was downloaded from facility's electronic medical records system on 10/19/22, showed the care plan initiation date as 2/17/22, indicating the required assistance for Resident # 3's Activities of Daily Living (ADL) as 2-person physical assistance for toilet use. The care plan revision history showed that since 2/17/22 to 8/9/22 during the event of fall (8/9/22 at 4:29 AM), Resident # 3 required the assistance of 2 staff members for toilet use. However, on the same date of 8/9/22, despite Resident # 3's fall at 4:29 AM, the care plan was revised to lower the required physical assistance to 1-2 staff members for toilet use. The progress notes showed Resident # 3's fall with injury during toilet use with 1 staff physical assistance, as follows: On 8/9/22 at 7:00 AM, revealed that at on 8/9/22 at 4:30 AM, Resident # 3 rolled too far and fell out of bed to the floor, while Staff R, Certified Nurse Assistant (CNA) was removing the bedpan from beneath her. The progress notes indicated that Resident # 3 landed on left side with arm underneath her. Resident # 3 complained of ribs hurting a little bit while on the floor. On 8/9/22 at 8:30 AM, it was noted that the NP did not want a rib X-ray ordered because Resident # 3 will be admitted to the hospital after appointment at the wound clinic and they can do a better x-ray at the hospital. On 8/9/22 at 12:15 PM, Resident # 3 complained of increased pain. On 8/9/22 at 10:45 PM, an order for x-ray was obtained related to Resident # 3's complaints of increased pain. On 8/10/22 at 4: 59 PM, Resident # 3's X-ray results showed acute fracture involving the posterior portion of the left 5th and 6th ribs with mild displacement. Staff interviews related to Resident # 3's fall on 8/9/22, showed: On 10/25/22 at 2:58 PM, Staff N, LPN, reported coming in the morning and was told she fell and that Staff N saw Resident # 3 complaining and groaning, like almost crying when we were getting her up. Yes, she had pain but that pain was different and she was complaining so bad. We used a Hoyer for transfer and she was groaning. Staff N said she thought Resident # 3's ribs might have been broken during the fall. Staff N said that she was told that NP was not ordering X-ray because Resident # 3 might be admitted to the hospital and X-ray will be done there. Staff N said that Resident # 3 returned to the facility in the afternoon without an x-ray being done, and Resident # 3 continued to complain of pain. Staff N said that during the night of 8/9/22, a X-ray order was finally obtained, and results arrived following day showing fractured ribs. Staff N said she was worried about Resident # 3's complaints of pain on chest area because it could affect breathing. On 10/26/22 at 8:02 AM, Staff M said she remembered Resident # 3's fall on 8/9/22 when a CNA was assisting with the bed pan and Resident # 3 rolled out from bed. Staff M said she could not think of any thing that should have been done differently, saying Staff R did what any other could have done. Staff M said, What I told her was when doing cares with residents like that to roll resident toward her (staff) and not away from her so that she could have more control, and that if she was uncomfortable doing anything to always call for help. When asked how many staff did Resident # 3 require for physical assist with toilet use at the time, Staff M replied, I honestly do not know the answer to that. On 10/26/22 at 8:20 AM, Staff R, CNA acknowledged being by herself assisting Resident # 3 for using the bedpan. Staff R said that Resident # 3 had a bowel movement during that time. Staff R also said, I was holding the bedpan and the resident at the same time and I was trying to catch her but she kept rolling. Staff R said she was then educated about Resident # 3's care plan that there should be 2 staff members and we should make sure there were 2 people at hand during peri-cares. On 10/26/22 at 12:40 PM,the Director of Nursing (DON) and the Administrator verbalized that they did not see that something was missed that led to Resident # 3's fall on 8/9/21. The DON stated that the staff members correctly followed the care plan with 1 staff assisting Resident # 3 during use of bed pan. When pointed out that all MDS assessments indicated Resident # 3 needed 2 persons for toileting, the DON replied that it is because of many agency staff members working who do not know the residents and they chart such during the look-back period and that explains the coding in the MDS. 2. Resident # 9's Quarterly MDS assessment dated [DATE], listed Resident # 3's active diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety disorder. The MDS indicated that Resident # 9 is on hospice level of care. Resident # 9's care plan directed staff to provide the extensive assistance of 2 staff members for transfers. The care plan indicated moderate risk for falls related to impaired mobility, and the care plan also showed multiple revisions indicating frequent falls. On 10/20/22 at 8:59 AM, Staff T, CNA while facing Resident # 9 in her wheelchair said, Give me a hug so I put you to bed. Staff T then hugged Resident # 9 and pivot-transferred her from wheelchair to bed. At 9:20 AM, the DON entered Resident # 9's room and surveyor asked Staff T to review the transfer process she just completed for Resident 9, Staff T then verbalized that she hugged Resident # 9 and transferred her to bed. Staff T acknowledged that she did not use a gait belt during the transfer. The DON said that Resident # 9 is a 2-person assist with the use of gait belt. The DON acknowledged that all care givers follow residents' care plans. The facility's policy titled, Fall Prevention, dated 10/18/2013, provides that it is the policy of Christian Horizons to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The policy provides, Residents are identified as at risk for falls, clinically appropriate interventions will be put into place to reduce the risk for falls and/or to prevent recurrence of falls. The facility's Resident Assessment (RAI) of MDS policy, dated 10/1/19, provides that the facility will use the most current version of RAI to conduct assessment of each resident's needs. The policy indicated use of the results of the assessment to develop, review, and revise the resident's comprehensive care plans. The facility's policy titled, Comprehensive Care Plans, dated 5/18/17, provides, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also indicated that a person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. The policy provides that the care planning process will include a review of the resident ' s strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The policy further provides that the comprehensive care plan will be developed within 7 days after the completion date of the comprehensive MDS assessment. 3. Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status 5 out of 15 for Resident 12. A BIMS of 5 indicated a significant cognitive impairment. Diagnoses documented dementia, [CONDITION(S)], tibia fracture and urge incontinence. Alarms documented a wander guard. Care plan dated 9/1/22 documented a risk for falls. Interventions included call light within in reach and right lower extremity brace must be on when up. Interventions included snacks between meals, activities, Record review revealed the following: Orders dated 9/6/22 directed the use of a hinge knee brace. Progress Notes revealed the following Resident 12's admission to the facility for a right tibia fracture on 8/2/22. Prior falls dated 8/6/22 (x2) 8/23/22, 10/4/22 and 10/10/22. 10/4/22 documented a urine test was performed to rule out a urinary tract infection after a fall. 10/7/22 started on [MEDICATION(S)] for a urinary tract infection pending culture and sensitivity. 10/9/22 Resident 12 was last visualized 2:20 AM and was found on the floor at 2:35 AM with right lower extremity shortened and rotated outward. 10/10/22 transferred to hospital after a fall and admitted for right hip fracture. Hospital documentation dated 10/24/22 documented comfort measures. Interviews revealed On 10/19/22 10:32 AM Staff G, CNA stated that Resident 12 had a broken right leg and wore a brace on that leg. On 10/19/22 at 11:51 AM Staff E, CNA stated she was headed to break and saw Resident 12 in the fish room, in a chair and her wheelchair was next to her. She was unable to report if Resident 12 was wearing her leg brace. She reported she knew Resident 12 was a fall risk. She was told that [NAME] was restless because she wanted to go outdoors. She was unable to confirm a time of the observation but stated she typically took breaks between 2:30 and 3:30 and when she came back from break she was told Resident 12 had been sent out after a fall. She confirmed there were no other staff or residents around and the resident wore a wander guard but did not have access to a call light in the fish room. On 10/19/22 at 11:24 AM Staff F PTA stated resident was ordered to wear hinge brace at the time of the fall. She stated a hinge brace would offer support to a weakened leg and may assist in preventing a fall.

Based on observations, clinical record review, family interviews, provider interviews and staff interviews the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents reviewed (Resident #2, 10 and 11). The facility reported a census of 59 residents. Findings include: The MDS identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The MDS assessment tool dated [DATE] for Resident #2 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) test, which indicated she demonstrated moderate cognitive impairment. The MDS documented the resident required total assist of one staff for a bath; total assist of two staff for transfers; extensive assist of two staff for bed mobility, dressing, toileting and hygiene and was not ambulatory. The MDS documented she did not have pressure ulcers but was at risk. It documented she had a pressure reducing device for her bed and chair but was not on a turning/repositioning program. The MDS documented she had moisture associated skin damage (MASD). The Care Plan focus dated [DATE] documented Resident #2 has a self-care deficit related mobility and weakness. The care plan directed staff that she requires a mechanical lift with two staff assist for transfers. The care plan focus lacked and directions to the staff on bed mobility. The Care Plan focus dated [DATE] documented Resident #2 has the potential for pressure injury development related to immobility and weakness. The care plan focus lacked any directions to the staff on turning and repositioning. The Care Plan focus dated [DATE] documented the resident has a pressure injury to the coccyx and a Stage III to her right buttock related to immobility. The care plan documented an air mattress was placed on her bed and a cushion in her wheelchair and recliner on [DATE]. The care plan documented to reposition her from side to side every two hours on [DATE]. The facility policy Wound Management dated [DATE] included the following: Pressure Ulcers- A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Pressure ulcers are staged to determine the extent of tissue damage. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Managing Tissue Load- Tissue load will be managed and tissue tolerance to pressure, friction, and shearing forces will be improved. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support surfaces. The Braden Scale for Predicting Pressure Sores dated [DATE] documented the resident scored 16 indicating she is at risk. The Admission Screener dated [DATE] documented the resident had impaired skin integrity but lacked descriptions or measurements. The Skin and Wound Total Body Skin assessment dated [DATE] documented the resident has 5 new wounds but lacked descriptions or measurements. Review of the clinical record revealed staff did not document any skin impairments on [DATE] except for the moisture associated skin damage to the resident's sacrum. The Skin and Wound Evaluation to the sacrum for Resident #2 documented the following: On [DATE] the sacrum described as MASD to the sacrum in house acquired. Measures 5.2cm in area, 3.2cm in length and 2.5cm in width. No evidence of infection, no drainage On [DATE] the sacrum described as MASD measures 0.5cm in length and 0.1cm in width. On [DATE] the sacrum described as MASD measures 22.6cm in area, 6.4cm in length and 4.5cm in width. No drainage and no signs of infection. On [DATE] the coccyx described as a Stage III pressure that is in house acquired of unknown date. Measures 3.5cm in area, 2.9cm in length, 1.8cm in width and 0.2cm in depth. 90 percent granulation, 10 percent slough. Evidence of infection with redness and inflammation. Light serous drainage. On [DATE] the coccyx is staged as unstageable and measures 7.8cm in area, 5.4cm in length and 2.3cm in width. 10 percent granulation, 80 percent slough, 10 percent eschar with evidence of infection documented redness/inflammation and bleeding. Moderate sanguineous bloody drainage. On [DATE] the coccyx is unstageable and measures 12.9cm in area, 4.9cm in length, 3.7cm in width and 1.4cm in depth. 10 percent granulation, 80 percent slough and 10 percent eschar. Evidence of infection with redness, inflammation and moderate drainage. On [DATE] the coccyx is staged as unstageable and measures 8.7cm in area, 4.1cm in length, and 3.1cm in width and no depth documented. 20 percent granulation tissue, 40 percent slough and 40 percent eschar. Evidence of infection with redness, inflammation, [MEDICATION(S)] and odor present after cleansing. Moderate serosanguineous drainage with [CONDITION(S)] of surrounding tissue. On [DATE] the coccyx unstageable pressure measured 13.9cm in area, 5cm in length, 3.8cm in width and 2.5cm in depth. Evidence of infection with increased drainage, increased pain, redness, inflammation and odor after cleansing. Moderate serosanguineous drainage with faint odor after cleansing. Surrounding tissue excoriated with [CONDITION(S)]. Documentation that the wound stalled in healing and the wound nurse is to debride next week. The Skin and Wound Evaluation to the right buttock for the resident documented the following: On [DATE] the right buttock described as stage III pressure in house acquired of unknown date. Measures 2cm in area, 1.7cm in length and 1.7cm in width. 50 percent granulation and 50 percent slough present. Evidence of infection is redness, inflammation, and light serous drainage. On [DATE] the right buttock stage III pressure measures 0.9cm in area, 1.6cm in length and 0.8cm in width. 30 percent granulation and 70 percent slough tissue present. Light sanguineous drainage with [MEDICATION(S)] and redness/inflammation documented. On [DATE] the right buttock stage III pressure measures 1cm in area, 1.5cm in length and 1.2cm in width. Redness/inflammation documented with light serous drainage. Surrounding tissue excoriated and blanching. No induration. Area documented as improving. On [DATE] the right buttock stage III pressure measures 2.7cm in area, 2.4cm in length and 1.6cm in width. 100 percent granulation tissue with evidence of infection due to redness/inflammation documented. No drainage. Surrounding tissue excoriated with [CONDITION(S)]. No induration. The Progress Notes for Resident #2 documented the following: On [DATE] at 1:53 PM MASD to sacrum is now a Stage 3 pressure. Nurse Practitioner (NP) made aware with new orders. New order to cleanse the area with soap and water, pat dry, apply plurogel and fill with opticell saturated with saline. Change every three days and PRN. Air mattress ordered and to be applied. Daughter made aware. On [DATE] at 3:03 PM NP notified regarding supplement and discontinue current treatments for healed bruises and abrasion. NP added a protein supplement for wound healing and to apply a cushion to the resident's wheelchair and recliner. Daughter also made aware of air mattress and protein supplement. Cushion applied to wheelchair and recliner. The MDS dated [DATE] documented she should have had a wheelchair cushion in place. On [DATE] at 11:08 AM air mattress placed today on the residents' bed. On [DATE] at 3:37 PM wound team meeting held. Pressure stage 3 to coccyx new this week. NP made aware and new orders received for treatments. New orders today for prostat and wound nurse from the hospital to see next time she is in the facility. Family is aware of new orders. Air mattress placed today. Prostat in place for wound healing. On [DATE] at 9:27 PM the registered dietician reviewed the resident's status. Resident with new wound Stage 3 to the sacrum. New order for prostat twice a day for wound healing. Current weight 234.4 pounds. Weight loss noted but resident had [CONDITION(S)]. Will review new weight, some weight loss desired. Appetite is good. On a regular diet. Estimated needs based on adjusted weight approximately ,d+[DATE] calories. ,d+[DATE] grams protein and 1825cc fluid. Supplement in place. No new recommendations. On [DATE] at 11:37 AM pressure area on coccyx has deteriorated since last week. 80 percent slough to wound bed and 20 percent granulation to wound bed. Periwound is red and excoriated. NP notified about restaging area. Wound nurse to assess today. Restaged area to unstageable to coccyx. Family made aware. Air mattress and nutritional supplement in place. Education with resident regarding positional changes and with staff. Also while using air mattress use only a sheet on her bed. No pads or extra things under her bottom. On [DATE] at 11;42 AM talked with NP regarding decline in resident. New verbal order for urinalysis with culture and sensitivity due to increased confusion. Daughter notified and told her the NP coming in to see the resident and will call her later to discuss plan of action and what is going on with her. On [DATE] at 3:37 PM return call to son requesting end of life and adjustment issues. Message left. On [DATE] at 11:57 AM daughter called for status of wounds and decline of resident. Information shared on hospice. On [DATE] at 3:37 PM daughter aware of new order for wound vac to be applied to coccyx. Okay to start tomorrow or Friday when supplies available. Reposition side to side every two hours. Do not lay on back/coccyx unless up for meals. On [DATE] at 10:53 AM new order to discontinue wound vac and start wet to dry dressing changes daily and PRN. Daughter is aware of new orders and talked about what is next. Tried to call the NP but she is not answering. Orders faxed to wound nurse. On [DATE] at 8:20 AM area on bottom has slough and eschar in wound bed with redness around it. Wound nurse notified. On [DATE] at 9:35 AM new order for santyl daily and prn. Left message for daughter. On [DATE] at 10:05 AM coccyx has 90 percent yellow slough and 10 percent granulation. Santyl to wound bed nickel thick and [MEDICATION(S)] to be placed daily to help with debridement. Wound nurse to obtain consent for debridement. Apply 4 percent [MEDICATION(S)] cream to coccyx wound 30 minutes prior to debridement and cover with dressing after application. Husband notified of need for consent and given. On [DATE] at 8:44 PM resident presents with trouble swallowing. Provider and family notified with order to send to hospital for neuro change. On [DATE] at 1:20 AM resident admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:00 PM daughter called to inform facility that the resident passed away on [DATE]. The Death Certificate for Resident #2 documented the cause of death [CONDITION(S)] due to or as a consequence of the sacral wound. On [DATE] at 9:44 AM the daughter stated her mom's wound care nurse, Staff E, told her there are pictures of the wounds at the nursing home and the staff were not moving her every two hours like they should have been and that caused the wounds. [NAME] told her the staff were putting multiple layers of towels under her to manage the incontinence and that was causing issues with the wound healing. The daughter stated she told the NP one to two weeks before she died that if they needed to send her to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Right before she passed away, they had to demand they take her to the hospital. Shortly after she was there, the hospital called her and told her they had to take her in for surgery because she had a sacral wound the size of a grapefruit. They chose not to do the surgery because they knew her mom would not survive it. She died shortly after that from [CONDITION(S)]. On [DATE] at 3:14 PM the Wound Care Nurse Practitioner stated she saw the resident only a few times at the facility. She stated each time she was at the facility the resident was in bed and on her back but she does not know if that was normal for her or not. She stated when she ordered the wound vac they decided not to start it due to there was still quite a bit of slough present in the wound. She stated she does not remember anything unusual with her cares. On [DATE] at 11:25 AM the Administrator stated the resident would have had a pressure reducing foam mattress on her bed the facility uses for the majority of the residents. He added that they have some of the residents on non-drive gravity 8 mattresses but those are meant for residents more at risk. He stated they are in the process of phasing out the pressure reducing foam mattresses that she had. On [DATE] at 11:56 AM Staff E stated she was the wound care nurse that took care of the resident. She stated the resident had MASD but it deteriorated into a pressure sore due to the aides were not turning her every two hours, as they should have been. She stated the resident also had multiple comorbidities and was a larger woman so those are contributing factors. She stated towards the end of the time the resident was at the facility she was yelling and screaming a lot so that deterred the staff from wanting to go in and take care of her. She stated the facility was short staffed and any time there were call-ins the nurse managers were required to help cover the holes on the schedule. She stated this would affect the nurse's ability to get their responsibilities done. On [DATE] at 10:55 AM the Wound Care NP stated when she went in to the facility to see Resident #2 the resident was always on her back. On [DATE] at 1:12 PM the resident's NP stated Staff E took care of wounds at the facility when the resident was there. She stated Staff E was the best wound nurse she had worked with. She stated she kept her informed and they would talk every one to two days so she is certain she was aware of the deterioration of the wounds at all times. She stated the wounds would wax and wane because the resident was having loose stools and was non-compliant. The resident had a disposition that she did not care and had given up. She stated that regardless of the resident's non-compliance the staff still should have been going into the room and trying to turn and reposition her every two hours. 2. The MDS assessment tool dated [DATE] for Resident #10 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] on the BIMS test, which indicated she demonstrated she is cognitively intact. The MDS documented she requires extensive assist of one staff for bathing, bed mobility, transfers, dressing and toileting. The MDS documented she is frequently incontinent of bowel and bladder. The MDS documented she does not have a pressure ulcer but is at risk of developing pressure ulcers. The Care Plan focus dated [DATE] documented Resident #10 has a self-care deficit related to immobility. The care plan directed staff that she requires extensive assist by one staff to turn and reposition in bed and requires a mechanical lift for assist with transfers. The Care Plan focus dated [DATE] documented the resident has the potential for pressure injury development related to impaired mobility. The care plan documented she had MASD on [DATE]. The care plan directed staff to reposition her frequently on [DATE]. The Care Plan focus dated [DATE] documented the resident has a pressure injury, DTI, to her left distal heel related to immobility. The Care Plan focus dated [DATE] documented the resident has a pressure injury, DTI, to her left proximal heel related to immobility. The Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented the resident scored 15 indicating she is at risk. The Skin Check UDA dated [DATE] documented the resident did not have any skin issues except for redness of her coccyx and sacrum. On [DATE] at 11:20 AM observed wound care to the resident's left heel and lateral foot. The resident was up in her wheelchair with an ace bandage on her left foot and compression stocking on her right foot. Prevalon boots on both feet and lift sling under her. The resident complained of pain during cares. The nurse stated she would check to see if she was due for pain medication. The resident stated she had been up in her chair since breakfast at 7:30 AM with no position change. The Skin and Wound Evaluations for the left heel on Resident #10 documented the following: On [DATE] the left heel is a DTI in house acquired on [DATE]. The area measures 1.8cm in length and 1.1cm in width. No evidence of infection. Surrounding tissue black/blue in color. On [DATE] the left heel measures 1.6cm in length and 0.5cm in width. On [DATE] the left heel measures 0.8cm in length and 0.7cm in width. On [DATE] the left heel measures 1.1cm in length and 0.7cm in width. Wound bed has 100 percent eschar. On [DATE] the left heel measures 1.2cm in length and 0.5cm in width. Wound bed has 100 percent eschar. The Skin and Wound Evaluations for the left lateral foot on Resident #10 documented the following: On [DATE] the left lateral foot is a DTI in house acquired but no date documented. The area measures 2.2cm in length and 2.1cm in width with 100 percent epithelial tissue in the wound bed. No evidence of infection and no exudate. On [DATE] the left lateral foot measures 2.9cm in length and 3cm in width with 100 percent eschar in the wound bed. No signs of infection and no exudate. On [DATE] the left lateral foot measures 1.6cm in length and 1.8cm in width with 100 percent epithelial tissue in the wound bed. On [DATE] the left lateral foot measures 1.5cm in length and 2cm in width. On [DATE] the left lateral foot measures 1.2cm in length and 0.7cm in width. On [DATE] the left lateral foot measures 0.9cm in length and 0.7cm in width with 100 percent eschar in the wound bed. No signs of infection and no exudate. 3. The MDS assessment tool dated [DATE] for Resident #11 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] on the BIMS test, which indicated he demonstrated he is moderately impaired for cognition. The MDS documented he is totally dependent on two staff for bathing and transfers; requires extensive assist of two staff for bed mobility, dressing, toileting and hygiene; and is not ambulatory. The MDS documented he is frequently incontinent of urine and always incontinent of bowel. The MDS documented the resident does not have a pressure ulcer but is at risk of developing pressure ulcers. The Care Plan focus dated [DATE] documented Resident #11 has a self-care deficit related to immobility, weakness and incontinence. The care plan directed staff that he is one assist with toileting for perineal care and clothing management and uses a full body lift for transfers at all times. The Care Plan focus dated [DATE] documented the resident has a pressure injury stage II to his left buttock related to immobility. The care plan directed staff to reposition him frequently. The Admission Screener dated [DATE] for Resident #11 documented he did not have any impaired skin integrity. The Braden Scale documented he scored 15 indicating he is at risk for pressure sores. The Skin and Wound Evaluations for the left buttock documented the following: On [DATE] the resident has a Stage II pressure to his left buttock in house acquired measuring 1cm in area, 1.7cm in length, 0.8cm in width and no depth. The form documented he is on a turning/repositioning program. On [DATE] the left buttock Stage II measures 3.2cm in length and 2.2cm in width. On [DATE] the left buttock Stage II measures 1.7cm in length and 2cm in width. During observations in the facility observed the resident always on his back. Observations included: On [DATE] at 9:50 AM observed the resident in bed lying on an air mattress flat on his back. On [DATE] at 11:15 AM observed Staff F enter Resident #11's room. She stated she was just checking him. Resident observed to be lying flat on his back when she entered. She exited his room at 11:28 AM carrying trash and the resident was still lying on his back. She stated she is supposed to check and change him every two hours. She stated she was not aware of any open areas on his skin because she was just coming back to work from six days off. She informed the nurse he did not want to get up for lunch so she left him down. The resident is lying on a low air loss mattress flat on his back. On [DATE] at 12:50 PM observed the resident in bed lying on an air mattress flat on his back. On [DATE] observed the resident lying flat on his back at 10:00 AM, 11:12 AM, 12:12 PM and 1:10 PM. On [DATE] at 1:15 PM observed Staff G and Staff K enter the resident's room. They explained to him that they needed to change him and do his wound care. The resident screamed out in pain during all cares. The nurse stated she gave him [MEDICATION(S)] 20 minutes ago. Observed an open area to the residents left buttock. After wound care, on [DATE] at 1:45 PM, the nurse [NAME] stated staff are to turn and reposition him every two hours. She stated any resident that is unable to turn themselves is to be turned every two hours. On [DATE] at 3:31 PM the Administrator stated The Skin and Wound Evaluations for the left buttock is showing it is the right buttock. He stated the evaluations are for the left buttock and he is working with his IT department to correct it. He does not understand why it is pulling through to the software as his right buttock. He stated the open area and the evaluations are for his left buttock.

Based on record review, and family and staff interviews, it was determined the facility failed to conduct a comprehensive assessment of a resident's wounds when she returned from the hospital, failed to provide care and services consistent with professional standards to promote wound healing and prevent infection, and failed to demonstrate the subsequent pressure ulcer deterioration was unavoidable for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 68 residents. Findings include: The Admission Minimum Data Set (MDS) assessment tool dated 3/6/20, revealed Resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS revealed the resident displayed modified cognitive impairment and required extensive assist of 1 staff for bed mobility and dressing and extensive assist of 2 staff for transfers and toilet use. The MDS documented the resident had no pressure ulcers, but had 4 venous ulcers. The MDS identified Resident #1 as at risk of developing pressure ulcers. The resident's Care Plan initiated on admission (March 2020) directed staff to assess and document the appearance of any wounds at least weekly and as needed. The Progress Note dated 4/3/20 at 5:56 PM revealed she returned from an appointment with order for a [DEVICE] (vac), which had been applied by the wound nurse. The Discharge Instructions from the hospital dated 4/3/20 revealed the resident had open areas to her right calf that had been debrided with a wound vac placed. The instruction also contained a referral to a wound care physician for follow up. The Wound Assessment from the wound care clinic dated 4/6/20 documented a Stage IV pressure ulcer on the right lower extremity that measured 5.5 cm by 3.5 cm, with a depth of 0.7 cm. The physician progress notes [REDACTED]. The note described the area as in the process of healing with the wound vac in place. The Skin and Wound Evaluation from the facility dated 4/10/20 revealed resident's right lateral calf measured 4.3 cm in length by 2.6 cm in width with 90 percent granulation and 10 percent slough. It revealed the wound had been debrided at an outpatient procedure last week and showed no signs of infection with a wound vac placed. The Progress Note dated 4/13/20 at 3:44 PM revealed the resident was sent to the hospital from the wound care appointment [MEDICAL CONDITION] and a wound infection. The History and Physical from the hospital dated 4/21/20 revealed Resident #1 presented to the hospital due to increased right lower extremity pain and a chronic right lower extremity ulcer. An arterial Doppler revealed right popliteal artery occlusion. The H & P documented she previously had the ulcer debrided on 4/3/20 and had been started on an antibiotic for a wound infection related to cultures that grew staph, diptheroids, and proteus. The Progress Note from the hospital dated 5/10/20 documented the wound as improving with Resident #1's pain controlled. The Adult Assessment and Intervention from the hospital dated 5/15/20 revealed the wound to Resident #1's right lower extremity measured 8 cm in length by 7 cm in width, with light exudate and eschar tissue present. The Transfer Discharge Active orders dated 5/15/20 from the hospital revealed active wound orders that included: a. Turn side to side b. Assess pressure points on heels every shift c. Float heels d. Ace wrap daily around wound vac to help with [MEDICAL CONDITION], keep tubing on outside of ace to prevent pressure injury e. No weight bearing f. Wound vac cares every Monday, Wednesday and Friday to right lower heel. Veraflo cleanse dressing to run at continuous pressure 125 mmHg g. Rooke boot to right extremity continuously h. Prevalon boots to have on when in bed i. Sacral [MEDICATION NAME] Resident #1's Face Sheet revealed she readmitted to the facility on [DATE] with a principal [DIAGNOSES REDACTED]. The Braden Form dated 5/15/20 revealed a score of 15 and documented the resident as at risk for pressure related breakdown. The Admission Screener dated 5/15/20 revealed Resident #1 had pressure ulcers and wounds to bilateral feet, but the form did not contain any assessments related to wound measurements. The Progress Notes dated 5/15/20 at 1:20 PM documented the resident readmitted from the hospital with impaired skin integrity but did not include any wound assessments or measurements. During an interview with Staff B on 7/13/20 at 2:25 PM, she verified she had completed the admission for Resident #1. Staff B reported the resident arrived at the facility with a KCI dressing which was not compatible with any of the [DEVICE] at the facility. She added the infection control nurse ultimately brought the wound vac, but she could not recall when or if she (Staff B) hooked it up at that time. She did remember changing the dressing so it would be compatible with the Cardinal [DEVICE] that the facility used. The facility's Wound Assessment Policy dated 1/14/14 directed staff that assessing the resident for any wounds begins at the time of admission and is to be done weekly for all residents by licensed staff. Review of the clinical record revealed it failed to contain any documentation regarding a skin assessment completed upon the resident's admission on 5/15/20. During an interview with the Infection Control Nurse on 7/13/20 at 3:05 PM, she stated she remembered ordering the wound vac and all the supplies from Cardinal because the machine required by Resident #1 was different and required irrigation. She stated the specific irrigation the hospital had ordered did not work with the facility vac, so it all had to be changed. She stated she remembered ordering it all but does not remember specifically when she took it to the unit where Resident #1 resided. The Treatment Administration Record for May 2020 revealed staff had not signed that the wound vac ran continuously until 5/15/20 at 9:00 PM. During an interview with the resident's daughter on 7/13/20 at 2:55 PM, she reported she had spoken with her mother the day she returned from the hospital to see how she was doing. She stated Resident #1 told her the wound vac was not hooked up and running and asked her daughter if she needed to hook it up. She stated that Resident #1 told her the wound vac was in her room leaning against the wall in the corner. The daughter stated that according to her call log on her phone, she had called the facility at 7:39 PM and spoke to the night charge nurse. She remembered she had asked him if the wound vac had been hooked up and the nurse stated he hadn't gotten to it yet. The daughter stated it concerned her because although her mother had been doing well at the hospital, she developed an infection within a couple days and stated complaining of more pain. The Progress Note dated 5/16/20 at 1:20 AM documented staff applied the wound vac to her right lower extremity with suction at 1:25 AM. During an interview with Staff A on 7/9/20 at 2:40 PM, he stated it was probably about 9 pm on 5/15/20 when he started Resident #1's wound vac. He reported he charted that he turned it on later because at that time he had been playing catch up with his documentation. He stated residents come from the hospital without their wound vac hooked up because they typically use the facility's wound vac. Staff A reported he had hooked up the machine, but did not change the dressing because it was already in place. The Cardinal Health Clinician User Manual contained safety tips that directed the catalyst should be operated at least 22 hours out of every 24 hour period and if therapy is terminated or the vac is off for more than two hours in a 24 hour period, the dressing should be removed During a second interview with Staff A on 7/14/20 at 9:10 AM, he stated he did not know why the wound vac was not hooked up earlier on day shift except for the possibility that they might have had to wait for another one to be delivered. He stated transfers from the hospital never go smoothly and added he did not remember where the wound vac was when he went to get it and hook it up, but he did remember hooking it up at 9 pm since that is when he signed it. He stated that when he gets to work at 6 pm he has to start medication and insulin pass so any wound care is going to occur later. During an interview with the Wound Care Clinic Nurse on 7/13/20 at 2:50 PM, he stated he was returning the call for the wound care physician. He reported the wound vac could not be unhooked, not in in operation, or alarming for more than 2 hours. He stated with the dressing in place and the wound vac not hooked up for more than 2 hours, the resident's risk for a wound infection increased. The Progress Notes dated 5/18/20 at 11:14 AM, revealed the wound vac dressing to the right lower extremity was removed with immediate odor, maceration, and a lot of fluid present. The wound vac was unable to be replaced due to maceration of the skin so staff applied a wet to dry dressing. A note at 7:22 PM documented the Nurse Practitioner had been in the facility, saw the resident, and wrote new orders to discontinue wound irrigation, hold the wound vac until 5/25/20, begin wet to dry dressings daily, culture the wound, and start the resident on Keflex. The Progress Notes dated 5/19/20 at 1:23 AM revealed the wound to the right lower extremity emitted a foul odor, displayed maceration, and drained a moderate to large amount. At 3:06 PM, staff obtained wound cultures and at 4:43 PM, the wound to the right lower extremity had deteriorated from the last assessment. The Skin and Wound Evaluation form dated 5/19/20 revealed the wound to the resident's right lateral calf measured 12.5 cm by 6.2 cm in width with 80 percent slough present, increased green drainage, increased pain rated at 9/10, and a moderate odor noted after cleansing. The note described the wound as deteriorating with denuded and macerated surrounding tissue. The Microbiology Report from the resident's right extremity wound culture dated 5/19/20 revealed many pseudomonas and proteus species present with a new order for [MEDICATION NAME]. During an interview with the Director of Nursing on 7/16/20 at 12:20 PM, she stated that she was aware the wound vac was not started until the night nurse initiated it at 9 pm. She stated that she expected it to be started earlier by the admitting nurse when she changed the dressing, but did not know why it wasn't.

Based on record review, observations and staff interviews, the facility failed to provide care consistent with professional standards to prevent a deterioration of a Stage III pressure ulcer and also failed to ensure pressure relief interventions were always in place for 1 of 3 residents observed (Resident #63), The facility also failed to complete treatments and dressing changes according to physician's orders [REDACTED].#51) dressing change(s) observed. The facility reported a census of 79 residents. Findings include: The Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #63 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated the resident displayed moderately impaired cognition. The MDS revealed Resident #63 required extensive assist of 1 staff for bed mobility, transfers and ambulation (walking). According to the MDS, Resident #63 was at risk of developing pressure ulcers, but was coded as having no pressure ulcers. Record review revealed no documentation that showed facility staff assessed the resident's skin upon admission. A Significant Change in Status MDS dated [DATE] documented Resident #63 had a Stage III pressure ulcer present on admission and a BIMS score of 3/15 indicating severe cognitive deficit. The MDS assessment defined a Stage III Pressure Ulcer as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The Wound Assessment facility policy revised 7/1/19 revealed the facility's practice to provide ongoing wound assessment at least weekly or more often when indicated by wound complications or changes in wound characteristics. The facility procedure directed staff to assess all wounds upon on admission, monitor daily, and assess weekly. The Care Plan for Resident #63 dated 8/16/19 documented a focus area initiated on 6/14/19, which identified the resident as at risk for impairment to skin integrity related to immobility, incontinence, diabetes, [MEDICAL CONDITION], dysphagia, weight loss and an [MEDICATION NAME] level of 3.0. The Care Plan directed staff to complete treatment as ordered, turn or reposition frequently or as resident allows, pressure reduction cushion in wheelchair, and pressure relieving mattress on the bed. Another focus area initiated on 6/14/19 identified Resident #63 as at risk for (Activities of Daily Living (ADL) self-care deficiency related to weakness, falls and cognitive status with decline expected. The Care Plan directed staff to wear a Prevalon boot (to relieve pressure) when heel of foot rested on the bed or chair, and float heels whenever possible. Physician order [REDACTED]. The resident's record did not contain information related to a pressure wound on the resident's right heel until an entry on 6/10/2019 at 1:06 PM in the Nurse's Notes that documented the order staff received when the resident returned from the wound clinic. An order from a wound clinic appointment dated 6/10/19 directed staff to clean the resident's right heel with normal saline, cover with xeroform, then apply [MEDICATION NAME]. Change on Mondays, Wednesdays, and Fridays and as needed (PRN). The order also directed staff to ensure the resident wears Prevalon boots when heel of foot rests on bed or chair, float heels whenever possible, and resident to return to the clinic in 2 weeks. The Wound Assessment Details form from the Wound Care Clinic dated 6/10/19 documented a right lateral calcaneus area as a Stage III Pressure Ulcer measuring 0.5 cm x 1.2 cm x 0.1cm that contained a medium amount of serosanguineous exudate and a small amount of adherent slough present. Record review for Resident #63 revealed the facility did not begin to document weekly skin assessments until 7/4/19. The Skin and Wound Evaluation from the facility dated 7/4/19 revealed a Stage III Pressure Ulcer on the resident's right heel that measured 0.3 cm x 0.5 cm x 0.6 cm with 90 percent [MEDICATION NAME] tissue, 10 percent granulation, and no exudate present. The Wound Assessment Details form from the Wound Care Clinic dated 7/8/19 documented a right lateral calcaneus area as a Stage III Pressure Ulcer that measured 0.9 cm x 0.3 cm x 0.1 cm with a large amount of granulation, small amount of serosanguineous exudate, and a small amount of adherent slough present. The Patient Information form for Hospice revealed Resident #63 admitted to a hospice service on 7/22/19. The Skin and Wound Evaluation from the facility dated 7/24/19 revealed a Stage III Pressure Ulcer on the resident's right heel that measured 0.7 cm x 0.9 cm x 0.7 cm with 90 percent [MEDICATION NAME] tissue, no granulation tissue, and a scab present. A fax sent by the facility to the physician on 7/31/19 revealed Resident #63 right heel was stable with the surrounding tissue macerated. Staff requested to change the treatment order to skin prep and foam border dressing. A Hospice Routine Visit note dated 8/7/19 revealed hospice ordered a low air loss mattress for the resident. The Skin and Wound Evaluation from the facility dated 8/13/19 revealed a Stage III Pressure Ulcer to Resident #63's right heel that measured 2.4 cm x 1.5 cm x 2.1 cm with 90 percent [MEDICATION NAME] tissue, no granulation tissue, and light serosanguineous exudate present A fax sent by the facility to the physician on 8/13/19 revealed Resident #63's right heel pressure injury deteriorated when compared to last week's measurements: 0.6 cm x 1.2 cm vs. 1.5 cm x 2.1 cm. Facility staff requested to change the dressing to Puracol plus and [MEDICATION NAME]. Observation on 08/20/19 at 11:25 AM revealed Resident #63 in a reclining wheelchair in stocking feet which rested on metal foot pedals. Resident unable to sit still in wheelchair, attempted several times to stand up, and then fidgeted in wheelchair. One Prevalon boot found in the resident's room. Observation on 08/21/19 at 12:20 PM revealed Resident #63 sat upright in a wheelchair in the dining room with feet in socks, and rested against the metal wheelchair pedals. Further observation revealed one Prevalon boot lay on the resident's bed in her room. Observation on 08/22/19 at 09:26 AM revealed Resident #63 in her wheelchair at the dining room table wearing socks and no Prevalon boots, heels resting against the metal wheelchair pedals. Observation attempted/requested on 08/20/19 at 11:21 AM. Staff B, RN reported she had already assessed the wound and changed the dressing on the resident's right heel that morning (ordered every 36 hours). In an interview on 08/20/19 at 11:30 AM with Staff C, Hospice Nurse and she reported the reclining wheelchair the facility provided for Resident #63 in last week is causing her discomfort. Hospice nurse reported she will have staff go back to the standard wheelchair and will order a tilt and space wheelchair for her to help off load (remove pressure) her heels. Staff C stated the resident should have her heel protector on but hospice nurse reports she doesn't like to wear it. Hospice nurse also informed surveyor when Resident #63 first admitted she had a mattress brought in by family so there was a delay in ordering a low air loss mattress. During an interview on 08/21/19 at 1:05 PM, the facility Regional Consultant reported she expected the staff to attempt to put the resident's prevalon boots on as directed or ordered on the TAR and Care Plan. If a resident refuses or removes them, staff should document that and add it to the Care Plan. In a subsequent interview at 2:59 PM with the facility Regional Consultant and she informed the surveyor that she could not find any skin assessments completed by staff at the time the resident admitted to the facility. In an interview on 08/21/19 at 03:15 PM with Staff D, she reported they only apply the Prevalon boots at bedtime. In an interview on 08/21/19 at 03:50 PM, the podiatrist that saw Resident #63 at the Wound Care Center verified he ordered the Prevalon boots and expected staff to keep them on the resident's feet at all times except when the resident ambulated. The podiatrist reported he expected staff to also keep her heels floated and added if the boots were not on she would be at risk for further skin breakdown. Based on record review, observations and staff interviews, the facility failed to provide care consistent with professional standards to prevent a deterioration of a Stage III pressure ulcer and also failed to ensure pressure relief interventions were always in place for 1 of 3 residents observed (Resident #63), The facility also failed to complete treatments and dressing changes according to physician's orders [REDACTED].#51) dressing change(s) observed. The facility reported a census of 79 residents. Findings include: The Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #63 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated the resident displayed moderately impaired cognition. The MDS revealed Resident #63 required extensive assist of 1 staff for bed mobility, transfers and ambulation (walking). According to the MDS, Resident #63 was at risk of developing pressure ulcers, but was coded as having no pressure ulcers. Record review revealed no documentation that showed facility staff assessed the resident's skin upon admission. A Significant Change in Status MDS dated [DATE] documented Resident #26 had a Stage III pressure ulcer present on admission and a BIMS score of 3/15 indicating severe cognitive deficit. The MDS assessment defined a Stage III Pressure Ulcer as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The Wound Assessment facility policy revised 7/1/19 revealed the facility's practice to provide ongoing wound assessment at least weekly or more often when indicated by wound complications or changes in wound characteristics. The facility procedure directed staff to assess all wounds upon on admission, monitor daily, and assess weekly. The Care Plan for Resident #63 dated 8/16/19 documented a focus area initiated on 6/14/19, which identified the resident as at risk for impairment to skin integrity related to immobility, incontinence, diabetes, [MEDICAL CONDITION], dysphagia, weight loss and an [MEDICATION NAME] level of 3.0. The Care Plan directed staff to complete treatment as ordered, turn or reposition frequently or as resident allows, pressure reduction cushion in wheelchair, and pressure relieving mattress on the bed. Another focus area initiated on 6/14/19 identified Resident #63 as at risk for (Activities of Daily Living (ADL) self-care deficiency related to weakness, falls and cognitive status with decline expected. The Care Plan directed staff to wear a Prevalon boot (to relieve pressure) when heel of foot rested on the bed or chair, and float heels whenever possible. Physician order [REDACTED]. The resident's record did not contain information related to a pressure wound on the resident's right heel until an entry on 6/10/2019 at 1:06 PM in the Nurse's Notes that documented the order staff received when the resident returned from the wound clinic. An order from a wound clinic appointment dated 6/10/19 directed staff to clean the resident's right heel with normal saline, cover with Xeroform, and then apply [MEDICATION NAME]. Change on Mondays, Wednesdays, and Fridays and as needed (PRN). The order also directed staff to ensure the resident wears Prevalon boots when heel of foot rests on bed or chair, float heels whenever possible, and resident to return to the clinic in 2 weeks. The Wound Assessment Details form from the Wound Care Clinic dated 6/10/19 documented a right lateral calcaneus area as a Stage III Pressure Ulcer measuring 0.5 cm x 1.2 cm x 0.1cm that contained a medium amount of serosanguinous exudate and a small amount of adherent slough present. Record review for Resident #63 revealed the facility did not begin to document weekly skin assessments until 7/4/19. The Skin and Wound Evaluation from the facility dated 7/4/19 revealed a Stage III Pressure Ulcer on the resident's right heel that measured 0.3 cm x 0.5 cm x 0.6 cm with 90 percent [MEDICATION NAME] tissue, 10 percent granulation, and no exudate present. The Wound Assessment Details form from the Wound Care Clinic dated 7/8/19 documented a right lateral calcaneus area as a Stage III Pressure Ulcer that measured 0.9 cm x 0.3 cm x 0.1 cm with a large amount of granulation, small amount of serosanguinous exudate, and a small amount of adherent slough present. The Patient Information form for Hospice revealed Resident #63 admitted to a hospice service on 7/22/19. The Skin and Wound Evaluation from the facility dated 7/24/19 revealed a Stage III Pressure Ulcer on the resident's right heel that measured 0.7 cm x 0.9 cm x 0.7 cm with 90 percent [MEDICATION NAME] tissue, no granulation tissue, and a scab present. A fax sent by the facility to the physician on 7/31/19 revealed Resident #63 right heel was stable with the surrounding tissue macerated. Staff requested to change the treatment order to skin prep and foam border dressing. A Hospice Routine Visit note dated 8/7/19 revealed hospice ordered a low air loss mattress for the resident. The Skin and Wound Evaluation from the facility dated 8/13/19 revealed a Stage III Pressure Ulcer to Resident #63's right heel that measured 2.4 cm x 1.5 cm x 2.1 cm with 90 percent [MEDICATION NAME] tissue, no granulation tissue, and light serosanguinous exudate present A fax sent by the facility to the physician on 8/13/19 revealed Resident #63's right heel pressure injury deteriorated when compared to last week's measurements: 0.6 cm x 1.2 cm vs. 1.5 cm x 2.1 cm. Facility staff requested to change the dressing to Puracol plus and [MEDICATION NAME]. Observation on 08/20/19 at 11:25 AM revealed Resident #63 in a reclining wheelchair in stocking feet which rested on metal foot pedals. Resident unable to sit still in wheelchair, attempted several times to stand up, and then fidgeted in wheelchair. One Prevalon boot found in the resident's room. Observation on 08/21/19 at 12:20 PM revealed Resident #63 sat upright in a wheelchair in the dining room with feet in socks, and rested against the metal wheelchair pedals. Further observation revealed one Prevalon boot lay on the resident's bed in her room. Observation on 08/22/19 at 09:26 AM revealed Resident #63 in her wheelchair at the dining room table wearing socks and no Prevalon boots, heels resting against the metal wheelchair pedals. Observation attempted/requested on 08/20/19 at 11:21 AM. Staff B, RN reported she had already assessed the wound and changed the dressing on the resident's right heel that morning (ordered every 36 hours). In an interview on 08/20/19 at 11:30 AM with Staff C, Hospice Nurse and she reported the reclining wheelchair the facility provided for Resident #63 in last week is causing her discomfort. Hospice nurse reported she will have staff go back to the standard wheelchair and will order a tilt and space wheelchair for her to help off load (remove pressure) her heels. Staff C stated the resident should have her heel protector on but hospice nurse reports she doesn't like to wear it. Hospice nurse also informed surveyor when Resident #63 first admitted she had a mattress brought in by family so there was a delay in ordering a low air loss mattress. During an interview on 08/21/19 at 1:05 PM, the facility Regional Consultant reported she expected the staff to attempt to put the resident's Prevalon boots on as directed or ordered on the TAR and Care Plan. If a resident refuses or removes them, staff should document that and add it to the Care Plan. In a subsequent interview at 2:59 PM with the facility Regional Consultant and she informed the surveyor that she could not find any skin assessments completed by staff at the time the resident admitted to the facility. In an interview on 08/21/19 at 03:15 PM with Staff D, she reported they only apply the Prevalon boots at bedtime. In an interview on 08/21/19 at 03:50 PM, the podiatrist that saw Resident #63 at the Wound Care Center verified he ordered the Prevalon boots and expected staff to keep them on the resident's feet at all times except when the resident ambulated. The podiatrist reported he expected staff to also keep her heels floated and added if the boots were not on she would be at risk for further skin breakdown. 2. Review of the quarterly MDS dated [DATE] revealed Resident #51 had a BIMS score of 15/15, indicating no cognitive impairment demonstrated. The MDS indicated Resident #51 required extensive assistance of 1 staff for transfers and bed mobility. The MDS listed a [DIAGNOSES REDACTED]. Review of Resident #51's care plan revised 5/2/19 revealed she was at risk for pressure injury development and/or venous stasis ulcers, and directed staff to administer treatments as ordered and monitor for effectiveness of the treatment(s). Observation on 08/20/19 at 9:10 AM revealed Staff B Registered Nurse (RN) had completed Resident #51's treatment and dressing change while Staff J Unit Manager observed. Staff B removed the top dressing on Resident #51's back and it was dated 8/14/19 and bottom dressing was dated 8/20/19. Observation on 08/20/19 at 9:20 AM revealed Staff O CNA and Staff N CNA provided cares for Resident #51. Resident #51 was rolled on to her left side and it was noted she had a coccyx dressing with a date of 8/14/19. Resident #51 was noted to have a [MEDICAL CONDITION] and urinary catheter. Review of Resident #51's Electronic Health Record (EHR) revealed the following orders: -Foam Dressing: Cleanse coccyx with normal saline/wound cleanser, then apply and cover foam sacral dressing every evening shift every 3 day(s) for skin integrity and as needed (PRN) for skin integrity, with a start date of 7/23/19. -foam border dressing to spinal prominence every 72 hours for wound care with a start date of 4/26/2019. Record review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed the coccyx dressing was last signed as completed on 8/19/19. The spinal prominence dressing was last signed as completed on 8/18/19. Review of Resident #51's (MONTH) 2019 TAR and progress notes revealed there was no documentation related to the PRN dressing change and it was scheduled to be changed on 8/22/19. During a staff interview on 08/22/19 at 2:17 PM Staff J Unit Manager stated the dressing should be changed every three days. When asked about the dates on the dressings, she reported she did not look at the dates on the back and coccyx wound dressing because she did not want to make the staff nervous by standing right by them during the observation. She stated staff should be following the orders and changes the dressing as ordered.

Based on clinical record reviews, facility policy review, and interviews, the facility failed to assure each residents received adequate supervision and assistance to prevent accidents for 1 of 5 resident records reviewed (Resident #4). On 2/4/19, Staff B attempted to turn Resident #4 in bed without another staff member present to assist as required. In the process, the resident sustained [REDACTED]. The facility identified a census of 78 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 1/25/19, documented [DIAGNOSES REDACTED].#4. The same MDS documented a Brief Interview of Mental Status (BIMS) score of 7, which indicated the resident displayed moderately impaired cognition. The MDS also documented the resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene, and had no limitations of functional range of motion of shoulder, elbow, wrist or hand. The care plan problem initiated 1/30/13 identified the resident required assistance with completion of activities of daily living (ADL's) and directed staff to use 2 persons to assist with bed mobility. The Progress Notes entry completed by Staff A, licensed practical nurse (LPN) on 2/4/19 at 7:20 PM documented a Staff B, a certified nursing assistant (CNA), in the process of rolling the resident in bed heard a pop sound from the resident's right shoulder. Assessment revealed the resident would not move the right arm and complained of pain. Staff A administered pain medication to the resident and obtained an order for [REDACTED]. During interview on 3/21/19 at 2:05 PM, Staff A stated Staff B reported to her he heard a pop when he rolled the resident over in bed. She asked Staff B if he had used a turn sheet to move the resident and he stated he had, but she really did not think he had, and he turned the resident without assistance of another CNA. Staff A stated she educated all CNA's on duty that evening to use a draw sheet when turning and repositioning residents in bed. During interview on 3/21/19 at 6:15 PM, Staff B stated he rolled the resident in bed in order to change his incontinent brief when he heard a pop sound. He stated he pushed on the resident's right shoulder to turn him and he did not use a draw sheet on the resident's bed. He turned the resident by himself and did not know what the resident's care plan directed. He stated he had turned this resident, as well as other residents, without a draw sheet and never had an issue. During interview on 3/21/19 at 4:15 PM Staff C, CNA, stated the resident required assistance of only 1 staff to turn in bed, but might require 2 if the resident was tired. She stated staff have been instructed to turn residents in bed with the use of a draw sheet, but had witnessed other employee not use them. She stated she had witnessed Staff B turn the resident by pushing on him with one hand, and stated she had also done this in the past. During an interview on 3/22/19 at 10:50 AM, the administrator, and the former director of nursing (DON), stated she instructs CNA's to use a draw sheet to turn or reposition residents in bed. She would also expect staff utilize the number of assistants to perform tasks as directed by the resident's care plan. The facility's Positioning the Resident policy revised 10/21/11 directed the following: 10. To turn resident on side: a. put the rail up on the far side of the bed b. grasp the edge of the pad and gently roll the resident to the side. adjust shoulders, hips and knees and ankles for comfort d. support with pillows as necessary. Note: be sure the resident is not lying on the arm. During interview on 3/27/19 at 12:34 PM the resident's primary care physician stated he reviewed the resident's medical file and noted the resident had a bone scan on 2011 that showed the resident had [MEDICAL CONDITION]. He stated the resident also had a history of [REDACTED]. He reported he did not consider the fracture to be a major injury. During interview on 4/19/19 at 9:47 AM the resident's orthopedic physician stated he consulted with the resident's primary care physician and reviewed an x-ray completed 2/26/19 which showed the [MEDICAL CONDITION] humerus had no signs of healing. He stated the resident had multiple medical conditions and advanced age which can complicate healing of fractures and did not consider the fracture to be a major injury. He stated the resident was not a candidate for surgical repair and suggested the conservative treatment, as previously ordered, of keeping the right arm in a sling for support.

Based on clinical record review, observation, staff interviews and facility policy review, the facility failed to always provide assessment and intervention for a resident with low urine output and dark urine for one of two residents sampled with urinary catheters (Resident #4). The facility identified a census of 91 current residents. Findings include: 1. According to the MDS (minimum data set) assessment dated [DATE], Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 11 which indicated moderate cognitive impairment. According to the MDS, the resident required the assistance of two with bed mobility, transfers, toilet use and bathing, The assessment documented Resident #4 required an indwelling catheter for urination. The resident's care plan focus area for self care deficiency, dated 1/3/18, instructed staff to provide Foley (urinary catheter) cares every shift and as needed. Under the catheter focus area, dated 1/10/18, the care plan directed to check the catheter tubing for kinks each shift and monitor for signs/symptoms of discomfort due to the catheter. The catheter interventions also instructed to monitor/record/report to the medical doctor signs/symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and/or change in eating patterns. The Order Summary Report dated 1/8/18 directed staff to monitor the resident's Foley catheter site every shift for signs and symptoms of injection. If infection noted, document and notify the physician. Review of the Intake/Output record dated 12/27/17 through 1/11/18 revealed the resident had the following outputs from her urinary catheter: a. 1/10/18 at 4:24 AM - 120 cc (cubic centimeters); b. 1/10/18 at 1:27 PM - 75 cc; c. 1/10/18 at 9:09 PM - 50 cc; d. 1/11/18 at 3:40 AM - 60 cc; e. 1/11/18 at 4:15 AM - 300 cc; f. 1/11/18 at 11:19 AM - 100 cc. Review of the Skilled Note dated 1/11/18 at 1:36 AM revealed the resident had a Foley indwelling catheter patent and draining dark tea colored urine. Staff offered fluids offered and the resident took minute sips. The note also identified the resident seemed to want to do less and less; she just wanted to stay in bed. Review of the Progress Notes dated 1/11/18 at 7:52 AM revealed the resident presented with a change in condition in the morning of 1/10/18. The change in condition related to bleeding and staff reported the change in condition to the resident's physician at 8:10 AM. Staff notified the resident's family/healthcare agent on 1/11/18 at 8:15 AM. The Progress Note dated 1/11/18 at 2:11 PM recorded Resident #4 admitted to the hospital for acute kidney injury, rapid fibrillation and hematuria. The resident's record revealed no further assessment of urine output/catheter patency. Review of the Hospital Discharge Documents dated 1/16/18 revealed the resident had been lethargic for 2 days and sleeping most of the time and was noted to be very sweaty in her bed. She then developed some hematuria (blood in the urine) which was seen in her Foley catheter. She had continued complaints of pain and describes the pain as all over. Emergency department evaluation included a Foley catheter exchange with findings of several large blood clots which once passed resulted in 1200 cc of urine drained from the bladder. She was also noted to be in [MEDICAL CONDITION] with a resting ventricular rate 150's. She admitted with urinary tract infection with [MEDICATION NAME] (antibiotic), gross hematuria, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The hematuria cleared and the clinician suspected hematuria secondary to UTI (urinary tract infection) with gross overdistention of the resident's bladder. During an interview with Staff A, CMA (certified medication assistant) on 3/20/18 at 1:20 PM, she stated remembered the resident had a small output of dark colored urine the day before she went to the hospital. She stated she told the nurse but could not remember which one. She stated she did not see any blood in the urine and the resident did not complain of pain. During an interview with Staff G, CNA (certified nursing assistant) on 3/20/18 at 1:40 PM she stated Resident #4 had brown urine towards the end of her stay. She stated the resident had been going downhill but she did not recall the resident complaining of pain. She stated she did not tell the nurse about the brown urine because the regular CNAs on her hall would have told the nurse. During an interview with Staff E, RN (registered nurse) on 3/20/18 at 2:00 PM she stated it had not been reported to her that Resident #4 had the low outputs on 1/10/18; this was the first she'd heard of it. She further stated they would irrigate the resident's catheter or call the physician if there had been no order related to the concern. During an interview with Staff H, LPN (licensed practical nurse) on 3/21/18 at 2:20 PM, she stated she clocked in at 4:00 AM on 1/11/18 and worked CNA duties. She completed rounds with the resident at approximately 4:00 PM and emptied approximately 200 to 300 cc of extremely dark and blood tinged urine. She asked the night nurse if she had seen the urine and she said yes and it had been that way due to the catheter had been changed out the other day. Staff H stated it had not been that color previously and she told the nurse she didn't think it was right. Staff H finished rounds and received nursing report and instructed the day CNAs to watch the resident closely. She went to the resident's room, assessed her and took her vital signs. The resident stated her belly hurt a little bit; she had hyperactive bowel sounds in the upper quadrants and normal bowel sounds in the lower . The resident also had approximately 400 cc of real red urine at that time. She called the physician and he gave an order to send the resident to the hospital. Approximately 5 to 6 hours later, a urologist called and reported the catheter had been empty when at the hospital and they put in a new catheter and returned a large amount of urine. Staff H further stated it had not been reported to her the resident had a low output the day before. Review of the facility's Incontinence and Catheter Management policy dated 4/2017 revealed that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

Based on clinical record review and staff interviews, the facility failed to protect 1 of 11 residents from physical/environmental hazards (Resident # 8). Interview revealed staff did not use the wheelchair foot rests when transporting Resident #8. Resident #8 put his/her feet down and fell forward out of the wheelchair, hitting his/her head and sustained a complex facial laceration to his/her left eyelid and forehead laceration. Record review identified no assessment regarding Resident #8's ability to maintain and or hold his/her feet/legs up during wheelchair transports. The facility reported a census of 93 residents. Findings included: Resident #8's 5/13/16 Minimum Data Set (MDS) documented the resident had moderately impaired cognitive function based on a Brief Interview Mental Status (BIMS) score of 9 out of 15. The resident required staff assistance for transfers, ambulation, dressing, toileting, and personal hygiene. The resident used a walker and a wheelchair. The resident's Active [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, and History of Falling. The resident's Care Plan close date of 8/15/16 documented the resident had potential for injury related to a history of falls.The care plan noted the resident required assistance with activities of daily living and he/she experienced unsteadiness at times. The care plan identified Resident #8 received psychoactive medications for depression and anxiety. The Care Plan lacked any direction to staff in regard to use of wheelchair foot rests. Nursing Progress Notes dated 7/25/16 at 7:55 p.m. recorded that staff had been taking the resident to his/her room in a wheelchair when the resident put his/her feet down when the wheelchair was moving, causing the resident to fall head first out of the wheelchair to the floor. Resident #8 sustained a laceration to the left eye and laceration to the forehead in two areas. The notes documented Resident #8 had no response after the fall. Staff sent the resident to the emergency room due to the eye laceration. A 7/25/16 Physician's Emergency Department Note documented at the nursing home an aide had attempted to push the patient and didn't put the patient's feet on foot plates, which caused the patient to fall out of chair and strike his/her head on the ground. The patient received lacerations to the left side of the face. The note documented the left cheek laceration 4 centimeters (cm) in the shape of a flap with bloody discharge. The left forehead lacerations measured 1 cm. The note documented a plan to transfer the resident to another hospital for evaluation of the lacerations by a plastic surgeon. The resident sustained [REDACTED]. Facility staff documented in the Nursing Progress Notes on 7/26/16 at 12:05 a.m. the hospital kept the resident overnight for observation. A 7/28/16 CHI Weekly Wound Flow Sheet documented the resident had an incision (unmeasured) to the face, well approximated with sutures intact and bruising and abrasions around the incision. During interview on 8/31/16 at 1:59 p.m. Staff A, Certified Nursing Assistant (CNA) stated she had been the staff involved with the resident's fall from the wheelchair on 7/25/16. She stated she had not put the foot rests on the wheelchair. The resident had just come from the shower and the foot rests were in the bag on the back of the wheelchair. She asked the resident if he/she could hold their feet up and the resident said yes. The CNA stated she had been trained at the facility if the resident could hold their feet up they didn't need foot rests. She stated she had pushed the resident a ways, stopped and the resident got medications. She pushed the wheelchair further and the resident put his/her feet down and fell forward out of the wheelchair. She tried to reach the resident's shoulder to prevent the fall but it happened too fast. She stated the resident hit his/her face on the carpet but couldn't effectively break the fall because the resident had their left arm in a sling. The CNA stated she felt terrible about the resident's fall. During interview on 8/31/16 the Director of Nursing (DON) confirmed it had been facility policy that if a resident could make decisions they asked the resident if they wanted foot rests on. During interview on the same date at 2:41 p.m. when asked how they decide who to ask about foot pedals on or off the DON stated they asked anyone who could answer questions, everyone else they automatically put foot rests on the wheelchair. During further interview on 9/1/16 at 9:12 a.m. the DON stated the facility had no actual policy related to use off foot rests on wheelchairs and they did no formal assessment of a resident's ability to hold legs up.

Based on observation, interviews and facility policy review, facility staff failed to assure all medication carts were locked when unattended. The facility reported a census of 93. Findings include: 1. Observation on 7/14/16 at 5:18 PM revealed an unlocked and unattended medication in the hallway outside the C hall dining area. Observation revealed no staff in the hallway. A pair of scissors and an open box of Symbicort (medication to treat breathing problems) unit dose nebulizer vials lay on top of the cart. At 5:23 PM Staff A, registered nurse (RN) came to the cart from the C Hall dining area. Staff A stated she thought she had locked the cart prior to leaving it and acknowledged the Symbicort and scissors should have been secured. During interview on 7/14/16 at 5:30 PM, the C Hall unit manager stated she expected all medication carts to be locked when unattended. The facility's Storage of Medications policy approved on 7/1/05 directed the following: Point # 6. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended.

Based on observation, record review, staff interviews, and review of the facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards when transferring a resident with a mechanical lift (Resident #1, #4). The sample consisted of 16 residents and the facility reported a census of 94 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 12/11/15. The MDS identified the resident had [DIAGNOSES REDACTED]. A brief interview for mental status score of 8 revealed moderate cognitive impairment. A Care Plan, initiated on 4/17/13, established focus areas of potential for injury related to falls, staff assistance with activities of daily living including two staff with transfer/1 staff assist with a sit to stand lift, extensive assist one staff with toileting, mobility and eating. An updated Care Plan dated 12/28/15 directed staff to use a Hoyer lift (requiring two staff to assist with a mechanical lift) for all transfers. Progress notes dated 12/22/15 at 5:05 p.m. documented an incident that occurred earlier that morning. A certified nursing assistant (CNA) assisted the resident out of bed using a sit to stand lift. The resident legs gave out and the resident had to be placed back into bed. Staff reported no injury had occurred. Staff assisted the resident into a wheelchair and no injuries noted. Staff assessed the resident later after completion of a shower and noted a small bump on the left ankle. Staff contacted the physician and the physician ordered an x-ray. The Progress Notes dated 12/22/15 at 9:00 p.m. reflected the resident received Tramadol HCI tablet 50milligrams (1/2 tablet) (for pain). An incident report dated 12/22/15 indicated the incident happened at 7:05 a.m. The incident report noted similar verbiage as recorded in the above progress note with additional information that the resident complained of pain and pain medications were give. Medication administration records dated 12/22/15 revealed Tramadol 50 milligrams .5 tablet had been given for pain at 8:30 a.m., 4:02 p.m. and 9:00 p.m. Staff recorded the resident's pain level for each of three shifts that day. Radiology report dated 12/22/15 at 7:42 p.m. identified an acute fracture of the left distal fibula and malleolus with modest angulation and displacement. Joint alignment is maintained and there is associated soft tissue swelling. A physician order dated 12/23/15 at 10:48 a.m. directed staff to keep the resident as non- weight bearing on the left leg using a cam-walker (boot) at 90 degrees. Ace wrap the ankle and check circulation every shift for altered skin integrity. A follow-up physician appointment, with new orders dated 12/23/15 directed staff to continue using the cam-walker (boot) as no surgery indicated, and no weight bearing on the left lower extremity. An investigative summary conducted by the facility on 12/24/15 at 11:25 a.m. revealed staff demonstrated (re-created) their involvement in the incident of 12/22/15 at 7:05 a.m. Staff A, CNA reported she sat the resident on side of bed, uncrossed the resident's feet and strapped the resident into the sit to stand lift, placed the strap around the resident's legs; which were not tightened but buckled. Staff A reported she did not buckle the strap around the resident's waist. She then raised the resident up and when moving the lift, the resident placed feet on to the floor. Staff A unbuckled the foot straps and tried to maneuver the lift possibly hitting the resident's legs. She could not get the resident's feet back on to the foot board and called for assistance. Staff A pushed the left back toward the bed and lowered the arms of the lift with the intent of getting the resident's buttocks on the bed. Staff B, CNA arrived into the room and the resident's feet were under the bed. Staff B assisted in positioning the lift so they could get the resident back into bed. Staff C, CNA came into the room and the resident leaned forward while Staff A and Staff B were pulling the resident to the bed. Staff D, a licensed practical nurse (LPN) and Staff A reported to Staff D the resident had chicken winged (elbows were raised above the shoulders) and the feet were off the lift foot pad before they could get the resident to bed. During an interview dated 1/25/16 at 9:00 a.m. Staff A reported she had gone to the resident's room at approximately 6:30 a.m. to get the resident up for breakfast. The resident is a two staff assist or a sit to stand lift with one staff; as the resident could bear weight. Staff A stated she had the resident positioned on the side of the bed and moved the lift in front of the resident. She lowered the bed, placed the resident's feet on the platform and placed the foot straps loosely around the feet. She placed the sling around the back and under the resident's arms, but didn't place the waist strap (safety belt) that secures the sling around the resident's waist. She stated she had forgotten to attach the safety belt prior to lifting the resident. She raised the resident up but the resident was unable to bear weight and moved feet off the foot platform. Staff A reported she unbuckled the upper sling (earlier she reported she hadn't used the safety belt), so she could maneuver the lift and tried to lift the resident further, causing the resident's elbows to be pulled back and up into a chicken wing position. She lowered the lift and the resident's leg buckled further and so she then raised the resident up in order to move the resident closer to the bed without running over the resident's feet. Staff A called for assistance and Staff B entered and both attempted to lean the resident backward to place the resident's buttocks on the bed. Staff C entered and Staff A unhooked the sling from the resident and held the resident up when the resident's knees buckled further causing the resident's feet to go further under the bed. Staff D came into the room and moved the left and Staff A and Staff B transferred the resident back into bed. During interviews dated 1/26/16 Staff B, C, and D were interviewed and each confirmed the events as described by Staff A from her interview with little variation in events. The facility's policy titled Mechanical Lift transfers, with a revision date of 2/4/14, directed the staff to follow the manufacturer's instructions for the specific type of mechanical lift. Sit to stand lift procedures require staff to apply the harness around the resident's waist and secure. Move the lift close the resident and place resident's feet on the foot plate. Move the lift toward the resident so the resident's knees touch the knee bracket pad. If a caregiver deems it necessary to keep a resident's shins or feet on the foot pad, secure the shin strap around the resident's legs. During an interview dated 1/26/16 at 7:10 a.m., the acting director of nursing stated she expected staff to follow the training they received and to follow the policy and procedures established on the use of mechanical lifts. 2. Resident #4 had a MDS assessment with a reference date of 12/11/15. The MDS identified the resident had [DIAGNOSES REDACTED]., pain, and osteoarthritis of the knee. The assessment indicated the resident required extensive physical assistance of 2 staff members for transfers. The Care Plan focus area dated 9/4/14 identified a risk for ADL (activities of daily living) self- care deficiency related to impaired mobility and occasional incontinence. The Care Plan directed staff to use the sit/stand (mechanical lift used for residents that can bear weight) for transfers and a Hoyer (a full body mechanical lift) with the assistance of 3 staff as needed. The focus area revised 7/13/15 for a risk of falls directed staff to ensure the resident wore appropriate footwear. Observation on 1/26/16 at 11:52 a.m. revealed Staff E, certified nurse aide (CNA), and Staff F, CNA, assisted Resident #4 to the toilet in the B-hall shower room. Staff E and Staff F assisted the resident to transfer to the toilet using the sit/stand lift. When Staff E and Staff F assisted the resident to stand with the lift; the resident urinated again soiling his/her pants. The CNAs lowered the resident back down on the toilet. Staff F exited the shower room to obtain new pants. Staff E disconnected the resident from the lift and removed the soiled pants. Without looking at the resident, Staff E moved the lift and Resident #4 stated oh, oh. The surveyor had to point out to Staff E that the sit/stand lift had ran over the resident's toes and half of the resident's sock was pinned under the wheel of the lift. Staff G, licensed practical nurse (LPN) / B-hall unit manager, observed the transfer with the surveyor and removed the resident's sock commenting there was no redness present to the toes. In an interview on 1/26/16 at 12:10 p.m., Staff G confirmed Staff E had ran the lift over Resident #4's toes. Staff G stated she would have expected staff to completely remove the lift from the area or to lock it in place to lessen the chance of running the lift into Resident #4's feet. Staff G further commented that Staff E had been picking up the dirty clothing with her back turned and didn't pay attention or see that she had pushed the sit/stand into the resident's toes. Observation on 1/26/16 at 1:02 p.m. revealed Staff E assisted Resident #4 to finish lunch in the dining room; the resident did not have shoes on. Staff E tilted the resident's wheelchair back and quickly turned the wheelchair brushing the bottoms of Resident #4's feet on the edge of the table. Staff E then quickly transported the resident out of the dining room. The care plan was updated on 1/27/16 under the focus area risk for falls to include an intervention for staff to encourage/assist the resident to wear shoes for transfers. The Mechanical Lift Transfers policy and procedure directs the following instructions under the Sit to Stand Mechanical Lift: Point 18. Lock the wheels of the lift. Point 19. Gently lower the resident into the wheelchair/bed and guide resident to a safe sitting position. Point 20. Disconnect the harness from the lift and remove the lift away from the resident.

Based on record review and staff interviews, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 90 residents. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date 4/3/15. The MDS reflected the resident had short and long term memory problems and moderately impaired for cognitive skills for daily decision making. The MDS identified the resident experienced signs and symptoms of inattention and disorganized thinking. The resident required extensive assistance of one staff for mobility, dressing, toileting and hygiene. A balance during transitions and walking test identified the resident as not steady and only to stabilize with staff assistance when walking, turning around, moving from seated to standing position, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] identified the resident scored a 9 on the assessment scale. A score of 10 or above represented the resident at a high risk for falling. The Care Plan, revised on 1/6/15, identified the resident at risk for falls due to being unsteady and had a [DIAGNOSES REDACTED]. The interventions included and directed the staff to encourage the resident to wear non-skid footwear when up, fall alarms in place to alert staff if attempts to get up, ambulate with walker and with staff assistance. A fall incident report dated 5/8/15 at 11:30 p.m. reflected the staff discovered Resident #1 on the floor on his/her left side. The nurse assessed the resident and identified the resident had limited range of motion to the left lower extremity. The nurse obtained a physician's orders [REDACTED]. An x-ray report dated 5/9/15, reflected the resident sustained [REDACTED]. The hospital progress note dated 5/9/15 identified the resident had just been admitted into Hospital that week because of a progressive decline in activities of daily living and weight loss. The resident had previously had experienced a fall had suffered a vertebral fracture with pain. The fracture was treated with vertebral plasty several months ago. The note reflected the resident had gotten up during the night and fell again. The order directed staff to give 5 milligrams of morphine orally every 1 hour as needed for mild pain and tramadol (analgesic) 50 milligrams by mouth every eight hours for severe pain. On 5/20/15 at 4:35 p.m. Staff H, registered nurse (RN) was interviewed and stated Resident #1 required the use of oxygen due to low oxygen saturation (pulse ox) levels on the shift prior to his/her fall. Staff H stated once Resident #1 would get in bed, the resident would become agitated and require staff to sit with her for a while to calm the resident. Staff H stated when she left the facility at approximately 11:00 p.m. she observed Resident #1 no longer tugging on the oxygen tubing (agitated). Staff H confirmed Resident #1 required the use of an alarm for safety due to fall. On 5/20/15 at 4:43 p.m. Staff I, certified nursing assistant (CNA) was interviewed and stated Resident #1 had low oxygen saturation levels and required oxygen on the shift prior to the fall. Staff I stated the resident required staff to sit beside him/her in attempt to calm him/her and keep the oxygen tubing on. Staff I stated she left the facility at approximately 10:00 - 10:15 p.m. and Resident #1 was in bed fighting with the oxygen tubing. Staff I confirmed Resident #1 required alarms and was a fall risk. Staff I stated she had observed Resident #1 remove his/her pad alarm in the past. On 5/20/15 at 4:55 p.m. Staff C, CNA, stated she notified the nurse (Staff H) Resident #1 had a low oxygen saturation level on the shift prior to the fall. Staff C stated Resident #1 fought the oxygen cannula/tubing and required staff sit with him/her because he/she did not want to wear the oxygen. Staff C recalled when she left the facility at approximately 10-10:30 p.m. the alarm was on and Resident #1 was resting in bed with oxygen on. On 5/20/15 at 6:39 p.m. Staff B, CNA, stated Resident #1 was restless and did not want to be touched the night Resident #1 fell and sustained a fracture. Staff B stated the resident showed agitation and kept trying to get out of bed. Staff B confirmed she responded to a sounding alarm to alert staff the resident was out of bed prior to the resident's fall. Staff B stated Staff A, registered nurse, transferred Resident #1 to the recliner in his/her room prior to the fall. Staff B confirmed knowledge that Resident #1 would pull the alarm pad out from under him/her. Staff B stated she told the charge nurse. On 5/20/15 at 6:27 p.m. Staff A, registered nurse (RN) was interviewed and stated she was notified at shift change that Resident #1 was restless and required oxygen due to low oxygen saturation levels. Staff A stated Resident #1 was confused as to the time of day and was up and down in his/her room. At approximately 10:30 p.m. Staff A stated she dressed the resident, donned socks and shoes and toileted the resident and then assisted the resident into a recliner in his/her room. Staff A stated she left Resident #1 alone in the recliner in his/her room to get pain medication. Upon return to the resident's room, she observed Resident #1 on the floor. Staff A confirmed the alarm did not sound to alert staff prior to the fall. Staff A could not recall if she placed the alarm prior to exiting the resident's room, however, noted after the fall, the alarm was on the arm of the resident's recliner after the resident's fall. Staff A had not observed Resident #1 disarm his/her alarm before, but thought the resident could have set the alarm off and placed the alarm on the arm of the recliner. On 5/20/15 at 5:05 p.m. Staff D, CNA was interviewed and stated if the resident saw the alarm cord, he/she would pull out the alarm pad. Staff D stated she had told the nurses of the resident removing the alarm pad. Staff D stated because Resident #1 was a fall risk, the resident could not be left in his/her room alone unless placed into bed. Staff D stated Resident #1 had an alarm in his/her chair and bed for safety. On 5/20/15 at 5:15 p.m. Staff E, licensed practical nurse (LPN) was interviewed and stated Resident #1 required an alarm in his/her bed and chair for safety; the sound of the alarm irritated the resident. Staff E confirmed knowledge the resident removed the alarm because staff heard the alarm and (he/she) then would observe the alarm in the resident's hand.

Based on record review, staff interviews and review of the lift manufacturer's instructions, the facility failed to provide adequate supervision to ensure against hazards from self and unsafe equipment which had not been maintained (Resident #1). The sample consisted of 6 residents and the facility reported a census of 90 residents. Interviews with staff identified the lift needed repaired but was still used. Staff transferred the resident in the lift and did not adequately apply safety straps around the resident ' s legs and used a damaged sling which caused the resident to be injured. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 1/16/15. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. The MDS reflected the resident with a brief interview for mental status score of 9. A score of 9 determined the resident had moderately impaired cognitive status. The resident required extensive assistance with transfers and toilet use and had unsteady balance with all activities. The Care Plan dated 1/27/15, directed staff to transfer the resident with the use of a sit/stand lift. An incident report dated 3/11/15 at 8:15 PM identified the CNA (Certified Nursing Assistant) stated she had put the resident to bed with a sit stand (lift) and the resident ' s arms became weak. The resident slipped through the harness. The resident laid on his/her right side on the floor with the right arm stretched out behind (the resident). The resident ' s feet rested near the lift. The resident obtained a cut above the left eyebrow cut to the right cheek and also complained of pain to the right arm. Review of the progress notes dated 3/11/15 at 10:00 PM revealed the resident went to the hospital via an ambulance. The Progress note dated 3/12/15 at 2:10 AM documented the physician admitted the resident into the hospital with [DIAGNOSES REDACTED]. The note reflected the physician performed a closed reduction of the shoulder (shoulder put back into place, without incision). Review of the x-ray report dated 3/11/15 revealed anterior right shoulder dislocation and mild the bibasilar atelectasis. The hospital History and Physical report dated 3/12/15 recorded Resident #1 had a fall and dislocated the right shoulder and obtained cuts to the face. The resident had a closed reduction of the shoulder in the emergency room and routine labs (laboratory tests) showed an elevated white blood cell count. The resident had a chest x-ray which identified atelectasis (area of the lung collapses or closes) with a suspicion of pneumonia on admission. Review of the order sheet dated 3/18/15 revealed the order of a deluxe comfort sling size large. During an interview with Staff C, CNA on 3/26/15 at 1:30 PM, she stated she saw the stitching off on the sling and reported it to the Staff D, RN (Registered Nurse). Staff H, supply staff, came by and Staff D and Staff H had discussed ordering a new sling. She stated she had placed the lift in a corner in the bathroom. When she had finished her shift it had been taken care of by Staff D. Staff C stated she could not be a hundred percent sure if a sign had been placed on the lift (not to use) but thought the arms of the lift were in a raised position and a note attached. During interviews with Staff A, CNA and on 3/26/15 at 2:05 PM she stated that she worked on 3/11/15 and went to lunch break at approximately 7:00 PM to 7:30 PM. Staff A stated she had been told the sling for the lift had a rip and she saw the rip. Staff A stated she saw the lift in B hall and saw staff moving it and taking the lift down the hall way, but did not see staff physically use the lift on another resident. Staff A stated she did not use that lift. On 3/26/15 at 2:30 p.m. Staff B, Certified Nursing Assistant, was interviewed and stated she did not work her scheduled shift on 3/11/15. Staff B stated the resident always let staff know if they had forgotten something or something was loose on the lift. If something had been wrong with a lift, then staff are to report, make out a work order to maintenance and put the equipment aside. Staff C stated the lift was down for a week prior to the incident and kept in the shower room with a sign on the lift to not use. . During an interview with the DON (Director of Nursing) on 3/26/15 at 3:10 PM, she stated she had known the sit/stand sling had been out of commission. The DON stated she learned the morning of the incident on 3/11/15. The DON stated she did not know the lift to be out on the floor (being used). The waist clip was off and obvious that it would have been impossible to use the sling correctly. She stated she had assumed it (repairs) had been taken care of. During an interview with Staff D, RN on 3/26/15 at 4:00 PM, she stated Staff C had reported to her the sling had been broken. Supply staff were told to order a new sling. Staff D stated Staff C and the supply staff person looked at the sling. Staff D stated she walked away and thought the supply staff and Staff C had handled the situation. During an interview with Staff E, CNA on 3/26/15 at 4:45 PM she stated she came to work at 6:00 PM on 3/11/15. She had been going down the hall and saw the resident in the room on the floor lying on the right side and 2 nurses assessing the resident. Staff E stated she saw the lift in the highest position possible. The resident's legs had not been strapped in. Staff E stated she had used the broken lift with another resident; however, that particular resident could stand better than Resident #1. On 3/26/15 at 6:58 PM, Staff F, Certified Nursing Assistant, was interviewed and stated she went to put the resident to bed and hooked him/her to the lift. The resident ' s feet slipped down and flipped through the buckles. The resident then lifted his/her arms up and fell through the lift sling and fell to the floor. Staff F ran to the door and yelled for the nurse to come to the resident's room. The abdominal strap on the sling had been broken. She further stated she had seen Staff B use the lift with the broken strap. She stated it had been broken for a while and she had figured the nurses and everyone knew about it. Staff B stated the broken lift had been on the hall and did not have a sign on it until after the incident occurred. Staff B stated she hooked the leg straps but the straps must have come unhooked. Staff B stated she must not have snapped it completely. During an interview with Staff H, supplies staff on 3/27/15 at 9:45 AM, she stated a CNA had told her the strap had been broken. She did not have documentation of the exact date she had been notified but remembered it had been the 3/11/15 to 3/13/15. Staff H stated she ordered a new sling on 3/18/15 and had to go back and forth with the company before ordering in order to get the correct type of sling. During an interview with Staff I, CNA on 3/27/15 at 9:50 AM she stated she had seen the lift in the hall for a while until the incident. She had seen a couple of staff use it while broken, but did not remember who used it or for which resident. She stated it had been broken several days up to a week but unsure exactly how long. Staff I stated staff are educated to put a sign to not use on the piece of broken equipment, complete a work order for maintenance to repair and do not use the broken piece of equipment. During an interview with the Quality Compliance Nurse on 4/15/15 at 9:00 AM, she stated the facility expects staff to take broken equipment off of the floor right away and let management know. A work order may be filled out for maintenance and can be filled out by management or the employee. They are to identify the equipment broken. The manufacturer ' s instruction document for the SARA 3000 lift identified a chapter titled Care and Preventive Maintenance. The instructions identified warning, In some cases due to heavy use of the product and exposure to aggressive environment, more frequent inspections shall be carried out. Continuing to use this product without conducting regular inspections or when a fault is found will seriously compromise the user and the residents ' safety. The instruction document included and identified Caregiver Obligations as: Examine the sling, straps and clips for damage or fraying before each use. Visually check sling attachment points. Do not use if damaged.

Based on record review, observation and staff interviews, the facility failed to identify, assess and prevent an avoidable pressure sore for 1 of 11 sampled residents. (Resident #8). Upon arrival at the hospital, Resident #8 was identified with an avoidable pressure sore, located on the penis, from an indwelling catheter (tube inserted into the bladder and left in place to drain urine). The facility reported a census of 88 residents. Findings include: Resident #8 had a Minimum Data Set (MDS) assessment with a reference date of 3/7/14 which reflected the resident with a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 identified the resident did not have a cognitive impairment. The MDS reflected the resident required extensive assistance of one staff for bed mobility, dressing, use of the toilet and extensive assistance of two for transfers. The resident had a catheter for urinary elimination and a [MEDICAL CONDITION] for bowel elimination. The assessment identified the resident had no pressure ulcers or skin problems. The resident had [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #8, initiated on 6/19/13 and revised on 6/10/14, revealed the resident had a potential for impaired skin integrity in regard to impaired mobility. The resident was admitted to the facility with nephrostomy tubes (tubes from the kidneys and out through the skin) and a [MEDICAL CONDITION] (a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall). The intervention initiated on 6/19/13 included and directed the staff to notify the nurse immediately of any new areas of skin breakdown noted during bath or daily care. The Care Plan identified the resident had a potential for infection regarding the nephrostomy and a Foley catheter (tube inserted into bladder to remove urine) and at risk for deficit in activities of daily living self-care. The interventions included and directed staff to provide Foley catheter cares every shift and as needed. The Care Plan did not address a potential problem for a pressure ulcer and interventions to prevent the development or interventions in the event a pressure ulcer develops. Review of the Progress Notes/Nurses Notes dated: On 3/18/14 at 1:16 PM the note reflected the resident ' s daughter telephoned the nurse and thought the resident had more confusion. The nurse noted the resident had confusion and also noted increased mucous like drainage from the catheter. The nurse sent a fax to the physician and requested an order to obtain a urine specimen for a test. The physician ordered staff to collect a urine specimen and check for possible urinary tract infection. The note reflected the urine had a cloudy yellow appearance. On 3/19/14 at 5:07PM revealed the physician [MEDICATION NAME](antibiotic) 250 mg (milligrams) and to be given twice each day for 5 days. The antibiotic was initiated on 3/20/14. On 3/20/14 at 8:30 PM the note revealed the resident had been found lying on the floor with the wheelchair in front of the resident. The resident ' s skin was assessed. On 3/22/14 at 1:23PM, the note reflected the resident continues on antibiotic. The urine remains cloudy. On 3/25/14 at 10:09 PM the note identified the urine as clear amber in color. On 3/27/14 at 5:20 PM the staff had changed the [MEDICAL CONDITION] without difficulty. On 3/28/14 at 8:45 AM, the resident left the facility to the hospital for the nephrostomy tube change, and returned at 3:04 PM. The follow-up care at the wound clinic scheduled for April 1st due to an area on the resident ' s meatus (penis). Review of the skin assessment at the facility dated 3/28/14 identified the tip of the meatus as noted to be split from the Foley catheter, treatment completed as ordered. Review of the Treatment Administration Record (TAR) dated 3/1/14-3/31/14 directed licensed nurses to: a. Apply gauze and [MEDICATION NAME] (dressing) to bilateral lower back nephrostomy sites, change every other day and prn (as needed), order date (by the physician) as of 6/6/13, b. Change [MEDICAL CONDITION] twice a week and prn. The order date of 8/21/13 c. Foley catheter, 16Fr (French) 10 cc (cubic centimeter) to be changed monthly and prn. Order date of 8/6/13 and discontinued on 5/15/14. d. Skin checks (to be done) every Friday. The order date of 5/31/13, e. Drain left and right nephrostomy tube every shift. The order date of 5/31/13. f. Measure amount of urine in Foley catheter drain bag. The order date documented of 8/7/13 and discontinued on 5/15/14. g. Measure amount of urine in ostomy bag. The order date documented of 7/30/13. h. Apply [MEDICATION NAME] cream, apply to groin and scrotum every shift and prn until healed. The order date documented of 6/6/13. Review of the TAR identified an order to apply [MEDICATION NAME] cream to groin and scrotum area prn, the record revealed no treatment to this area 3/1/14-3/28/14. Review of the hospital nurses notes dated 3/28/14 at 10:29 AM, revealed Resident #8 arrived per wheelchair for the nephrostomy tube change. When assisting the resident into a hospital gown, hospital staff noted the [MEDICAL CONDITION] bag was not adhered to the resident's abdomen and had paper tape placed all around it to hold it in position. Staff documented formed stool leaking from the edges and under the wafer. The resident's adult brief had a large amount of yellow foul smelling pus coming from the meatus and the urinary catheter had pulled to the side of the meatus. The meatus had eroded to the left side by approximately 2.5 cm (centimeters). Staff notified the resident's primary care physician of the resident's condition. Review of the hospital History and Review of Systems Details dated 4/1/14 (page 9 of 95) revealed Resident #8 had a new [DIAGNOSES REDACTED]. The document revealed the patient had a Foley catheter that had been pulled against the meatus area and it had caused a pressure ulcer. No necrosis, purulence or [MEDICAL CONDITION]. The resident also had a chronic split in the glans of the penis and the left groin was red with no open areas present. Review of the hospital Wound Assessment Details (page 20) dated 4/1/14 included the following measurements: length=2/5 cm (centimeters), width=1 cm, depth= 0.1 cm. Review of the hospital Wound Assessment Details (page 92) dated 4/23/14 revealed the pressure ulcer was resolved. On 8/29/14 at 11:12 AM, the resident ' s primary care physician was interviewed and stated he has known the resident for years and the resident did not have pressure ulcers in the past, the ulcer on the meatus likely had been caused from the catheter tubing and was avoidable. On 9/2/14 at 10:55 AM, Staff H, LPN (licensed practical nurse) stated the resident did not have any skin problems prior to 3/28 that she could remember. She also could not remember if she was at work the day that the resident went out for nephrostomy tube replacement and further stated the aides are trained and responsible for assuring the residents are clean and ready for their doctor appointments. During an interview on 8/27/14 at 10:50 AM, Staff I, CNA (certified nursing assistant) stated she has worked at the facility for almost two years. She did not recall the day the resident went to OR (operating room). Staff I always worked day shift and when caring for the resident, she got the resident ' s clothing out, obtained the supplies for peri-cares, then assured the resident is clean, dry and dressed in clean clothing every morning. Staff I checked the drain bags and emptied them routinely and used alcohol to clean the tubing away from the resident each time she empty ' s the drain bags. Staff I stated she remembered seeing a gauze bandage on the resident for about a month and then it was healed. She stated she would never allow the resident to leave the facility in poor condition. During an interview on 8/29/14 at 11:15 AM, Staff RN (Registered Nurse) from Jennie Edmundson Hospital stated she will never forget this resident. She stated she saw him/her immediately after arriving to the hospital on [DATE] at around 8:30 AM. The resident had a [MEDICAL CONDITION], the wafer was almost off of the skin and had been reinforced loosely with paper tape and formed/hard stool/feces under the wafer against the skin and she further stated that it had been on like that for some time, because of the color and condition of the tape. She called the hospital ostomy nurse and both of them removed the wafer, cleaned the resident and replaced the wafer with a new collection bag. They both then removed the resident ' s brief and immediately noticed a foul odor and found his/her groin red, wet, excoriated with pus present in the resident ' s brief. The resident ' s Foley catheter had been pulled tight against the meatus; the tubing went through the legs of the brief and no anchor. When they moved the tubing, they found a one inch pressure sore under the tubing on the meatus. Staff notified the resident ' s primary care physician. She then stated the resident ' s nephrostomy tubes had been down through the legs of the soiled brief adding more concerns for infection. The resident was then taken to the operating room for the nephrostomy tubes to be changed. On 8/27/14 at noon, Staff G, LPN was interviewed and stated she only see ' s the resident for skin issues when they have a problem area that needs assessed. The floor nurses do the weekly skin assessments. She stated the resident ' s ulcer had healed within a few weeks and it remains healed. She stated that she recommended a suprapubic catheter and it had been placed in May 2014. During an interview on 9/9/14 at 10:00 AM, Staff E, CNA stated she had not been assigned on the hall where Resident #8 lived during the month of February and March due to illness and weakness. She stated when residents ' have a Foley catheter, staff are expected to cleanse the site on the body where the tubing comes from including the tubing, every time they do peri-care and to keep the tubing loose to reduce pressure. Review of the orders and note from the Wound Clinic dated 4/1/14 revealed the resident had Stage II ulcer of the meatus with instructions to keep the catheter in the center of the meatus, cleanse the end with [MEDICATION NAME] before applying Adapt, then apply Xeroform gauze to ulcer on skin area changing it daily or PRN (as needed). The orders also directed to bring the Foley catheter tubing out of the resident's brief at the 5 o'clock position and not to the side and to assure no tension on the catheter. Review of the Catheter Care Skills Assessment Checklist dated September 1, 2005 directed staff to cleanse the urethral meatus using soap, water, and a clean washcloth. The skills directed staff to first wash around one side of the catheter and then the other, and then down the length of the catheter away from the meatus. During interview on 8/27/14 at approximately 10:00 AM, the facility DON stated she would expect the nursing staff to position the catheter tubing loosely to reduce pressure and the aides are expected to report any skin concerns following cares and during bathing. During observation on 7/15/14 at 10:48 AM, Resident #8's nurse, Staff F, LPN (licensed practical nurse) entered the resident's room and stated staff is expected to check all of the tubes at each shift. She stated the nephrostomy tubes are placed bilaterally at the T10 space and the tubes are positioned along each side of the resident as observed, the [MEDICAL CONDITION] and suprapubic catheter is checked and appears clean and intact. The urologist History & Physical report dated 5/1/14 revealed the resident had an indwelling catheter (Foley) for more than two weeks at that time. The area had no [MEDICAL CONDITION] or ulcers and the physician planned for a suprapubic catheter procedure to be scheduled. Review of the History & Physical dated 5/12/14 completed by the resident ' s primary care physician revealed the altered mental status likely increased due to a urinary tract infection, a [DIAGNOSES REDACTED]. Review of the History & Physical Update, revealed the resident had a suprapubic cystotomy (incision into the bladder) procedure completed on 5/12/14.

Based on record review, observation, review of policy/procedures and staff interview, the facility staff failed to ambulate Resident #1 with the use of a gait belt (safety device) and ensure the resident wore appropriate footwear for safety. The sample consisted of 11 residents and the facility reported a census of 88 residents. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 11/29/13 which revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3. A score of 3 identified the resident had severe cognition problems. The resident required extensive assistance of 1 for transfers, ambulation and use of the toilet. The MDS identified active [DIAGNOSES REDACTED]. Review of the resident care plan initiated 6/18/13 revealed the resident had the potential for falls due to a history of a CVA (Cerebral Vascular Accident-stroke) with weakness, impaired balance and psychotropic use. The following interventions included and directed staff to perform the following: a. Encourage the resident to wear nonskid footwear when up, b. Assistance of 2 (staff) for transfers, toileting and (use) wheelchair for locomotion (initiated on 3/12/13), Review of the Progress Notes dated 1/29/14 at 8:31 p.m. revealed while being assisted from the restroom back to the recliner by staff, the resident lost his/her balance and fell . The resident voiced complaints of right upper arm pain and a skin tear to the right elbow. The Primary Care Physician ordered the resident be sent to the ER (emergency room ) for an x-ray to rule out a fracture. Later that night the resident was admitted to the hospital with [REDACTED]. Review of the radiology report dated 1/29/14 revealed Resident #1 had an intertrochanteric right hip fracture and a second report that documented a transverse impacted fracture at the surgical neck right humerus (upper arm). Review of the Investigative Conclusion form dated 1/29/14 for Resident #1 revealed the aide assisted the resident back to the recliner from the bathroom when the resident lost his/her balance and fell . Plan of action to prevent reoccurrence is to use gait belt and nonskid footwear. The aide was educated and disciplined. Review of the Transfer-One Person Pivot policy and procedure revealed the gait belt is to be applied around the resident's waist unless the resident requires no more assistance than supervision or requires a mechanical lift. During an observation on 7/14/14 at 10:40 AM, two aides assisted the resident to transfer from the wheelchair to the toilet, the AFO (orthotic food device for positioning) was positioned on the residents right foot, gait belt placed in position, transfer completed safely with resident assisting. The resident able to hold onto grab bar to balance self during the transfer. After toileting, the 2 aides assisted the resident back into the wheelchair for lunch. During an interview on 7/15/14 at 3:00 PM, Staff C, certified nursing assistant (CNA) stated she assisted Resident #1 out of the restroom the night h/she fell . She stated the resident used a wheeled walker and as the resident moved around the recliner, the resident lost his/her balance, and she tried to grab the resident around the hips to prevent a fall. She stated she had not used a gait belt and the resident wore socks with worn circles on the bottom. Staff C stated she would never forget to use the gait belt again.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment and failed to provide adequate assistance during a mechanical lift transfer (Residents#1, #8, #10). The sample consisted of 17 residents and the facility reported a census of 99 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, with a reference date of 9/21/12 identified Resident #8 with [DIAGNOSES REDACTED]. The MDS reflected the resident required extensive assistance of 2 or more persons with transfer, bed mobility and toilet use. The MDS documented the resident had encountered 2 falls since admission/entry or re-entry or prior assessment. The MDS identified the falls as one with no injury and one fall with a non-major injury. Review of a Fall Risk assessment tool dated 10/8/12 revealed a score of 18, indicating a high risk for falls. The Care Plan dated 4/20/12 revealed the resident had a potential for injury related to being unsteady, had a [DIAGNOSES REDACTED]. The same care plan provided an intervention initiated on 9/7/12 for staff to place alarms on the bed and chair to alert staff when the resident tried to get up unassisted. The fall report dated 9/9/12 at 5:10 AM revealed the resident was found on the dayroom floor holding themselves up with left arm, with the left palm down on the floor with legs slightly flexed to the right side. The fall report documented the immediate action from the staff was to initiate crani-checks and pain medication was administered. The staff assisted the resident up and into a wheelchair. The fall report documented no injuries observed. Review of a second fall report dated 10/8/12 at 5:40 AM revealed the resident was heard saying, "help me, oh, help me". The staff ran into the room and found the resident lying on his/her right side on the floor facing the sink with all extremities slightly flexed. The resident complained of left arm pain with swelling laterally, causing decreased movement to the area. The fall report documented the resident stated he/she fell out of bed. The report documented the immediate action by the staff was to perform vital signs, crani-checks, administer pain medication and check the pressure alarm for proper functioning. The report documented the injury as swelling to the back of the left hand. Review of a radiology report dated 10/8/12 revealed a comminuted impacted fracture of the left radial metaphysis. The report described the fracture as transverse through the metaphysis with a longitudinal component extending to the mid articular surface with mild displacement. Review of a handwritten note on the radiology report revealed a physician order [REDACTED]. On 10/18/2012 at 8:40 a.m., Staff F (Registered Nurse) was interviewed and stated the resident ' s alarm had not sounded when the resident fell and broke his/her arm. Staff F stated the staff either changed out the alarm-either the whole alarm, the pad or battery, possibly the whole thing. 2. Resident #1 had an MDS with a reference date of 10/9/12 which identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance with bed mobility and total dependence with transfers. Review of the Fall Risk assessment dated [DATE] revealed the resident with 1-2 falls in the past 3 months, chair bound and unable to perform function for gait/balance. The care plan dated 9/13/12 directed staff to use the Hoyer lift with 2 person transfer. Review of the Fall report dated 9/14/12 revealed a CNA (Certified Nursing Assistant) in the resident's room and attempted to transfer the resident from the bed to the shower chair with 1 staff assistance. The resident stood up and the resident ' s legs gave out causing the resident to fall down to his/her knees. The CNA did assist with the fall with no injuries noted. 3. The MDS assessment dated [DATE] documented [DIAGNOSES REDACTED].#10. The same MDS documented the resident did not walk and required extensive assistance for completion of bed mobility and transfers and incontinent of bowel and bladder. The Care Plan dated 6/27/12 identified the resident at risk for falls and had a self-care deficit. The plan directed staff to transfer the resident with a mechanical lift. The Progress Notes dated 10/10/12 at 11:56 AM documented CNAs assisted the resident out of bed and the resident slipped in urine and had to be lowered to the feet of one of the CNAs. The resident had a 6 centimeter (cm) scratch to the upper right leg and two 1 cm scratches on the right big and second toe. During interview on 10/17/12 at 9:40 AM, Staff C (CNA) stated she and Staff D (CNA) transferred Resident #10 from the bed to the shower chair without the use of a mechanical lift or a gait belt on 10/10/12. She stated the resident had no clothing or brief on and voided (urinated) incontinently during the transfer and the resident's feet slipped in the urine. Staff C stated she, and other staff, had transferred Resident #10 to a shower chair without the use of a gait belt or mechanical lift in the past without incident. Staff C stated she and Staff D have been educated to use a mechanical lift for all transfers for Resident #10 as directed by the care plan. 4. Observation on 10/17/12 at 8:30 AM revealed an unlocked treatment cart in front of the C Hall nursing desk. Observation revealed no ambulatory residents or staff present in the area. Staff F locked the cart after observation of the contents. The cart contained the following: a. 2 containers DiaScreen reagent strips for urinalysis b. Nystatin powder c. 2 skin staple remover kits d. Tubes of triamcinolone 0.005%, clobetasol cream 0.05%, 3.75 ounce tube of Derma Fungal cream, 22 individual packages of triple antibiotic ointment, a tube of trixaicin cream and 3 jars of Lantiseptic cream all which contained the directive to keep out of reach of children. e. Boxes of alcohol prep pads and skin prep wipes, 10 Cavi-Wipes XL, 21 packages of Betadine swabs, a 7.5 ounce bottle of Restore Cleanser and Moisturizer and two bottles of iodoform gauze all of which contained the directive to keep out of reach of children.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent falls for 1 of 12 residents reviewed (Resident #4). The facility reported a census of 97 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 11/28/12 which revealed [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 staff for transfers and toileting. The resident had unsteady balance and could stabilize him/herself only with assistance. The assessment documented Resident #4 had 1 fall with injury since admission or the previous assessment. The assessment documented the resident entered the facility on 11/21/12. Review of the Initial Care Plan, dated 11/21/12 revealed the resident had a problem/ need for potential for fall related to high fall risk on fall assessment with a score of 14. Interventions included: Point # 3. Fall protocol Point # 4. Complete fall risk assessment Point # 5. Provide assistive devices as needed. Point # 6. Physical therapy/ Occupational therapy to screen/ evaluate/ treat per physician order. Point # 7. Fall alarms in place/ low bed in place/ mattress on floor when resident in bed. Resident allowed to roll out of bed and onto mattress on floor. Review of the High Risk for Falls report, dated 11/26/12 revealed the resident had a score of 14 which signified the resident a high risk for falls. Review of the Progress Notes revealed that on 11/23/12 at 8:05 AM the nurse called to the resident's room by the Certified Nursing Assistant (CNA). The nurse noticed the resident lying on the floor on his/her right side. Both staff rolled the resident to a supine position. The resident stated he/she fell . The nurse examined the resident and found a 2 inch laceration above the right eye on the right forehead. The resident had a history of [REDACTED]. At 8:10 AM, staff notified the resident's family and physician and the physician requested the resident be sent to the emergency room . At 9:00 AM the resident transferred to the emergency room . At 11:07 AM the staff of the emergency room called the facility and stated the CAT scan negative and the resident received sutures at the laceration. Review of the Incident Description report dated 11/23/12 documented the resident found in the bathroom lying on the floor. Staff noted a 2 inch laceration on the right side of the forehead. Predisposing physiological factor included a recent change in cognition and predisposing situation factor included a room change. Review of the Post Fall Management Quality Assurance Form revealed the root cause determination revealed the resident left alone on the toilet and fell off of the toilet. The Emergency Department- Patient Summary dated 11/23/12 instructed to remove an undetermined amount of sutures in 6-7 days. An interview with Staff E (Certified Nursing Assistant) on 12/5/12 at 11:25 AM revealed he worked the 6 AM -2 PM shift on 11/23/12. He said he entered the resident's room and transferred the resident from the bed to the bathroom. He left the bathroom door open and walked across the room (about 5 feet) to make the resident's bed and the resident fell from the toilet. Staff E stated the resident had an alarm on prior to the transfer but did not have an alarm on while sitting on the toilet. Staff E stated he knew the policy of the facility required staff to stay with residents in the bathroom which required alarms and were fall risks.

Based on record review, observation and staff interviews the facility failed to provide interventions for weight loss recommended by the Dietitian and receive instruction for the planned diets and the health service supervisor failed to direct the nursing care services so each resident ' s needs are met for weight loss ((Resident #2, #3, #11 & #14). The sample consisted of 17 residents and the facility reported a census of 99 residents. Findings include: 1. The Care Plan dated 8/30/12 for Resident #2 identified [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment with a reference date of 9/24/12 revealed the resident could feed self and required set up only. The MDS identified the resident with a 5% or more weight loss in the last month or a loss of 10% or more in the last 6 months and not on a physician prescribed weight loss regimen. The care plan dated 8/30/12 directed staff to give diet per physician order [REDACTED]. Review of the Physician facsimile to the Physician dated 10/11/12 revealed the following weights: 9/9/12 176 pounds 9/10/12 176.8 9/14/12 170.2 9/29/12 162.1 10/3/12 159.5 10/6/12 158.3 10/8/12 156.4 10/9/12 152.1 This represents 13.57% in 30 days The Physician facsimile dated 10/11/12 directed staff to increase the Health Shakes from 2 times a day to 3 times a day. The MAR (Medication Administration Record) dated October 2012 indicated the health shakes continued to be administered 2 times a day and not increased to 3 times a day. Review of the Diet orders dated 10/15/12 revealed the resident with recommendation for the NIP program. The NIP program consisted of: Breakfast: super-cereal, whole milk and cheese on eggs. Lunch and supper: whole milk, cheese sauce on appropriate vegetables, gravy on meats/mashed potatoes, and cheese added to baked potatoes and cream soups. Snacks: ice cream or equivalent for PM snack and fortified pudding for HS (hour of sleep) snack unless another appropriate substitute is desired. Observation on 10/17/12 at 9:25 AM revealed the resident served the Morning meal of scrambled egg, sausage, muffin, V-8 juice and water. The resident did not receive items on the NIP program. At 12:35 PM the resident requested pie dessert only. The resident given juice and water to drink and staff did not offer items on the NIP program. On 10/18/2012 at 10:45 a.m. the Dietary Manager stated all residents with the NIP program are to be given fortified milk. The Dietary Manager stated the facility staff has struggled with the NIP program. On 10/16/2012 at 4:30 p.m. the Director of Nursing was interviewed and stated the list of residents using the NIP program is posted in the dining room. The Director of Nursing stated the program is to increase calories. 2. Resident#3 had an MDS with a reference date of 10/8/12 which identified [DIAGNOSES REDACTED]. The MDS indicated the resident ate independently and required set up only for meals. The MDS reflected the resident had weight loss of 5% or more in the last month and not on physician prescribed weight loss regimen. The care plan dated 10/4/12 directed staff to serve a regular diet and monitor meal intake and weight. The plan directed staff to notify the physician of significant weight changes. Review of the facsimile to the Physician dated 10/4/12 identified notification of a 5.6 % weight loss and questioned if could be related to [MEDICAL CONDITION]. The Physician documented on the facsimile the resident had been in the office on 10/2/12 and had been fine. Review of the Weights and Vitals Summary dated 10/18/12 revealed the following weights: 9/24/12 158 9/28/12 152.5 9/30/12 148.5 10/7/12 146.5 10/14/12 143.5 The Progress Notes dated 10/15/12 revealed the resident with a 5.0 % weight loss over 30 days. The note indicated the recommendation to add the resident to the NIP program and continue weekly weight and notify the Physician of further weight loss. Review of the resident's Diet card dated 10/18 revealed the resident on a regular diet with the NIP program. Observation on 10/17/12 at 8:00 AM revealed the morning meal. The meal consisted of cold cereal, muffin, coffee, milk, water and orange juice. The resident received 2% milk. Observation revealed no fortified milk in the dining room. Observation on 10/17/12 at 12:23 PM revealed the resident in the dining room. The resident was served the noon meal of chicken, mashed potatoes, green beans, water, juice and 1/2 slice of pie. The resident did not receive milk. 3. Resident #11 had an MDS with a reference date of 9/17/12 which identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with eating and had a weight gain of more than 5% in 30 days or 10% or more in 180 days and on a physician-prescribed weight-gain regimen. The Care Plan for Resident #11 identified the resident required physical assistance with all activities of daily living which included eating. The Weights and Vitals Summary Report for Resident #11 identified the following weights: a. 179.3 # on 9/2/12 b. 176. 0# on 9/9/12 c. 163.6 # on 9/16/12 d. 175.2 on 9/23/12 e. 178.0 # on 9/30/12 f. 175. 7# on 10/5/12 g. 173.0 # on 10/12/12 h. 172.5 # on 10/14/12 The Progress Notes dated 8/12/12 completed by the facility's Registered Dietician documented the resident had a significant 5% weight loss in 30 days and identified the resident as supplemented with 1 scoop of protein powder TID (three times a day), received med pass supplement 90 cubic centimeters TID and on the NIP program. The Consolidated Orders for Resident #11 directed staff to administer 1 scoop of protein powder BID (two times per day) in 8 ounces of fluid. The Progress Notes dated 9/20/12 completed by the facility's Registered Dietician documented the resident with a significant 5% weight loss in 30 days and a 7.5% weight loss over 90 days. The Notes documented the resident as admitted to hospice care and the resident eating fairly well and remained on the same interventions which included the NIP program. The facility's NIP List dated 10/16/12 and posted in the main dining room identified 26 residents on the program. Observation of the breakfast meal served on 10/18/12 revealed the resident's dietary choices chosen by the student nursing assistants. The student served scrambled eggs in addition to 1 piece of toast and 1 sausage patty. Observation revealed the scrambled eggs contained no cheese and no super cereal served. The resident's meal choice slip identified the resident on a NIP program and a regular consistency diet. During an interview on 10/18/2012 at 8:50 AM Staff H (Cook), identified the following items available from the steam table: a. sausage, regular and ground b. omelet casserole which contained cheese c. plain scrambled eggs d. regular bacon e. malt-o-meal cereal, oatmeal and super cereal. Staff H stated all residents with pureed diets receive the NIP interventions and it is marked on the diet choice slips. 4. Resident #14 had an MDS with a reference date of 9/14/12 which identified [DIAGNOSES REDACTED]. The MDS documented the resident as dependent upon staff for completion of all activities of daily living which included eating. The MDS identified the resident had a significant weight loss of 5 % in 30 days or 10 % in 180 days and not on a physician-prescribed weight loss plan. The care plan problem dated 6/21/12 documented the resident has a nutritional problem, or a potential for a nutritional problem, related to decrease in appetite, needs oral supplement, a mechanically altered diet and needs to be fed by staff and directed staff feed the resident a pureed diet with nectar thick liquids and oral supplement as ordered by the physician. Observation of the breakfast meal on 10/18/12 at 8:45 a.m. revealed the resident ' s diet choice slip identified the resident on the NIP program. Observation revealed the resident served hot cereal, pureed cheese omelet, a 4 ounce Mighty Shake and an 8 oz. carton of Thick and Easy thickened dairy product made from 2% (low fat) milk. On 10/18/2012 at 9:14 AM Staff F was interviewed and provided the box of cereal used for super cereal. The box contained Farina Hot Wheat Cereal-no sugar added. The label on the box identified one serving of the cereal contained 0% fat, 0% cholesterol and sodium, 24 grams of carbohydrate, 1 gram of fiber, 4 grams of protein and 110 calories per serving if made with water or 290 calories per serving when made with low fat milk. Staff F identified the cereal prepared with water. Staff F identified no cheese available to put on the scrambled eggs. At this time the Dietary Supervisor Manager (DSM) stated the facility has struggled with the implementation of the NIP and he had recently discussed it the the facility's consulting dietician. The DSM provided a list of between meal supplements ordered by the dietician. This list identified Resident #14 should be served ice cream in the afternoon and fortified pudding at bedtime. On 10/18/2012 at 1:25 PM, Staff N (Certified Nursing Assistant) stated the resident supplements at mealtimes are documented on the meal intake sheets in a box marked specifically for supplements. Observation of the meal intake sheets for August, September and October, 2012 revealed supplement intake for Resident #11 documented only 33 of 109 meals. On 10/18/2012 at 1:00 PM, the Director of Nursing was interviewed and stated the facility had not been monitoring intake of between-meal supplements ordered by the dietician. On 10/19/12 at 2:23 PM the facility's Dietician was interviewed. The Dietician voiced being unawareness of the facility using Farina as super cereal. She stated she had discussed the NIP program during the facility's weekly weight meeting, but the DSM had not been in attendance recently. She stated the facility will take steps to assure proper implementation and monitoring of the NIP program and to make changes in the documentation process for supplements and snacks to assist in better monitoring of resident ' s consumption.