Every finding on record at Chariton Specialty Care

Based on observations, clinical record review, provider interview and staff interviews, the facility failed to follow physician orders while administering medications through a feeding tube for 1 of 1 residents reviewed for tube feeding (Resident #38). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated medical diagnosis of traumatic subdural hemorrhage with loss of consciousness of unspecified duration. The MDS revealed the resident utilized a feeding tube.The Care Plan revealed a focus area dated 7/15/25 for tube feeding osmolyte 1.2 calorie. The Electronic Medical Record (EMR) revealed the following Physician Orders: Enteral Feed- dated 9/22/25- three times a day Flush feeding tube with at 60 ML of water before and after administration of medicationsThe January Medication Administration Record (MAR) revealed hydralazine 25 mg given on 1/12/26 at mid morning and qualified oral liquid 20 ml given on 1/12/26 at midmorning. The Orders Administration Note revealed the qualified oral liquid give 20 ml via PEG (percutaneous endoscopic gastrostomy) tube three times a day for congestion x 14 days. Called [name redacted] to verify Tussin of 20 ml is correct dosage. During an observation on 1/12/26 at 1:06 PM, Staff E, Licensed Practical Nurse (LPN) mixed a crushed hydralazine (blood pressure medication) with warm water and liquid Tussin (cough suppressant). During an observation on 1/12/26 at 1:11 PM, Staff E shut off the continuous feeding tube, flushed the feeding tube with 30 milliliters (ml) of warm and then administered the mixed medications into the feeding tube. Staff E then again flushed the feeding tube with 30 ml of water before turning the continuous feeding tube back on. During an interview on 1/13/26 at 3:31 PM, Staff E queried on the order to flush with 60 ml before and after medication administration and Staff E confirmed the order indicated 60 ml before and after medication administration. Staff E asked if she needed an order to be able to mix Resident #38 medications prior to giving them through the feeding tube and Staff E stated she would have to look at Resident #38 orders. During an interview on 1/14/26 at 8:21 AM, the Nurse Practitioner (NP) confirmed the order revealed to flush with 60 ml of water before medication administration and then 60 ml of water after medication administration. The NP stated the facility needed an order to slurry Resident #38 medications together so they could give the medications all at the same time. During an interview on 1/13/26 at 3:49 PM, Staff E stated the facility was going to get an order for a crushed cocktail for Resident #38. During an interview on 1/14/25 at 1:18 PM, the Director of Nursing (DON) queried on Resident #38 order for flushing with 60 ml of water before and after medication administration and the DON stated the nurse was new and read the order wrong and thought it was 60 ml total. The DON stated that was not an excuse, but her assumption. The DON stated she expected the orders to be read thoroughly and carried out efficiently and orders were written for a reason. The DON stated the facility received an order for a crushed cocktail, but the pharmacy did review Resident #38 medications and after today, the facility will not do crushed cocktail with Resident #38 because he has too many medication changes. The Facility Enteral Tube Feeding via Continuous Pump dated November 2018 did not address flushing the feeding tube before or after medication administration or mixing medications prior to administration into a feeding tube.

Based on clinical record review, observations, facility policy review, resident and staff interviews, the facility failed to ensure staff provided therapy prescribed restorative nursing services to maintain a resident's ability to walk and transfer for 1 of 1 sampled residents (Resident #20). The facility reported a census of 33.Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #20, dated 10/30/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which was indicative of a mild cognitive impairment. The MDS assessment revealed the resident utilized a walker and wheelchair for mobility, required substantial/maximum assistance for transfers and had not attempted to walk during the assessment period. Resident #20 had diagnoses of stroke, abnormalities of gait and mobility, muscle weakness, lack of coordination, and a history of falls. Review of the Care Plan for Resident #20, last revised 12/29/25, revealed the resident required assistance with Activities of Daily Living (ADLs) including an intervention for the assistance of one staff with transfers, dated 3/15/24, and the assistance of two staff with ambulation (walking) 20 to 30 feet with a FWW (front wheeled walker) and wheelchair to follow to meals, dated 10/31/25.Review of Physical Therapy (PT) Evaluation and Plan of Treatment notes, dated 8/28/25 through 11/18/25, revealed Resident #20 received PT services to, in part, safely ambulate 20 feet using two-wheeled walker on level surfaces with Partial/Moderate Assistance in order to prepare for walk to dine for meals and safely perform functional transfers with Partial/Moderate Assistance for safe maneuvering in small spaces in the presence of high sensory demand situations in order to decrease level of assistance from caregivers. The notes identified the resident discharged from PT services on 11/18/25 due to meeting all therapy goals, and in part, included, Pts (patient's) primary mobility is in WC (wheelchair) and is safe and indep (independent). Pt (patient) needs 1 assist for safe transfers and short distance walks with FWW. The physical therapist recommended the following: Dc (discharge) with RNP (restorative nursing program) in place; Restorative Ambulation Program, Restorative Range of Motion Program. The physical therapist documented, in part, Ambulation Program Established / Trained: walk to dine. Range of Motion Program Established / Trained: Omnicycle (type of leg exercise machine) and standing with Ad. The physical therapist documented, in part, Prognosis to Maintain CLOF (Current level of functioning) = Excellent.A progress note for Resident #20, titled Nursing/Therapy Communication, dated 11/4/25, revealed the patient was to amb (ambulate) 20 to 30 feet with FWW and wheelchair to follow to meals. Assist x 2 (assist of two staff).A progress note for Resident #20, titled Nurses Note, dated 11/18/25, revealed the following note: Communication received from therapy for New Restorative Program. pt (patient) to complete 3-5x/week (3 to 5 times per week) or as tolerated: STS (sit to stand) from w/c (wheelchair) to FWW (front wheeled walker) x 5 (5 times) with use of UEs (upper extremities). Omnicycle L4 10-15 mins (minutes) (;) standing: heel raises, hip abd (abductions), marching, x 10-15 reps, continue with walk to dine program. Care plan updated and resident aware.On 1/11/26 at 11:18 AM, during an interview in Resident #20's room, Resident #20 reported staff were supposed to help him walk to the dining room for meals. The resident reported staff had not helped him walk since before Thanksgiving. He reported having to go to the dining room in his wheelchair. The resident reported staff was not doing any leg exercises with him and he had not used the Omnicycle since working with therapy. The resident was unsure if he had a recent decline in his ability to walk. An observation, during the same interview with Resident #20 revealed a sign posted on the wall by the resident's room door that read to walk with resident to each meal. On 1/11/26 at 11:45 AM, observation revealed Staff F, Certified Nurses Aide (CNA), enter Resident #20's room, close the door, and then exited the room at 11:49 AM. Resident #20 exited his room and self propelled his wheelchair to the dining room for lunch.On 1/12/26, review of the clinical record for Resident #20 revealed a lack of documentation regarding the task completion of the restorative program by facility nursing staff. The clinical record lacked documentation of the resident's inability to walk to dine and the need for the assistance of two staff with transfers. The clinical record lacked documentation staff had performed restorative exercises including the Omnicycle, sit to stand exercises, heel raises, hip abductions and marching exercises. On 1/13/26 at 8:03 AM, observation revealed Resident #20 to be self-propelling his wheelchair down the hall towards the dining room. Resident #20 stopped his wheelchair by the nurses station. At 8:05 AM, Staff C, Licensed Practical Nurse (LPN), asked the resident if he wanted a boost. Staff C then helped to wheel resident around nurses station toward dining room. The Laundry/Housekeeping Supervisor assisted the resident with donning a clothing protector, and Resident #20 continued to propel himself to a table in the dining room for breakfast. On 1/13/26 at 9:06 AM, observation revealed Resident #20 self propelled his wheelchair from the dining room to his room independently. On 1/13/26 at 9:45 AM, during an interview with Staff A, CNA, and Staff B, CNA, Staff A thought nursing staff had discontinued Resident #20's walk to dine due to unsteadiness. Both Staff A and Staff B reported it was now taking two staff to assist the resident with transfers.On 1/13/26 at 9:55 AM, during an interview, the Director of Rehabilitation reported she had worked with Resident #20 on transfers and walking the last time he had received PT services, dated 8/28/25 to 11/18/25. She reported at the completion of therapy, therapy determined the resident was appropriate for walk to dine and recommended that the resident ambulate 20 to 30 feet with a FWW, w/c to follow. The Director of Rehabilitation explained therapy staff had been walking with the resident and he was doing wonderful. She reported she had not seen the resident since he completed therapy and no one had reported to her that he was struggling with transfers and not able to do the walk to dine restorative program. On 1/13/26 at 10:06 AM, during an interview, Staff C, LPN, reported Resident #20 was in the walk to dine restorative program, but the resident was not standing the best, so staff was not doing the walk to dine with him. Staff C, LPN, reported she had spoken with the Director of Rehabilitation this morning (1/13/26) and told therapy that the resident was not walking, because he was unsteady with transfers. Staff C, LPN, reviewed the resident's electronic health record (EHR), and reported the record lacked documentation of staff walking with the resident in December 2025 and January 2026.On 1/13/26 at 10:13 AM, during an interview, the Director of Nursing (DON) explained the Kardex (CNA assignment of tasks) for Resident #20 included an intervention for the CNAs to do walk to dine. The DON reported the walk to dine restorative program was on the resident's care plan, as well. The DON reported that for some reason the tasks related to restorative were not triggering under the assigned tasks for the CNAs to document on. The DON confirmed staff had not documented the walk to dine restorative program November 2025 through present date. A Visual/Bedside Kardex Report for Resident #20, dated 1/13/26, revealed the following, in part, for restorative: a. Omnicycle L4 10-15 mins (minutes).b. standing: heel raises, hip abd (abduction), marching, x 10-15 reps, STS (sit to stand) from w/c (wheelchair) to FWW (front wheeled walker) x 5 with use of UEs (upper extremities).c. Walk to Dine: Ambulate 20-30' (feet) with FWW and wheelchair to follow to meals. Assist x 2.On 1/13/26 at 12:06 PM, during an interview, with Staff A, CNA, and Staff B, CNA, both staff reported they were unsure of the last time they had walked with Resident #20. Staff B reported the resident had required the assistance of two staff for transfers intermittently for the last couple weeks. Staff B reported Resident #20 had refused to walk with her frequently. Staff B was unsure if she was documenting the resident's refusals. Staff A reported the resident had been sick with a bad respiratory infection three to four weeks ago, and she had not walked with him since then. Staff A reported the walk to dine restorative program was not in the computer for the CNAs to document on it. Both Staff A and Staff B reported they were responsible for completing the restorative program with residents.Review of a progress note, titled Encounter Note, dated 11/11/25, revealed a note completed by Resident #20's healthcare practitioner which identified the resident had been diagnoses with pneumonia (the respiratory infection occurred prior to the resident's successful completion of physical therapy on 11/18/25).On 1/13/26 at 12:12 PM, observation revealed the DON and Staff D, CNA, both assisted Resident #20 to stand from his wheelchair to a FWW. Staff A, CNA, stood behind the resident's wheelchair. The resident's were legs shaky per the DON. The DON and Staff D assisted the resident to sit. Staff D then moved the resident's catheter from the wheelchair to the walker. The DON and Staff A assisted the resident to stand to the walker while Staff D followed with the wheelchair. The resident walked approximately 10 feet before having to sit down. The resident reported being too tired and weak to walk further. On 1/13/26 at 12:17 PM, during an interview, Staff A, CNA, reported she had been doing range of motion with Resident #20; she denied performing any other restorative exercises. On 1/13/26 at 12:18 PM, the Regional Director of Clinical Services reported the DON was responsible to ensure staff completed restorative exercises with the residents. The Regional Director reported there was no documentation that staff completed restorative exercises with Resident #20 and the exercises were not getting done. Review of the facility policy, titled Restorative Nursing Services, dated 7/2017, revealed, in part, restorative goals and objectives were individualized and resident-centered, and were outlined in the resident's plan of care.

Based on observation, food temperatures during food service and resident interview, the facility failed to serve food at an acceptable temperature during one of three meals sampled. The facility reported census was 40. Findings include:The Minimum Data Set for Resident #5 dated 8/18/25 documented a Brief Interview of Mental Status score of 15 indicating intact cognition.Observation on 9/18/25 at 12:30 p.m. a sample tray, consisting of a grilled cheeseburger, macaroni salad and potato salad was provided to this surveyor. The hamburger patty was served well done, at room temperature and with a slice of cold cheese on a bun. The macaroni salad and potato salad was served cold and had good flavor.In an interview on 9/18/25 at 10:50 a.m. Resident #5 stated the meals are often not very good and the facility does not always follow their menus.

Based on record review, staff interviews, and policy review, the facility failed to develop a personalized Care Plan for 4 of 12 residents (#2, #7, #16, and #24) reviewed for Care Plans. The facility reported a census of 32 residents. Findings include: 1. On 1/27/25, a record review of Resident #2's Electronic Health Record (EHR) revealed she received antipsychotic and antidepressant medications. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of End-Stage Renal Disease (ESRD), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, Bipolar Disorder, and depression. It also revealed the resident received antipsychotic (AP) and antidepressant (AD) medications during the last 7 days. The EHR included a physician's order for an antipsychotic medication, Quetiapine fumarate 100 milligrams (mg) by mouth at bedtime for Bipolar Disorder and an antidepressant medication, Trazadone hydrochloride (HCL) 125 mg by mouth one time per day for depression. It also included a physician's order to monitor target behaviors and side effects every shift and identified the target behaviors as Codes: 0=No Behaviors, 1= (tearful), 2=(self-isolation), 3=(agitation), 4=other (see progress notes). The Progress Notes included two (2) monitored target behavior entries dated 2/20/24 and 1/17/25. The Care Plan revised 11/28/24 included the resident's antipsychotic and antidepressant medication use but did not include the associated target behaviors for staff to monitor. 2. On 1/27/25, a record review of Resident #7's Electronic Health Record (EHR) revealed he received antianxiety, antipsychotic, and antidepressant medications. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Heart Failure (HF), Diabetes Mellitus (DM), Alzheimer's Disease, Schizoaffective Disorder, and depression. It also revealed the resident received antianxiety (AA), antipsychotic (AP) and antidepressant (AD) medications during the last 7 days. The EHR included a physician's order for two (2) antianxiety medications, Buspirone hydrochloride (HCL) 7.5 mg by mouth two (2) times per day related to Schizoaffective Disorder and lorazepam 0.5 mg by mouth two (2) times per day related to Schizoaffective Disorder, an antipsychotic medication, Quetiapine fumarate 100 milligrams (mg) by mouth two (2) times per day related to Schizoaffective Disorder, depressive type, and two (2) antidepressant medications, citalopram hydrobromide 20 mg by mouth in the morning related to Major Depressive Disorder, and Trazadone hydrochloride (HCL) 50 mg by mouth at bedtime for Major Depressive Disorder. It also included a physician's order to monitor target behaviors and side effects every shift and identified the target behaviors as Codes 0=No Behaviors, 1=yelling, 2=(aggression), 3= (pacing), 4=other (see progress notes). The Progress Notes included four (4) monitored target behavior entries dated 3/04/24, 8/10/24, 12/22/24, and 1/10/25. The Care Plan revised 11/15/24 included the resident's antianxiety, antipsychotic, and antidepressant medication use but did not include the associated target behaviors for staff to monitor. 3. On 1/27/25, a record review of Resident #16's Electronic Health Record (EHR) revealed he received antianxiety and antidepressant medications. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Heart Failure, anxiety, depression, and psychotic disorder. It also revealed the resident received antianxiety (AA) and antidepressant (AD) medications during the last 7 days. The EHR included a physician's order for an antianxiety medication, Buspirone hydrochloride (HCL) 10 mg by mouth two (2) times per day related to anxiety disorder and three (3) antidepressant medications, Duloxetine HCL 30 mg by mouth one (1) time per day related to Major Depressive Disorder, Trazadone hydrochloride (HCL) 150 mg by mouth one time per day related to Major Depressive Disorder, and Bupropion HCL 100 mg by mouth one (1) time per day related to Major Depressive Disorder. It also included a physician's order to monitor target behaviors and side effects every shift and identified the target behaviors as Codes: 0=No Behaviors, 1=tearfulness, 2=refusal of cares, 3=suicidal ideations, 4=other (see progress notes). The Progress Notes included four (4) monitored target behavior entries dated 5/09/24, two times on 11/12/24, and 12/24/24. The Care Plan revised 11/15/24 included the resident's antianxiety and antidepressant medication use but did not include the associated target behaviors for staff to monitor. 4. On 1/27/25, a record review of Resident #24's Electronic Health Record (EHR) revealed he received antipsychotic and antidepressant medications. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of Diabetes Mellitus (DM), Non-Alzheimer's Dementia, Alzheimer's Disease, adjustment disorder anxiety, and depression. It also revealed the resident received antipsychotic (AP) and antidepressant (AD) medications during the last 7 days. The EHR included a physician's order for an antipsychotic medication, Quetiapine fumarate 50 milligrams (mg) by mouth one (1) time per day related to dementia with mood disturbance and an antidepressant medication, sertraline HCL 100 mg by mouth two (2) times per day related to depression. It also included a physician's order to monitor target behaviors and side effects every shift and identified the target behaviors as Codes: 0=No Behaviors, 1=agitation, 2=combativeness, 3=tearfulness, 4=other (see progress notes). The Progress Notes included fourteen (14) monitored target behavior entries between 11/06/24 and 1/13/25. The Care Plan revised 11/30/24 included the resident's antipsychotic and antidepressant medication use but did not include the associated target behaviors for staff to monitor. On 1/29/25 at 3:35 PM, the Assistant Director of Nursing (ADON) stated Care Plans should include target behaviors with each medication class (category). A policy titled Care Plans, Comprehensive Person-Centered revised 12/2016 indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, staff interview, guidance from the 2022 US Food and Drug Administration (FDA) Food Code, and facility policy review, the facility failed to use proper sanitation and glove use during lunch service. The facility reported a census of 32 residents. Findings include: The facility's posted menu for lunch on 1/29/25 identified the menu to be: Pulled pork sandwich Broccoli Banana Cream Pie Continuous observation of lunch service began on 1/29/25 at 11:30 am. The Dietary Services Manager (DSM) first prepared pureed broccoli for the residents who required a pureed diet. After this task, the then stated she would puree the pulled pork. The DSM placed gloves on her hands. She picked up the food processor bowl and carried it to the counter. She placed four servings of pulled pork into the food processor bowl. She then obtained a measuring cup and added some barbeque sauce to it. She walked to the coffee maker and obtained hot water from the coffee maker and added it to the cup, still wearing the same gloves. After adding the water and sauce mixture to the pork, she picked up two slices of bread with her gloved hand and added it to the pork mixture to puree the pork. Following the puree process, the DSM then opened a kitchen drawer and obtained a silicone spatula to transfer the pork to a steam pan and then placed the steam pan in the oven to keep warm. The DSM then removed her gloves, pureed the dessert and continued to prepare for lunch service. On 1/29/25 at 11:58 am, the DSM took a gallon size container of barbeque sauce and poured a small amount into a squeeze container for serving. She then stated she was going to make two grilled cheese sandwiches for residents who had requested an alternate meal. The DSM obtained a bagged loaf of bread, a container of butter and a container of cheese and placed all on a clean surface. She placed gloves on her hands with no hand hygiene prior to placing the gloves. She removed the lid off of the container holding the cheese, and picked up one slice of bread and placed it into the palm of her gloved hand. She picked up the container of butter and opened the container, then obtained a spatula and spread the butter on the slice of bread. She repeated this for a second slice of bread and placed both slices into a skillet on the stove to grill the bread. She obtained cheese with the same gloved hands and placed the cheese on the bread. After making the first grilled cheese sandwich, she repeated this for a second sandwich. She then transferred both sandwiches using a spatula to a steam pan. On 1/29/25 at 12:07 pm, the DSM removed her gloves, performed hand hygiene, and then set up serving utensils on the steam table to begin lunch service. She then entered the walk in cooler and returned with a wheeled cart holding multiple slices of banana cream pie on individual plates. The pie slices were open to air and not covered. On 1/29/25 at 12:10 pm, the DSM performed hand hygiene and placed new gloves on her hands. After placing the gloves on her hands, she walked to the plate warmer, opened the lid, and obtained a stack of plates and placed them in the steam table area. She then picked up a stack of plate covers and placed them near the plates. Still wearing her gloves, she pulled a tray cart closer to her, then turned and obtained a box of plastic wrap. She pulled out a portion of the plastic wrap to cover a slice of pie, then placed the pie plate on a tray. She then returned to the steam table area, picked up a sandwich bun with her gloved hand, and placed it on a plate. She placed a scoop of pork on the bottom bun, picked up the squeeze bottle of barbeque sauce, applied sauce to the pork, then picked up the top bun and covered the pork to form a sandwich. She then used the serving scoop to place broccoli on the plate, carried the plate to the serving cart and placed it on the tray, and covered the plate with plate cover. This process was repeated for each tray, making each pork sandwich with her gloved hands, touching plates, serving utensils, tray covers, plates of pie, and plastic wrap for each tray on the first cart. When the first side of the cart was full, still wearing the same gloves, she turned the cart 180 degrees to fill up the second side of the cart. When the cart was full, the dietary aide added drinks to the cart and then took the cart to the dining room. The DSM then brought the second tray cart over to the steam table area. She removed her soiled gloves and placed new gloves on her hands without washing her hands. She opened the plate warmer, obtained another stack of plates and placed them at the steam table area. She adjusted the tray cart and then placed a plate of pie on each tray on the cart. She then plated the meals for this cart following the same process as the first cart, touching the plates, the plate covers, the serving utensils, the barbeque sauce and the sandwich buns all with her gloved hands. On 1/29/25 at 12:32 pm, she pushed the second tray cart out to the dining room. She then returned, removed her gloves and discarded them, and placed new gloves on her hands. She then pushed the third tray cart to the steam table area and the process was repeated for the last cart. The final three plates to be served were the plates for the pureed diet residents. After making their plates, she walked to the walk-in cooler, still wearing gloves, and obtained the pureed banana cream pie and then returned and placed these bowls on the trays. She then pushed the final cart to the dining room for staff to distribute the meals. When the DSM returned to the serving area, she removed her gloves, and placed a new set of gloves on her hands. She again walked to the walk-in cooler and returned a moment later. She was then wearing one glove and had the other glove in the palm of her hand along with a raw onion. She placed the second glove back on her hand, and obtained a cutting board and a knife and sliced the onion. She picked up a portion of the sliced onion with her gloved hand and placed it in a bowl and covered the bowl with a lid. She carried it to the dining room and gave it to a staff member for a resident who had requested some onion for her sandwich. On 1/29/25 at 12:43 pm, the DSM stated she had completed lunch service. On 1/29/25 at 12:50 pm, the State Surveyor asked the DSM if, when wearing gloves, then touching plates and plate covers and serving utensils and multiple other surfaces, would the DSM still consider those gloves to be clean. The DSM stated no, the gloves would no longer be clean. She stated she was unsure of what she should have done differently, however. She stated she had not thought to use tongs to pick up the bread or buns. Chapter 3 of the 2022 FDA Food Code documented the following: 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The facility policy dated April 2019 and titled, Food Preparation and Service, identified a Policy Statement of Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area, Point 5: Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Food Service/Distribution, Point 6: Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use.

Based on clinical record review, staff interview, and instructions of CMS form 10123-NOMNC, the facility failed to appropriately provide a Notice of Medicare Non Coverage (NOMNC) to 2 of 3 (Resident #35 and #36) residents reviewed for Beneficiary Notification. The facility reported a census of 32 residents. Findings include: 1. The census portion of the Electronic Health Record (EHR) of Resident #35 revealed the resident began receiving skilled care under Medicare A payer source on 9/9/24 and Medicare continued to pay for her stay through 11/22/24. The facility was unable to provide documentation of Resident #35 receiving a Notice of Medicare Non Coverage (NOMNC) form. 2. The census portion of the EHR of Resident #36 revealed the resident began receiving skilled care under Medicare A payer source on 7/26/24 and Medicare paid for his stay through 9/11/24. The facility did provide Resident #36 a NOMNC form on 9/10/24, one day prior to his Medicare services ending. The document titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 directed: A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. On 1/27/25 at 1:01 pm via email, the Administrator stated the facility could not locate a NOMNC for Resident #35. On 1/29/24 at 3:23 pm, the Administrator stated her expectation is for NOMNCs to be issued at least 2 days prior to Medicare discharge.

Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete a Significant Change Minimum Data Set (MDS) Assessments following a significant change within federal guidelines for 1 of 5 residents (Res #4) reviewed for significant change. The facility reported a census of 32 residents. Findings include: The Census Line portion of the Electronic Health Record (EHR) of Resident #4 documented the resident enrolled in hospice care on 9/12/24. The Significant Change MDS of Resident #4 documented an Assessment Reference Date (ARD) of 10/3/24. Page 58 of the MDS documented the MDS was signed as Assessment Completion on 10/8/24 which is 26 days following hospice admission. According to the 2024 RAI, a Significant Change (comprehensive) assessment, the ARD must be no later than the 14th calendar day after determination that a significant change in the resident's status occurred. The RAI stated a Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program. On 1/28/25 at 10:59 am, the MDS Coordinator stated she was on vacation during the time frame that Resident #4 enrolled in hospice care. She stated when she returned and was notified of her hospice enrollment, she then set up and completed the Significant Change MDS. On 1/29/25 at 3:23 pm, the Administrator stated the Corporation that owns the facility has a traveling Regional MDS Coordinator. She stated anytime the facility MDS Coordinator is not in house, the facility will notify the Regional Coordinator to ensure assessments are completed timely. The facility policy titled Resident Assessments documented the following: Point 3: A Significant Change in Status Assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guidelines for major improvement or decline. Point 4: A SCSA cannot be completed until after a comprehensive Admission Assessment is submitted. Point 5: A SCSA is required when a resident: a. Enrolls in a hospice program; b. Changes hospice providers and remains in the facility; c. Discontinues hospice services; or d. Experiences a consistent pattern of changes with two or more areas of decline from baseline.

Based on observation, resident and staff interviews, and clinical record review, the facility failed to follow the physician's orders for 1 of 12 residents (Resident #7) reviewed. The facility reported a census of 32 residents. Findings include: On 1/27/25 at 9:42 AM, Resident #7 was observed lying in his room. The bottom half of the resident's legs were uncovered and noted to be discolored. The resident stated he was supposed to have tubigrips (a tubular bandage that provides support for sprains, strains, swelling, and other injuries) on the lower half of both legs. He stated they were to be applied in the morning and removed at night. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Heart Failure (HF), Diabetes Mellitus (DM), Alzheimer's Disease, Schizoaffective Disorder, depression, left lower limb cellulitis, and erythematous condition (redness of the skin typically caused by inflammation). It also revealed the resident required moderate assistance with bathing and was independent with all other aspects of Activities of Daily Living (ADLs) and mobility and received application of nonsurgical dressings (with or without topical medications) other than to feet. The Electronic Health Record (EHR) included a physician's order dated 2/21/24 for tubigrips to bilateral lower extremities (BLE) two (2) times per day for edema; on in AM and off at hour of sleep (HS - bedtime). The Care Plan, revised 3/04/24, indicated the resident wore tubi-grips on in AM and off at HS. On 1/28/25 at 1:30 PM, Resident #7 was observed sitting on the side of his bed not wearing his tubigrips. The tubigrips were observed lying on a stack of newspapers on his 4-wheeled walker. The resident stated he had not removed the tubigrips because the staff never applied them in the AM. At 1:33 PM, Staff C, Registered Nurse (RN) confirmed Resident #7 was supposed to have the tubigrips on but stated she hadn't put them on yet. She also stated the resident hadn't refused to wear the tubigrips that morning. The Progress Notes did not include documentation on 1/27/25 or 1/28/25 regarding the tubigrips not being placed on the resident. The Treatment Administration Record (TAR) revealed the resident did not refuse the tubigrips on 1/27/25 or 1/28/25. On 1/29/25 at 3:35, the Assistant Director of Nursing (ADON) stated staff should have followed the physician's orders and put the tubigrips on the resident in the AM. The facility did not have a policy specifically regarding following physician's orders.

Based on observation, facility menu review, and staff interviews, the facility failed to follow the posted menu and serve the appropriate portions for 3 of 3 residents who received pureed diets (Resident #9, #23, #29). Findings include: The facility's menu for lunch on 1/29/25 included the following items to be served to the residents. 2 oz of pulled pork 1 slice of bread 1/2 cup of broccoli 1 slice banana cream pie Continuous observation of lunch service began on 1/29/25 at 11:30 am. The Dietary Services Manager (DSM) stated she would first puree the broccoli for the puree diet residents. She used a #8 (4 oz) scoop and placed four servings of broccoli into a blender cup. She stated the facility had three residents who received pureed diets but she always made one extra serving. She then placed an unmeasured amount of chicken broth into the blender cup and blended the food to an appropriate texture. She transferred the broccoli into a steam pan with no measurement of the total volume (Measuring the volume of the entire product and dividing by the number of servings calculates the appropriate serving size for each person, as adding extra liquid and other ingredients to puree will increase the total volume of the pureed food). The DSM next obtained the food processor bowl and used a two ounce scoop and placed four 2 oz servings of pulled pork into the food processor bowl. She added an unmeasured amount of barbeque sauce and hot water, along with two slices of bread and added this to the pork. She then blended this mixture to an appropriate texture and used a silicone spatula to transfer the pork to a steam pan with no measurement of total volume performed. The DSM then obtained three slices of banana cream pie and placed them into a blender cup. She added an unmeasured amount of milk and a carton of ready to eat vanilla pudding and blended the mixture to an appropriate texture. She used a silicone spatula to transfer the mixture into 3 bowls. She did not measure the total volume to assure each resident got an equal serving. On 1/29/25 at 12:10 pm, the DSM began making plates for each resident and placing the plates on serving carts. As she completed each cart, she rolled the cart to the dining room for other staff to distribute to the residents. The final three plates made during lunch service were the pureed diet plates. Each plate consisted of a two ounce portion of the mixture of pureed pulled pork, bread and barbeque sauce and a four ounce scoop of the pureed broccoli along with the pureed banana cream pie. The DSM verified these plates were for Resident #9, #23 and #29. On 1/29/25 at 12:43 pm, the DSM stated she had completed lunch service after all meals were completed and sent to the dining room. On 1/29/25 at 12:50 pm, the DSM stated she had never been taught about the volume method or seen the chart for volume method for the puree process until one day prior, on 1/28/25 when the Registered Dietitian (RD) was in the building. She said the RD had explained the volume method on 1/28/25 but the DSM explained she did not feel confident that she understood it. She verified the menu was for one slice of bread and for four servings of pureed pork, she had only used two slices of bread instead of four. On 1/29/25 at 3:25 pm, the Administrator stated her expectation is for the dietary staff to use the volume method for puree foods and to serve the posted menu.

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to implement infection control practices to prevent urinary tract infection (UTI) for 2 of 2 residents (Resident #26 and #21) reviewed. The facility reported a census of 32. Findings include: 1. On 1/28/25 at 9:20 AM, observed Resident #26 to have an indwelling urinary catheter. The Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of Non-Alzheimer's Dementia, benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate that affects urination), and age-related macular degeneration (eye condition that affects central vision). It also revealed he was independent with eating, required setup assistance with oral and toileting hygiene, moderate assistance with dressing and personal hygiene, and maximum assistance with bathing. It did not include an indwelling catheter. The Progress Notes indicated the resident's indwelling catheter was inserted 1/12/25 due to urine retention. The Care Plan revised 1/26/25 included the resident's indwelling catheter and directed staff to use Enhance Barrier Precautions (use of PPE) when performing high-contact care activities. On 1/28/25 at 1:45 PM, Staff D, Certified Nurse Aide (CNA) entered Resident #26's room and prepared to perform the resident's catheter and perineal care. The Interim Director of Nursing (IDON) accompanied Staff D for observation. Staff D performed hand hygiene and donned the Personal Protective Equipment (PPE - gown and gloves). She then reached in a cabinet, grabbed the periwipe package, entered the bathroom and obtained a clear, plastic garbage bag. She reached into her right pocket then her left pocket and pulled out alcohol wipe packets. She placed the alcohol wipes, the clear plastic bag, and the periwipe package on the resident's bedside table. She opened the periwipe package and removed, expanded, and placed each individual periwipe into the clear plastic bag. She did not perform hand hygiene nor change gloves between touching items in the resident's environment and manipulating the wipes. She grabbed her walkie-talkie and asked for assistance to perform the resident's full perineal care. At 1:51 PM, Staff E, Licensed Practical Nurse (LPN) entered the resident's room, performed hand hygiene and donned PPE. At 1:53 PM, Staff D stated she and Staff E would be performing the resident's catheter and perineal care using the normal process. She placed her left gloved hand on the resident's walker and assisted the resident in removing his briefs. Staff D did not change gloves or perform hand hygiene at this point in the process. Staff D grabbed one periwipe from Staff E and wiped the resident's penis tip three (3) times from a top-to-bottom motion using the same periwipe and threw it in the clear plastic garbage bag she placed on the resident's bed. She used a second periwipe and wiped the bottom of the resident's penis and threw the periwipe in the clear plastic garbage bag. At 1:56 PM, Staff D got an alcohol swab and cleaned the catheter tubing in a distal motion (moving away from the resident's penis). She removed her PPE, placed it in the clear plastic garbage bag, and exited the room. At 1:57 PM, Staff D returned to Resident #26's room with a box of gloves. She performed hand hygiene, donned PPE, grabbed the clear plastic garbage bag with her right gloved hand and used her left gloved hand to push the bag's contents further into the bag. She moved the bag further away from the resident, turned back around toward the resident, grabbed the urine drainage bag, opened the drainage spigot and emptied the urine into a graduated cylinder. No hand hygiene or glove change was performed between touching the contaminated bag contents and manipulating the resident's urinary catheter drainage bag and spigot. At 2:09 PM, Staff D stated she felt she performed the process correctly and did not identify any missed hand hygiene or glove changing opportunities. She stated she received Infection Prevention training and verbalized hand hygiene should be performed when moving from a dirty area to a clean area when providing resident care. When asked, she confirmed the bag on the bed was considered contaminated and stated she should have performed hand hygiene and changed her gloves prior to manipulating the resident's drainage bag and spigot. On 1/29/25 at 3:35 PM, the Assistant Director of Nursing (ADON) stated staff should have performed hand hygiene between handling the trash and the resident's catheter. A policy titled Handwashing/Hand Hygiene revised 8/2019 directed staff to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food; p. Before and after assisting a resident with meals; and q. After personal use of the toilet or conducting your personal hygiene. 46873 2. The Minimum Data Set (MDS) of Resident #21, dated 11/28/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented the resident used a wheelchair for mobility independently with no assistance from staff. The MDS coded the presence of a urinary catheter. The Care Plan of Resident #21 identified a Focus Area of Risk for Urinary Tract Infection (UTI), revision date 12/5/24. The Care Plan documented the resident to be at risk of UTI due to a suprapubic catheter related to neuromuscular dysfunction and history of UTI. It directed staff to follow enhanced barrier precautions when performing high-contact care activities. On 1/27/25 at 7:52 am, Resident #21 was observed propelling herself across the dining room in her wheelchair with her catheter tubing dragging the floor. On 1/27/25 at 10:16 am, Resident #21 was observed self propelling in the hallway toward her room. Her urinary bag attached to her catheter was secured to the bottom of her wheelchair, and the tubing was dragging on the floor as she propelled down the hallway. On 1/28/25 at 8:06 am, Resident #21 was observed sitting in the dining room eating breakfast. Her catheter tubing was on the floor and her foot was sitting on top of the tubing as she sat at the table. On 1/28/25 at 1:56 pm, observation was completed of catheter cares for Resident #21 by Staff F, Certified Nurse Aide (CNA). Resident #21 was in her room, and privacy was provided. Staff F washed his hands and donned Personal Protective Equipment (PPE). Rather than a single use disposable isolation gown, Staff F donned a cloth hospital gown over his clothing. After donning the PPE in the resident bathroom, Staff F brought paper towels, a graduated cylinder in a plastic bag and alcohol swabs to the resident who was sitting in her wheelchair. He placed the paper towels on the floor, then the graduated cylinder in the plastic bag on top of the towels. He removed the drain from the bag, cleansed the outlet of the drain with alcohol then drained the urine into the graduated cylinder. When the urine bag was empty, with a clean alcohol swab he again cleansed the outlet before closing it and securing it to the bag. He carried the graduated cylinder to the toilet and dumped the urine. He rinsed the cylinder and dumped the rinse water in the toilet and placed the cylinder in a clean plastic bag. He removed his PPE, disposing of his gloves and turning the gown inside out as he removed it, rolled it up and placed it in a plastic bag. He washed his hands and then exited the room and took the bagged soiled gown to the laundry. On 1/28/25 at 2:10 pm, the Interim Director of Nursing stated the facility only had disposable isolation gowns and no cloth gowns. She stated the white cloth gowns are hospital gowns, not isolation gowns. On 1/28/25 at 2:12 pm, the Regional Director of Clinical Services stated Staff F wears a hospital gown over his scrubs to protect his clothing when he gives residents showers. She stated she would provide education on this. On 1/28/25 at 3:21 pm, the Assistance Director of Nursing stated Staff F was unaware he was not to use a hospital gown for catheter cares and had received education and will wear a disposable isolation gown in the future. On 1/29/25 at 3:23 pm, the Administrator stated her expectation for residents with catheters is for any excess tubing to be tucked into a catheter dignity bag on a wheelchair or otherwise clamped up to stay off of the floor.

Based on observation, policy review and staff interview the facility failed to follow practices of safe food handling during 2 of 2 meals observed. The facility reported a census of 71 residents. Findings include: During an observation of the noon meal on 3/5/24 beginning at 12:14 PM, Staff G, Non-CNA (NC) was observed handling multiple residents' beverage glasses touching the drinking surface. Staff B, Restorative Aide (RA) did not sanitize hands prior to touching the glasses. During an observation of the noon meal on 3/6/24 beginning at 12:30 PM, Staff G, NC was observed handling multiple residents' beverage glasses touching the drinking surface. Staff B, RA was observed handling two resident beverage glasses touching the drinking surface. Staff B, RA was observed touching her face multiple times between delivering meal trays to residents without properly sanitizing hands. During an interview on 3/7/24 at 3:34 PM the Administrator provided facility policies. She explained her expectation of the staff was that they would grab the side of the glass, not the top of the glass where the resident is going to be drinking from. The facility provided a policy titled Preventing Foodborne Illness - Food Handling revised July 2014, documented: All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.

Based on observations and staff interviews and the facility policy review, the facility failed to maintain a clean, free from possible hazards, and homelike environment. The facility reported a census of 71 residents. Findings include: An observation of room [ROOM NUMBER] on 3/4/24 at 12:30 PM revealed a wall located at the head of a residents' bed with multiple areas of scratched up paint with shallow holes. On 3/4/24 at 1:10 PM an observation of the main Nurses Station near the Dining room revealed a wall with missing floor board, wallpaper torn and mismatched paint. On 3/6/24 at 12:10 PM an observation of the main Dining Room where 24 residents were seated at noon meal, 5 out of 22 ceiling lights were not on. During an interview on 3/7/24 at 2:34 PM the Administrator confirmed that room [ROOM NUMBER] did not appear homelike. She further confirmed the missing paint on the wall near the dining room and the ceiling lights did not meet her expectations. The facility did not have any maintenance personnel on site. A facility provided policy titled Homelike Environment revised in February, 2021 documented The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.

Based on clinical record review, policy review, staff and resident interview, the facility failed to ensure one of one allegation of abuse was reported to the appropriate State Agency (SA). Resident #2 reported an allegation that Staff D, Certified Nursing Aide (CNA) was rough with Resident #21 during cares. Staff interviews confirmed the facility Administrator and the Director of Nursing (DON) were notified of Resident #2's allegation involving Staff D, CNA with no evidence the allegation was reported to the SA. Staff D remained actively working with access to all residents. The facility reported a census of 42 residents. Findings include: On 3/04/24 at 11:26 AM, a resident stated she reported Staff D, Certified Nursing Aide (CNA) to Staff E, Dietary Aide (DA) and Staff F, Cook for being rough with Resident #21 while providing cares. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a BIMS score of 03 of 15, which indicated severe cognitive impairment and included diagnoses of Non-Alzheimer's dementia, malnutrition, anemia, and macular degeneration (disease affecting central vision). The MDs also indicated the resident required maximum assistance with bathing but was dependent in all other ADLs. On 3/04/24 at 1:11 PM, Staff E, DA stated Resident #2 told her Staff D helped Resident #21 get in bed and Resident #21 cried because Staff D was rough. Staff E stated she and Staff F, Cook immediately reported the allegation to the facility Administrator through a phone call. On 3/05/24 at 4:00 PM, Staff F, Cook stated Staff E asked him for his opinion regarding the allegation because he had been here longer. Staff F revealed a text he sent the Administrator which indicated the need for an important topic needing discussed. On 3/06/24 at 11:00 AM, the facility Administrator confirmed one (1) Facility Reported Incident was made to the SA since 1/01/24 but did not involve the aforementioned allegation. She confirmed she was notified of the allegation the same day at 8:44 PM. On 3/06/24 at 11:10 PM, the DON confirmed she entered the facility within an hour after the allegation was reported and initiated an investigation. She stated Resident #2 was interviewed and admitted she wasn't able to see Resident #21, but claimed Staff D threw Resident #21 in the air. The DON stated she didn't think it needed to be reported to the SA based on the inconsistencies of the claim. On 3/06/24 at 11:15 AM, the DON stated Staff D was not removed from resident care but finished her shift 40 minutes after the allegation was reported. She stated Staff D was not separated from the residents during her investigation. On 03/06/24 at 12:50 PM, a punch report revealed Staff D clocked out at 8:24 PM but returned to work a 12-hour shift the following day. On 3/07/24 at 9:55 AM, the Administrator stated allegations should be reported immediately and the alleged perpetrator should be separated from the alleged victim pending investigation. She stated alleged perpetrator staff members should be removed from the building pending investigation. A document titled Abuse and Neglect - Clinical Protocol revised March 2018 indicated the facility management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on clinical record review, policy review, staff and resident interview, the facility failed to prevent further potential abuse by failing to separate the alleged perpetrator from the alleged victim pending an investigation of an abuse allegation. Resident #2 reported an allegation that Staff D, Certified Nursing Aide (CNA) was rough with Resident #21 during cares. Staff interviews confirmed the facility Administrator and the Director of Nursing (DON) were notified of Resident #2's allegation involving Staff D, CNA with no evidence the alleged perpetrator was immediately separated from the alleged victim pending the allegation investigation. Staff D remained actively working with access to all residents. The facility reported a census of 42 residents. Findings include: On 3/04/24 at 11:26 AM, a resident stated she reported Staff D, Certified Nursing Aide (CNA) to Staff E, Dietary Aide (DA) and Staff F, Cook for being rough with Resident #21 while providing cares. The Quarterly MDS dated [DATE] revealed Resident #21 had a BIMS score of 03 of 15, which indicated severe cognitive impairment and included diagnoses of Non-Alzheimer's dementia, malnutrition, anemia, and macular degeneration (disease affecting central vision). It also indicated the resident required maximum assistance with bathing but was dependent in all other ADLs. On 3/04/24 at 1:11 PM, Staff E, DA stated Resident #2 told her Staff D helped Resident #21 get in bed and Resident #21 cried due to Staff D was rough. Staff E stated she and Staff F, Cook immediately reported the allegation to the facility Administrator through a phone call. On 3/05/24 at 4:00 PM, Staff F, Cook stated Staff E asked him for his opinion regarding the allegation because he had been here longer. Staff F revealed a text he sent the Administrator which indicated the need for an important topic needing discussed. On 3/06/24 at 11:00 AM, the facility Administrator confirmed one (1) Facility Reported Incident was made to the SA since 1/01/24 but did not involve the aforementioned allegation. She confirmed she was notified of the allegation the same day at 8:44 PM. On 3/06/24 at 11:10 PM, the DON confirmed she entered the facility within an hour after the allegation was reported and initiated an investigation. She stated Resident #2 was interviewed and admitted she wasn't able to see Resident #21 but claimed Staff D threw Resident #21 in the air. The DON stated she didn't think it needed to be reported to the SA based on the inconsistencies of the claim. On 3/06/24 at 11:15 AM, the DON stated Staff D was not removed from resident care but finished her shift 40 minutes after the allegation was reported. She stated Staff D was not separated from the residents during her investigation. On 03/06/24 at 12:50 PM, a punch report revealed Staff D clocked out at 8:24 PM but returned to work a 12-hour shift the following day. On 3/07/24 at 9:55 AM, the Administrator stated allegations should be reported immediately and the alleged perpetrator should be separated from the alleged victim pending investigation. She stated alleged perpetrator staff members should be removed from the building pending investigation. A policy titled Protection of Residents During Abuse Investigations revised April 2021 indicated if the alleged perpetrator is an employee or staff member, the individual is immediately reassigned to duties that do not involve resident contact or are suspended until the findings of the investigation are reviewed by the administrator.

Based on observation, record review, staff interview, and policy review, the facility failed to provide the necessary services to maintain personal and oral hygiene for 2 of 12 residents reviewed (#20 & #21). The facility reported a census of 42 residents. Findings include: 1. On 3/04/24 at 11:07 AM, Resident #20 was observed positioned at the front edge of his wheelchair seat with his feet resting on the floor past the foot plates. Three staff members repositioned Resident #20 in his wheelchair. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 03 of 15, indicating severe cognitive impairment. The MDS documented that the resident had bilateral lower extremity impairment, normally used a wheelchair, was dependent on staff for chair/bed-to-chair transfer, and toilet transfer. The MDS included diagnoses of Non-Alzheimer's dementia, Traumatic Brain Injury, lack of coordination, and hydrocephalus (abnormal buildup of fluid in the brain). It also indicated the resident required set-up assistance with eating, moderate assistance with oral and personal hygiene and upper and lower body dressing, maximum assistance with toileting, and was dependent with applying and removing footwear. The MDS dated [DATE] revealed the resident's BIMS was 03 of 15, but indicated the resident required set-up assistance with eating, maximum assistance with upper body dressing, and was dependent with all other areas of Activities of Daily Living (ADLs). On 3/06/24 at 9:15 AM, Staff A, Physical Therapist (PT) stated Resident #20 ended physical therapy on 11/09/23. She stated the restorative recommendations were lower and upper extremity Omnicycle for two (2) to five (5) times per week as tolerated by the resident on level one (1); which she indicated was 15-minute standard time. On 3/06/24 at 9:18 AM, Staff B, Restorative Aide (RA) stated she did not have a restorative aid plan for Resident #20. She stated the therapist lets her know when a resident has a restorative plan. The Electronic Health Record (EHR) progress notes included Therapy to Nursing communication that recommended lower and upper extremity Omnicycle for 2 to 5 times per week as tolerated by the resident on level 1. On 3/06/24 9:22 AM, Staff C, Assistant Director of Nursing (ADON) stated she received Resident #20's restorative recommendations from PT on 11/09/23 and added them to the Care Plan. The Care Plan indicated the resident's restorative plan was initiated 11/13/23 and resolved 1/01/24 and directed staff to have the resident perform lower and upper extremity Omnicycle on level 1 as tolerated to maintain strength. On 3/06/24 at 9:58 AM, the Regional Director of Clinical Services (RDCS) stated there was no restorative note documentation in her report to indicate the restorative recommendation was done other than a progress note entry dated 11/09/23. On 3/06/24 at 10:55 AM, the ADON provided documentation that revealed restorative care was documented for 11/14/23, 11/16/23, 11/28/23, 11/30/23, 12/07/23, and 12/28/23. There was no restorative documentation for weeks 11/19/23-11/25/23; 12/10/23-12/16/23; or 12/17/23-12/23/23. On 3/07/24 at 10:05 AM, the Director of Nursing (DON) stated restorative care should be completed as ordered. 2. On 3/04/24 at 11:11 AM, an observation of Resident #21's teeth revealed food particles between lower teeth. The resident had malodorous breath. The EHR revealed the resident ate 26% - 50% of breakfast. The Oral Hygiene Response History indicated the resident did not receive oral hygiene after breakfast. The Quarterly MDS dated [DATE] revealed Resident #21 had a BIMS score of 03 of 15, which indicated severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's dementia, malnutrition, anemia, and macular degeneration (disease affecting central vision). It also indicated the resident required maximum assistance with bathing but was dependent in all other ADLs. The Care Plan indicated the resident was not independent with oral hygiene. On 3/05/24 at 2:25 PM, Staff B, RA stated Resident #21 was dependent with oral hygiene. On 3/07/24 at 10:05 AM, the DON stated staff should provide dependent residents with daily oral care. A policy titled Restorative Nursing Services revised 7/2017 revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. It indicated residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. It indicated restorative goals include developing, maintaining or strengthening a resident's physiological and psychological resources and maintaining a resident's dignity, independence and self-esteem.

Based on clinical record review, physician, family and staff interviews and policy review, the facility failed to provide necessary assessment, treatment, and services to promote healing of skin injuries, prevent infection, and prevent additional skin damage. The facility failed to implement appropriate interventions with follow-up measures for wound care and physician notification. The facility failed to seek a higher level of care to provide treatment for the wounds that failed to heal. Resident #1 obtained a puncture to the left posterior calf identified on 6/1/23, progressed to a large venous ulceration that became infected with bacteria with purulent green drainage and a strong odor and the right lower leg wound became infected with bacteria as well. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 29, 2023 on September 13, 2023 at 1:15 P.M. The facility staff removed the Immediate Jeopardy on September 13, 2023 by implementing the following actions: 1. Facility and agency staff educated on identifying resident change in condition and provider notification. 2. Facility and agency staff educated on completing full wound assessments when identified. 3. Facility and agency staff educated on appropriate wound intervention to include an advanced level of treatment for wound care if needed. 4. Facility and agency staff educated on signs and symptoms of wound infection. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed a diagnosis of diabetes mellitus with diabetic peripherial angiopathy (narrowing of arteries), heart failure, venous insufficiency, wound infection and required assistance of 1 person to transfer, ambulate and dress. The Brief Interview for Mental Status (BIMS) of 14 sugested Resident #1 had an intact cognition. The Care Plan dated 8/15/23 directed staff to assess for signs and symptoms of skin and soft tissue infection, monitor and document location, size and treatment of injury and to report abnormalities, failure to heal, signs and symptoms of infection to the physician. The History and Physical dated March 25, 2023 revealed: 1. Admit Resident #1 to the nursing home with a diagnosis of non-pressure chronic ulcer right lower leg limited to breakdown of skin, Type 2 diabetes mellitus with diabetic peripheral angiopathy (reduced circulation of blood) without gangrene, and venous insufficiency (chronic, peripheral). 2. Resident #1 had two venous wounds to her right lower extremity and was treated at the wound clinic by application of a dry dressing daily, apply a xeroform dressing daily until unna boot supplies come in and reassess. 3. Right calf shin wound measures 7.78 centimeters (cm) x 3.68 cm. Right posterior calf measures 4.95cm x 2.98 cm. The Physician Orders dated August 2023 for Resident #1 revealed: a. Hydrofera Blue to left leg wounds, covered with an ABD dressing, and secure with kerlix. b. Apply calmoseptine to the peri wound area prior to dressing every day. c. ACE wrap to Right leg every day. The Treatment Administration Record (TAR) for Resident #1 revealed: a. 8/30/23 Hydrofera Blue to left leg wounds, and cover with ABD secure with kerlix. Apply calmoseptine to the peri wound area prior to dressing, change every day. b. Documentation on 8/30/23 & 8/31/23 was completed as ordered. c. Documentation on 9/1/23 & 9/2/23 was completed as ordered. d. Documentation on 9/3/23 Resident #1 hospitalized . The Progress Notes revealed: a. On 6/1/23 provider Staff K, Advanced Registered Nurse Practitioner (ARNP) documentation: 1. Resident #1 reported pain to the back of the left leg, weeping on occasion. Resident #1 reported she scratched it on her bed sometime ago, the facility fixed the bed. Resident #1 reported she did not think the area was bad so she never told anyone. 2. Measured 5.36 cm x .67 cm. Abrasion of left calf, initial encounter. 3. Barrier spray to back of left calf daily every shift, monitor for signs and symptoms (s/s) of infection such as redness and warmth to touch. b. On 6/7/23 Staff K, ARNP, documentation: 1. Abrasion of left calf worsening. 2. Apply xeroform to wound cover with non-stick telfa and wrap with kling. Change daily and PRN (as needed). 3. Monitor for s/s of infection such as redness and warmth to touch. c. On 7/11/23 at 11:51 PM, Resident #1 completed doxycycline. Wound continues to be painful and had drainage, redness to both legs surrounding wounds, pale yellow drainage noted from all 3 wound sites (1 left calf, 2 right calf), continues to be lethargic and easily tired with activity. Incontinent of bladder and continent of bowels. Will continue to monitor. d. On 7/10/23 Staff K, ARNP documentation: Abrasion of left calf, subsequent encounter: 1. Wound is worsening. Left calf wound measures 7.5 cm x 3.6 cm 2. Santyl not in from pharmacy. Apply aquacel AG to wound and cover with non-stick telfa and apply tubi grips. Change daily and as needed. Monitor for s/s of infection such as redness, warmth to touch and report to provider. 3. Continue Gabapentin Oral Capsule Give 500 mg by mouth three times a day for pain related to the wounds. 4. Continue Trazadone 50 mg at bedtime, if difficulty sleeping continues, could increase Trazadone to 100 mg in the future. 5. Increase Hydrocodone to 5/325 mg 2 tablets TID (three times a day). e. On 8/29/23 Staff K, ARNP, documentation: 1. Resident #1 reported wet dressings, discussed with nurses who reported an increase in drainage and odor to wound, and smells strongly of urine, and the provider was unable to determine if urine was on wound dressing or on the brief. 2. A white blood count (WBC) of 9.49 (normal WBC 4.5-11). 3. The provider offered the wound clinic but Resident #1 refused to go and informed Resident #1 that the wound was not healing and will need sharp debridement. f. On 8/29/23 at 12:46 PM, Staff K, ARNP requested a wound culture during the dressing change due to suspected infection. g. On 8/31/23 Continue to wait on wound culture results from 8/29/23. h. On 9/2/23 at 4:24 PM wound culture growth gram positive cocci (bacteria), providencia rettgeri (bacteria capable of causing septicemia), enterocococcus faecalis (bacteria found in feces) and serratia marcescens (bacteria associated with urinary infections). Provider Staff K, ARNP aware, awaiting sensitivity results. i. On 9/2/23 at 8:15 PM, Staff D, Registered Nurse (RN) documented Resident #1 lowered to the floor during ambulation due to weakness. j. On 9/2/23 at 9:15 PM Unable to obtain orthostatic (sitting and standing) blood pressures due to Resident #1 inability to stand long enough to obtain blood pressure. k. On 9/3/23 Staff K, ARNP recieved message from Staff L, Licenced Practical Nurse (LPN), Staff K returned call at 8:48 AM, Resident #1 was weak, required assistance with transfers, the wound culture & sensitivity had not returned yet, Staff K ordered a complete blood count drawn, urine sent to the lab, gave the order to send Resident #1 to the emergency room (ER) due to increased weakness throughout the day and wound infection. l. On 9/3/23 at 12:32 PM, Power of Attourney (POA) notified of Resident #1 condition and requested to send Resident #1 to the ER. m. On 9/3/23 at 2:22 PM The emergency room (ER) nurse called facility, admitted Resident #1 and will transfer to a tertiary hospital for a higher level of care, debriedment of wounds, when a bed is available. The Provider and POA was notified. During an interview on 9/11/23 at 1:45 PM, Staff J, Wound Care Nurse stated Resident #1 was treated in the wound clinic last on 2/20/2023 for the stasis wound on the right leg and was not seen again until 9/3/23 after the emergency room visit and Resident #1 was admitted for infected necrotic wounds on both legs. Staff J stated that Resident #1 ' s wounds to the right lower leg was worse and a new wound to the left lower leg was black, surrounded by red skin, with purulent (thick) green drainage. Staff J stated the odor from the wound smelled as one entered the hospital room. The Podiatrist documentation revealed Resident #1 was admitted with infected necrotic wounds on both legs that had not received formal treatment for the wounds, the resident suffered from severe pain in both legs and Systemic Inflammatory Response Syndrome (SIRS). During an interview on 9/11/23, Staff N, Podiatrist stated, Our concern is a possible delay of care. During an interview on 9/11/23, Staff M, Hospitalist stated, This should have been treated sooner, just by the general appearance of this wound, it appeared to have been neglected for a while. Staff M stated Resident #1 expressed fear of losing her lower legs due to the wounds. Staff M stated that Resident #1 was transferred to a tertiary hospital on 9/8/23 for a surgical debridement of bilateral lower legs on 9/11/23, IV antibiotics and pain management. During an interview on 9/12/23 at 9:24AM, the Power of Attourney (POA) stated Resident #1 was treated in a tertiary hospital, heavly sedated due to her pain and debridement of her wounds due to the infection. The POA stated Resident #1 aquired the original wound on her left leg from a screw on the bed she was using in the nursing home. The POA expressed a concern as Resident #1 would call and report that her dressing were soaked, the bed was wet from the drainage and she could not get staff to change her dressing. Document titled health center Progress Notes dated 9/7/23 revealed Resident #1 was treated for SIRS and lower leg wound infection. Staff N, Podiatrist at health center was not comfortable taking Resident #1 to the Operation Room (OR) due to the extent of the ulcerations and significantly reduced pulses on both lower legs. Recommendation for transfer to a higher level of care. Document titled hospital Final Report dated 9/8/23 revealed Resident #1 was recommended and prepared for surgical debridement and pain management. During an interview on 9/13/23 7:27 AM, Staff D, RN stated Resident #1 ' s wound care was completed on the day shift. Staff D stated that for 2 weeks the dressings were wet and oozing daily. Staff D stated the wound had an odor for a week and Resident #1 became weak and had fallen the evening before being admitted to the hospital. During an interview on 9/13/23 at 10:56 AM, Staff L, LPN stated the wound culture was completed on 8/29/23 then the odor increased and the wound progressed quickly. Staff L stated, No one spoke about sending her to the ER. Staff L stated Resident #1 became weak, lowered to the floor on 9/2/23 and could not stand due to the pain in her legs. Staff L stated Resident #1 ' s legs were weepy and could smell the odor in the hallway. Staff L stated she notified the provider on 9/3/23. Interview on 9/13/23 at 11:28 AM, Staff K, ARNP stated when she started working in this facility in May 2023, she was unaware that Resident #1 was being treated by the wound clinic before admission to the facility. Staff K stated Resident #1 made her aware in May 2023 that she had acquired a wound to the back of her left leg from a screw on her bed, that she told 3 people and the bed was fixed. Staff K stated staff did not make her aware of the initial wound. Staff K stated she offered Resident #1 the option for the wound clinic, she was worried about pain control. Staff K stated she did not remember giving another option. Staff K stated that Resident #1 reported that the staff was not changing the dressing when it became wet with drainage. Staff K stated she ordered a culture for the wound and when staff called with the results, she was not given an update and was not aware of the fall on the evening of 9/2/23 until 9/3/23 when Staff L, LPN reported the wound appearing 3 times worse. Policy titled Wound Care dated 2010 revealed: Documentation; The following information should be recorded in the resident ' s medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident ' s condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. During an interview on 9/13/23 at 12:41 PM, The Director of Nursing (DON) stated her expectation for the nurse to do wound documentation once a week with measurements, and documentation for further concerns. The DON stated Resident #1 was non compliant with dressing changes due to pain. The DON stated she would expect the nurses to call her and the provider if there was a condition change. During an interview on 9/13/23 at 1:01 PM, The Administrator stated her expectation would be for the nurse to document changes of condition and to notify the DON and the provider.

Based on staff interview, employee record review, and facility internal investigation notes, the facility failed to employ competant nursing staff to care for the residents. The facility reported a census of 42. Findings include: On 9/11/23 at 2:32 pm, Staff A, Licensed Practical Nurse, former employee stated that in February of 2023 she was working an evening shift at the facility, she believed this to be either 2/26/23 or 2/27/23. She reported Staff C, housekeeper, was working this shift as well. At that time Staff C was an Environmental Aide (EA). Staff A stated she was in a resident room and heard something odd. She stepped into the hall to investigate and heard screaming from another resident room. She stated she knocked on the door of the resident room and entered the room. She witnessed Staff C in the room with the resident standing at her bedside performing cares. She stated he had his arm over her hip repositioning her and the resident was screaming. She said that Staff C told her the resident had been hitting him. She asked him to step away from the resident and leave the room which Staff C did, telling her he was leaving. She stated Staff C was the only person in the room with the resident when she entered. She called for another staff person to come assist and complete care of the resident. They transferred the resident to a wheelchair and kept her in the common area with staff. She stated she placed a call to the MDS Coordinator who was the manager on call. Per Staff A ' s report, the MDS Coordinator was to call her back but never did. When Staff C returned to the building, Staff A spoke with him in the presence of two other nurses to discuss the resident cares. She placed another call to the MDS Coordinator who stated it was fine for Staff C to stay and work the night shift. She reported she wrote a note to the Director of Nursing and left it under her door and also spoke to the Business Office Manager about her concerns. The Business Office Manager was to discuss it with other management. On 9/11/23 at 3:16 pm, Staff B, former EA stated she had been hired at the facility to become a Certified Nurse Aide (CNA). She stated she had taken no classes or had any training to be a CNA. She reported she was assigned to do duties that were not part of the position of EA which were required for her to get into school for CNA. She further said that when she when told other staff she was not to do these duties, they told her to do it anyway. She felt she was not in a position to argue so she would do as she was told. This included dressing and showering residents unsupervised. On 9/12/23 at 11:38 am, the Business Office Manager stated she did recall a nurse coming to her of concerns of nothing that was witnessed but Resident #3 had been heard screaming. She stated Resident #3 was known for screaming and this happened frequently. She stated she was not in a position to do investigations so she gave the information she had to the Administrator and the DON. She stated the facility does use non certified aides (Environmental Aides). She said they are to be support for the licensed or certified staff but are not to do any hands on direct care with the residents. On 9/12/23 at 12:03 pm, the Administrator stated Resident #3 often yelled when any cares were being done and it had been reported to her that Resident #3 had been screaming on the shift in question. She stated no allegation of abuse had ever been made. She stated the duties of the EAs or non licensed aides varied based on where in the training process they were, and whether they had been to CNA school yet and had competencies checked off yet. Once competencies are checked off, they can provide patient care side by side with a CNA. On 9/13/23 at 7:27 am, Staff D, Registered Nurse stated she had been one of the other two nurses who was on shift with Staff A and spoke with Staff C on the night in question. She stated Resident #3 was deaf and would whine or yell because she couldn ' t communicate. She stated she was not aware of exactly what happened but knew management had completed an investigation and Staff C was allowed to continue to work but was not to be caring for the residents. She stated Staff C did quit employment but returned at a later time in the position of housekeeping. She stated EAs are supposed to work directly with a CNA, can answer call lights, etc but not do direct care. She stated other CNAs had complained about EA but that EAs were counted on the schedule for staffing for resident care. On 9/13/23 at 10:39 am, Staff G, one of the Assistant Directors of Nursing, stated she was also working that night on another hall. She also stated it was common for Resident #3 to yell during cares, especially if she was not wearing her cochlear implant. She stated she was the third nurse there when Staff A spoke to Staff C. She stated Staff A had concerns about making sure Staff C waited for a Certified Aide to be with him before performing care, and to slow down and not rush Resident #3. On 9/13/23 at 12:27 pm, The Director of Nursing (DON) stated she had received a call during this time period from Staff A. She remembered Staff A was in the hallway and heard Resident #3 yelling out. She entered the room and saw Staff C rolling/repositioning the resident. She also stated it was not at all unusual for Resident #3 to yell and she did it frequently. She stated no allegations of abuse were made but she talked to all staff that were there and she had no concerns. She thought to her memory there was another CNA in the room with Staff C at the time. She stated she had written a report and would provide it. In the undated document titled (Resident Initials) Interviews/investigation provided by the DON, she stated she had spoke to all employees on duty at the time of the incident. This included Staff E, a now former employee. She stated Staff E was in the room with Staff C at the time of the incident. Per her report Staff E stated Staff C was repositioning/rolling Resident #3 when the resident yelled out and Staff A entered the room. The document also stated she spoke with Staff I, CNA who stated she was not present during the incident with Staff C. On 9/14/23 at 8:34 am, Staff E, former employee, stated she worked the morning shift. She stated she did know who Staff C was but she never worked directly with him. She stated she had no knowledge of an incident with Resident #3 and had never been spoken to about it by anyone. On 9/14/23 at 9:18 am, the MDS Coordinator stated she did not have any memory of the incident in question. She stated her normal procedure if such an incident were to occur when she was on call would be to remove the staff person from the room and not allow the staff person to care for the resident until an investigation was done. The Nurses and Aides schedule for February, 2023 reflected Staff A, Staff D, and Staff I all worked the evening of 2/26/23. Staff E was not found to be anywhere on the schedule for the entire month as a CNA. The Environmental Aide schedule for February 2023 reflected Staff C worked the evening of 2/26/23. The Environmental Aide schedule also reflected an employee with the same first name as Staff E listed an an EA, not as a CNA. No last names were documented on the schedule. Review of Staff C's employee file revealed the following: Staff C had a hire date of 11/18/22 Staff C received a bonus wage for working the 10 pm to 6 am shift on 12/20/22, authorized byStaff H, Assistant Director of Nursing (ADON) and the Administrator. Staff C received additional bonus wages for working 2/4/23, 2/5/23 and 3/5/23. Staff C was enrolled to begin CNA class on 1/2/23. Staff C was to test to become certified as a nurse aide on 3/13/23. The Orientation Checklist: Nursing Assistant for Staff C reflected Staff C received orientation for hands on resident care on 12/16/22 and 12/21/22, weeks before beginning any classes. The facility document titled Job Description, Environmental Aide, reviewed 4/2018 documented the Essential Functions of the job. These functions include things such as distributing ice/water to residents, making beds, cleaning equipment, emptying trash, and laundry duties along with multiple other duties. The only direct patient care included in the job description was listed as transporting residents in wheelchairs to meals or activities.

Based on record review, observations, resident and staff interviews and policy review, the facility failed to provide Activity of Daily Living (ADL) care to 3 out of 3 residents reviewe, (Resident #6, #9 and #10). The facility was not providing oral hygiene for residents. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a diagnosis of dementia, heart failure, malnutrition and required the extensive assistance of one staff member to provide personal hygiene. Resident #6 had a Brief Interview for Mental Status (BIMS) of 0 which indicated a severe cognitive impairment. The Care Plan revision date of 4/4/23 for Resident #6 directed staff to assist for all ADL care. The Point of Care (POC) document titled Oral Hygiene dated September 2023 for Resident #6 revealed: 9/11/23 at 1:59 PM completed and 9:59 PM not completed. 9/12/23 at 1:59 PM not completed, 9:59 PM completed. 9/13/23 at 1:59 AM and 9:59 PM not completed. 2. The MDS dated [DATE] for Resident #9 revealed a diagnosis of gastro-esophageal reflus disease, stroke with hemiplegia (paralysis) and required extensive assistance of one staff member for hygiene. Resident #9 ' s BIMS score was 11 which indicated a moderate cognitive impairment. The Care Plan dated revised on 8/2/23 directed staff to assist Resident #9 with all ADL care. The Point of Care (POC) document titled Oral Hygiene dated September 2023 for Resident #9 revealed: 9/11/23 at 1:59 PM not completed, 9:21 PM completed. 9/12/23 at 1:59 PM and 9:27 PM completed. 9/13/23 at 1:59 PM and 9:59 PM not completed. During an observation on 9/13/23 at 1:59 PM Staff O, Certified Nursing Assistant (CNA) and Staff P, CNA completed personal care for Resident #9 but did not offer nor complete oral hygiene. During an interview on 9/14/23 at 1:55 PM Resident #9 stated had not received oral hygiene today. 3. The MDS dated [DATE] for Resident # 10 revealed a diagnosis of Alzheimer ' s disease, aphasia (inability to speak), diabetes mellitus, and required extensive assistance of one staff member for hygiene. The Care Plan dated 8/9/23 for Resident #10 directed staff to assist with personal hygiene. The Point of Care (POC) document titled Oral Hygiene dated September 2023 for Resident #10 revealed: 9/11/23 at 1:59 PM completed, 9:42 PM not completed. 9/12/23 at 8:22 AM not completed and 9:59 PM completed. 9/13/23 at 1:51 PM and 9:59 PM not completed. During an interview on 9/13/23 at 12:41 PM The Director of Nursing (DON) stated the expectation was that the staff would complete oral care twice a day. The policy titled Activities of Daily Living (ADL ' s) dated March 2018 revealed: 1. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems).

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure two of three sampled residents (Resident (R) R21 and R3) respiratory equipment was maintained and stored appropriately. The facility's deficient practices increased the resident's risk of respiratory complications. Findings include: Review of facility-provided undated user manual titled Oxygen Concentrator, revealed .It is an electronically operated device that separates oxygen from room air. It provides high concentration of oxygen directly to you through a nasal cannula .DO NOT operate the concentrator without the filter installed .Remove the filter and clean at least once a week depending on environmental conditions .NOTE: Environmental conditions that may require more frequent cleaning of the filters include but are not limited to: high dust, air pollutants, etc . Review of facility provided policy titled Oxygen Concentrator undated revealed .To provide Oxygen for therapeutic use by utilizing a concentrator that concerts ambient air to a higher concentration level of oxygen. It is commonly used to provide oxygen therapy .Precautions and Hazards DO NOT operate the oxygen concentrator without a filter or with a dirty filter .Verify and understand the physician's order .Know the flow rate and duration of use Check the inlet filter pad and ensure that it is in place and clean .Adjust the flow meter control knob and set the flow setting prescribed by the physician .Daily Maintenance Check the water level in the humidity bottle. Change the bottle as needed .Clean the air inlet filter PRN [as needed] and weekly . 1. Review of R21's undated Admission Record located in the resident's Electronic Medical Record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) and chronic kidney disease. Review of R21's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22 and located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Continued review of the MDS revealed R21 was provided oxygen treatment. Review of R21 's Physician's Orders located in the resident's EMR under the Orders revealed no order to clean R21's oxygen concentrator internal or external filters. Review of R21's Medication Administration Record (MAR) and Treatment Administration Record (TAR) under the Orders tab located in her EMR revealed no order to clean R21's oxygen concentrator internal or external filters. Review of R 21's comprehensive Care Plan under Care Plan tab located in her EMR revealed no intervention to maintain R21's oxygen filters internal or external including cleaning. During an observation and interview on 01/16/23 at 9:55 AM, R21 confirmed she was administered oxygen therapy continuous. R21 had oxygen administered via nasal cannula. R21's oxygen water bottle was empty without a date change on it. R21 stated she had not had the staff fill the water bottle lately. R21's oxygen concentrator filters on both lateral sides were unclean and covered with dust (color was grey). Additionally, R21's nebulizer oxygen mouthpiece was not stored in a bag. R21 confirmed she self-administered her breathing treatment every six hours. During an observation on 01/17/23 at 3:05 PM, R21 was sitting on her bed in her room with oxygen administered via nasal cannula. R21's oxygen concentrator's external filter (on the lateral sides of her oxygen concentrator) were unclean and covered with dust particles. During an observation on 01/18/23 at 9:57 AM, of R21's oxygen equipment with Registered Nurse (RN) 2, RN 2 confirmed R21's oxygen concentrator filters (on both lateral sides) were unclean and covered in dust particles. RN2 confirmed R21's internal oxygen concentrator filter was undated (with date of change), unclean, and had dust particles on it. RN2 confirmed R21's oxygen nebulizer mouthpiece was not stored in a bag and should be. During an observation on 01/18/23 at 10:14 AM of R 21's oxygen concentrator in her room with the Director of Nursing (DON) and the Corporate Lead Registered Nurse (CLRN) the CLRN confirmed R21's oxygen concentrator filters on both lateral sides were unclean and covered in dust particles. The CLRN confirmed R21's internal oxygen concentrator filter was undated (with date of change), unclean with dust particles on it. The DON confirmed R21's nebulizer mouthpiece was not stored in a bag and should be. The DON stated R21 self-administered her nebulizer treatments; however, she was unsure if R21 was provided education of care of oxygen and nebulizer mouthpiece including storage of the equipment. The DON confirmed unclean internal and external oxygen concentrator filters increased R21's risk of respiratory infections and oxygen equipment failure. During an interview 01/18/23 at 10:07 AM the DON, the Administrator and CLRN confirmed the facility oxygen concentrator services/maintenance was provided by an outside vendor. The DON confirmed she was unsure how often the company provided the services and what services/maintenance was provided. The DON confirmed she was responsible for ensuring the company provided oxygen concentrator services/maintenance. During an interview on 01/19/23 at 10:43 AM, the DON confirmed she expected the nursing staff to clean the resident's oxygen concentrator external filters and the orders should be included on resident's physician's orders and the resident's care plan interventions. The DON confirmed she expected the oxygen concentrator's supply company to maintain the oxygen concentrator's internal filter every six months. The DON confirmed it was her responsibility to ensure the supply company performed maintenance of the resident's oxygen concentrators. 2. Review of R3's undated Admission Record located in his Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disorder (COPD) and pneumonia. Review of R3's quarterly Minimum Data Set (MDS) with an ARD of 10/20/22 and located in his EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was cognitively intact. Continued review of the MDS revealed he was administered oxygen therapy. Review of R3's Physician's Orders dated 01/2023 under Orders tab located in the EMR revealed no order to clean R3's oxygen concentrator internal or external filters. Review of R3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 01/2023 under the Orders tab located in the EMR revealed no order to clean R3's oxygen concentrator internal or external filters. Review of R3 's comprehensive Care Plan under Care Plan tab located in the EMR revealed no intervention to maintain R3's oxygen filters internal or external including cleaning. During an observation/interview on 01/16/23 at 1:13 PM, R3 confirmed he was administered oxygen therapy by the facility. R3's oxygen nebulizer mask was on his nightstand, not in a bag and without a label of date of change. R3's oxygen concentrator vent cover on the back was covered in dust and unclean. R3's oxygen water bottle was empty without date of change. R3 stated he used his oxygen at night and his nebulizer machine several times a day. During an observation on 01/17/23 at 1:47 PM R3's oxygen concentrator's external filter vent cover was unclean and covered in dust. During an observation and interview on 01/18/23 at 9:25 AM, R3 stated the facility staff finally changed his oxygen water bottle but had not cleaned the dust off his oxygen concentrator back vent cover. R3 confirmed the vent cover was dirty and covered with dust. During an observation and interview on 01/18/23 at 9:55 AM with RN2 of R3's oxygen concentrator, RN2 confirmed R3's oxygen concentrator vent cover on the back of his machine was unclean and covered in dust. RN2 also confirmed R3's internal filter was unclean, covered in dust with date of change of 08/21[08/2021]. During an observation and interview on 01/18/23 at 10:11 AM with the DON and CLRN of R3's oxygen concentrator's vent cover on the back of his machine revealed the CLRN removed the internal filter cover and confirmed R3's internal filter was unclean, covered in dust and dated 08/2021. The DON confirmed R3's oxygen nebulizer mask was not stored in a bag and should be stored in a bag. The DON stated she was unsure if R3 was educated regarding storage of his oxygen equipment tubing. The DON confirmed R3 should be educated regarding his oxygen equipment tubing maintenance, including storing his oxygen nebulizer mask in a bag.

Based on interviews, record review, and facility policy review, the facility failed to ensure nursing staff were competent with knowledge and skills to provide treatment/care for two residents (Resident (R) R21 and R26) out of two sampled residents with nephrostomy tubes [A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects]. The facility's deficient practice placed R21 and R26 at an increased risk for nephrostomy tubes complications. Findings include: Review of facility-provided policy titled Competency of Nursing Staff, date 05/2019, revealed .All nursing staff must meet the specific competency requirements . licensed nurses and nursing assistants employed (or contracted) by the facility will participate a facility-specific, competency-based staff development and training program .demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .The staff development and training program is created by the nursing leadership .Specialized skills or training needed based on the resident population . Review of facility-provided policy titled Nephrostomy Tube, Care of, dated 10/2010, revealed .The purpose of this procedure is to provide guideline for the care of the residents with nephrostomy tube .Assess the resident for indications of bleeding in the insertion site every .8 hours till area healed .Check placement of the tubing and integrity of the tape during assessments .If the tubing is dislodged, cover stoma with sterile 4x4 and notify the Attending Physician immediately .Empty drainage bag once per shift as needed. Measure output .Change dressing every 1-3 days .Use sterile technique during dressing changes .Report any of the following signs or symptoms to the physician .Redness, inflammation, reports of pain, or other signs of infection at the insertion site, Reduced output or output below established parameters .Inability to irrigate tube or signs of obstruction of the tube .Signs of skin breakdown around the dressing site .If the tube becomes dislodged . 1. Review of R21's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with diagnoses which included urinary tract infections, hydronephrosis [swelling of a kidney due to build-up of urine] and chronic kidney disease Review of R 21's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/ 22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Continued review of the MDS revealed R21 was assessed to have an indwelling catheter. Review of R21's Physician's Orders dated 01/23, located in the EMR under the Orders tab revealed .Change dressing to nephrostomy tubes weekly and PRN every day shift every Mon .10/17/2022 . Further review of the order revealed no order to monitor nephrostomy tube output or observe for complications of nephrostomy tubes. Review of R21's Medication Administration Record (MAR) and Treatment Administration Record (TAR) under Orders tab located in the EMR revealed .Change dressing to nephrostomy tubes weekly and PRN every day shift every Mon .10/17/2022 . Continued review of the MAR and TAR revealed for the entry 01/02/23 was blank and without staff initials indicating procedure was not performed and R21 did not have an order to monitor nephrostomy collection tube drainage or assess for nephrostomy tube complications. Review of R21's comprehensive Care Plan under Care Plan tab located in the resident's EMR revealed . Follow physician orders for nephrostomy tubes Date Initiated: 10/14/2022 .Revision on: 10/19/2022 . without interventions for assessing form nephrostomy tube complications. During an observation and interview on 01/16/23 at 9:59 AM, R21 confirmed she had two nephrostomy tubes on her right and left lower back. During an observation on 01/18/23 at 11:34 PM, R21 was sitting on the side of her bed with her feet on the floor. R21 pulled her blouse up partially and exposed her dressings to her right and left lower back without dates and covering insertion sites. Blue sutures were intact and noted around both tubes. R21 pulled her pants down partially and exposed her drainage bags to her upper legs. R21's tubing had leg straps above and below the drainage bags. R21 collection bags had scant/small amount of yellow liquid. During an interview on 01/18/23 at 12:01 PM, Certified Nursing Assistant (CNA) 3 confirmed she was employed at the facility since 10/2022. CNA3 confirmed she did not know what a nephrostomy tube was. CNA3 stated the facility had not provided her with training for residents with nephrostomy tubes complications, management, or care. CNA3 confirmed she was assigned to provide care for both residents with nephrostomy tubes. CNA3 stated the facility should have provided her with training for residents with nephrostomy tubes. CNA3 stated she would report to nurse if resident's nephrostomy tube fell out. During an interview on 01/18/23 at 1:22 PM, Registered Nurse (RN) 1 confirmed she was an agency employee and had worked for the facility for two weeks. RN1 confirmed she had provided care for R21 and had every time she was scheduled to work at the facility. RN1 confirmed R21 had nephrostomy tubes. RN1 stated she just monitored R21's tubes for signs or symptoms of infection. RN1 stated she was not responsible for emptying R21's collection drainage bags or monitoring the output. RN1 stated she was not responsible for changing R21's insertion site dressings. RN1 stated R21's dislodgement of her nephrostomy tubes was considered an emergency. RN1 stated she had not had experience with nephrostomy tubes in two years. RN1 confirmed she was not aware of which organ nephrostomy tubes were inserted in to. RN1 confirmed nephrostomy tubes were considered specialized care. RN1 stated the facility should have provided education and competency for nephrostomy tubes and did not. RN1 confirmed she provided care for R26 at times, and he had nephrostomy tubes. During an interview on 01/18/23 at 1:58 PM, Licensed Practical Nurse (LPN) 1 stated she was unsure why R21 had nephrostomy tubes, but she had something wrong with her kidneys. LPN1 stated complications of nephrostomy tubes were plugged tube, dislodged tubes, infection of the kidney. LPN1 confirmed complications of nephrostomy tubes could be considered life threating. LPN1 stated the dislodgement of nephrostomy tubes was not considered a life threating emergency. LPN1 stated the facility had not provided her nephrostomy tube training or checked her skills or knowledge for caring for a resident with nephrostomy tubes and should have. LPN1 confirmed she had provided care for R21 and R26 at times including changing his dressing around their nephrostomy tubes. LPN1 confirmed both residents had monthly appointments to have their nephrostomy tubes replaced. LPN1 confirmed R21 was sent to have her tubes replaced twice in the month of December because one of her nephrostomy tubes was blocked and she reported no output. During an interview on 01/18/23 at 3:13 PM, the Director of Nursing confirmed the DON and ADON were responsible for providing education to the clinical staff including RNs, LPNs, CMAs [Certified Medical Assistant] and CNAs. The DON confirmed she had not provided any skills check list competency training for the facility clinical staff including for caring for residents with nephrostomy tubes or ensured the staff were knowledgeable and competent to provide care for residents with nephrostomy tubes and should have. The DON confirmed the facility had not provided clinical staff or auxiliary staff with nephrostomy tube training or ensured the nurses were competent with care for nephrostomy tubes and should have provided to the staff. The DON confirmed she was unsure why the facility had not provided training or ensured staff were competent in the past year for nephrostomy tubes. The DON confirmed complications of nephrostomy tubes were infection, it was direct access to the kidney so bleeding, dislodgement of the tube and complications could be life threating. The DON confirmed management of resident's nephrostomy tube complications should be included on resident's care plan and physician's orders when to monitor how to monitor and what to report, signs and symptoms of infection and complications. The DON confirmed that the facility nurses should place a 4x4 (gauze) over insertion site and call the physician immediately if the resident's nephrostomy tube became dislodged. The DON confirmed the nursing staff should inform the physician if residents with nephrostomy sutures were broken. The DON confirmed all staff, including direct care and housekeeping, should be educated on care and emergency management of nephrostomy tubes. During an interview on 01/19/23 at 12:37 PM, the Nurse Practitioner (NP) confirmed she expected the facility to ensure the staff were competent with skills and knowledge to provide care for residents with nephrostomy tubes and were trained. 2. Review of R26's facility provided Face Sheet revealed R26 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, stage four. Review of R26's Physician's Orders, located in the resident's EMR under the Orders tab revealed . Do progress note on skin around urostomy [terminology incorrect] sites and dressings . No other directives regarding R26's nephrostomy care was noted. Review of R26's Care Plan located in the resident's EMR under the Care Plan tab revealed a Comprehensive Care Plan dated 11/15/22 that included I have renal insufficiency related to kidney disease, stage 4 chronic kidney disease. I have bilateral nephrostomy tubes that I do drain myself and sometimes do not wait for staff to drain and get accurate measurement. During an interview/observation with R26 on 01/17/23 at 3:32 PM revealed R26's nephrostomy tubes draining into bags on his left and right calves. During an interview on 01/18/23 at 1:22 PM, Registered Nurse (RN) 1 confirmed she was an agency employee and had worked for the facility for two weeks. RN1 confirmed she had provided care for R21 and had every time she was scheduled to work at the facility. RN1 confirmed R21 had nephrostomy tubes. RN1 stated she just monitored R21's tubes for signs or symptoms of infection. RN1 stated she was not responsible for emptying R21's collection drainage bags or monitoring the output. RN1 stated she was not responsible for changing R21's insertion site dressings. RN1 stated R21's dislodgement of her nephrostomy tubes was considered an emergency. RN1 stated she had not had experience with nephrostomy tubes in two years. RN1 confirmed she was not aware of which organ nephrostomy tubes were inserted in to. RN1 confirmed nephrostomy tubes were considered specialized care. RN1 stated the facility should have provided education and competency for nephrostomy tubes and did not. RN1 confirmed she provided care for R26 at times also, and he had nephrostomy tubes.

Based on staff interview, clinical record review, and facility policy review, the facility failed to prevent the development and worsening of a facility acquired pressure ulcer which required transfer to the hospital for fever, wound check, and excisional debridement of an unstageable pressure ulcer down to the ischial tuberosity for 1 of 4 residents reviewed (Resident #36) for pressure ulcers. The failures resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented the resident scored 11 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had moderately cognitive impairments. Resident #36 required the extensive assistance of two staff for bed mobility and transfer, and did not have a pressure ulcer/injury, scar over bony prominence, or non-removable dressing/device. The MDS assessment documented the resident was at risk for developing pressure ulcers/injuries, and did NOT have one or more unhealed pressure ulcers. The clinical record for Resident #36 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 10/29/21 revised 11/12/21 documented, I am at risk for pressure ulcers I have stage 3 to right buttock. Interventions per the Care Plan included the following: a) Initiated 10/29/21, I have a cushion on my wheelchair. b) Initiated 11/2/21, I have a pressure relieving mattress to my bed. c) Initiated 10/29/21, I need weekly skin evaluation weekly with bath/shower. d) Initiated 10/29/21, Lay down between meals and offload pressure to buttocks. e) Initiated 10/29/21, Resolved 11/2/21, Reposition me every (FREQUENCY). f) Initiated 10/29/21, Teach me the risk factors for development of pressure ulcers. g) Initiated 10/29/21, Use my pillows or other supportive/protective devices to assist with positioning. Review of the Braden Scale for Predicting Pressure Sore Risk dated 8/12/21 and 10/26/21 identified Resident #36 at moderate risk. Resident #36 scored 13 on both assessments. The Task Documentation for RN/LPN Documentation-Weekly Skin Check on Tues, 2-10 revealed frequency had been scheduled as necessary. Review of 30 day look back documentation for the task revealed documentation present for dates of 10/19/21 and 11/9/21. Documentation for 10/19/21 documented the resident had no new skin injuries. It was noted the resident had left the facility to the hospital prior to 11/9/21. The Task Documentation for Check the residents skin and notify a nurse of any new injuries/skin conditions was reviewed for a thirty day look back period. Per the question, does the resident have any new skin injuries, the following, in part, had been documented: On 10/18/21 at 1:59PM and 8:28PM, it had been documented Resident#36 had an open area and a red area present. Task documentation for 1:59PM and 8:28PM revealed the identified areas as new skin injuries. The Progress Note on 10/18/21 did not address an open area. Documentation on 10/19/20, 10/20/21, 10/21/21, 10/22/21, 10/23/21, 10/24/21, 10/25/21, 10/26/21, 10/27/21, and 10/28/21 did not identify Resident #36 had an open area. Documentation on 10/28/21 at 1:59PM, identified Resident #36 had an open area, which had been identified as not new. Task documentation for the same date at 8:19 PM did not identify an open area, however did note the presence of an abrasion and a discoloration. Physician Notes for Resident #36 were requested and provided by the facility. The most recent note provided dated 10/7/21 by Staff H (Nurse Practitioner) (NP), documented the resident had been seen for diabetes mellitus type 2, hypertension, [CONDITION(S)], and [CONDITION(S)]. The physical exam dated 10/7/21 at 8:28AM revealed the following skin assessment: Normal Temp, Skin Moist, No Unusual Rashes or [CONDITION(S)]. The Skin & Wound Evaluation V5.0 assessment dated [DATE] authored by Staff A (Licensed Practical Nurse) documented an open lesion which was in-house acquired. Measurements were not present in the progress note, and it had been documented it was unknown how long the wound had been present. It was documented 70% of wound was filled with eschar (dead or devitalized tissue). The evidence of infection section of the assessment documented increased pain and redness/inflammation. Under this area of the assessment it was documented, other: pink or red. The wound did not have exudate or odor after cleansing per the assessment, and it had been documented the edges were non-attached: Edge appears as a cliff. Surrounding tissue was documented as black/blue discoloration, [CONDITION(S)], and fragile. This had been documented as a new area. The Progress Note dated 10/30/21 at 5:59AM authored by Staff F (Registered Nurse) documented, in part, Dressing remains in place to left buttock. Resident has been turned from side to side to keep him off his back. Review of the Treatment Administration Record (TAR) for October 2021 did not reveal documentation of treatment to the wound. The SPN-Focused Evaluation Note dated 11/1/21 at 5:52AM and 11/2/21 at 5:39AM, both authored by Staff F noted the presence of a dressing that was dry and intact to the left buttock. The SPN-Focused Evaluation dated 11/2/21 at 1:30PM documented, dressing changed this am. The SPN-Focused Evaluation Note dated 11/3/21 at 5:37AM authored by Staff F documented, Resident has open draining area on buttocks. Area cleaned and new dressing placed. He has been repositioned q (every) 2-3 hours and kept off his back while in bed. He does c/o (complain of) pain to area when dressing change done. The Skin & Wound Evaluation V5.0 assessment dated [DATE] at 6:39PM revealed the resident had an in-house acquired Stage 3 (full thickness skin loss) Pressure Wound. The note documented it was unknown how long the wound had been present. Measurements documented an area of 0.5 cm2, 0.5cm (centimeters) Length, and 0.9 cm width. Depth, undermining, and tunneling had been documented as not applicable. Wound bed description documented 40% of wound was filled with slough. Exudate was light and serosanguineous, and no odor was noted after cleansing. Surrounding tissue was documented as fragile, and no induration or [CONDITION(S)] were present. Per the treatment section of the form dressing appearance had been documented as missing, and cleansing solution documented generic wound cleanser. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The SPN-Focused Evaluation Note dated 11/5/21 at 5:27AM authored by Staff F (Registered Nurse) documented, Resident dressing on buttock replaced this shift d/t (due to) soiling. Wound with yellow brown eschar at bottom. The SPN-Focused Evaluation Note dated 11/7/21 at 11:34AM authored by Staff G (Licensed Practical Nurse) documented, Dressing changed per order, large amount of yellow/brown drainage noted on old dressing. odor noted. Resident tolerated well, did report has discomfort at times. Encouraged to stay out of w/c (wheelchair) and keep pressure off area. Resident cooperative thus far. The Nurses Note dated 11/7/21 at 11:44AM authored by Staff G Licensed Practical Nurse) documented he/she had to change dressing again at this time as its not staying on with incontinence of bowel and bladder. The Nurses Note dated 11/7/21 at 2:36PM by Staff G (Licensed Practical Nurse) documented, Certified Medication Aide called Staff G down to resident's room and resident with temp of 100.7. Nurse [Staff A] called PCP (primary care provider) to see what they want done d/t (due to) wound and possible infection. The Nurses Note dated 11/7/21 at 5:16PM authored by Staff A (Licensed Practical Nurse) documented, Certified Medication Aide notified nurses of temp 100.8. Staff A called on call physician for possible antibiotic prescription. On call provider prescribed [MEDICATION(S)] 100 milligrams (mg) two times a day. Previous nurse changed resident's buttock ulcer dressing at 11am this morning, upon inspection from Staff A after phone call with provider, recognized the dressing saturated with green/dark brown purulent drainage and had a foul odor present. Necrotic skin falling out of ulcer. VS (vital signs) taken, HR (heart rate) sitting at 98 while res laying down, resting-close to [CONDITION(S)] usual baseline. With the heightened temp and heart rate, decision to send this resident to emergency room (ER) for stronger antibiotics and debridement, along with checking labs for infection. Responsible Party notified of all actions taken and met resident at ER. The Emergency Department Provider Note from the hospital dated 11/7/21 date of service time 5:22PM the chief complaint documented the resident presented with wound check and fever. It was documented, wheeled over from the nursing home for a worsening pressure ulcer. The nurse at the nursing home noted the first time they noticed the pressure ulcer on Sunday of last week. The nurse who saw him today at the nursing home stated she last saw it on Tuesday and it is much worse now. Patient notes he has had pain on his bottom. He has started to run a fever today. He was started on [MEDICATION(S)] today, for possible infection. The skin section of the documented noted referred to a photo of the sacral pressure ulcer, and documented it was unstageable (inability to see the wound bed), had eschar present, and surrounding tissue was reddened and warm to touch. The Hospitalist Progress Note date of service 11/8/21 at 7:42AM documented, in part, Patient and his wife are very concerned about the rapid breakdown of the sacral ulcer. I explained to him that this did not happen rapidly that it has actually been there for a while it is just that it started getting attention and therefore was noted more. I discussed with him about surgical debridement and they were in agreement and therefore I consulted Dr. [Name Redacted] who was able to do surgery today. When I examined [Resident Name] I found multiple pressure ulcers on his left foot/toes as well. The Op note for wound care for date of service 11/8/21 at 1:02PM documented, in part, the patient was taken to the operative suite and placed in the left lateral decubitus position .the area surrounding the pressure ulcer on the left ischial tuberosity was prepped and draped in the sterile sterile manner .The wound was explored. A culture and sensitivity was obtained. There was a cavity measuring approximately 4 x 4 x 6 cm going down to the ischial tuberosity. There was a fair amount of gray necrotic tissue. Using scissors and Russian forceps, the necrotic tissue was denuded back to bleeding healthy tissue. The size of the wound after debridement was approximately 6 x 6 x 6cm. The Hospitalist Progress Note date of service 11/9/21 at 10:57AM documented the principal problem as pressure ulcer of sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon or muscle). The plan section of the note documented, in part, Continue IV (intravenous) antibiotics. We will place a wound VAC (vacuum assisted closure) when it becomes available today. Anticipate patient to be needing antibiotics and continued treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/21 at 2:44PM, Staff I (Certified Nursing Assistant), queried about documentation for skin. Staff I acknowledged there was a way to document in the electronic health record. Per Staff I, the facility used to have a stop and watch process that would be signed by the nurse and forwarded to the DON and Minimum Data Set (MDS), however this process was no longer used at the facility. Staff I explained they could document whether any skin issues were present, and the secondary part of this would be whether the issue was new. Staff I was queried about the process when an area was found and explained she would talk to the nurse. When queried how they would determine whether an area was new or not, Staff I explained as a Medication Aide she had access to the Treatment Administration Record (TAR), however as a Nurse Aide she would not have access to the TAR. On 11/16/21 at 8:05 AM, Staff H (Nurse Practitioner), queried about Resident #36. Staff H explained they had worked with the facility since April, and had seen the resident as his provider. Staff H was queried if they had seen the resident in October or November and explained they had last seen the resident October 7. Staff H acknowledged this had been the last time they had seen Resident #36. Per Staff H, residents were seen once a month minimum unless something else was going on, and the resident did not have anything else going on per nursing staff. Staff H explained she had been on vacation for the first week of November and did not get a chance to examine the resident's wound. On 11/16/21 at 10:09 AM, Staff J (Certified Nurse Aide/Medication Aide) queried about Resident #36's wounds, and explained the resident had one where the resident's leg met the resident's butt cheek. Staff J was not able to recall the side of the body where the wound was present. Staff J was queried when they had seen the wound, and explained they had helped nurses with treatment a few times. Staff J acknowledged she had not been the first person to see the resident's wound. Staff J was queried as to the process when a wound was found, explained they put documentation in on their electronic device as to type of wound and if the area was new. The nurse would be notified. If there was no skin injury that would also be documented. Staff J explained this documentation occurred every shift. On 11/16/21 at 12:26 PM, Staff F (Registered Nurse) queried about wounds for Resident #36. Staff F explained she was aware the resident had a red area that turned into an open area on the left buttocks. Staff F was queried about progression of the wound and responded she would have to look at her notes to be able to answer the question. Staff F was queried if treatment orders were in place, and Staff F responded she believed there were. Staff F was queried when she would notify a physician about a wound, and responded this would occur anytime when she thought what was being done was not effective or if something was worsening. On 11/16/21 at 1:59PM, Staff A (Licensed Practical Nurse) queried about Resident #36's wound. Staff A explained there had been a Nurse Aide who had been changing the resident who had requested the nurse to look at a spot on the resident's bottom. Staff A explained before she would look at the skin she would review the resident's chart, and there had been nothing in the chart that referenced the area. Per Staff A, they grabbed the ipad and went to evaluate, and the resident had a stage 2 or stage 3 pressure ulcer present to the left buttock under the butt cheek area. Staff A explained she did the wound evaluation, picture, measured and had put him under the hot charting communication. Staff A explained she placed a bandage on the wound and initialed and dated the bandage, and when she returned to the facility on Tuesday the resident had the same bandage with the initials and date from Sunday. Per Staff A, the following Sunday she worked and the resident had an elevated temperature. Staff A explained she had not looked at the ulcer since the prior Tuesday, and immediately called the on-call physician. Per Staff A they called the on-call, explained what was going on, and had contacted the Responsible Party about starting antibiotics. Staff A explained she could smell the area as soon as she entered the room, and the previous nurse told Staff A the bandage saturated twice between 6:00AM and 2:00PM. Per Staff A, she looked at the area and it was completely saturated, with a green/brown bandage with necrotic tissue coming out of it. Staff A described the area as a deep hole, and explained she had told the resident she was sending him to the hospital. Staff A queried who she had told about the resident's dressing that had not been changed, and explained she had notified the DON. Staff A queried about treatment orders for Resident 36, and explained she had filled out a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per Staff A, this information was placed in Staff H's (Nurse Practitioner) folder. On 11/16/21 at 1:35 PM, the Director of Nurses (DON) queried who had initially found Resident #36's buttocks wound and explained Staff A had found it on Sunday. The DON explained she had been on vacation when this had occurred. The DON explained the facility did not have a wound care nurse and other persons had been coming over to assist. The DON explained skin assessments should occur twice a week and PRN (as needed). The skin assessment documentation in the task section for Resident #36 which was scheduled as necessary was reviewed with the DON, and the DON explained this must have been a click error. The DON was asked about an initial treatment order, and explained the facility had a protocol to initiate an immediate treatment until assessment findings could be given to the doctor for the initial physician order. The DON was queried how long it should take to obtain the initial order, explained it should be immediate, and further explained there was always an on-call doctor so that something could be put into place. The DON was queried if a Nurse Practitioner (NP) or physician had seen the resident's wound and acknowledged this had not occurred. The DON explained she had been on call the weekend the resident's wound worsened, and Staff A had reached out to her. The DON was queried if she had seen the resident's wound after 11/3/21, and said she did not believe she had seen it after the Wednesday. On 11/16/21 at 3:03 PM, Staff G (Licensed Practical Nurse) who had documented on the resident's wound late morning and early afternoon of 11/7/21, was queried about Resident #36's wound. Staff G explained it had been reported in report that a wound had been found. Staff G explained she had gone in to change the dressing and had done so twice. Staff G explained it had been pretty bad. Per Staff G, the resident initially had not had a temperature, however when the medication aide did the 2-10 temperatures the resident did have a temperature. Staff G explained Staff A had called the provider. Staff G was queried if the wound had been draining when she saw it, and explained that's why they had to change it as it was so saturated. Staff G was queried if she had notified the doctor, and acknowledged she had not done so as there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/21 at 10:25 AM, the DON acknowledged they were not able to locate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/21 at 11:53 AM, Staff B (Licensed Practical Nurse) queried about wounds for Resident #36. Per Staff B, they didn't know the resident had the wound to the bottom until the night nurse worked and the nurse (identified by Staff B as Staff A) and aide had done rounds. Per Staff B, this is when the wound had been discovered. Per Staff B the resident had had a stroke and was unable to move around in his chair. When queried if she had heard anything about the resident having a wound prior to this, Staff B shook her head. Staff B explained she had asked for more aggressive treatment to the resident's wound as previously a [MEDICATION(S)] was placed over it. When Staff B saw the wound she noticed it had started to tunnel. Staff B explained this was her first time seeing it, and explained the date of the order for Santyl (identified as 11/3/21 per physician order), was when she had seen it. Staff B explained she had reached out to the on-call Nurse Practitioner for the treatment order. Review of a document provided by the DON on 11/17/21, dated 10/29/21, and locked 11/14/21 documented the following: Incident Description Nursing Description: Nurse Aide changed the resident and noticed he had an open area on his left buttock. Nurse Aide called this nurse in to assess the area. Nurse identified stage 3 pressure ulcer on left buttock. Dressed with foam [MEDICATION(S)]. The Resident Description section documented, Nurse Aide asked resident if buttock area hurt, he stated yes that's why I don't like to stay in my chair for very long. The description of action taken section documented, dressed wound with foam [MEDICATION(S)], risk management, wound evaluation, family and physician notified. Resident to lay down between meals to offload pressure to bottom. Responsible Party agrees. Review of the Wound Care Protocols dated 1/15 documented The Prevention of Pressure Ulcers guidelines documented to report all areas of concern to a Charge Nurse for evaluation and follow-up .DOCUMENTATION to include: 1. Preventative measures used, 2. Any change noted in skin integrity, 3. Resident/family education and notification, and 4. Physician involvement. The State Agency informed the facility of the Immediate Jeopardy on November 17, 2021 at 2:30 p.m. The Facility removed the Immediate Jeopardy on November 17, 2021 by implementing the following actions: a. Conducted education for all licensed staff regarding the assessment, staging, notification to the physician and implementing timely treatments. b. Completed a head to toe assessment of all residents to identify skin alterations. Residents with identified wounds assessed for stage and appropriate treatment. c. Conducted education for Direct Care Staff regarding documentation during weekly bath task. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on record review and interview, the facility failed to provide timely assessments and intervention when residents had blood glucose levels outside of normal parameters, failed to administer insulin according to the manufacturers recommendations, and failed to recheck a blood glucose level when requested for 2 of 4 sampled. Resident #1 requested to have her blood glucose rechecked and the Nurse declined. The staff later found Resident #1 unresponsive with a blood glucose level of 30 and administered two doses of [MEDICATION NAME] prior to transferring to the Emergency Department. The facility reported a census of 41. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED].#1 required setup assistance for eating and extensive assistance of 2 staff for bed mobility, transfers, walking, dressing, toilet use, personal hygiene, and bathing. Resident #1 had a Brief Interview for Mental Status score as 13 indicating intact cognition. The Care plan entry dated 5/22/20 revealed Resident #1 had diabetes and directed staff to administer insulin medications as ordered, monitor blood glucose as ordered, and monitor for side effects such as low blood sugar, headache, weakness, sweating, and [MEDICAL CONDITION]. According to the American Diabetes Association@ www.diabetes.org a normal blood glucose ranged from 80 to 130 milligrams (mg)/deciliter (dl). Review of the Weights and Vitals Summary from June 23, 2020 to July 20, 2020, Resident #1 had the following blood glucose readings below 60 mg/dl and exceeding 350 mg/dl: a. On 6/25/20, 347 mg/dl. b. On 6/27/20, 12 mg/dl. c. On 6/28/20, 353 mg/dl. d. On 6/30/20 at 4:45 a.m., 51 mg/dl. e. On 6/30/20 at 7:53 a.m., 481 mg/dl. f. On 7/1/20, 384 mg/dl. g. On 7/2/20 at 8:32 a.m., 52 mg/dl. h. On 7/2/20 at 12:41 p.m., 404 mg/dl. i. On 7/4/20, 50 mg/dl. j. On 7/9/20, 54 mg/dl. Review of the Clinincal Record revealed a lack of Physician notification and assessments and intervention for the above abnormal blood glucose levels. A physician's orders [REDACTED]. The Clinical Record lacked documentation of a food diary every shift for 7 days and lacked documentation submitted to the Physician for review on 7/1/20. A Progress Noted dated 7/13/20 1:35 p.m., revealed the resident's blood sugar was 343 mg/dl. The facility obtained an order for [REDACTED]. A Weights and Vitals summary 7/13/20 at 2:43 p.m., documented Resident #1 had a blood glucose level of 109 mg/dl. On 7/13/20 at 4:28 p.m., Resident #1 had a reading of 102 mg/dl. The Medication Administration Audit Report dated 7/13/20 at 4:33 p.m. revealed Resident #1 received [MEDICATION NAME] per sliding scale. The July 2020 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A facility meal intake record indicated on 7/13/20, the resident ate 76-100% of breakfast and refused lunch. The record stated not applicable for the supper entry. The Progress Note dated 7/13/20 6:32 p.m. revealed a Nurse Aide summoned the Nurse to Resident #1's room due to Resident #1 slouched forward in her recliner, unresponsive, and diaphoretic (sweating profusely). The Staff checked Resident #1's blood glucose level and obtained a reading of 30 mg/dl. The Staff administered and injection of [MEDICATION NAME] (medication to raise blood glucose) and informed the physician. The Physician directed staff to administer another dose of [MEDICATION NAME] if the resident did not respond. The Progress Note dated 7/13/20 6:40 p.m., documented the Nurse administered a second dose of [MEDICATION NAME] due a blood glucose reading of 48 mg/dl. The Progress Notes dated 7/13/20 7:42 p.m., revealed Resident #1 transferred to the Emergency Department. The Emergency Department report dated 7/13/20 revealed Resident #1 had a blood glucose reading in the 400 mg/dl range at lunchtime and the physician ordered of 10 units of regular insulin and to recheck the reading. The facility called the Physician at 6:32 p.m. and stated the resident was unresponsive and had a blood glucose reading of 30 mg/dl. The Physician ordered [MEDICATION NAME] and Resident #1 did not respond well. The resident transferred to the Emergency Department unresponsive but aroused when her blood glucose level raised. In the emergency room , the resident's blood sugar was 101 mg/dl. The report stated that the resident did not eat any food for lunch or dinner and stated a facility CNA asked the resident's nurse to check the resident's blood sugar but she did not and went on break instead. Resident #1 transferred from the Emergency Department to another hospital for further cardiac workup. A handwritten statement dated 7/13/20 composed by Staff C (Registered Nurse) documented Staff B (Nurse Aide) informed Staff C that she asked Staff A (Registered Nurse) to check Resident #1's blood glucose level twice prior to finding Resident #1unresponsive. Staff A sat at the Nurses Station eating and stated she was too busy. The facility lacked documentation of an investigation carried out related to the concern submitted by Staff C. The [MEDICATION NAME] Patient Information sheet provided by the facility on 8/26/20, stated [MEDICATION NAME] acted fast and a meal should eaten within 5-10 minutes after injection. The Blood Glucose Monitoring policy dated January 2015 directed staff to notify the physician for blood glucose levels below 60 mg/dl or above 200 mg/dl. The Diabetic Management of Hypo/[MEDICAL CONDITION] policy dated January 2015 instructed the facility to establish blood glucose parameters with the physician including at what level to treat and when to notify in order to identify serious complications. The Grievance/Concern Investigations policy dated June 2019 stated investigation forms were intended to assist in making concerns known in order to take action and follow up. During an interview on 8/25/20 at 9:12 a.m., the Dietary Manager stated the evening meal was at 5:00 p.m. and this would be the earliest they would serve. During an interview on 8/25/20 at 7:54 a.m., Staff E (Licensed Practical Nurse) stated she worked the day shift on 7/13/20 and the resident's blood sugar was high. She stated the physician gave an order to give her a dose of insulin. She didn't remember the specifics but she was to give a lower dose of insulin if the resident did not eat lunch. The resident did not end up eating so Staff E gave her the lower dose. Staff E stated when she administered insulin, she tried to make sure the resident ate within 15-20 minutes. She stated she informed the evening nurse coming on shift that the resident's blood sugar was high and she did not eat. She stated the evening meal began at 5:00 p.m. and would not be earlier than this. During an interview on 8/24/20 at 3:51 p.m., Staff B (Nurse Aide) stated on 7/13/20 4:20 p.m. or 4:30 p.m. Resident #1 put her call light on and told Staff B she wasn't feeling very well. Staff B thought the resident's blood glucose level was low and reported this to Staff A (Registered Nurse). Staff B then assisted other residents. At 5:00 p.m., she took Resident #1's dinner tray into her and sat it in her lap as the resident preferred. The resident requested to have her blood glucose level checked. Staff B encouraged the resident to eat something and informed Staff A. Staff B stated Staff A was sitting at the nursing station eating. She stated Staff A said the resident's blood glucose level was fine when she administered her insulin and stated she didn't have time to take it again. According to Staff B, Staff A stated she would go into the resident's room when she had time. Staff B then assisted other residents and when she entered Resident #1's room at 6:15 p.m., the resident was slumped over in her chair and her food was on the floor. Staff B stated it appeared as though she dropped her tray. She tried to rouse the resident and called for a nurse. Staff B stated Staff A was still on break but Staff C (Registered Nurse) had just arrived for her shift and she came to the resident's room to assist her. Staff B stated she remained in the room until the paramedics came to transport her to the hospital. Staff B stated she reported to Staff C that she had informed Staff A of the resident's condition earlier but Staff A did not take action. During an interview on 8/24/20 at 12:08 p.m., Staff C (Registered Nurse) stated she arrived for her shift around 6:30 p.m. on 7/13/20. She stated a Nurse Aide asked for a nurse and she and Staff D (Licensed Practical Nurse) went to the resident's room and she was unresponsive in her recliner. She took her blood sugar and it was very low. They gave her a shot of [MEDICATION NAME] and called the doctor. Staff A returned from break and they updated her. During an follow-up interview on 8/25/20 at 9:00 a.m., Staff C stated Staff B reported to her she reported the resident's condition to Staff A and she did not check on the resident. Staff C stated she documented this concern and submitted it to the Administrator. During an interview on 8/24/20 at 3:18 p.m., Staff D (Licensed Practical Nurse) stated on 7/13/20 she heard a nurse was needed in Resident #1's room. She stated she and Staff C went to the resident's room and she was slumped over in her recliner and was unresponsive. She stated they checked her blood sugar and it was around 32 or 34. They gave her a shot of [MEDICATION NAME]. She stated Staff A (Resident's #1's nurse) was on break and when she returned they updated her and she took over. She stated Resident #1 was a brittle diabetic and she would not give the resident her insulin until she had the tray in front of her. She stated supper trays did not come out before 5:00 p.m. During a follow-up interview on 8/25/20 at 10:20 a.m., Staff D stated Staff B had informed her she reported the resident's condition to Staff A but Staff A stated she was too busy. During an interview on 8/24/20 at 1:12 p.m., Staff A stated on 7/13/20 when she gave the resident her insulin, it was dinner time and she had her tray in front of her. She stated she was not sure if she ate anything or not. She stated she was not the nurse who found the resident unresponsive as she was on break at the time. She stated Resident #1 had a high blood glucose level earlier in the day and the doctor ordered a one-time dose of insulin. During an interview on 8/25/20 at 10:48 a.m., the Director of Nurses (DON) stated she received a call on 7/13/20 of the resident's low blood glucose level and the resident was sent to the Emergency Department. She stated earlier her blood glucose level was high. She stated she would want the nurse to make sure she was eating or hold the insulin. She stated she did not remember any staff members reporting any concerns with other staff. During an interview on 8/26/20 at 10:15 a.m., the DON stated she would expect the nurses to double check when inputting blood sugars. She stated there should have been parameters on the Medication Administration Record [REDACTED]. She stated moving forward, the facility would do this. She stated the facility should have followed through with getting the resident a mechanical soft diet and acknowledged the food diary was not done. She stated the evening meal was at 5:00 p.m. and not before then. She stated Staff A should not deny care to a resident. During an interview on 8/25/20 at 8:41 a.m., Resident #1's Physician stated Resident #1 had a high blood glucose level around 500 mg/dl and he ordered a dose of insulin. He stated on the evening shift, the resident would not eat and the aide told the nurse to check on her but the nurse did not. He stated by the time the nurse checked on her, her blood sugar was 30 mg/dl. The staff subsequently gave an injection of [MEDICATION NAME] but the resident did not respond. He stated if a resident did not eat, nurses should recheck blood sugars. During an interview on 8/25/20 at 10:58 a.m., the Administrator stated as far as she knew no one had spoken to Staff A regarding the concern Staff C submitted regarding her not responding to a resident after a Nurse Aide told her the resident was not doing well. She stated normally they would investigate. During an interview on 8/26/20 at 11:00 p.m., the DON stated they did not have a policy regarding family and physician notification or assessment and intervention and stated they followed the federal standard of practice. 2. The Face Sheet revealed Resident #3 admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Progress Notes dated 8/19/20 revealed Resident #3 had a fall at home with a blood glucose reading of 29 milligrams (mg)/deciliter (dl). The Weights and Vitals Summary dated 8/22/20 at 8:00 p.m., listed a blood glucose reading of 433 mg/dl. Review of the Clinical Record revealed a lack of documentation to reflect the staff notified the Physician, completed further assessments and carried out interventions for the high glucose reading. The Care Plan entry dated 8/20/20 revealed Resident #3 had diabetes and directed staff to monitor blood glucose levels and side effects.

The following deficiency relates to incident -C: Based on observation and interviews with staff, the facility failed to provide a safe environment for residents when they repeatedly used space heaters in Hallways. The onsite investigation revealed the space heaters tested between 108 to 200 degrees Fahrenheit. The staff interviews determined no provisions were in place to protect residents from hazards when the space heaters were being used in hallways accessible to residents including three residents selected for review (Residents #6, #7, #8). The findings constitute an immediate jeopardy to residents health and safety. The facility reported a census of 66 residents. Findings include: Observation: Upon entering the facility on 1/9/14 at 11:10 a.m. an electric space heater was seen on Hall 3 as the surveyor passed by the hall. There were no noted space heaters on any other halls or in the common areas of the facility. Upon returning to hall 3 for a closer inspection, the space heater had been removed. A similar appearing space heater was promptly discovered along with two other space heaters in the Administrator's office across the hall from where the space heater was originally observed. In an interview on 1/13/14 at 3:42 p.m. the Administrator acknowledged the presence of a space heater on Hall 3 which was observed by the surveyor on 1/9/14 at 11:10 a.m. The Administrator reported the space heater had been placed in her office shortly after the surveyor's arrival. The Administrator denied knowing who placed the heating unit in her office. The Administrator indicated she did not believe the heating unit was being used. In an interview on 1/14/14 at 11:46 a.m. Staff P, MDS Coordinator, indicated on Thursday, January 9, 2014, she moved the ceramic heater off of hall 3 per the Administrator's request. Staff P indicated the heating unit was on prior to her removing it. On 1/13/14 at 2:30 p.m., observation found 3 different electric heating units used by the facility from 1/5/14 through 1/9/14. Each unit was tested and turned to the highest setting and ran in excess of five minutes before the temperature of the external grid was checked. The temperatures obtained are as followed: 1) Power Heat Infra-Red Quartz unit was 108 F. (1 unit). 2) Lasko Cyclonic ceramic heater was tested and measured at 200.4 degrees F. (The facility had 2 units of this brand). The ceramic heater was re-tested on 1/14/13 at 3:00 p.m. with a reading at 218 degrees F. 3) Honeywell 360 degree Surround Heat unit measured at 234 degrees F. (The facility had 5 units of this brand); and when re-tested on [DATE] at 3:00 p.m., measured at 150 degrees F. Both the Lasko ceramic heater and Honeywell heaters were excessively hot when touched and contact with the external grids could only be maintained momentarily before causing discomfort. Lasko Cyclonic Ceramic Heater operating manual indicated under Warning section: *Extreme caution is necessary when any heater is used or near children or (others). The heater should not be left operating unattended. Under Caution section: *This Heater is HOT when in use. To avoid burns, do not let bear skin touch hot surfaces. Honeywell 360 degree Surround Heat operating manual indicated under Warning section: Your responsibilities: Electrical appliances may expose people to hazards that can cause severe injury as well as death. *Warning- This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. *Warning- Extreme caution is necessary when any heater is used near children or (others), and whenever the heater is left operating and unattended. Record review for a resident from Hall 3 identified the following : a. According to Resident #6's Minimum Data Set (MDS) assessment with assessment reference date of 11/28/13, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 4 indicating short and long term memory deficits with severely impaired cognitive skills for daily decision making. Resident #6 required supervision with mobility in his/her room and limited assistance with mobility when in the hallway. Resident #6 utilized a walker or wheelchair for mobility. Resident #6's [DIAGNOSES REDACTED]. Resident #6's care plan indicated a nursing [DIAGNOSES REDACTED]. Record review for a resident from Hall 2 identified the following : b. According to Resident #7's Minimum Data Set (MDS) assessment with assessment reference date of 11/7/13, Resident #7 had a Brief Interview for Mental Status (BIMS) score of 4 indicating short and long term memory deficits with severely impaired cognitive skills for daily decision making. Resident #7 required limited assistance with mobility and utilized a wheelchair for mobility. Resident #7's [DIAGNOSES REDACTED]. Resident #7's care plan indicated Resident #7 as independently ambulatory with the use of a front wheeled walker and needs direction on where to go. Record review for a resident from Hall 2 identified the following : c. According to Resident #8's Minimum Data Set (MDS) assessment with assessment reference date of 12/19/13, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 10 indicating short and long term memory deficits with moderately impaired cognitive skills for daily decision making. Resident #8 was independently mobile. Resident #8's [DIAGNOSES REDACTED]. Resident #8's care plan indicated Resident #8 as independently mobile throughout the facility utilizing a 4 wheeled walker. In an interview on 1/13/14 at 3:30 p.m. the facilities Director of Nursing (DON) identified Residents #6, #7 and Resident #8, had [DIAGNOSES REDACTED]. The residents were selected as those with impaired safety awareness and the potential to come in contact with the heating units. The DON indicated that during the times the heating units were used, there were no incidents in which a resident was injured or observation of a resident showing interest in or making contact with the heating units. In an interview on 1/9/14 at 1:50 p.m. Staff A, Registered Nurse, indicated she worked a double shift on Sunday, January 5, 2014. That morning at about 9:00 a.m. to 10:00 a.m. she noticed Halls 1 and 2 were cold. Staff A contacted the Administrator who directed her to contact the maintenance person. At about 10:00 a.m. the maintenance person came into the facility and started working on the heating system. The maintenance person worked for about two hours, but the halls remained cold. At 2:00 p.m. Staff A contacted the Director of Nursing (DON) about the cold halls. The DON instructed her to contact the Administrator again and to call her back. Staff A indicated by this time extra blankets were provided to the residents. At 4:00 p.m. Staff A contacted the Administrator and informed her she had checked temperatures in several rooms on Halls 1 and 2 and temperatures ranged from 64-68 degrees Fahrenheit (F). Staff A indicated the Administrator informed her that she did not have a solution and they could move the residents to the front dining rooms. Staff A contacted the DON and got approval to call in additional staff. The Administrator called back and stated she was going to look for some space heaters. At around 8:00 p.m. the Administrator arrived with several space heaters, dropped them off and left. Staff A indicated the space heaters were placed in the hallways and plugged in. In an interview 1/13/14 at 11:00 a.m. the Administrator indicated on Friday, January 3, 2014 it was cold down Hall 2. It had been below zero the evening before. The Administrator instructed the maintenance person to call and have the boilers checked. The boilers were checked that same day. On Sunday, January 5, 2014 the Administrator was contacted at 10:00 a.m. that Hall 2 was cold. The Administrator informed the staff calling that the boilers had just been checked and they could call the maintenance person. The Administrator also suggested that they could move residents to Hall 4 (area currently not occupied by any residents), if it was warmer. The Administrator was again called at around 6:00 p.m. and informed the rooms were getting colder and the maintenance person was unable to fix it. The Administrator contacted her supervisor to report the issue and was instructed to have the residents moved to the dining room and purchase space heaters for the halls. The Administrator contacted the facility and informed them she was going to get heaters and would be there as soon as she could. The Administrator indicated she arrived at the facility around 7:00 p.m. with seven heaters which were placed in the hallways. The Administrator indicated she checked the temperatures at the end of Hall 1 and Hall 2 and the temperatures were 69.8 F and 68.4 F. On Monday morning, January 6, 2014, the Administrator indicated the halls were still cool and she purchased another heater. By 10:45 a.m. they were able to maintain temperatures above 71 F. Walmart receipt dated 1/5/14 at 7:27 p.m. indicated 7 heating units purchased. Two units were Cyclonic (ceramic heaters) and five units were Honeywell (360 degree Surround Heat). All units were observed in storage on 1/9/14 at 2:35 p.m. In an interview on 1/9/14 at 4:47 p.m. the Director of Nursing (DON) indicated at 2:00 p.m. on Sunday, January 5, 2014 she turned on her cell phone and discovered a text from Staff A indicating Hall 2 was cold. At 2:05 p.m. Staff A called the DON and Staff A was instructed to contact the Administrator. At 6:50 p.m. Staff A called the DON and informed her she had talked to the Administrator and they were moving residents to the front dining room areas and needed extra staff. The DON approved the extra staff and indicated she would be right in to help. The DON arrived around 7:00 p.m. and instructed staff to ask residents if they would like to relocate to the front lounge. Staff immediately started moving willing residents to the front. At some point the Administrator arrived with heaters for the halls. Before leaving the Administrator instructed the DON to make sure the heaters remained in the halls and away from any items and they were not placed in resident rooms. The DON checked the heaters, instructed available staff and wrote a note to staff with those instructions and left it at the nurse's station. The DON then checked on residents and those choosing to remain their room were provided extra blankets and pulled their beds away from the windows. Curtains were closed and blankets placed at the base of exterior doors. The DON checked to see if everyone was settled and if staff had any questions, then left the facility a little after 9:00 p.m. In an interview on 1/9/14 at 2:13 p.m. the maintenance person indicated he was called into the facility on Sunday, January 5, 2014 due to the halls being cold. The maintenance man checked the heating system and found it to be working properly. In an interview on 1/9/14 at 4:23 p.m. Staff B, Licensed Practical Nurse, indicated she worked the day shift on Sunday, January 5, 2014. Staff B indicated that morning the hallways were getting cold. Staff were instructed to check the windows to assure they were shut and locked. Maintenance person was called in and stated the boiler system was working fine. Staff B indicated extra blankets were provided to the residents and the temperature on the thermostat up front read 70 F. Staff B indicated she did not have a thermometer to monitor temperatures. In an interview on 1/9/14 at 1:29 p.m. Staff C, Certified Nurse Aide, indicated she worked the weekend on day shift on January 4 and 5, 2014. Staff C indicated it was very cold on down hall 2 and they had to get residents into sweaters and extra blankets. They brought space heaters down the halls which helped. Staff C indicated it was so cold she had to wear a jacket to stay warm. In an interview on 1/9/14 at 1:16 p.m. Staff D, Certified Nurse Aide, indicated she worked the weekend on day shift on January 4 and 5, 2014. Staff D indicated "more" space heaters were brought in for the halls. Staff D indicated residents were brought up earlier for meals so they could get heat and at night time some residents beds were brought to the dining room, where it was warmer. Staff D indicated residents were dressed in warmer clothes and covered with blankets. Staff D indicated every winter when it gets real cold, space heaters are placed in the hallways, however on Sunday, January 5, 2014 the heating system was not working properly and additional heating units were brought in. In an interview on 1/9/14 at 1:38 p.m. Staff E, Certified Nurse Aide, indicated she worked the day shift on January 5, 2014 and returned back to the facility that evening to help move residents. Staff E indicated it was super cold all day and they contacted the Administrator to get permission to move the residents. Staff E indicated 9 females were brought to the dining room and 1 male resident was brought up to the west dining room area. Staff E indicated the Administrator later brought in heaters for all three halls. The next morning all of the residents were returned to their rooms before breakfast. In an interview on 1/9/14 at 3:07 p.m. Staff F, Certified Nurse Aide, indicated she worked the day shift on January 5, 2014. Staff F indicated it was cold down Hall 2 and the maintenance was here during the day trying to fix the problem. Staff F indicated the aides went around the rooms to make sure all the windows were closed and pulled curtains to keep the heat in. Residents were provided extra blankets. Staff F indicated she did all she could do to keep the residents happy. In an interview on 1/13/14 at 4:45 p.m. Staff G, Licensed Practical Nurse, indicated she worked the evening shift on January 5, 2014. Staff G indicated after supper staff was instructed to bring residents from halls 1 and 2 to the front and west lounges due to their rooms being so cold. Staff G indicated the moves were completed by 9:00 p.m. and the Administrator had brought in heaters for the halls and instructed staff to keep the heaters in the hallway and not in resident rooms. Residents who chose to remain in their rooms were provided extra blankets and monitored throughout the shift. Staff G indicated the heating units were observed but not formally monitored or assigned to anyone. In an interview on 1/9/14 at 3:16 p.m. Staff H, Certified Nurse Aide, indicated she worked the evening shift on January 5, 2014. Staff H indicated residents were complaining of being cold and extra blankets were provided. At around 7:00 p.m. to 7:30 p.m. staff was instructed to move residents to the front dining room areas. Several additional staff came in and helped with the move. Staff H indicated there was 11 females and 1 male moved to the front. Staff H indicated several heaters were brought in an placed in the hallways and blankets placed at the exit doors. Staff H indicated she was concerned with residents getting burnt as the heating units got hot fast. In an interview on 1/14/14 at 10:11 a.m. Staff I, Certified Nurse Aide, indicated she worked a double shift on January 5, 2014. Staff I indicated it was chilly on hall 2 that day. Staff provided residents extra blankets and sweaters and asked if anyone would want to move to the front dining room where it was warmer. Staff I was working on hall 3 that evening and didn't participate in moving the residents off halls 1 and 2. In an interview on 1/9/14 at 3:46 p.m. Staff J, Certified Nurse Aide, indicated he worked the evening shift on January 5, 2014. Staff J indicated his co-workers were involved that evening moving residents from halls 1 and 2 due to the weather and it being cold. Staff J indicated he was not involved with any moves. Around 9:00 p.m. the Administrator came in and placed some heaters in the halls. In an interview on 1/13/14 at 4:04 p.m. Staff K, Certified Nurse Aide, indicated she worked the evening shift on January 5, 2014. Staff K indicated it was cold on hall 2 and that evening they started going around and asking residents if they would like to move to the front dining room. At 7:00 p.m. to 8:00 p.m. they began moving residents. Those that remained in their rooms were provided extra blankets. In an interview on 1/13/14 at 10:11 p.m. Staff L, Registered Nurse, indicated she worked the overnight shift on January 5, 2014. Staff L indicated several residents had been moved to the front dining room area in their beds for the evening due to the cold. Staff L indicated there were several space heaters in the halls and a note at the nurse's station indicating heaters were not to be placed in resident room. In an interview on 1/9/14 at 4:10 p.m. Staff M, Certified Nurse Aide, indicated she clocked in around 7:00 p.m. on January 5, 2014. Staff M was called in early to help move residents to the dining room due to the cold. In an interview on 1/13/14 at 6:45 a.m. Staff N, Certified Nurse Aide, indicated she worked the overnight shift on January 5, 2014. Staff N indicated several residents had been moved to the front dining room area due to excessive cold down their hallways. Staff N indicated she saw several space heaters in the hallways. Hall Temperatures checked 1/6/14 through 1/8/14 noted temperatures consistently maintained above 71 F by 2:45 p.m. on 1/6/14 and in excess of 75 F by 8:45 a.m. on 1/8/14. Document indicated heaters removed from halls at 10:30 a.m. on 1/8/14. A email dated 1/6/14 from the Administrator to the State Fire Marshall ' s office documented the following: Just need to let you know that we had some electric heaters in the hallway. We were unable to maintain the temperatures above 65 degrees in resident rooms with the wind and low temps. We are using new heaters that have overheat protection and tip protection (they go off if the heater is tipped). We are not allowing them in the resident rooms only the halls. Please advise on what further steps we need to take ... Temperatures for Chariton, Iowa according to web site, wunderground.com as follows: high low wind speed Sunday, January 5, 2014 10 F -9 F 21 mph Monday, January 6, 2014 -4 F -13 F 17 mph Tuesday, January 7, 2014 21 F -7 F 6 mph Wednesday, January 8, 2014 15 F 5 F 5 mph The facility abated the IJ on 1/15/14 when they implemented the following: Developed a written directive as follows: The purpose of the written directive was to ensure the facility would protect residents from potential harm by: Notifying the Administrator or designee when declining temperatures are noted as a concern. If the temperature could not be corrected by maintenance intervention or outside repair intervention in a timely manner then space heaters would be used ONLY in the following circumstances: Only use infrared units. Units may be only placed halls. A dedicated staff member must be assigned to complete ongoing safety rounds throughout the halls in which heaters are present. Rounds should be documented similar to " a fire watch " manner- staff should review the fire watch policy. Staff will document the start and stop time of heaters. Once the facility reached appropriate temperatures heaters used will be immediately discontinue and heater removed from halls. These actions lowered the deficiency from a scope and severity of K to E, with the need for ongoing monitoring to ensure the provisions are being followed for potential hazards in the residents environment.

Based on observation, resident clinical record review, and staff and witness interviews the facility failed to ensure each resident received adequate supervision to ensure against hazard from self, others, or elements in the environment for one resident (#3) out of a sample of ten residents. The facility reported a census of 57 residents. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] stated the resident had a BIMS (Brief Interview for Mental Status assessment) cognition rating of 9 which indicates moderate impairment of the resident's cognition. The MDS assessed the resident's mobility as needing supervision of one staff member to turn in bed, assistance of two staff members to transfers into a wheelchair with self sufficiency once in the wheelchair. Range of motion assessment indicated the resident was impaired in all four extremities. The resident's care plan prior to 4/14/11 noted the resident was diagnosed with [REDACTED]. Treatment was "as ordered". Nutrition status on the care plan dated 3/18/11 revealed the resident could feed himself/herself with set-up assistance. Assistive devices (i.e. cups with lids) were not listed. An incident report dated 4/14/11 was reviewed and stated Resident #3 spilled coffee in his/her lap and was returned to his/her room so cool wet towels could be placed to the groin. A blister measuring 10 centimeters (cm) X 2 cm was noted on the right upper anterior thigh. The resident's physician and family members were notified of the injury at 11:55 a.m. Nurses notes stated at 11:40 a.m. the resident was at the dining room table and let out a yell. Noting the resident had spilled coffee in his lap the Assistant Director of Nurses (ADON) returned him/her to his/her room. The nurses noted the resident had red areas to his/her lower abdomen and to the right anterior thigh (wound site A) with a 10 cm X 2 cm blister noted which had opened up. Red areas were noted to be on the resident ' s left anterior thigh (wound site B). Entries in the nurse's note concerning the resident's injuries continued through 4/14/11 at 3:30 p.m., 10:50 p.m., and 4:30 a.m.(4/15/11). Assessment of burn areas on the resident left and right upper anterior thighs were noted in the entries. The area on the left thigh was not measured. An entry at 6:45 a.m. on 4/15/11, 18 hours after the incident, revealed the discovery of third burn site with an open blister and redness on the resident ' s right posterior thigh just under the resident's right buttock (wound site C). This wound was not measured at that time. A skin sheet was initiated for wound site A on 4/14/11 and listed the location of the burn and measurements at 10 cm X 2 cm. On 4/20/11 the site was reassessed and measured as 5 cm X 14 cm. A skin sheet for site C was initiated on 4/20/11 and measurements for three separate burn areas on the right posterior thigh were 2 X 1.5 cm, 3 cm X 3 cm, and 6 cm X 7 cms on 4/20/11. A skin sheet was initiated for Site B on 4/21/11 after it was noted by the surveyor one had not been started. The measurements for Site B were 2.5 cm X 3 cm and involved a blister that had not yet broken. A physician order [REDACTED]. The physician made rounds on 4/15/11 and examined the resident's burns. An interview with the ADON (and written statement) on 4/21/11 at 1:00 p.m. revealed she was sitting at the front nurses station doing paper work when she heard the resident scream. She looked up and saw the activity director run to the resident. She stated she saw no other staff in the dining room at the time and there were a few residents scattered throughout the room. She went to assist the resident and initiated care by trying to place a cold wet clothes protector under the resident's denim pants to ease the heat from the burn. She then took the resident to his/her room for easier access to the skin. An interview (and written statement) with the Activity Director on 4/21/11 at 12:45 p.m. revealed she was sitting in her office across from the nurse' s station when she heard yelling from the dining room. She went into the dining room and assisted the ADON who was administering first aid. She noted a yellow Casey cup with a lid on the table and picked up a silver cup from the floor. She stated the lid was on the silver cup securely. She did not test the lid of the Casey cup and was unsure if it was on correctly. She stated she was not sure if any staff was in the dining room at the time as her attention was on the resident. During an interview with Resident #3 on 4/21/11 at 9:45 a.m. he/she answered "yes" when he/she was asked if he/she asked Resident #12 to get him/her some coffee from the pitcher on Resident #12's table. Resident #3 stated that Resident #12 did get him/her coffee but it spilled on Resident #3's lap when he/she took a drink. Resident #3 stated that only staff can get him/her coffee now. The resident was unable to recall which cup his/her coffee was in or if anyone else in the past besides staff had given him/her coffee. Resident #3's impaired cognition was evident during interview. It was difficult to illicit information from him/her. He/she started to cry when talking about his/her wounds. Resident #12's MDS assessment dated [DATE] of this resident revealed he/she had a BIMS score of 15 which indicated a non-impaired cognition. During an interview with Resident #12 on 4/21/11 at 11:00 a.m. the resident stated he/she and Resident #3 were friends. On 4/14/11 Resident #12 decided to pour Resident #3 a cup of coffee just to "be nice". Resident #12's table had a carafe of coffee and Resident #3's did not. Resident #12 stated he/she poured 1/2 cup of coffee for Resident #3 but did not put the lid back on the cup securely. Resident #12 stated he/she just laid the lid on the cup because he/she had seen Resident #3 drink from his/her cup this way previously. As Resident #3 raised his/her cup to drink the coffee fell into his/her lap. Resident #12 stated he/she did not mean to harm the resident. Resident #12 stated he/she felt everyone in the facility blamed him/her for the accident. During an interview (and written statement) with Staff F, Food Service Supervisor on 10:15 a.m. and again at 1:30 p.m. she stated that the kitchen coffee policy for serving coffee before the incident was to put coffee carafes on designated tables for residents who were able to serve themselves coffee safely. She stated Resident #3 was care-planned to use a cup with a lid for fluids and not to have a carafe of coffee on his/her dining room table. Resident #12 sat at a table adjacent to Resident #3 and did have a coffee carafe at his/her table and the FSS felt Resident #12 was probably being helpful in pouring Resident #3 a cup of coffee. The routine was for staff to place carafes of coffee on designated dining room tables approximately 20 minutes prior to serving food. No one was assigned to specifically monitor coffee carafe use. The FSS stated on the days she worked she would monitor the use of the carafes. The FSS stated on the days she did not work or was at a meeting the nursing staff was responsible for monitoring the carafe use when bringing residents into the dining room. An interview with Staff A, dietary aide, on 4/21/11 at 1:35 p.m. she stated she used to take coffee carafes out to the designated tables and would take two carafes to Resident #12's table. This was so one carafe could be used to pour coffee for the adjacent table where Resident #3 sat. She did not know who poured coffee for Resident #3's table. An interview with Staff B, dietary aide, on 4/21/11 at 1:45 p.m. revealed she was working in the West dining room when she heard someone scream. She moved to the opening into the East dining room and saw a nurse was at the resident's side. She stated they used to put hot coffee carafes on the dining room tables 20 minutes prior to serving food. She stated if she saw anyone "messing" with a carafe who should not be she would take the carafe away. She stated when she is in the West dining room she cannot always see into the East dining room. She stated the FSS would tell them which tables were not to have coffee on them. During an interview & written statement by Certified Nurse's Aide Staff C, she stated on 4/21/11 at 11:00 a.m. she had not witnessed Resident #12 serving coffee to Resident #3 before. She was aware that coffee was not to be placed on the table of Resident #3. Observation of lunchtime prep on 4/21/11 at 11:45 a.m. revealed ten carafes of coffee sitting on the counter in the kitchen with the lids off. The FSS checked the temperatures of the carafes 10 minutes later and the temperatures ranged from 152-158 degrees. The carafes were placed on the fluid carts. The FSS took one carafe and went out to the dining room to serve coffee. Observation of the CNAs job during this pre-lunch time period was to prepare a resident for lunch, bring them up to the dining room at meal time, and then to return to the hallways to prepare another resident to come to the dining room. A phone call was placed to Resident #3's physician who examined the burns during rounds on 4/15/11. The physician was unavailable however the office nurse was able to access the physician's progress notes from that visit. The physician labeled the burns as 2nd degree burns (In a second degree burn the damage from the heat extends through the epidermis- top layer of skin- and into the dermis- second layer of skin. These burns are also known as partial thickness burns) and ordered a treatment of [REDACTED]. Observation of wound care on 4/21/11 at 10:00 a.m. revealed Staff D treating the resident's wounds. She did not measure the three sites as she disclosed she measured them on 4/20/11. The resident stated the wound care hurt him/her, particularly when the adhesive tape was removed from his/her skin. Staff D noted she was switching to paper tape for this reason. The resident broke into tears during the treatment of [REDACTED]. Pictures were taken of site A, B, and C at 1:30 p.m. to aid in determining the measurements and characteristics of the wounds. The Director of Nurses and Staff E, staff trainer, assisted with the pictures. Observation during wound care revealed measurements for the wounds as approximated by the surveyor: Site A- 17 cm X 5 a.m. at the widest point. Site B- a closed blister measuring approximately 2 cm X 2 cm. Site C- three defined areas - #1- 6 cm X 5 cm (horizontal bottom wound), #2 - 7 cm X 2 cm (middle vertical wound), and #3 area-4 cm X 3 cm (parallel to #2). During a subsequent interview on 4/21/11 with the FSS she identified interventions initiated in the kitchen since the incident on 4/21/11. She stated the temperature of the coffee right after being poured into the carafes from the coffee machine was approximately 180 degrees. Instead of taking the coffee out at that temperature the kitchen staff now has the carafes sit in the kitchen with lids off for 15 minutes. The coffee is then temped and not taken out to the dining room until the temperature is below 160 degrees. The coffee carafes will no longer be

Based on clinical record review, and staff interview, the facility failed to plan for and direct nursing services and provide the necessary provisions to ensure Resident #10 received adequate supervision to prevent accidents. Record review and staff interviews acknowledged the resident with confusion and lacked the ability to consistently use the call light effectively to alert staff of his/her needs and the care plan lacked any interventions to address this until the resident fell and sustained a hip fracture. Concerns were identified for one of four residents with reported census of 76 residents. Findings include: 1. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 9/2/10 identified Resident #10 with short term and long term memory problems and severely impaired for daily decision making. The MDS identified the resident independent with bed mobility and required limited assistance for activities of daily living (ADL's) including transfers, ambulation in the room and hallway, dressing, eating, toilet use and bathing. The MDS defined limited assistance as follows: the resident highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times- or- more help provided only 1 or 2 times during the last seven days. The resident required extensive assistance with personal hygiene. The MDS reflected the resident required partial physical support during the balance test; or stands (sits) but does not follow directions for the test. The MDS identified the resident with a [DIAGNOSES REDACTED]. The MDS reflected the resident had conditions/diseases which made the resident's cognitive, ADL, mood or behavior status unstable-(fluctuating, precarious, or deteriorating). The MDS with an assessment reference date of 6/24/10 identified the resident had [DIAGNOSES REDACTED]. Review of the care plan entry dated 6/1/10 revealed staff identified the resident with impaired mobility and directed staff to provide the resident stand-by assistance of staff for redirection in the facility as needed. Review of a care plan entry dated 8/20/10 revealed staff updated the care plan by drawing a line through a previous entry and identified the resident no longer independent in his/her room. The care plan entry dated 8/20/10 directed staff to provide assistance of 1 staff for mobility at all times and identified goals to maintain the resident's present functional mobility, transfer and ambulate safely and to be free of injury from falls with the following interventions: assist the resident with positioning, transfers and ambulation as necessary or as requested by resident, PT (Physical Therapy) screen as indicated, Restorative Program and observe for signs of fatigue and allow for rest periods. The care plan entry dated 7/22/10 directed staff to ensure the resident be one of the first residents out of the dining room after meals. Review of the care plan entry dated 9/30/10 revealed staff initiated a bed sensor alarm to the resident's bed and on 10/5/10 staff documented staff placed a mat on the floor next to the resident's bed. Review of the care plan with a goal date of 1/5/11 and updated on 2/25/11 revealed staff identified the resident needed staff assistance with transfers and ambulation due to a recent ORIF (Open Reduction Internal Fixation - surgical intervention for a fractured hip) of the resident's left hip. The care plan directed staff transfer the resident with 2 staff and a gait belt and use the wheel chair for long distances. The care plan dated 10/5/10 directed staff apply a chair pressure sensor alarm on the resident's wheel chair and place a floor mat on the floor next to the resident's bed. On 10/14/10 staff documented the resident placed on the Falling Star Program. Review of the Fall Risk assessment dated [DATE] revealed staff documented the resident' status/condition evaluated and identified the resident's fall risk total score at 11. On 6/23/10 and on 9/1/10 staff documented the resident's fall risk scores each at 13. A total Score of 10 or above represented the resident at high risk for falls. Review of the Incident/Accident/Unusual Occurrences Form dated 5/20/10 revealed the resident fell on floor in his/her room. Staff documented an entry on the form to add to the resident's care plan to lay out the resident's night clothes on the foot of the bed. Review of the Incident/Accident/Unusual Occurrences Form dated 7/22/10 at 1:00 p.m. revealed the resident up without assistance, leaving the dining room, lost his/her balance and fell backwards and the resident hit his/her head on the floor. Staff documented an entry at the bottom of the form to add to care plan directing staff to ensure the resident first out of dining room after meals. Review of the Incident/Accident/Unusual Occurrences Form dated 9/30/10 at 3:50 p.m. revealed staff documented staff found the resident laying on the floor in room by his/her clothes closet. Staff documented the resident held his/her left hip, guarded the area and said "ouch". Staff documented the resident transferred to the local hospital by ambulance per the physician's orders [REDACTED]. Review of the Nurse's Notes dated 5/20/10 staff documented staff ambulated the resident to his/her room after supper with 1 staff assist and a gait belt. Staff documented shortly after staff ambulated back to the room, staff heard a loud sound and staff found the resident on the floor in front of his/her chair. Staff documented the resident's roommate reported to staff the resident had reached for his/her nightgown when she/he fell . Staff documented the resident complained of right lower extremity pain. Staff notified the family and physician and then the resident refused to be sent to the hospital for evaluation. On 5/22/10, staff documented the resident ambulated in the hall with 1 staff assist and a gait belt was used. Review of the Nurse's Notes dated 6/9/10 at 8:45 a.m. revealed Staff S documented the resident very confused this a.m. and staff found the resident attempting to put his/her shirt/blouse on his/her legs. Staff S documented she notified the facility's Care Plan Coordinator and Social Worker about safety concerns for the resident and suggested the resident be moved to East Side of the facility where there was more ability to provide more supervision and staff help. Staff S also documented her concern for the resident would begin to wander or attempt to dress self as he/she attempted incorrectly this a.m. and become tangled in clothing and fall. Staff O documented the family came to the facility at 2:00 p.m. and talked with Social Services. Staff O documented the family requested the resident be kept in the same room. At 8:00 p.m., Staff O documented staff frequently checked on the resident, reminded the resident to use the call light. Staff O documented the resident had been up unassisted or assisted by his/her roommate. The Nurse's Notes on 6/16/10 at 1:45 a.m., the staff nurse documented the resident ambulated to the bathroom without staff assistance and the resident remained confused per his/her normal. At 10:00 a.m., the nurse documented the resident stared at the medications she gave to the resident and required cueing to take meds and required cueing to eat. At 7:00 p.m., the nurse documented staff found the resident up in room looking in the closet. Staff located the resident's night gown, placed it on the foot of the bed and assisted the resident to prepare for bedtime. On 7/2/10 at 1:15 a.m., Staff documented the resident used the call light for assistance to bathroom at times. On 7/22/10 at 1:40 p.m., staff documented the resident up without staff assistance to leave the dining room after lunch as witnessed by the facility's housekeeper. She reported the resident stood up, took a couple steps forward, stumbled backwards, lost his/her balance and fell striking his/her head on the floor. The nurse documented the resident had a bump and bruise - 3 cm (centimeter, a unit of measure) in length and 2.5 cm in width to the back of the head. On 7/22/10 at 5:40 p.m., staff documented the resident was oriented to self and unable to remember to use the call light. On 7/25/10 at 7:25 a.m., staff documented the resident alert and with increased confusion from the previous day, held the side of his/her neck and responded "yes" when asked by the nurse if had pain. Staff noted the resident was unsteady this a.m., with cares. Staff notified the physician and the resident transferred to the local hospital emergency for evaluation. At 10:15 a.m., the resident returned to the facility and assisted to bed. The resident's family reported the resident had a CT scan (Computerized Tomography- a special X-ray with more accurate details) and x-rays of the head and neck and told the results were negative for injury. At 3:00 p.m., staff documented the resident disoriented to time, place and person. On 7/27/10 at 8:30 a.m., Staff documented the resident appeared more confused today, shuffling feet when he/she ambulated, mumbling and slow to answer questions. At 8:20 p.m., the nurse documented the resident up twice in the hallway without staff assistance, continued to be confused and required redirection by staff. On 8/2/10, staff documented they moved the resident to room 42-bed 1. On 8/4/10 at 1:10 a.m., staff documented the resident up in the room without staff assistance to help the roommate. Staff documented they instructed resident to stay in bed and they would assist roommate. On 8/21/10 at 2:30 p.m., staff documented the resident ambulated into the bathroom without staff assistance, did not utilize the call light for staff assistance. On 8/24/10 at 1:00 a.m., staff documented the resident ambulated the resident with 1 staff assist, gait belt and walker to the toilet. On 9/10/10 at 2:25 a.m., staff documented the resident taken to the toilet with 1 staff assist, the resident was confused at all times, is able to use the call light but the resident did not choose to often. On 9/30/10 at 3:50 p.m., staff documented they found the resident on the floor of room by the closet and his/her left lower leg at an irregular angle. The resident unable to straighten his/her left leg and cried out in pain with palpation of the area. Staff notified the resident's physician and the resident transferred to the local hospital per ambulance at 4:05 p.m. At 5:00 p.m., staff documented the local hospital staff called and notified the facility staff the resident was being transferred to a Des Moines hospital for further care. On 10/5/10 at 2:35 p.m., Staff documented the resident returned to the facility by ambulance. At 3:00 p.m., staff documented the resident had 2 incisions of the left hip and staples intact. The resident confused, decreased thought processes and had difficulty making needs known. The resident required transfer assistance of 2 staff and used the commode at the bedside. Staff documented the resident attempted to get out of bed without assistance and the resident had a bed alarm and a chair alarm. Review of the fall investigation form dated 9/30/10 revealed the resident was confused all the time with internal risk factors of unsteady gait, and [DIAGNOSES REDACTED]. The form identified the fall was not witnessed by staff would apply a bed/sensor alarm to alert staff to prevent another episode. Review of the fall investigation form dated 9/30/10 for CNA revealed the same set of facts regarding the resident ' s confusion and [DIAGNOSES REDACTED]. Staff O stated during an interview on 3/31/11 at 4:15 p.m. she had reviewed her notes from the fall that occurred on 9/30/10. Staff O stated the staff found the resident on the floor near his/her closet. Staff O stated the resident did not have alarms for fall prevention prior to his/her fall and broken hip. Staff O indicated the resident could use the call light, but chooses not too and was able to make his/her needs know, therefore there was no indication that the resident needed an alarm. During an interview on 3/10/11 at approximately 11:55 a.m., Staff V stated she recalled the resident not consistently using his/her call light and the resident's roommate put his/her call light on for the resident. Staff V stated "the roommate would see the resident wiggle in bed and would call the staff for the resident." Staff V stated she recalled the resident very confused and required a lot of verbal cueing and prompting needed. Staff V stated she did not recall the resident needing ambulation or transfer assistance prior to his/her fall and fractured hip. During an interview on 3/10/11 at 9:30 a.m., Staff I stated the resident had more confusion before he/she fell and fractured a hip. She stated she was unsure if the resident had an alarm placed prior to his/her fall and fractured hip. She stated she was concerned about the resident getting up without help because the resident did not use his/her call light. Staff I stated the resident had a history of [REDACTED]. Staff I stated she remembered the resident required 1-2 staff to transfer, ambulated him/her to the toilet and then they walked the resident to meals before she fell and fractured his/her hip. Staff I stated she was unsure if the resident had alarms on before she fell . She stated the resident still tried to get up without help now and had a bed alarm, a chair alarm and a floor mat next to his/her bed. During an interview on 3/10/11 at 11:25 a.m., Staff U stated before the resident broke his/her hip from the fall (on 9/30/10) he/she needed two staff with transfers and a gait belt to walk. Staff U stated she did not think the resident had alarms on when he/she fell and broke his/her hip. Staff U stated the resident had an increase in confusion and the stated the resident was not aware of safety issues. Staff U stated she remembered the resident's roommate yelled at the staff when the resident tried to get up without staff assist. Staff S stated during an interview on 3/30/11 at 4:45 p.m. several months prior to the fall on 9/30/10, she had told the MDS/care plan nurse that she was concerned about the resident ' s safety after she found Resident #10 trying to put his/her shirt on his/her legs. Staff S indicted Resident #10 ' s judgment and safety varied, and stated the resident would be ok and then 15 minutes later, he/she would obviously be confused. During an interview on 3/7/10 at 9:00 a.m., Staff W stated the resident not interviewable and required transfer assistance of 2 staff and a gait belt. Staff W stated the resident was independent with transfers and ambulation at the time of the resident's fall and fractured hip and would have to check the date of the resident's fall and fracture. Staff W clarified her statement on 3/10/11 at 12:00 p.m. and stated she may have been mistaken when she reported the resident's mobility was independent before the fall with fracture and she would need to review the record.

Based on clinical record review, observation and staff interview, the facility failed to provide the necessary provisions to ensure Resident #1 received adequate supervision during transfers according to his/her plan of care. Record review and staff interview acknowledged the resident as non-weight bearing and staff did not use the EZ lift for transfers or the safety bar during the resident's shower on 11/22/10.The resident had been found on the floor and the facility staff immediately moved Resident #1 rather than allow a nurse to assess the resident. Resident #1 sustained a fracture left femur after the incident. The Director of Nursing failed to plan for nursing services when she assisted and directed staff to use three persons during EZ-lift transfers for showers, however failed to share this communication with the care plan coordinator. Concerns were identified for one of six residents with reported census of 75 residents. Findings Include: 1. The MDS (Minimum Data Set) assessment dated [DATE] reveals a problem with short term memory only, moderately impaired-decisions poor; cues/supervision required for decision making and required extensive assistance of two staff for all transfers. The assessment revealed pertinent [DIAGNOSES REDACTED]. The assessment revealed Resident #1 69 inches tall and his/her weigh at 170 pounds. The assessment revealed the resident had functional limitations in range of motion of one side of his/her arm, hand, leg and foot. The assessment identified the resident unable to complete a test for balance while sitting or standing without physical help and had an unsteady gait. The Progress Note dated 11/12/10 signed by the resident ' s primary care physician revealed Resident #1's overall condition seemed stable. The physician documented the resident seemed alert and reactive, somewhat sleepy today but overall he/she appeared fairly stable during the examination. A fall risk assessment completed on 9/9/10 revealed a score of 16 with a score of 10 or greater identifying the resident at high risk for falls. The same assessment dated [DATE] revealed a score of 18. The physician's orders [REDACTED]. The care plan for Resident #1 dated 4/15/10 documented he/she had impaired mobility. The care plan directed staff to provide transfers with assistance of two (staff) weight bearing as tolerated. The care plan directed staff to use the EZ lift PRN (as needed). After the resident fell on [DATE] and sustained a fracture left femur, the facility updated the care plan to directed staff to only use the EZ lift for transfers. The Incident/Accident/Unusual Occurrences Form dated 11/22/10 at 8:20 A.M. documented the resident in shower, in the shower chair, while C.N.A. (certified nursing assistant) was drying the resident off, the resident kept sliding in the shower chair, when the resident leaned forward to place the towel behind h/her back, the resident slid forward, the resident guided to the floor with feet out in front per the C.N.A. statement. At 1:30 P.M. the resident complained of left knee pain, physician notified. Around 12;10 p.m., the resident complained of left knee pain. The Nurse's Notes dated 11/22/10 at 2:20 P.M. the resident's primary care physician ordered ice for his/her left knee 15-20 minutes, every 2 hours through the evening. The Nurse's Notes dated 11/23/10 at 8:20 A.M. documented Resident #1 ' s left knee swollen with increased warmth and no redness. The facility contacted the physician who requested the resident go to the emergency room for an X-ray. The Medical Imaging report dated 11/23/10 at 8:02 P.M. showed Resident #1 with a markedly comminuted distal femoral (long bone above the knee joint) fracture. The fracture begins approximately 17 cm (centimeters) above the knee joint with numerous fragments some of which are displaced within the medullary (middle) cavity or marrow of the distal (lower) femur and others which are displaced both medially (to the middle) and laterally (to the side). The report revealed hemorrhage in the adjacent musculature and tissues as well as throughout the medullary shaft of the femur. The MDS assessment dated [DATE] documented Resident #1 with pertinent [DIAGNOSES REDACTED]. The assessment also documents a BIMS (Brief Interview for Mental Status) scale of 10 which means the resident's cognition as moderately impaired and required total dependence of two staff for transfers. During an interview on 12/14/10 at 1:20 P.M., with Staff A, C.N.A., she stated that on 11/22/10 she needed to give Resident #1 a shower and she took him/her to the shower room. Staff A stated Staff B ( C.N.A.) and herself completed a two person lift with a gait belt into a shower chair from the resident's wheelchair. Staff A stated Staff B left the room and she started cleaning Resident #1. Staff A stated she did not use the shower chair safety bar. Staff A stated the resident began to slide from the shower chair and she lowered the resident to the floor with the resident's legs out in front of them. Staff A stated she lowered the resident from the resident's left side (the side with weakness). Staff A stated Staff B entered the room and they used as gait belt and assisted the resident from the floor on to his/her wheelchair. Staff A stated she did not know why they did not use the EZ lift for transfers before the fall or after the fall. During an interview on 12/20/10 at 2:30 P.M., with Staff B, C.N.A., she stated she observed Resident #1 sleepy at breakfast this morning. Staff B stated Resident #1 was also sleepy and not able to help much when Staff A and her use a gait belt to transfer the resident into the shower chair (on 11/22/10). Staff B stated she assisted Staff A to position the resident into the shower chair and she left to return to work on the floor but had observed the safety bar on the shower chair not in place. Staff B stated when she returned to the shower room, Staff A directed her to help get the resident off the floor because she had lowered the resident to the floor. She stated she observed the resident on the floor, exposed. She stated she used a blanket to cover the resident, then transferred the resident into the wheelchair, positioned the resident and assisted Staff A with a transfer, with use of a gait belt and lifted the resident into his/her bed. During an interview on 12/15/10 at 11:30 A.M., with the resident's primary care physician, he stated it was a significant fracture and he did not think that happen from a pound or two of pressure that you would have when being lowered to the floor. The physician stated what is being stated just does not add up right. He stated he would expect staff to leave the resident on the floor and have the nurses check them out before moving them. During an interview on 12/21/10 at 9:30 A.M. the DON (Director of Nursing) stated she expects the safety bar on the shower chair to be used at all times because that's a safety intervention. She expects the staff to follow the care plan for transfers and not to move a resident when a fall occurs. During an interview on 12/14/10 at 1:05 P.M. Staff F, RN stated she expects the staff to use the call light when they need help and further stated nobody could have transferred Resident #1 by themselves because of his/her height, weight and stiffness, plus the resident leans badly to the front. During an interview on 12/8/10 at 2:20 P.M. Staff C, RN, ADON, stated she expects the staff to use the safety bar during showers and to follow the care plan for transfers. During an interview on 12/8/10 at 2:00 P.M. Staff D, MDS Coordinator stated she expects the staff to keep the resident safe when the resident was in the shower chair and keep them secure (positioned correctly with use of safety bar), and comfortable, stay with the resident, put the call light on when finished and wait for help to arrive. Staff D stated the resident can assist when alert, otherwise he/she was non-weight bearing. During an interview on 12/13/10 at 1:55 P.M., Staff E, C.N.A. stated she expects staff to use the shower chair bar, if it slips, try to position the resident, use the call light for help, and report it to the nurse right away. Observation of Resident #1 on 12/13/10 at 3:30 P.M. revealed Staff G, C.N.A. and Staff H, C.N.A. transferred the resident using the EZ lift into the shower chair, (a new chair that reclines and elevates the feet), and observed the staff visiting that they needed another person to complete the transfers safely. The DON was present at the time of the observation and assisted the two C.N.A.'s by supporting the resident's left leg during the transfer. The DON directed the CNA to use a third person for transfers from then on. During an interview on 12/13/10 at 5:10 P.M. the DON stated Staff G and Staff H had never used the new shower chair before and had not worked with Resident #1 much and she stated the aides that usually works with the resident was off that day. She stated the new shower chair works just like the others only the back of the new chair reclines back. During an interview on 12/16/10 at 10:30 A.M. Staff C, RN (registered nurse), ADON (assistant director of nursing), stated they have QA (Quality Assurance) meetings every morning and any changes that needs to be addressed on the care plans was completed by Staff D. Staff C stated the DON must have forgot to communicate she stood in on the shower and transfer and a third person was required. During an interview on 12/16/10 at 10:45 A.M. Staff D, RN, stated no one discussed Resident#1 had problems during a shower, so the care plan did not get addressed following the 12/13/10 shower.