Every finding on record at Chautauqua Guest Home #3

Based on observation, staff interview, and policy review the facility failed to thaw frozen chicken using one of the approved methods of defrosting. The facility reported a census of 44 residents.Findings include:On 8/10/26 at 9:24 AM an observation during an initial kitchen walkthrough revealed 3 bags of frozen breaded chicken leg drums sitting in a 3-compartment sink (three-part sink) without cold running water. On 8/10/26 at 9:35 AM an observation revealed 3 bags of breaded chicken sitting in a basin inside the 3-compartment sink without cold water. On 8/10/26 at 9:35 AM Staff A, Cook, reported thawing the chicken in the sink, stating she removed the bags from the freezer about an hour prior to thaw. On 8/10/26 at 9:36 AM a record review of the lunch menu documented chicken drumsticks. On 8/12/26 at 9:10 AM the Dietary Manager (DM) acknowledged Staff A thawed the frozen breaded chicken in the 3-compartment sink. The DM stated kitchen staff forgot to remove the chicken from the refrigerator earlier. The DM reported expecting staff to place chicken in the refrigerator or under cold running water to thaw. The DM noted a small hole in the chicken bag and stated staff didn't want the breaded chicken to get wet. On 8/12/26 at 9:12 AM the Administrator stated expecting dietary staff to thaw frozen chicken in the refrigerator or under cold running water. The Food Preparation Policy undated instructed staff to thaw all frozen meats and leftovers using approved defrosting methods:In refrigerated units at a temperature not exceeding 45 degrees Fahrenheit.Under running water at a temperature of 70 degrees Fahrenheit.In a microwave only when food transfers immediately to conventional cooking equipment as part of a continuous cooking process, or when the entire uninterrupted cooking process occurs in the microwave oven.As part of the conventional cooking process.

Based on clinical record review, staff interview and policy review the facility failed to assess for cause and notify the primary care physician (PCP) and family of a significant weight loss for 1 of 2 resident (Resident #8) assessed for weight loss. The facility reported a census of 44 residents.Findings include:Resident #8's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #8 entered the facility on 5/29/26. The MDS documented a weight of 182 pounds (lbs.). The MDS identified Resident #8 experienced a significant weight loss (a loss of 5% or more in the last month or 10% or more in the last 6 months) and didn't receive a physician-prescribed weight loss regimen. Resident #8's Care Plan lacked interventions related to weight loss. Resident #8's weight log documented the following:5/29/26 a weight of 210.8 lbs.5/31/26 a weight of 207.6 lbs.6/7/26 a weight of 195.8 lbs.6/25/26 a weight of 178 lbs. (15.5% weight loss in 1 month)7/5/26 a weight of 180.4 lbs. (7.6% weight loss in 1 month)7/26/26 a weight of 179.6 lbs.8/2/26 a weight of 174.6 lbs.8/9/26 a weight of 176.8 lbs. (16.1% weight loss since admission) The Nutrition/Dietary Progress Note dated 6/7/26 documented a weight loss of 4.5% for Resident #8 since admission, noting staff planned to continue monitoring weight. The Progress Note dated 6/17/26 at 12:39 PM documented Resident #8 transferred to the hospital (short-term medical facility). The Progress Note dated 6/25/26 at 2:50 PM documented Resident #8's return from the hospital. The Nutrition/Dietary Progress Note dated 7/15/26 at 12:08 PM documented Resident #8's weight decreased 9.2% in 30 days. Resident #8 received no nutritional supplements, staff planned to continue monitoring, and staff notified the Dietitian (nutrition specialist). The Progress Notes lacked Primary Care Provider (PCP) (main doctor) or Resident #8 Representative (family or legal representative) notification regarding the 9.2% weight loss in 1 month. The Progress Notes lacked further documentation addressing weight.

Based on clinical record review, review of staff training records, facility policies, observation and staff interviews, the facility failed to ensure residents are treated with dignity and respect for 1 of 1 resident (Resident #13) reviewed. The facility reported a census of 42 residents.Findings include:Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 99, indicating the inability to conduct the resident interview. The MDS documented Resident #13 ate independently. The MDS included diagnoses of Alzheimer's disease, non-traumatic brain dysfunction (brain damage that occurs due to internal factors, rather than external trauma), and depression.The Medication Review Report dated and signed by the Advanced Registered Nurse Practitioner (ARNP) on 4/15/25, listed Resident #13's diet as a general diet, regular texture, regular consistency, small portions and mechanical soft consistency as needed. Observation on 7/2/25 12:16 PM revealed Resident #13 sat at the second table away from the nurses' station. Resident #13 had her back towards the wall with the nurses' station located to her right with 2 medication carts between the nurses' station and the dining area. Staff B, Certified Nursing Assistant (CNA), sat to the left of Resident 13. The table had 2 other residents there. Resident #13 ate by herself with a spoon in her right hand and lowered her right hand below table height when Staff A, CNA/Certified Medication Aide (CMA), approached the table and forcibly pulled the spoon out of Resident 13's right hand. Staff A pulled up on the handle of the spoon raising Resident 13's hand above the table. Resident #13 had her hand clenched tightly to the handle of the spoon before letting go of the spoon. Resident #13 didn't grimace, make any expression, or speak during this interaction. Staff A used the spoon to cut Resident #13's chocolate cake into pieces. Staff A scooped up a piece of cake up and handed the spoon back to Resident #13. Resident #13 continued to eat independently. Staff A made no comment to Resident #13 or to Staff B prior to pulling the spoon from her hand. Staff A returned to the medication cart located closest to the front entrance after returning the spoon to Resident #13. In an interview on 7/2/25 at12:19 PM, Staff A acknowledged they pulled the spoon away from Resident #13. Staff A verbalized she didn't explain to Resident #13 what she planned to do. Staff A admitted she shouldn't have pulled the spoon from her hand. Staff A commented if you cut her food and give her a bite, she will finish eating. Staff A reported Resident #13 didn't have other silverware provided as she had a known history of placing silverware up her sleeves. In an interview on 7/2/25 at 12:22 PM, Staff B witnessed Staff A pull the spoon from Resident #13's right hand. Staff B reported Staff A didn't verbalized anything prior to pulling the spoon away. Staff B reported it shouldn't have happened and revealed Resident #13 ate at her own pace. In an interview on 7/2/25 at 12:32 PM, the Administrator, Registered Nurse (RN)/ Bachelor of Science in Nursing (BSN), verbalized they allowed Resident #13 the time to eat independently. The Administrator described Resident #13 as a slow eater. The Administrator acknowledged staff members shouldn't pull the silverware away from a resident.Resident #13's July 2025 Documentation Survey Report related to eating listed on 7/2/25 at 12:27 PM Resident #13 completed the activity by themselves with no assistance from a helper. The Documentation Survey Report revealed staff documented Resident #13 ate 0-25% of the meal and drank 0-25% of fluids. Staff training records revealed the following:Staff A completed Dependent Adult Abuse Mandatory Reporter Training on 3/1/24.Staff B completed Dependent Adult Abuse Mandatory Reporter Training on 1/24/23.The facility's undated Resident' [NAME] of Rights stated the following:A. Residents Rights - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.(1) A facility must treat each resident with respect and dignity and care for each resident in a manner in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.The undated Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy documented the following:All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including taking or using photographs or recording in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and/or recordings on social media or through multimedia messages. Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

Based on clinical record review, staff interview and review of the Resident Right the facility staff failed to treat one (1) resident of 1 resident with dignity and respect while providing personal cares (Resident #3). The facility reported a census of 44 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognitive status. On 3/7/25 at 12:09 PM observed Staff A, Certified Nursing Assistant (CNA), Staff B, CNA, and Staff C, Registered Nurse (RN), as Staff A and Staff B provided perineal cares and changed Resident #3's clothes. After completing care for Resident #3, he requested to stay in bed so the staff members positioned him for comfort and covered him, with his sweat pants positioned around his ankles and his disposable undergarment around his knees. Both CNA's indicated they completed his care and left the room along with Staff C. All 3 staff returned to the room after a request, Staff C confirmed the disposable undergarment and sweat pants positioned as documented above and agreed with the dignity issue. On 3/7/25 at 12:30 PM witnessed Staff A and Staff B as they returned to Resident #3's room and pulled up his disposable undergarment and sweat pants while they apologized several times. Review of the facilities Residents' [NAME] of Rights dated December 2016 directed the staff that each resident had the right to a dignified existence.

Based on observations, staff interviews, and facility policy review, the facility failed to practice proper hand hygiene during the lunch meal service and the facility failed to cover food when delivering room trays for 5 of 5 residents (Resident #2, #15, #26, #29, #34). The facility reported a census of 39 residents. Findings include: An observed on 1/16/24 at 11:30 AM, Staff B, Dietary Cook put on clean gloves prior to start serving. Throughout serving she touched the microwave door and buttons on the microwave. Then without changing her gloves or performing hand hygiene proceeded to serve a meal and touch the buttered bread with the dirty gloves and place on the resident's the plate. She then adjusted her mask with her gloved hands. Then without changing her gloves or performing hand hygiene grabbed another plate, dished food, and used her gloved hand to grab garlic bread and place it on the plate. During an observation on 1/16/24 11:40 AM Staff B, Dietary Cook continued to serve the noon meal with the same gloves on. She proceeded to get lunch meat from the refrigerator and touched the roast beef lunch meat with the dirty gloves, grabbed bread out of the bag and made a sandwich for a resident. Then without changing her gloves or performing hand hygiene she put a bowl of soup in the microwave and heated it up. She then took the soup out of the microwave wiped the over spill with a rag and with the same gloved hands proceeded to serve a plate of food. She took a buttered bread slice out of the bag and put it on the plate and served the plate. She then took off her gloves and took a dirty dish to the wash room and then wash her hands. During an interview on 1/16/24 12:29 PM the Dietary Manager reported she expects staff to change gloves between surfaces. A review of the facility Dietary Food Handling Policy, undated, directed staff must wash their hands prior to handling any food surfaces. The policy lacked direction for staff for glove use in the kitchen and when to change them. 42133 2. On 1/16/24 at 11:39 AM the following observations were observed as Staff A, Cook, delivered room trays to resident rooms: a. Staff A pushed a dietary cart of food trays from the kitchen approximately 75 feet into the Gold [NAME] hallway to Resident #15's room. Staff A delivered Resident #15's room tray with uncovered orange Jell-O on the meal tray. b. At 11:40 AM Staff A pushed the cart approximately 10-15 feet further to Resident #2's room and delivered a tray with an uncovered dessert bar. c. At 11:44 AM Staff A pushed the cart out of Gold [NAME] hallway approximately 80 feet into the Cardinal Hallway to Resident #34's room to deliver a lunch tray with an uncovered dessert bar. d. At 11:45 AM Staff A pushed the cart approximately 20 feet down the hallway to Resident #26's room and delivered a lunch tray with uncovered orange Jell-O. e. At 11:48 AM Staff A pushed the cart out of the Cardinal Hallway back to the Gold [NAME] hallway, approximately 100 feet to Resident #29's room and delivered a lunch tray with uncovered Jell-O. During an interview on 1/16/24 at 12:28 PM the Dietary Manager reported she expects all food that goes out on the room trays to be covered. Infection control is huge. The Resident Tray Delivery System Policy, undated, under Procedure directed plate covers will be used over hot foods and bread will be wrapped or placed under plate covers. The Policy lacked direction to cover all food items for transport out of the kitchen/dining room.

Based on clinical record review, policy review, and staff interview the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of status change for 2 of 2 residents reviewed for hospice care (Residents #31 & #39). The facility reported a census of 39. Findings include: The MDS for Resident # 31 showed a significant change assessment completed on 11/15/2023. The Physician Orders noted Resident #31 was admitted to St. Croix Hospice services on 10/26/2023. A Progress Note for Resident # 31 written on 10/26/2023 at 10:18 AM documented a hospice start date of 10/26/2023. The Hospice Admission Consent form, Medicare Hospice Benefit Election form, and the Election of Medicaid Hospice Benefit form were signed and dated on 10/26/2023. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.18.11 dated October 1, 2023 stated that the MDS assessment must be completed no later than 14 calendar days after there has been a determination of a significant change in the resident's status. It is noted that hospice enrollment qualifies as a significant change. During an interview on 01/17/2024 at 1:53 PM the MDS Coordinator explained that she was unaware that the MDS needed to be completed within 14 days of hospice admission. She also explained that the facility follows the RAI Manual in lieu of a separate facility MDS policy. During an interview on 01/17/24 at 2:04 PM the DON expressed that she expects timely completion of all MDS assessments. 42133 2. Resident #39 MDS with an assessment reference date (ARD) 12/27/23 documented Resident #39 was receiving hospice level of care. The MDS Coordinator signed the MDS, Section Z0500 (Registered Nurse (RN) Completion Date) 1/03/24. A Progress Note dated 12/13/23 at 11:41 AM documented Resident #39's legal representative had already requested hospice care. A Telephone Physician Order dated 12/13/23 at 5:30 PM documented Resident #39 appropriate for hospice care services. A Progress Note dated 12/13/23 at 5:32 PM detailed a fax had been received from the Provider documenting Resident #39 as hospice appropriate. A Hospice Physician Order Sheet documented to admit to hospice services on 12/14/23. The Hospice Admission Contract and the Hospice Benefit Election Statement detailed Resident #39's Legal Representative signed Resident #39 into hospice care on 12/14/23. A Hospice Certification and Plan of Care signed by the hospice Attending Physician documented a current benefit period from 12/14/23 to 3/12/24. The facility set the ARD within 14 days of the identification of resident significant change, but failed to complete the MDS within 14 days of the identification of the significant change(12/14/23) per the RAI manual, Chapter 2.

Based on observation, clinical record review, policy review, resident and staff interviews, the facility failed to respect resident rights for 3 of 7 residents reviewed for Dignity/Rights (Residents #1, #2, and #10). Staff failed to treat Resident #1 in a kind and consider manner by yelling at the resident and taking the resident to their room against their wishes. Staff failed to utilize a clean commode for toileting Resident #2 and failed to repeat peri-care after Resident #10 laid on a dirty mattress. The facility identified a census of 39 residents. Findings include: 1. Resident #1 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The Resident was independent in transfer and locomotion (how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities, or treatments). If facility has only one floor, how resident moves to and from distant areas on the floor) in a wheelchair. The MDS listed diagnoses of paranoid schizophrenia, Alzheimer's Disease, Parkinson's Disease, anxiety, depression, and psychotic disorder. The MDS identified the Resident utilized antipsychotic, antianxiety, and antidepressant medications 7 days a week and exhibited hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The Care Plan revised 11/18/22 documented Resident #1 with a behavior problem (yelling out disruptive/verbal abusive) related to hallucinations, a diagnosis of Alzheimer's Disease, generalized anxiety disorder, paranoid schizophrenia, and schizoaffective disorder. The Care Plan directed the staff in the following: a. Explain all procedures to resident before starting and allow her time to adjust to changes. b. Intervene as necessary to protect the rights and safety of others. c. Approach/speak in a calm manner. d. Divert the Resident's attention. e. Remove the Resident from situation and take to an alternate location as needed. f. Caregivers to provided opportunity for positive interaction. A Facility Self-Report documented an incident occurred on 5/25/23 at 9:40 PM. The Incident Summary detailed Staff F, Licensed Practical Nurse (LPN) was at the medication cart preparing medications when Resident #1 approached her and began yelling at her regarding her dentures not being taken care of. Staff G CNA was at the nurses station and said she had already done Resident #1 dentures. The Resident had been going on about her dentures since 7-8 PM and obsessing regarding her dentures despite two staff members taking care of them that night. Resident #1 yelled at Staff G that she was lazy and did not do her dentures; she was a liar. Staff G yelled back at Resident #1 that she had done her dentures and that Resident #1 was lying. Resident #1 proceeded into the dining room and continued to yell. Staff G told Resident #1 she needed to go back to her room. Resident #1 said no and continued to yell in the dining room. Staff G escorted Resident #1 back to her room via wheelchair with Staff F. Staff G and Resident #1 continued to argue back and forth. Staff F told Staff G to knock it off. Staff F directed Staff G to go home. The Report further detailed Staff G had been suspended. An Employee Warning Record for Staff G documented an incident occurred on 5/25/23 at 9:41 PM The Company Remarks noted Staff G yelled very loudly at Resident #1. Staff G got mad at Resident #1 because the Resident called her a liar. Staff G was asked several times by Staff F to quit yelling at Resident #1 and ignored Staff F direction. Staff G then told Resident #1 she had to go back to her room and pushed the Resident to her room in the wheelchair. Resident #1 screamed she didn't want to go. Staff G held onto Resident #1's door and Staff G kept trying to shut the Resident's room door. Staff G ignored Staff F when she told her to stop it. The Employee Warning Record detailed Staff G would be suspended pending an investigation. An undated Written Statement by Staff F detailed Staff G told Resident #1 to go back to her room and the resident stated no and continued to yell in the dining room. Staff G escorted Resident #1 back to her room with the nurse present. Staff G and Resident #1 continued to argue. Staff F intervened and told Staff G to stop and go home. The Statement documented Staff G left, clocked out of the facility at 9:50 PM. Staff F documented in her Statement there had been no physical contact, no profanity used, and Staff G did not call Resident #1 any names. No threats were made by Staff G toward Resident #1. A 5/26/23 Statement written by Staff G documented Staff G yelled back at Resident #1, I did clean your dentures. The Resident continued to yell. Staff G documented in her Statement she escorted Resident #1 back to her room. Resident #1 did not want to stay in her room and continued to yell. The nurse intervened and took over the situation. Staff G documented she never touched Resident #1 and knew she should not have yelled back at Resident #1. During an interview on 9/19/23 at 1:50 PM Resident #1 reported she doesn't feel very good with that aide around. She stated she is telling the truth. She was sitting at the top of the hallway talking to Staff F about how everyone is against her and running her down. She just wanted Staff F to tell Staff G to be nice to her. She was just sitting in her wheelchair when Staff G came took her back to her room and closed her door. She asked Staff G to open the door and she said no. She had a right to have her door open. She then reported Staff G choked her with her hands around her throat for a long time and slapped her. Staff F came down and told Staff G to quit that. Resident #1 denied she was talking about her dentures and said the incident had nothing to do with dentures. She voiced one other time she was sitting in the hallway and Staff G asked if she could go by her and then thanked her for letting her go by. Resident #1 reported it was just like she is trying to make up for something. Resident #1 reported she only tells the truth and verbalized being upset that others involved in the incident had to be interviewed. Resident #1 reported you only need to hear what I tell you, no one else. During an interview on 9/19/23 at 4:22 PM Staff F reported Resident #1 and Staff G were arguing up at the nurses station. Resident #1 kept yelling at Staff G that she didn't clean her dentures. When Resident #1 wants her dentures cleaned, she wants them done right now. Staff G reported she had already cleaned Resident #1's dentures. Resident #1 yelled at Staff G she was a liar and Staff G yelled back at the resident she was a liar. Both were calling each other liars. Staff F reported she felt it was a dignity issue when Staff G took the resident back to her room as Resident #1 clearly stated she didn't want to go to her room. Staff G shouldn't have closed the door on Resident #1 as she had the right to have her door open. She followed them down the hallway to the resident's room and intervened right away and told Staff G to knock it off. Once Resident #1's door was opened Resident #1 started yelling at Staff G calling her a liar again. Staff F had Staff G clock out and leave the facility to avoid further escalation. Staff F reported having eyes on both Resident #1 and Staff G the entire time. There was never any physical contact between them and Staff G never entered Resident #1's room. Staff F reported she did write up Staff G for primarily yelling at the Resident. She reported the incident to the Director of Nursing (DON). On 9/20/23 at 11:49 AM Staff H CNA reported she had been sitting at the nurses' station when Resident #1 came up and stated yelling at the nurse. Staff G walked over to the Resident and directed her back to her room. Staff H went back to her hallway to finish cares. Staff H verbalized she was in room [ROOM NUMBER] or 23 and heard Resident #1 and Staff G yelling back and forth at each other. When she came into the Resident's hallway, Staff F and Staff G were standing outside of Resident #1 doorway. Resident #1 had a hold of her door like she was trying to shut the staff out of her room. On 9/20/23 at 1:45 PM Staff I CNA/Certified Medication Aide (CMA) verbalized if a resident voices they do not want to go to their room and the staff take them anyway, that is very disrespectful to the resident and shouldn't happen. On 9/20/23 at 2:44 PM Staff J CNA reported Resident #1 would comment that Staff G had been in her room, but it was other aides. She did occasionally get staff mixed up. Resident #1 had accused her of being staff G a few times. Regarding 5/25/23 around 9:00 - 9:15 PM Resident #1 came up the hallway and started yelling at the nurse. Staff G sat at the nurses' station and heard her name and started yelling at the Resident. She couldn't remember the exact words but Staff G was upset and yelling. She recalled telling Staff G to lower her voice. She later saw Staff G leave the facility. She didn't recall exactly what was being yelled. During an interview on 9/20/23 at 3:01 PM Staff F reported Resident #1 voiced she didn't want to go back to her room and Staff G just wheeled her back to her room pretty quickly. The whole reason she wrote Staff G up was for yelling back and forth at Resident #1. The Resident had yelled she didn't want to go back to her room. She felt Staff G should have just left Resident #1 alone to calm down. Staff F expressed she felt Resident #1 resident rights had been violated when she took her back to her room, shut the door and Staff G had her hand on the door knob. It was only a few seconds and the resident did pull the door open. On 9/20/23 at 3:59 PM Staff G reported on 5/25/23 Resident #1 had been really agitated. She reported Resident #1 looked at her and stated you don't do shit around here. She stepped in to try to calm the Resident down. She assisted the Resident back to her room. Staff G reported she did recall that Resident #1 said she didn't want to go back to her room. Staff G she likes taking care of people and is not that kind of person. Staff G explained she can do small things for the Resident at the nurses station, but she does not do any cares for her in her room anymore. During an interview on 9/21/23 at 11:59 PM the Administrator with the DON present reported Staff G had been disrespectful toward Resident #1. Staff G should not have yelled back at Resident #1. Her reactions were poor and she made poor choices that night. Staff G had definitely been disrespectful of the Resident's rights and dignity. The Administrator reported she expected the staff to follow resident rights and treat all residents with dignity and respect. The Resident's [NAME] of Rights dated 12/16 provided by the facility in Section A Residents Rights directed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of residents. Under Section E Respect and Dignity the Policy directed the resident has a right to be treated with respect and dignity including (3) the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when doing so would endanger the health and safety of the resident or other residents. 2. Resident #2's MDS dated [DATE] showed a BIMS score of 15 indicating intact cognition. The resident required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene. The MDS identified Resident #2 as frequently incontinent of bladder and occasionally incontinent of bowel. The MDS listed diagnoses of Alzheimer's Disease with early onset, coronary artery disease (CAD), hypertension, depression, and age-related macular degeneration of the left eye (an eye disease that can blur your central vision). The Care Plan with a revised date of 4/11/23 documented Resident #2 has bladder incontinence related to limited mobility, unspecified urinary incontinence, and a cognitive deficit. The Care Plan directed the staff to offer toileting as needed before and after meals and activities to promote appropriate bowel and bladder emptying. During an observation on 9/18/23 at 12:43 PM Staff A CNA pushed a commode chair down the hallway toward Resident #2's room. The commode bucket visible under the chair had an approximate one inch brown substance with the appearance of bowel movement stuck down along the top rim of the pan and in four 3/4 inch scattered areas on the outside left side of the commode pan. Staff A stated Resident #2 wanted to use the commode. She stated she needed to go check to see if she could get her partner to help her. At 12:46 PM Staff A and Staff B CNA knocked on the door and asked permission to enter the resident's room with the commode. Staff B pulled the curtains to provide privacy to the resident for toilet use. Staff A and Staff B assisted Resident #2 to transfer to the commode, completed peri-care, and assisted to transfer the resident to the bed. At the end of Resident #2 care a check of the bottom of the commode chair was completed and revealed a dried brown stuck down substance splattered under the toilet seat of the chair that ran down the outer left-hand side of the toilet seat in addition to the brown substance on the commode bucket. Staff B reported the commodes are to be cleaned after each resident use. In an interview on 9/18/23 at 1:03 PM Staff B reported the commodes are to be cleaned after each resident use and disinfected with Oxivir. She reported the commode should not have been used for resident care. On 9/20/23 at 10:37 AM Staff C, CNA reported the commodes are to be cleaned after each use with the Oxivir. A dirty commode should not be used to toilet a resident. She reported that would not be treating a resident with dignity. On 9/20/23 at 11:00 AM Staff D, Registered Nurse (RN)/Assistant Director of Nursing (ADON) stated she expects the commodes to be disinfected with the Oxivir. The commodes are also scheduled to be deep cleaned at night. They are working on revising that cleaning schedule so that the staff sign their name and can be accountable if something is missed. They just started working on that revision recently. She reported using a dirty commode is not appropriate for the resident's dignity. She wouldn't want to use a dirty toilet herself. During an interview on 9/20/23 at 2:05 PM the Director of Nursing (DON) reported the commodes are to cleaned and disinfected with Oxivir after every resident use. A dirty commode should not be used for resident care. Resident's should absolutely be treated with dignity. 3. The MDS assessment dated [DATE] detailed Resident #10 with long/short term memory impairment and modified independence (difficulty in new situations only) in daily decision making. The Resident required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS detailed the Resident as continent of bladder and frequently incontinent of bowel. The MDS listed diagnoses of Non-Alzheimer's Dementia and hip fracture. The Care Plan revised 8/28/23 specified a focus problem of bladder incontinence related to dementia and benign prostatic hyperplasia (BPH, enlarge prostate). The Care Plan directed the staff to assist as needed towards cleaning peri-area with each incontinence episode. The Care Plan also detailed Resident #10 had a communication problem and directed the staff to anticipate and meet the resident's needs. During an observation on 9/19/23 at 9:39 a.m. Staff E, CNA cleansed the Resident's frontal peri-area using her right gloved hand. She then touched Resident #10 with the right gloved hand on his left outer hip and assisted him onto his right side. At 9:41 a.m. Staff E removed the Resident's dirty brief by breaking the side panel of the brief from underneath the resident. The brief was visibly soaked with urine and a large amount of brownish red wound drainage. Once positioned to his right side, observation further revealed a large circular area approximately 18 inches long by 18 inches wide of a dried yellow discoloration of the bed chux pad which continued with an approximate 10 inch long by 6 inch wide dried yellow discoloration onto the fitted mattress sheet. It had the appearance of dried urine. Staff E cleansed the buttock crease and removed her gloves. At 9:55 a.m. Staff D assisted the Resident to roll from his right side to his back and Staff E rolled the dirty fitted bottom sheet and chux pad out from under Resident #10. Resident #10 lay half on his back on the dirty mattress as Staff D performed his wound dressing change to his right hip. After the completion of the wound dressing change, Staff E assisted Resident #10 to dress his lower body while still laying on the dirty mattress. On 9/20/23 at 10:37 AM Staff C verbalized if a resident has dried urine on the bed linens that go to the mattress they should let housekeeping know or the aides should disinfect the mattress with Oxivir or the resident should be positioned on a clean chux over the dirty mattress before peri-cares are provided. The resident should have had peri-cares re-done after placing a clean chux over the mattress. She reported that would not be treating a resident with dignity. On 9/20/23 at 11:05 AM Staff D explained Resident #10 mattress should have been sanitized prior to peri-care or the staff should have placed a clean chux pad placed over the mattress before completing peri-cares and dressing the resident. She reported the staff had not treated the resident with dignity by letting him lay on the dirty mattress. During an interview on 9/20/23 at 4:30 PM the Director of Nursing (DON) reported the staff should have put a clean barrier underneath Resident #10 and then completed peri-care again before dressing the resident's lower body or should have sanitized the mattress and then completed cares. She reported it wasn't dignified for the staff to let the resident lay on the dirty mattress after peri-care and continue to dress the resident.

Based on observation, clinical record review, policy review, Center for Disease Control and Prevention (CDC) disinfection guidelines, and staff interviews, the facility failed to sanitize a commode used to toilet Resident #2 and failed to prevent potential cross contamination and potential for urinary tract infection when Resident #6 Foley Catheter bag came in contact with the floor for 2 of 5 residents sampled for infection control. The facility reported a census of 39 residents. Findings include: 1. Resident #2's MDS assessment dated [DATE] showed a BIMS score of 15 indicating intact cognition. The resident required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene. The MDS identified Resident #2 as frequently incontinent of bladder and occasionally incontinent of bowel. The MDS listed diagnoses of Alzheimer's Disease with early onset, coronary artery disease (CAD), hypertension, depression, and age-related macular degeneration of the left eye (an eye disease that can blur your central vision). The Care Plan with a revised date of 4/11/23 documented Resident #2 has bladder incontinence related to limited mobility, unspecified urinary incontinence, and a cognitive deficit. The Care Plan directed the staff to offer toilet use as needed before and after meals and activities to promote appropriate bowel and bladder emptying. During an observation on 9/18/23 at 12:43 PM Staff A, CNA pushed a commode chair down the hallway toward Resident #2's room. The commode bucket visible under the chair had an approximate one inch brown substance with the appearance of bowel movement stuck down along the top rim of the pan and in four 3/4 inch scattered areas on the outside left side of the commode pan. Staff A stated Resident #2 wanted to use the commode. At 12:46 PM Staff A and Staff B provided toileting cares to Resident #2 utilizing the dirty commode. At the end of Resident #2's care a check of the bottom of the commode chair was completed and revealed a dried brown stuck down substance splattered under the toilet seat of the chair that ran down the outer left-hand side of the toilet seat in addition to the brown substance on the commode bucket. Staff B reported the commodes are to be cleaned after each resident use. In an interview on 9/18/23 at 1:03 PM Staff B reported the commodes are to be cleaned after each resident use and disinfected with Oxivir. She reported the commode should not have been used for resident care. On 9/20/23 at 10:37 AM Staff C, CNA reported the commodes are to be cleaned after each use with the Oxivir. A dirty commode should not be used to toilet a resident. On 9/20/23 at 11:00 AM Staff D Registered Nurse (RN)/Assistant Director of Nursing (ADON) stated she expects the commodes to be disinfected with the Oxivir. The commodes are also scheduled to be deep cleaned at night. They are working on revising that cleaning schedule so that the staff sign their name and can be accountable if something is missed. They just started working on that revision recently. She reported using a dirty commode is not appropriate. She wouldn't want to use a dirty toilet herself. During an interview on 9/20/23 at 2:05 PM the Director of Nursing (DON) reported the commodes are to be cleaned and disinfected with Oxivir after every resident use. There is a schedule of when the commodes are to be cleaned at night. They are working on a schedule where CNA's would be assigned to deep clean the commodes weekly. There really hasn't been anything in place up to this point. They have been starting to work on this. They had pulled the list earlier this week as an issue was identified they were just placing a X on a calendar and then not signing who had actually cleaned it. It is a work in progress. She reported she did not have any documentation that she could show for commode cleaning or when the commode had last been cleaned. A dirty commode should not be used for resident care. The Sanitizing Reusable Equipment by Nursing Staff Policy, undated, provided by the facility documented sanitizing is the most commonly used method for cleaning reusable items for the residents or for cleaning equipment that is used by different residents. Items used by different residents must be sanitized after each use. 2. Resident #6's MDS assessment dated [DATE] showed a BIMS score of 15 indicating intact cognition. The Resident required extensive assistance with dressing, toilet use, and personal hygiene. The MDS identified Resident #6 utilized an indwelling urinary catheter and included diagnoses of Parkinson's Disease, cancer, heart failure, end stage renal disease, and obstructive uropathy (occurs when urine cannot drain properly through the urinary tract). The Care Plan revised 4/20/23 documented Resident #6 had an indwelling urinary catheter and directed the staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor for signs and symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, and to monitor for pain/discomfort due to the catheter placement. During an observation on 9/19/23 at 1:26 PM Resident #6 sat in his recliner with his Foley catheter bag attached to the garbage can with the bottom of the Foley catheter bag resting directly on the floor. The Foley drained yellow urine into a half full catheter bag. On 9/19/23 at 1:31 PM Staff A, CNA performed hand hygiene, applied gloves, laid two paper towels down on the floor, placed a plastic graduate on the paper towels and proceeded to pick up the Foley catheter bag from the side of the trash can and drain into the graduate. Staff A attached the hook of the Foley catheter bag back on to the side of the garbage can leaving the bottom of the catheter bag in direct contact with the floor. Before leaving the room, Staff A pushed the bedside table toward the resident with the wheel of the bedside table rolling over the bottom 1 inch of the catheter bag on the floor. During an interview on 9/19/23 at 1:37 PM Resident #10 reported he has not had any issues with bladder infections and he didn't want to have any bladder infections. On 9/20/23 at 10:37 AM Staff C stated the catheter bags should not be on the floor as that could place the resident at a risk of infection. On 9/20/23 at 11:08 AM Staff D explained the Foley catheter bags are to be covered by the black privacy bags up off the floor. It increases the risk of urinary tract infection if the catheter bags are on the floor. During an interview on 9/20/23 at 2:13 PM the DON reported they have a policy regarding care of the catheter bags. She expects the staff to keep the catheter bags from coming into contact with the floor.

Based on observation and staff interview the facility failed to cover garbage cans with tight fitting lids when not in use. The facility reported a census of 39 residents. Findings include: During an observation on 7/25/22 at 10:49 AM there was a large barrel trash can against the wall between the clean cup cart and the stand mixer. The trash was approximately half full with discarded food products and empty beverage cartons. No lid was observed in the area. During an observation on 7/27/22 at 10:32 AM the same trash can in the same location was heaping full and not covered. No lid was observed in the area. During an observation on 7/27/22 at 11:19 AM the same trash can in the same location remained heaping full and not covered. No lid was observed in the area. During an observation on 7/27/22 at 12:15 PM a dietary aide was observed placing an empty milk carton in the heaping full trash can and pushing down to make room for the carton. During an interview on 7/27/22 at 1:20 PM the Dietary Manager stated the trash can is always uncovered. She stated they usually take out the trash when it is full and after lunch. She stated she did not know why it was overflowing. She stated she would not expect the trash can to be heaping full and stated she was surprised it was. She stated she was unsure if there was a policy for taking out the trash. During an interview on 7/27/22 at 1:51 PM the Dietary Manager stated there is no policy for taking out the trash. She stated it should have been covered.

Based on clinical record review, staff interview and in room video surveillance along with photographic evidence, the facility failed to use proper Personal Protective Equipment (PPE) for infection control measures in attempts to mitigate the transmission of the Covid - 19 virus with one resident, (Resident #2). The facility reported a census of 46 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment with reference date 8/11/20, documented Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had scored 10 of 15 on a BIMS (brief interview for mental status) which indicated moderate impaired decision making abilities. The resident had required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #2's Care Plan with initiated date 1/16/20, showed resident had focus areas of heart failure, pacemaker related to heart failure, and alteration in psychosocial well being related to restrictions on visitation, communal dining, and activities during the COVID-19 restriction time. Interventions include: *Check breath sounds and monitor/document for labored breathing. *Give cardiac medications as ordered. *Monitor vital signs per facility protocol or per my physicians orders. Notify Medical Doctor of significant abnormalities. *Monitor/Document/report any signs/symptoms of Congestive Heart Failure, dependent [CONDITION(S)] of legs and feet, periorbital [CONDITION(S)], shortness of breath upon exertion, cool skin dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation. *Oxygen per doctor orders. *Monitor/document/report any signs or symptoms of altered cardiac output or pacemaker malfunction, dizziness, [CONDITION(S)], difficulty breathing, pulse rate lower than programmed rate, lower than baseline blood pressure. *Pacemaker checks per physicians/manufacturers recommendations and document in chart, heart rate, rhythm, battery check. *Assist with personal request for snacks, drinks, activities, cares and alternative options for communication, care packages. *Monitor for changes in psychosocial status, decreased conversations, change in mood, decreased interactions with staff. *Provide and encourage alternate options for activities interactions such as audio books, movies on portable players, hand held games, word finds/search puzzles, crafts, interactive games in the hall from the doorways of room. Review of in room photographic images provided by the family revealed: *At 7:42 a.m., no date, Staff B, Certified Nursing Assistant, (CNA) in Resident #2's room with no mask covering their mouth. *At 5:51 p.m., no date, Staff C, CNA in Resident #2' room with the face mask below their nose, not covering their mouth. *At 7:34 a.m., no date, Staff D, CNA in Resident #2's room with the face mask below their chin. *At 12:57 a.m., no date, Staff D, CNA, in Resident #2's room with the face mask below their chin. *At 7:00 a.m., no date, Staff B, CNA, in Resident #2's room with the face mask below their nose. *At 9:12 a.m., no date, Staff C, CNA, in Resident #2's room with the face mask below their nose. Review of the video surveillance the family provided, revealed on 6/28/20 at 7:25 p.m., Staff E, CNA in Resident #2's room with no face mask or face covering. Review of a facility form provided by the Administrator on 9/24/20 dated 4/6/20, showed the education staff had been provided for the facility policy on wearing masks. The form noted in response to some questions related to use of masks, here is some guidance we would like to offer: 1. Use of the masks while on duty and in the facility is not negotiable-everyone is required to wear one. During an interview on 9/23/20 at 3:40 p.m., the Administrator confirmed and verified staff are expected to follow facility protocol for wearing Personal Protective Equipment during patient cares and contact.

Based on clinical record review, staff interview and manufacturer guideline, the facility failed to follow the plan of care for a resident who sustained a fall while in a Lumex lift, (Resident #2). The facility census was 46 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) with assessment reference date 8/11/20, documented Resident #2 had diagnosis of [CONDITION(S)], Heart failure, Diabetes Mellitus, [CONDITION(S)], Depression, Age-related physical debility and chronic pain. The resident had a score of 10 of 15 on a BIMS (brief interview for mental status) which indicated moderate impaired decision making abilities. The resident had required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #2's balance during transitions and walking was not steady, only able to stabilize with staff assistance and wheelchair used for mobility device. Resident #2's Plan of Care with a initiated date of 2/17/18, documented resident was at risk for falls related to psychoactive drug use, weakness and history of falls. Interventions include: *Be sure call light/pendent is with in reach and encourage resident to use it for assistance as needed. *Resident had a fall with right clavicle fracture in October 2017 and on 4/4/19 resulting in left femur fracture. *Resident needs a safe environment with (even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light/pendent in reach, the bed at appropriate height, side rails as ordered, personal items within reach). *Staff to refer to Resident Care Guideline posted in resident room for safety instruction. The Resident Care Guidelines with a date of 6/5/20, instructed staff to use the Lumex with two assist on the 2nd and 3rd shift, and assistive device of the gait belt, and rolling walker. The Physician Notification Form/Progress notes dated 6/28/20 at 7:25 p.m., documented upon entering resident room, the resident was sitting on floor in front of recliner, legs extended out in front of resident. The Lumex was in front of resident just out of reach of feet, gait belt around resident. Resident was being transferred back into recliner after using the restroom. Resident laughing about incident, good spirits, resident had silky pajamas on and it appears the recliner was at an incline that coupled with a silky material made it easy to slip out of chair. Staff re-education. Administrative review: incident during staff transfer-no injuries noted, with related to staff and equipment. Intervention to make sure resident has no silk pajamas on and staff discipline. Review of the LUMEX LF 1600 Stand Assist Assembly and Operation Manual dated 2007, Instructed staff to: *Raise the two split seat units so they are parallel to the side of the Stand Assist. *Have the patient positioned at the edge of the surface to be transferred from. Move the Stand Assist in front of the patient. Position the patient so that her feet are firmly on the platform and her knees an shins are in contact with the two cupped kneepads. *Lock the casters by stepping on the [NAME] clip and pushing down. *Have the patient grasp the cross bar closest to her and, using her own strength, pull herself up into a standing position securely on the base platform. *Lower both of the split seat units down into position to form a complete seat. *Have the patient lower herself down onto the seat while keeping her knees and shins in the kneepads, and while continuing to hold the cross bar with both hands. *Unlock the casters. Place both hands on the cross bar furthest from the patient, and move the Stand Assist to the new surface. Ensure that the patient is secure and in proper position, before and during transfer. *Position the Stand Assist against the new surface, ensuring that the patient will be in a position to sit down firmly and safely on the transfer surface. *Lock the casters. *Have the patient pull herself back up to a full standing position. *Raise the two split seat units so that they are parallel to the side of the Stand Assist, to allow the patient to lower herself. *Stand beside the patient as she lowers herself down onto the new surface. *Ensure that the patient is safely positioned. Unlock the casters and move the Stand Assist to storage. Review of the video surveillance dated 6/28/20, revealed Staff A, Certified Nursing Assistant (CNA), failed to apply a gait belt to the patient prior to the use of the Lumex Stand Assist, failed to lock the casters and did the transfer with one assist instead of two. During an interview on 9/23/20 at 4:41 p.m., Staff A, confirmed and verified the gait belt was applied to the resident after the resident was on the floor and the casters to the Lumex Stand Assist were not locked and the Resident Care Guidelines state Resident #2 is a 2 person transfer and that Staff A, did the transfer alone. During an interview on 9/23/20 at 4:30 p.m., the facility Administrator stated the facility does not have a gait belt policy, however, the staff are to follow the Resident Care Guidelines (RCG) that are in the resident room, and if the RCG's states to use a gait belt than it is the expectation of staff to use a gait belt.

Based on clinical record review and staff interview the facility failed to submit a PASSAR (Pre Admission Screening and Resident Review) for review for one of one resident reviewed with a qualifying mental health diagnosis. (Resident #53). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) for Resident #53 dated 5/8/19, included a Basic Interview for Mental Status (BIMS) score of a nine which indicated moderate cognitive impairment. The MDS active [DIAGNOSES REDACTED]. Clinical record revealed a PASSAR assessment dated [DATE], which indicated the resident had no mental health diagnosis. A Medication Review Report printed 6/5/19, included [DIAGNOSES REDACTED]. On 6/5/19 at 8:16 a.m., the Director of Nursing stated during interview a new PASSAR should have been submitted for this resident.

Based on observation, clinical record review and staff interview the facility failed to ensure incontinence care was completed in a manner to prevent infection, odor and skin breakdown for one of four residents reviewed that required assistance with personal cares. (#56). The facility reported a census of 57. The Minimum Data Set ((MDS) dated [DATE] for Resident #56 listed [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance of two for bed mobility, transfers, toileting and personal hygiene. The MDS documented the resident had been frequently incontinent of bladder and had severely impaired cognitive skills. During an observation of incontinence care on 6/4/19 at 3:50 p.m., Staff A and Staff B, both Certified Nurse's Aides (CNA) washed their hands and donned gloves. Staff B removed a urine-soaked incontinence brief from the resident. Using disposable wipes, Staff A cleansed over the resident's frontal groin area with the same disposable wipe repeatedly using a scrubbing motion and without turning the wipe to a clean area. Staff A repeated this with 3 disposable wipes, removed her gloves, sanitized her hands and donned new gloves. The resident rolled to the left hip. Staff A used a disposable wipe to clean both buttocks with a scrubbing motion, not turning the wipe to a clean area. The CNA repeated this process with 3 disposable wipes in the same manner. Staff A wiped down the buttocks crease from the back towards the central perineal area. Wearing the same gloves, Staff A placed a clean incontinence brief under the resident and secured it before removing her gloves. Staff C, Registered Nurse (RN) verified during interview on 6/5/19 at 1:15 p.m., staff A completed improper incontinence care. Staff C stated staff are trained to wash the frontal area first, turning the cloth with each wipe and when washing the resident's backside to make a heart-shaped motion up the buttock and down the hip in one swipe. The Director of Nursing (DON) stated during interview on 6/5/19 at 2:30 p.m., the expectation is that staff complete incontinence care by cleansing the frontal groin area first, working from the center outward and cleansing from the front to the back, using a new disposable wipe for each area or turning the washcloth to a clean area. The DON stated after the resident is rolled to the side, staff are taught to make a heart-shaped motion up the buttock area and down the hip to cleanse the resident's posterior.

Based on clinical record review and staff interviews the facility failed to provide adequate supervision and assistance when staff transferred one of three residents without the use of a gait belt (Resident #1) that resulted in a fall and a right [MEDICAL CONDITION]. The facility reported a census of 55 residents. Findings include: 1.According to the MDS (Minimum Data Set) dated 4/28/2018, Resident #1 had moderately impaired cognitive skills for daily decision making, and transferred and ambulated in the room with extensive assistance of one staff. The MDS revealed the resident had [DIAGNOSES REDACTED]. The Care Plan initiated on 11/1/2017, identified Resident #1 dependence on staff to meet his intellectual, physical and social needs related to physical limitations. It instructed staff to refer to the RCG's (Resident Care Guidelines) posted in the resident's room for all direct care needs and safety instruction. It instructed staff to encourage the resident to use the call light to call for assistance and not expect the resident's use of call light. The Care Plan documented the resident had a risk for falls due to being unaware of safety needs. It instructed staff to provide a high-low bed when occupied, provide a safe environment, footwear and call light. It directed staff to refer to RCG's in the resident's room for safety instruction and attempt to anticipate the resident's needs. The resident had a fall risk prior to being admitted to the facility. The RCG's dated 3/29/2018 directed staff to provide transfers and ambulation with Contact Guard Assistance with the use of a gait belt and a rolling walker. The Major Injury Determination Form signed by the physician on 6/24/2018 revealed Resident #1 sustained a major injury when he had a witnessed fall in the bathroom on 6/23/2018. The Physician Notification Form dated 6/23/2018 revealed Resident #1 fell with Staff A, CNA (Certified Nurse's Aide) in the resident's bathroom. Staff A attempted to help the resident pull his pants down, the resident lost his balance and fell to the floor. The resident had no gait belt on. The resident also sustained skin tears to the left elbow, right hand and right wrist. The emergency room Report dated 6/24/2018 revealed Resident #1 fell at the nursing home and sustained a right femoral neck (hip) fracture. The emergency department transferred the resident to a larger hospital. The computed tomography CT (provides cross section images) scan dated 6/24/2018 revealed Resident #1 had [DIAGNOSES REDACTED]. The Chest x-ray indicated the resident had cardiomegaly and no consolidation to suggest pneumonia. The Right Hip x-ray revealed the resident had a possible nondisplaced greater trochanteric fracture on the right. No femoral neck fracture is identified. The Hospital History and Physical dated 6/25/2018 included: The patient with multiple underlying chronic comorbidities who had presented with [MEDICAL CONDITION], acute hypoxic [MEDICAL CONDITION], acute renal and heart failure. The patient's condition deteriorated despite medical management and family decided no further aggressive medical management or hospitalization and requested comfort care and symptom management under hospice care. The Discharge Summary dated 6/27/2018 revealed the resident received hospice care services. The State of Iowa Certificate of Death filed on 7/9/2018 included: Immediate cause of death:[MEDICAL CONDITION] Due to or as a consequence of right [MEDICAL CONDITION] due to accidental fall Other significant conditions: dementia. During an interview on 8/17/2018 at approximately 1:00 p.m. and 8/21/2018 at 3:30 p.m., Staff B, RN (Registered Nurse), DON (Director of Nursing) revealed when Resident #1 fell on [DATE] Staff A, CNA failed to use a gait belt during the transfer to the toilet. As Staff A pulled the resident's pants down, the resident lost his balance, fell to the floor and initially had no complaints of pain. The pain progressed into third shift and staff transferred the resident to the emergency room where tests determined the resident had a right [MEDICAL CONDITION]. The resident's RCG's documented staff were required to transfer the resident with Contact Guard Assist and a gait belt. The RCG's are posted in each resident's room. Contact Guard Assist means at least one hand on the gait belt at all times. During an interview on 8/17/2018 at 1:00 p.m., Staff A reported working on 6/23/2018 when Resident #1 fell in the bathroom. Staff A revealed he/she transferred the resident from the recliner to the wheel chair without a gait belt, transported the resident to the bathroom doorway. Next Staff A ambulated the resident from the doorway with a walker to the toilet without a gait belt. The resident held onto the grab bar while Staff A lowered the resident's pants and the resident lost his balance and fell landing on his right side. The resident had no complaint of pain but did sustain skin tears. Staff A received re-education regarding gait belt use. Staff A reported knowing the gait belt policy to use it for all residents who require assistance.

Based on clinical record review and staff interview, the facility administered as needed medications to five of 11 residents prior to 6:00 a.m., when most persons in our society consider the hours between 10:00 p.m. and 6:00 a.m. as normal sleep hours. (Resident #1, #4, #11, #8 & #9) The facility census was 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident received Hospice care. A Medication Review Report dated 10/4/16, documented an ordered for [MEDICATION NAME] suppository 10 milligrams insert 1 rectally one time a day as needed for constipation. The Medication Administration Record [REDACTED] a. 12/9/16 at 4:40 a.m. b. 12/13/16 at 5:10 a.m. c. 12/17/16 at 5:20 a.m. d. 12/21/16 at 5:30 a.m. The MAR for 11/1/16-11/30/16, documented the [MEDICATION NAME] suppository was administered on the following dates and times: a. 11/3/16 at 5:28 a.m. b. 11/14/16 at 5:15 a.m. c. 11/18/16 at 5:30 a.m. d. 11/29/16 at 4:50 a.m. 2. The MDS assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. and had a BIMS score of 8, indicating impaired cognition. A Medication Review Report form dated 10/12/16, documented an order for [REDACTED]. The MAR for 11/1/16-11/30/16, documented the [MEDICATION NAME] suppository was administered on 11/1/16 at 4:50 a.m. and on 11/24/16 at 4:45 a.m. 3. The MDS assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. A Medication Review Report dated 10/3/16, documented an order for [REDACTED]. The MAR for 12/1/16-12/31/16, documented the [MEDICATION NAME] suppository was administered on 12/3/16 at 4:50 a.m., on 12/4/16 at 5:20 a.m. and on 12/19/16 at 4:30 a.m. The MAR for 11/1/16-11/30/16, documented the [MEDICATION NAME] suppository was administered on 11/1/16 at 4:20 a.m. and on 11/14/16 at 4:50 a.m. During interview on 12/20/16 at 6:50 a.m., Staff C, licensed practical nurse stated when staff do rounds the suppositories are administered. Staff C stated some residents stay awake after the suppository and some will go back to sleep, all depends on the resident. During interview on 12/21/16 at 2:44 p.m., the assistant director of nursing stated the expectation was for nursing staff to administered medications after 6:00 a.m., unless the medication was scheduled prior. During the surveyor entrance conference on 12/19/16 at 9:45 a.m., the Director of Nursing, DON provided the surveyor with the facility medication pass guidelines which documented morning medication pass started at 7:00 a.m 5. The MDS assessment dated [DATE], documented Resident #8 had [DIAGNOSES REDACTED]. The MAR for the month of November 2016, included an order for [REDACTED]. Review of the MAR for the month of December 2016, revealed the resident received the medication on 12/6/16 at 5:45 a.m. 6. The MDS assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The MAR for the month of October 2016, included an order for [REDACTED]. Review of the MAR for the month of November 2016, revealed the resident received the medication on 11/12/16 at 5:35 a.m. Review of the MAR for the month of December 2016, revealed the resident received the medication on 12/3/16 at 5:40 a.m. During interview on 12/22/16 at 6:40 a.m., the DON stated they had posted a sign in the medication room to educate nurses on not giving medications prior to 6:00 a.m. The DON stated they did not know why the two nurses had been giving the suppositories prior to 6:00 a.m.

Based on observation and staff interview, the facility failed to ensure all resident areas were maintained in a clean and sanitary manner. The facility census was 45 residents. Findings include: 1. During the environmental tour on 12/20/16 at 2:03 p.m., observation in the beauty shop revealed a large amount of black hair on a folded white towel that lay stacked on a wheeled cart. The shelves of the cart had visible hair present. Observation revealed hair on the sink as well as on the beauty shop chair and base of chair. At the time Staff D, maintenance stated the beautician was responsible for cleaning the shop after each use. During the tour the shop was locked and not in use. On 12/21/16 at 3:00 p.m., Staff D stated housekeeping would now be cleaning the beauty shop.

Based on clinical record review and interviews, the facility failed to ensure 1 of 4 residents remained free from abuse. Resident #1 reported Staff H gave him/her a [MEDICATION NAME] bar . Staff interviews revealed Staff H confirmed giving Resident #1 a non-prescribed medication ([MEDICATION NAME]). The facility reported a census of 44 residents. Findings: 1. A Minimum Data Set (MDS) assessment dated [DATE] identify Resident #1 ' s Brief Interview for Mental Status scored 15 out of 15 which revealed no cognitive impairment. The resident did not walk and required assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of the clinical record for Resident #1 revealed an admitted on 5/28/15 to the facility. The resident ' s medical [DIAGNOSES REDACTED]. Care Plan dated 6/8/15 and revised on 11/24/15 included the following: Staff monitor/report signs and symptoms of [MEDICAL CONDITION] including: dizziness, lightheaded and altered vision. Resident continues to be educated on consequences of non-compliance but continues to make these choices. The resident ' s care plan also identified the following: a. Staff ensure safe environment, staff periodically check on resident. b. Staff monitor closely for signs and symptoms of [MEDICAL CONDITION]. c. Administer medications as ordered. Monitor/document for side effects and effectiveness. d. Monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. e. Monitor/record/report to physician as needed acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. f. Monitor/record/report to physician mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. g. Monitor/record/report to physician as needed risk for harming others. i. Observe for signs and symptoms [MEDICAL CONDITION] hypomania racing thoughts or euphoria; increase irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or [MEDICAL CONDITION]. Progress Note dated 2/16/16 at 9:22 p.m. documented Resident #1 very sleepy this shift, the resident had slept most of the last half of the shift. Resident #1 hard to arouse and understand at times, and his/her mental status lethargic. The resident ' s respirations were even and unlabored, and the resident had no shortness of breath. A Neuro/Sensory status documented his/her eye reacts sluggish; speech mumbled; limp extremities. The nurse called the physician, and a new order received to monitor the resident. The note documented call placed to resident's family. Progress Note dated 2/16/16 at 9:55 p.m. identified staff spoke with the resident, he/she reported taking some [MEDICATION NAME] but was sure how much. The staff educated Resident #1 for possible drug interactions with the medications normally (prescribed by his/her physician) and what could happen. Progress Note dated 2/16/16 at 11:30 p.m. Resident rested in bed, remained sleepy. The resident responsive and mumbles when asked questions. Progress Note dated 2/17/16 at 8:17 a.m. resident rested in bed, speech clear without slurring. His/her pupils equal and reactive. The resident had been able to state what time of day and name the year correctly. A Social Worker Progress Note dated 2/23/16 visited with Resident #1 today regarding the events of last week. Staff asked Resident #1 why he/she took [MEDICATION NAME]. Resident #1 stated because he/she felt like it. He/she stated they did not know the [MEDICATION NAME] would affect him/her like that or he/she would not have taken the [MEDICATION NAME]. When interviewed on 2/29/16 at 4:30 p.m. Resident #1 reported he/she took [MEDICATION NAME] and he/she did not want to identify who gave him/her the [MEDICATION NAME] and did not want to get anyone in trouble. When asked if a nursing assistant, Staff H gave him/her [MEDICATION NAME], he/she stated she might have, he/she really did not remember much from that day. When interviewed on 2/29/16 at 4:10 p.m. a nursing assistant, Staff C stated the night of the incident Staff H asked for her help to lay someone down. Staff H could hardly hook up the Hoyer Lift. Staff H looked out of it. Staff H gave Staff C a rides home shortly after 8:00 p.m. at which time, Staff H backed up into a snow bank and then she almost hit a car. Staff C asked Staff H if she was on something. Staff H stated she took a [MEDICATION NAME] bar. She asked Staff H what was up with Resident #1. Staff H stated she gave the resident [MEDICATION NAME]. Staff H stated she told the resident not to tell anybody because she could lose her job. Staff H stated she told the resident to only take a half of the bar but Resident #1 ended up taking the other half. Staff H said she had picked the [MEDICATION NAME] up before she came to work that day. When interviewed on 2/29/16 at 2:55 p.m. a nursing assistant, Staff D stated she worked the resident's hallway the evening of the incident. Resident #1 had been his/her normal self at the beginning of the shift. She went to his/her bedroom about 7:00 p.m. She found him/her asleep in his/her electric wheelchair. She tried to wake him/her up. He/she would not respond. She called for Staff H to help. She asked Staff H if she knew why the resident would not wake up. Staff H told her he/she took [MEDICATION NAME]. At 8:00 p.m. Staff H and Staff C left and she went to the nurse, Staff B and reported the resident was not responding. Staff D told the nurse that Staff H stated the resident took [MEDICATION NAME]. When interviewed on 2/29/16 at 12:19 p.m. a licensed practical nurse (LPN), Staff B stated the resident was a quiet person until he/she got to know you better. One night about 8:00 p.m. or 8:10 p.m. Staff D told her the resident took a drug and she did not know how much. She went to the resident's bedroom and he/she had been in bed. She tried to wake him/her up. She shook him/her and tapped him/her. Resident #1 aroused about 30 to 60 seconds later. He/she mumbled and was not alert, he/she could not talk. When interviewed on 3/1/16 at 2:50 p.m. a nursing assistant, Staff F stated she was walking down the hall when she saw a staff crying. Staff D told her that Staff H gave the resident some [MEDICATION NAME] and he/she was not responding. She went to the resident's room and tried to wake him/her up. The resident told her to leave him/her alone. She asked the resident if he/she took [MEDICATION NAME] and he/she stated yeah. She asked him/her if Staff H gave the [MEDICATION NAME] to him/her and he/she said yeah. She then told the nurse the resident was responding and that he/she stated Staff H gave him/her the [MEDICATION NAME]. Review of a Physician's Notification Form dated 3/1/16, the resident's physician, and documented [MEDICATION NAME] 4 milligrams would probably not be life threatening to Resident #1 and [MEDICATION NAME] 2 mg would be unhealthy for him/her. When interviewed on 3/1/16 at 12:54 p.m. with Staff H, nursing assistant she stated she worked the 6:00 a.m. to 2:00 p.m. that day and then returned to work 4:00 p.m. to 8:00 p.m. Staff H denied knowing who gave Resident #1 the [MEDICATION NAME]. The facility Abuse policy titled Abuse Prevention Plan Including Criminal Activity dated 4th Quarter 2015 documented residents will not be subject to abuse by anyone including facility staff. Dependent Adult abuse means any of the following as result of the willful misconduct or gross negligence or reckless acts or omission of a caretaker taking into account the totality of the circumstances. The policy revealed that Neglect is the failure of a caregiver to provide the goods or services that are necessary to maintain the resident's health and safety. The facility protection section of the abuse plan documented the facility pro-actively protects all residents from any type of abuse through intense monitoring, family involvement or even law enforcement as necessary. The investigation identified Resident #1 had not been protect from receiving the goods and services that were necessary to maintain the resident's health and safety.

Based on observation, clinical record review and staff interview, the facility failed to ensure safety interventions were planned and/or followed for two of six residents reviewed with falls histories (Resident #9 & #7). The facility identified a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool for Resident #9 dated 10/14/15, documented [DIAGNOSES REDACTED]. The MDS documented the resident ambulated (walked) independently in the corridor, but was not steady without staff assistance when turning and facing the opposite direction when walking. The resident ' s care plan revised 7/17/15, documented the resident as at risk for falls due to macular degeneration and history of a past fracture from a fall. The Care Plan directed staff to provide a safe environment with even floors free from spills and/or clutter. A physician notification form dated 10/20/15, documented the Hoyer lift was in the hallway against the wall. The form revealed staff witnessed Resident #9, while walking in the hallway and talking at the same time, trip over the outer Hoyer leg and land on his/her hands and knees. The resident did not hit his/her head and stated, I ' m ok. Staff documented no injuries noted and revealed the resident ambulated in the hallway per usual, refused pain medication and reported, My knee smarts. Assessment: Resident tripped over Hoyer in hallway. Recommendation: Clutter removed from hall immediately. Staff reeducated on importance of keeping hallways clear of clutter. At 2:30 p.m., Staff A (Registered Nurse) stated it would be expected a Hoyer lift not be stored in the hallway. Staff A stated this had to be re-enforced after the incident because the facility had hired some new staff members. 2. The MDS assessment tool dated 10/14/15, documented Resident #7 had [DIAGNOSES REDACTED]. According to the MDS, the resident experienced moderate cognitive loss and required extensive assistance of one person with bed mobility and transfers. A care plan dated 12/28/15, identified the need for extensive assist of one person to assist with transfers and standby assist with one person for ambulation. The care plan also directed staff to take Resident #7 to the bathroom to use the toilet. A physician's notification form dated 12/26/15 documented the resident had been dropped while at a home visit incurring bruising on the back with left arm discomfort. On 1/4/16 at 4:00 PM, Resident #7 stated the physician told him/her a chip broken from a bone in the left hand caused it to swell. A progress note dated 1/4/16 at 3:46 p.m., documented a visit to the emergency room . The physician ordered a sling for comfort at all times, use of a squeeze ball in left hand to reduce swelling and Tramadol 50 milligrams every four hours as needed for pain. Observation on 1-5-16 at 8:45 a.m. revealed Staff B and C, Certified Nursing Assistants (CNAs), entered the resident's room to transfer Resident #7 to a commode. Both CNAs, using a gait belt, lifted the resident to a standing position with some difficulty and transferred him/her to a commode. The resident was unable to use the left arm because it was in a sling. The two aides attempted two times to lift the resident from the commode without success. Staff B left the room and brought Staff D, CNA to the room to help. At 9:10, three CNAs attempted to lift the resident from the commode and were unable. Staff brought the VERA lift (an electric lift utilizing a back strap which lifts the resident to a standing position) Staff B stated they were going to utilize this lift. Resident #7 reported the lift, scares me to death. The lift was applied and staff tried to lift Resident #7 from the commode. This which failed because the resident's abdominal skin was stuck between the bars of the commode. The staff rubbed lotion on the resident's sides and were able to lift the resident from the commode to the wheelchair. Observation on 1/6/16 at 12:30 p.m. revealed the resident seated in a wheelchair. Staff B and E entered the room to transfer Resident #7 to the toilet. Using the VERA lift, staff transferred the resident to the toilet and back to a recliner. The surveyor asked Staff B what the resident's care plan directed regarding how to transfer the Resident #7 Staff B read the care plan posted on the bathroom door and stated it directed one to two persons necessary for transfer. Staff B stated that they could use more than one but never less. She reported the Director of Nursing (DON) told her on 1/5/16 to use the VERA lift, however, the change was not communicated to all staff via the care plan. During an interview on 1/7/16 at 7:40 a.m., the DON reported the therapist changed Resident #7's Care Plan on 1/6/16 in the afternoon to include the use of VERA lift with assist of one or two staff. The Care Plan in the Resident's chart and room directed staff to take the resident into the bathroom to use the toilet with one to two people to transfer and ambulate. Staff utilized an electric lift and a commode instead.

Based on observation, staff interviews and record review, the facility failed to provide appropriate care to prevent the development of pressure sores (Resident #5, #7). The sample consisted of 3 residents and the facility reported a census of 53 residents. Findings included: 1. Resident #7 had an MDS (Minimum Data Set) assessment with a reference date of 10/4/14. The MDS identified the resident had documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfer. The MDS reflected the resident at risk for pressure ulcers and had a Stage I pressure ulcer. A Stage I pressure sore consisted of intact skin with non-blanchable redness of a localized area and usually over a bony prominence. The MDS identified the resident had a pressure reducing device for the chair and bed. The MDS reflected the resident had a nutrition or hydration program and staff applied ointments/medication to the area. The Care Plan dated 3/25/14, identified the resident had a problem with the potential/actual impairment to skin integrity. The Care Plan directed the staff to perform the following interventions: a. The resident should avoid scratching and keep hands and body parts from excessive moisture. Keep the resident ' s fingernails short. b. Resident #7 had a pressure relieving/reducing mattress on the bed, to protect the skin. c. Resident is occasionally reluctant to reposition staff. The staff have educated the resident on the importance of repositioning and resident will report as comfortable and wishes to stay where they are. d. Resident uses a pressure relieving/reducing cushion to protect skin while up in the chair. e. Educate the resident/family/caregivers of causative factors and measures to prevent skin injury. f. Encourage good nutrition and hydration in order to promote healthier skin. g. Staff are to follow facility protocols for the treatment of [REDACTED]. A skin assessment dated [DATE], documented the resident had an area identified as an abrasion on the left buttock. The assessment had no measurement, but also documental the area as immeasurable excoriation. The same sheet included a skin assessment dated [DATE], which documented the area had been intact and pink on that date. A second skin assessment sheet included an assessment dated [DATE], and documented the resident had an immeasurable area of excoriation on the right buttock. The assessment also identified the area as an abrasion. The same sheet included an assessment dated [DATE], and documented the area on the right buttock measured 1.5 cm by 1.3 cm by less than 0.1 cm. at that time. During observation on 12/15/14 at 12:45 p.m., the resident sat in their room in a chair and ate lunch. The chair had no cushion on the seat of the chair. At 1:15 p.m., the resident remained in the same chair with no cushion. At 3:25 p.m., the resident remained in the same chair with no cushion. During an observation on 12/16/14 at 9:48 a.m., the resident laid in bed as Staff C (Licensed Practical Nurse) completed treatments. At that time, Staff C measured an area to the right of the resident ' s coccyx and reported it to be 1.0 cm by 2.8 cm. by 0.1 cm. Staff C also measured an open area on the residents left buttock and reported it to be 0.2 cm by 0.2 cm. Staff C stated the smaller of the two areas had been bigger the week before. Staff C told the resident the larger of the two areas looked pretty sore. The resident stated it had kept him/her awake all night. Staff C completed the dressing change. At 11:08 a.m., the resident sat in a recliner chair in their room with no pressure relieving cushion in the seat of the chair. At 12:10 p.m., the resident sat in the same chair with no cushion. On 12/18/14 at 8:15 a.m., the facility provided the surveyor with a copy of the skin assessment sheets for the resident ' s left and right buttock. The sheet for the left buttock included an additional assessment dated [DATE], which documented the area then measured 2.8 cm by 1.0 cm x 0.1 cm. The skin assessment sheet for the resident ' s right buttock, revealed an additional assessment dated [DATE], which documented the area then measured 0.2 cm by 0.2 cm by less than 0.1 cm. During an interview with the facility Director of Nursing on 12/18/14 at 9:30 a.m., reflected the cushion had probably been on the resident ' s wheel chair instead of the chair the resident had been sitting in. During an interview with the facility Director of Nursing on 12/18/14 at 1:05 p.m., she stated they had taken another cushion to the room and the resident now had a cushion in the recliner as planned. 2. Resident #5 had an MDS assessment with a reference date of 9/24/2014 which included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility and transfer. The MDS reflected the resident to be at risk for pressure ulcers and had an unhealed Stage II pressure ulcer on the left foot. The Care Plan dated 11/25/2013, included a problem of impaired skin integrity. The Care Plan directed staff to: a. Monitor the resident ' s skin during cares for potential skin breakdown. b. Notify charge nurse if signs observed. c. Administer treatment as ordered. d. Document weekly treatment of [REDACTED]. e. Pressure relieving mattress on bed and cushion on wheelchair. f. Wear heel lift boot on left heel at all times. g. Provide supplemental protein and vitamins as ordered. h. Provide pain medication prior to treatment/turning. i. Offer fluids to resident The Care Plan problem area did not identify the resident to be at risk for skin breakdown related to pressure or incontinence. The Care Plan reflected the resident had a history of [REDACTED]. The Braden Scale (a tool used to assess risk for pressure ulcer) performed on 10/30/2014 reflected the resident scored 15 out of 23. A score of 15 identified the resident at mild risk for developing pressure sores. A physician's orders [REDACTED]. The treatment included wound to be cleansed with wound cleanser, Triad (zinc dressing) to be applied to wound bed, extra protective cream (EPC) skin barrier to periwound and cover with [MEDICATION NAME] (dressing). The following current wounds were documented on a wound care assessment flow sheet: Left Buttock: On 11/19/2014, the wounds to the left buttock are due to shearing. The wound measurements documented length (L) 1.0 centimeter (cm) by width (W) 0.6 cm by depth (D) 0.1 cm. On 11/26/2014 the wound to the left buttock. No wound measurements documented. On 12/3/2014 the wound to left buttock was documented unable to measure. On 12/10/2014 & 12/17/2014 the wound on left buttock was documented unable to measure. Right Buttock On 11/19/2014, shearing and skin currently intact. On 11/26/2014, the wound measured L 1.0 cm by W 0.5 cm and L 0.3 cm by W 0.3 cm by D 0.1 cm On 12/3/2014 the wound measured L 0.8 cm by W 0.5 cm and L 0.4 cm by W 0.2 cm by D 0.1 cm On 12/10/2014 the wound measurements L 1.5 cm by W 0.5 cm by D 0.1 cm On 12/17/2014, the wound was intact and red. Coccyx Area On 12/12/2014 there was an abrasion/bruise, tear without subcutaneous wound above coccyx area. The wound measured L 2.4 cm by W 1.4 cm by D 0.1 cm with a small amount of bloody drainage. There were several reddened superficial scratch marks to the buttocks area. On 12/17/2014 there was an abrasion/bruise, tear without subcutaneous wound above coccyx area but wound measured L 2.5 cm by W 2.0 cm by D 0.1 cm with scant amount of serous drainage. The area around the wound was purple. Extended observation on 12/16/2014 revealed the following: a. At 7:50 am, the resident sat in a wheelchair in the dining room. The resident had no heel boots on the left foot. b. At 8:15 am, the resident sat in the wheelchair in room with call light activated. The resident wore no heel boots. c. At 8:30 am, the resident transferred from the wheelchair to the toilet via a Vera2 (mechanical) lift. d. At 8:34 am, Staff K, Certified Nursing Assistant (CNA) cleansed the resident ' s buttocks and reported the resident ' s bottom as red. e. At 8:39 am, the resident was positioned onto the left side in bed. f. At 9:58 am, the resident laid supine (on back) in bed with a pillow at the side of the resident and a pillow placed under the lower legs. No heel boots were applied to the resident's feet. g. At 11:33 am, the resident sat in a wheelchair in the dining room. The resident wore no heel boots. h. At 1:00 pm, the resident sat in the wheelchair in dining room. The resident wore no heel boots. Extended observation on 12/17/2014 revealed the following: a. At 6:30 am, the resident laid supine in bed. A pillow rested under the resident ' s lower legs with the right leg crossed over left leg. b. At 7:34 am, the staff transferred the resident with the mechanical lift and two staff members, from bed to shower chair. c. At 8:00 am, the resident was assisted to stand with a lift and two staff. Observation revealed a large egg shaped open area on the coccyx and white paste covered both buttocks. Staff C, Licensed Practical Nurse (LPN) cleansed the left buttock wound back to front with gauze, then wiped right buttock wound front to back with another gauze. Staff C applied Triad ointment to the wound bed, using gloved hand and applied [MEDICATION NAME] dressings to the wounds on the lower left and right buttock. The nurse then applied white cream over a portion of the [MEDICATION NAME] dressing and bilateral buttocks. d. At 8:05 am, the resident sat in the wheelchair and staff took to the dining room. The resident wore no heel boots. e. At 9:31 am, Staff O, Physical Therapist (PT) pushed the resident in the wheelchair. Staff O stated PT treatment included only resident working on wheelchair propulsion this morning. f. At 9:33 am, the resident was transported to room in wheelchair, and continued to sit in wheelchair after personal hygiene performed which included brushing teeth and resident shaving facial hair per self. g. At 10:21 am, the resident sat in the wheel chair and transported to the therapy room. h. At 10:45 am, resident wheeled to sit in room in wheelchair. i. At 11:25 am, the resident sat in the wheelchair in the dining room. j. At 12:17 pm, the resident sat in the wheelchair in the dining room. k. At 12:35 pm, the staff transferred the resident to the toilet by using the lift. During an initial tour on 12/15/2014 starting at 10:02 am, the MDS Coordinator denied any skin issues or wounds within the past six months. During an interview on 12/17/2014 at 1:35 pm, the facility Director of Nursing and Corporate Nurse Manager stated the standard for repositioning residents had been every two hours and Care Plans updated quarterly. During an interview on 12/17/2014 at 1:55 pm, Staff C, LPN, stated the resident's coccyx wound was bigger than it had been since the previous day. Staff C stated no phone contact to the physician or [MEDICATION NAME][MEDICATION NAME] therapy nurse to advise of change in condition or treatment. Staff C stated the wound to the left buttock had built up scar tissue and resident's buttock wounds looked better but the wound on the coccyx developed recently and the coccyx wound increased in size. Staff C reported the wound measurements were checked every Wednesday and documented on a wound assessment flow sheet.

Based on observation, and staff interview the facility failed to ensure electrical equipment was properly utilized to prevent accidents, failed to ensure all medications were kept locked in the medication cart and failed to ensure residents environment free from hazards. The facility reported a census of 53 residents. On the Department website in the February 2004 Insight, the State Fire Marshal's Office documented clarification on use of surge protectors. The posted information documented the electrical surge protector shall be of metal or steel construction and approved by Underwriters Laboratories or another recognized laboratory. The paper documented items that could be used with an electrical surge protector and items prohibited from use with a surge protector that included clocks, lamps, personal grooming and care devices, battery chargers, and motor drive appliances. Findings include: Observation on 12/15/14 at 11:30 a.m., revealed Staff performing blood sugar checks on residents and failed to lock the lancets and insulin syringes and left the container on top of the medication cart. Observation on 12/15/14 at 12:35 p.m., down the yellow hall way revealed an unlocked dirty utility room that contained a can of Microburst 9000 Air Neutralizer. The can directed keep out of reach of children and don't induce vomiting. The Material Safety Data Sheet stated to immediately rinse eyes with plenty of water if in contact, is skin contact to rinse affected area with plenty of water, if ingested to maintain airway and respiration and if inhaled to obtain medical attention. Observation on 12/17/14 at 9:30 a.m., revealed Staff M (registered nurse) left an unlocked and unattended medication cart in the red hallway. The cart contained residents' oral medications, ointments, creams, eye drops, insulin, and inhalers. During an interview on 12/17/14 at 9:33 a.m., Staff M confirmed and verified that the medication cart needed to be kept locked at all times or in the field of vision. 3. During an initial walk through of the facility on 12/15/16 at 9:35 a.m., observation revealed an unlocked shower room with a bottle of Hebiclens (antiseptic skin cleanser) which had a warning label which read if swallowed seek medical attention. No staff had been present in the shower room. 4. During observation on 12/15/14 at 1:40 p.m., an unlocked medication cart sat in the hallway, near the nurses station. A staff person stood at another medication cart with their back to the unlocked cart, and talked to a resident. No other staff had been present. At that time the surveyor had been able to open all of the drawers of the cart, which contained multiple bubble packs of resident medications and bottles of medications. At that time the surveyor had easily been able to remove a bubble pack from the cart, with no staff supervising it. The surveyor then went and found the facility Quality Assurance nurse and informed them. At that time the Quality Assurance nurse went to the cart and locked it. The facility Corporate Nurse stated on 12/18/14 at 12:55 p.m., the cart should have been locked. At 1:15 p.m., the facility provided a list of 12 residents who wore a secure care (alarmed) device that wandered. 5. During the facility environmental tour on 12/17/14 that began at at 9:40 a.m., observation revealed a surge protector with a fan plugged into it in Room 32. When discovered, Staff G reviewed the State Fire Marshall guidelines with Staff H. Staff G removed the cord from the surge protector.

Based on record review and interviews with staff, physicians, pharmacist, and family, the facility failed to adequately monitor anticoagulant medications for two (2) of four (4) residents reviewed (Resident #4 and Resident #3). On 9/9/13 Resident #4 had been discharged from the hospital to the nursing home without a physician's order to monitor his/her INR (International Normalized Ratio)/test for blood clotting). The nursing home had been aware of Resident #4's anticipated need for a PT/INR test when they completed a prescreening tool. On 9/23/13 the nursing home noted blood in the resident's catheter bag and tubing and staff took the resident to the restroom at which time he/she expelled a large amount of dark black fecal material. The nursing staff continued to administer [MEDICATION NAME] medication (blood thinner) without monitoring the impact of the anticoagulant medication. The resident transferred to another nursing home on 10/17/13, and his/her clinical record identified significant symptoms (bruising and rectal bleeding) and on 10/18/13 had been transferred to the emergency room with his/her PT/INR significantly elevated to high critical level of 20 (with a therapeutic INR range between 2.0-3.0.). The resident required Vitamin K therapy and 2 units of fresh frozen platelets while hospitalized to reduce the elevated INR. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 59 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 9/16/13, Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident required assistance of two staff with bed mobility, transfers, walking in his/her room, with dressing and using the bathroom. The resident showed no cognitive impairments according to his/her Brief Interview for Mental Status (BIMS) test score of 15 (out of 15). The medication assessment section identified the resident had taken an anticoagulant medication for 7 out of last 7 days and/or since admission/entry to the nursing home. The MDS had been signed by the Director of Nursing for the person responsible for the care plan decisions on 9/22/13. Hospital information prior to admission to the nursing home: a. An emergency room Report form dated 8/29/13, documented Resident #4 had been admitted to the hospital from his/her home with weakness, nausea and vomiting, [MEDICAL CONDITIONS] and back pain. The resident's laboratory (lab/s) values were determined as follows: a. Hemoglobin of 10.7. b. Hematocrit of 29.5. c. INR of 3.2. (The INR is a blood test used to monitor the clotting tendency of the blood when on anticoagulation ([MEDICATION NAME]) therapy. b. A Laboratory - Coagulation report form, documented Resident #4 had the following lab values as dated: 1. 8/30/13 - [MEDICATION NAME] (PT) - 34.3 and an INR of 3.1. 2. 8/31/13 - PT - 29 and an INR of 2.6. 3. 9/1/13 - PT 22.5 and an INR of 2.0. 4. 9/3/13 - PT 22.5 and an INR of 2.0. 5. 9/5/13 - PT 23.4 and an INR of 2.1. 6. 9/7/13 - PT 26 and an INR of 2.4. c. A lab report dated 9/5/13, documented the resident had a PT of 23.4 indicated as high due to a reference range of 9.0 - 12.0. Additionally, the form documented the resident with an INR of 2.1 with documentation that stated the target INR should have been individualized with a suggested INR therapeutic range standardly as 2.0 - 3.0 and higher at 2.5 - 3.5. d. A hospital Skin and Wound Assessment form dated 9/9/13, documented the resident had the following skin issues: 1. ) 2 areas of purple/ruddy/blue discoloration on his/her right hand. 2.) 2 areas of purple/ruddy/blue discoloration on his/her left arm. 3.) 1 area of purple/ruddy/yellow/green discoloration on his/her lateral right trunk/breast. 4.) 1 area of purple/ruddy discoloration on his/her left lower extremity. e. A hospital Non-Emergency Transfer Form dated 9/9/13, indicated the resident had [DIAGNOSES REDACTED]. A Chautauqua Guest Homes Pre-Screening Tool form dated 9/6/13 (prior to admission) identified the resident would need a PT/INR. The form identified Resident #4 had a [DIAGNOSES REDACTED]. The nursing home staff noted Resident #4 would need an anticipated lab draw of a PT/INR. The form did not contain a signature of the nursing staff that completed the pre-screening information. An Initial Nursing Assessment form (from the nursing home) dated 9/9/13 at 2 p.m., documented the resident had bruising on his/her bilateral arms. An Admission Record dated 9/9/13 at 6:09 p.m., documented the resident had [DIAGNOSES REDACTED]. A Medication Reconciliation/Physician Orders form dated 9/9/13 at 8:55 a.m., documented the resident had medications ordered that included the following: a. A Chewable Aspirin (ASA) 81 milligrams (mg) every day (QD). b. [MEDICATION NAME] 250 mg with the last dose given at the hospital on [DATE]. c. [MEDICATION NAME] 2.5 mg QD and to hold for an INR greater than 3.2. A fax form signed on 9/10/13 indicated a pharmacist consultant reviewed the resident's medications and had no concerns or interactions with the medications. A Progress Notes entry dated 9/10/13 at 10:09 p.m., documented the facility received an order for [REDACTED]. A Telephone Orders Audit form dated 9/10/13 at 9:30 p.m., documented the facility received a physician's order to administer [MEDICATION NAME] ([MEDICATION NAME]) 500 MG QD for the next 3 days. A Progress Notes form dated 9/11/13, documented a physician directed the facility staff to restart the resident on [MEDICATION NAME] due to a slight fever and cough. The form also documented the resident had a history of [REDACTED]. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. ASA 81 mg QD in the morning. b. [MEDICATION NAME] 2.5 mg QD (in the evening). A MAR form dated 9/12/13 through 9/13/13, documented the resident received [MEDICATION NAME] 500 MG, QD. A MAR form dated 10/1/13 through 10/31/13, documented the resident received the following medications as ordered: a. ASA 81 mg QD in the morning. b. [MEDICATION NAME] 2.5 mg QD in the evening. A Progress Note entry dated 9/23/13 at 3:22 p.m., documented the facility staff documented the resident had blood noted in his/her Foley bag and tubing and the resident complained of feeling full down there. The facility staff took the resident to the restroom at which time he/she expelled a large amount of dark black fecal material. The physician had been called and orders had been received to insert a new Foley catheter. A Telephone Order's Audit form dated 9/23/13, documented the facility received a physician's order to discontinue the old catheter and reinsert a new 16 French catheter. A Care Plan initiated on 9/16/13, revealed no documentation related to the use of an anticoagulant medication. The Care plan lacked any expectation to monitor the resident for potential concerns/actual risk or any indication to observe the resident for signs and symptoms associated with taking blood thinning medications or even to educate the resident on symptoms associated with the anticoagulant medication. A Medication Regimen Review form signed 9/28/13, indicated a pharmacist reviewed the resident's medications, noted the resident had a history of [REDACTED]. During an interview 11/7/13 at 3:15 p.m., the Pharmacist indicated she only made PT/INR recommendations for the residents if the levels were not within normal limits (WNL) and this resident's levels were therapeutic while he/she had been hospitalized (in September 2013). A nursing home progress note dated 10/5/13, identified Resident #4 had a condition change and had returned from the emergency room via private car with new orders to treat the resident for shingles. A nursing home progress note dated 10/11/13, identified new orders were received from the physician to discharge the resident to another nursing home. The facility attempted to reach the resident's family without success. A nursing home progress note dated 10/16/13 identified a new order to transfer the resident to the other nursing home on 10/17/13. The nursing home progress note dated 10/17/13 at 1:56 pm., identified Resident #4 had been discharged to the other nursing home with a transfer sheet sent. Clinical record review including the additional information the nursing home provided to the Department on 11/15/13 (Clinical Assessment Report Skilled Charting) revealed no INR/PT lab results for Resident #4 from 9/9/13 to 10/17/13. A Non-Pressure Skin Condition Record form dated 10/17/13 to 10/25/13, documented the resident had been admitted to the facility on [DATE] with the following skin conditions: a. A 3.0 centimeter (cm) x (by) 3.0 cm blackish-gray bruise on his/her lower right arm. b. A 2.0 cm x 2.0 cm blackish-gray bruise on his/her lower right arm. c. A 2.0 cm x 2.0 cm blackish-gray bruise on his/her lower left arm. d. A 3.0 cm x 3.0 cm blackish-gray bruise on his/her lower left arm. During an interview 11/7/13 at 11:45 a.m., a family member confirmed he/she accompanied the resident from the Chautauqua Guest Home to the other nursing facility on 10/17/13 and observed no incidents that would have caused any bruising and/or injury to the resident. The other nursing home form titled Physician's Admission/Monthly Orders dated 10/11/13, documented the resident would be admitted to the a new facility with the following orders: a. An [MEDICATION NAME] coated ASA 81 mg QD. b. [MEDICATION NAME] 2.5 mg QD. c. Check an INR every month plus as needed, do 10/18/13. An Interdisciplinary Progress Note from the other nursing home dated 10/18/13 at 9:30 a.m., documented the nurse had been called to the resident's room in regards to the resident bleeding a moderate amount of blood from the rectal area. The facility received an order from the physician to draw an INR intrafacility, hold [MEDICATION NAME] until Monday, give Vitamin K 5 MG po (by mouth) stat, draw another INR, send the vial to the laboratory stat and call the physician with an update. Upon receipt of a critical lab value the facility received an order to transport the resident via the ambulance service to the emergency room . A Clinical Laboratory report dated 10/18/13 at 9:35 a.m., indicated the resident had a [MEDICATION NAME] INR of greater than 20.0 and at a critical value. (The normal range = 0.8 to 1.2.) A hospital Discharge Summary form dated 10/21/13, documented the resident as admitted to the hospital from 10/18/13 through 10/20/13. The [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. The report documented there was a report that he/she had some black stools before this. The resident had been given 5 milligrams (mg) of Vitamin K prior to hospitalization and 2 units of FFP (Fresh Frozen Platelets) while hospitalized , which reversed his/her INR to 2.1. The hospital monitored his/her GI bleeding, which actually stopped and she no longer had any dark, black stools with his/ her bowel movements. The facility also gave the patient/resident 2 units of blood because his/her hemoglobin had only been 7.3 and he/she had a significant past medical [MEDICAL CONDITION]. The resident's hemoglobin increased to 11.9 after 2 units of blood. The hospital resumed the [MEDICATION NAME] but at a lower dose with the INR level at a 1.3 the morning of 10/20/13. During an interview 11/6/13 at 1:15 p.m., the emergency room physician confirmed the following information: The critical PT/INR level for the resident could have been prevented if properly monitored. No short term medication would have increased the (INR) level so high. The physician reported the resident ' s critical INR level would not have occurred overnight. The physician reported the highest PT/INR level she had ever witnessed had been 13. The physician reported the standard of practice had been to monitor a resident's PT/INR level at minimum every 30 days. The physician reported he/she would have expected the facility to have monitored the lab values for the resident. The medical condition of Resident #4 had been life threatening and he/she could have bled to death internally and/or externally at any moment. During an interview on 11/8/13 at 9:20 a.m., Resident #4's family physician confirmed they had monitored the resident's PT/INR closely when in hospital (on 8/29/13 onward) and this should have been on the transfer form. The physician reported PT/INR lab values should be monitored on a monthly basis if stable and more frequently as necessary. The PT/INR lab value for Resident #4 should have been monitored at least monthly. The therapeutic level for the PT/INR lab value for Resident #4 had been between 2 and 3 but she liked to keep this resident's closer to 2.5. The physician also reported the resident's [MEDICATION NAME] (an antibiotic) could affect a resident's PT/INR lab values on a short term basis. The physician reported a resident's diet could affect the PT/INR lab value. STAFF INTERVIEWS: During an interview 11/5/13 at 2:45 p.m., Staff A, Licensed Practical Nurse (LPN) indicated the facilities policy had been to check a resident's INR every month when on [MEDICATION NAME]. During an interview 11/5/13 at 3:20 p.m., Staff B, LPN indicated the facility had no standard of practice with the monitoring of PT/INR levels but that she would go by the physician's orders. If there had been no physician's order she indicated she would have called the physician to receive an order. During an interview 11/5/13 at 3:25 a.m., Staff C, Registered Nurse (RN) indicated the facility had no standard of practice with the monitoring of PT/INR levels but that she would go by the physician's orders. If there had been no physician's order she indicated she would have called the physician to receive an order. During an interview 11/6/13 at 10 a.m., the DON indicated she would have expected the consulting pharmacist to review resident medications and make suggestions as to the plan of care. According to a website called Drugs.com, the frequency of performing INR should have been based on the clinical situation but generally acceptable intervals for INR determinations are 1 to 4 weeks. According to website called WebMD.com the drug & medications of [MEDICATION NAME] and anticoagulants ([MEDICATION NAME]) you may experience an increased chance of bleeding including unusual busing or dark stools. If the physician has prescribed these two medications together, you may need to check your bleeding times more often. Your doctor may want to adjust the dose of the blood thinning medicine. According to a reference article titled, National Medical Policy, by Health Net, updated January 2013; the Scientific Rational Initial section revealed the following:, " [MEDICATION NAME] is an oral compound of significant medical importance ...It decrease the tendency of the blood to clot, and is very potent in doing so. However, it is a medication that must be taken maintained within the therapeutic range to minimize adverse events associated with inadequate or excessive anticoagulation such as serious bleeding or [MEDICAL CONDITION] events. Monitoring of the PT or INR is recommended to ensure that the dose levels remain within the therapeutic range. " According to another reference, INR by the Heart Rhythm Society, " the higher the INR, the longer it takes for blood to clot. If the INR is too high, there is a risk of uncontrolled bleeding. Report any unusual bleeding or bruising to your prescribing physician. " 2. According to a MDS assessment form dated 10/28/13, Resident #3 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 13 out of 15, required extensive assistance of staff with ADL's and on an anticoagulant for 7 out of last 7 days and/or since admission/entry or reentry to the facility if less than 7 days. A Care Plan goal dated 8/23/13, documented the resident had a focus area of a potential for impaired nutritional status with interventions that included the following: Lab tests as ordered. A MAR form dated 10/1/13 through 10/31/13, documented the resident received [MEDICATION NAME] 3 MG QD from 10/14/13 through 10/20/13. A Physician's Telephone Orders Audit form dated 10/15/13 at 3:40 p.m., documented the facility received an order to recheck the resident's PT/INR on Friday (10/18/13). A Laboratory - Coagulation report form dated 10/21/13, documented the resident had a PT level of 64.5 (normal 9.0 - 12.0) and an INR level of 5.8. (standard level indicated as 2.0-3.0 and higher at 2.5 - 3.5) . A Progress Note dated 10/21/13 at 3:14 p.m., documented the facility received a physician's order to hold the resident's [MEDICATION NAME] for 2 days. According to a fax form (not dated), the physician indicated the resident's INR goal as between 1.4 and 3.0. The facility abated the IJ on 11/8/13 when they implemented the following: On 11/8/13 the facility reviewed medication orders and audit all 8 residents taking anticoagulants medication to ensure PT/INRs had been completed; and had been reported to the physician with new lab draws as scheduled. The nursing management and consultant pharmacist created a PT/INR monitoring form for all 8 residents on anticoagulants medication. On 11/8/13 the facility complete all pharmacy medication reviews for new admission, readmission and continued stay residents to now include a review of the lab test orders in addition to lab test results based on medication administered. The facility policy regarding PT/INR was rewritten. The (policy)/procedure noted license nursing staff will review medication orders on admission and readmission, and if a resident has orders for [MEDICATION NAME] a PT/INR flow sheet will be initiated listing the last lab date, current [MEDICATION NAME] dose, PT/INR level and when the next lab is due. The nurse noting the admission orders [REDACTED]. The DON or Assistant DON will monitor weekly that the PT/INR flow sheets and labs are up to date. The nursing staff were educated on the use of the form and the new policy on 11/8/13 to 11/13/13. The DON or designee will check the form weekly to assure the facility policies are being followed. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring residents on anticoagulant medication(s).