Every finding on record at Cherokee Specialty Care

Based on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to provide a homelike environment by not replacing pillow cases on residents' beds for 1 of 5 residents (Resident #7) reviewed. The facility reported a census of 46 residents. Findings include:Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated Resident #7 had one or more unhealed pressure ulcers. The MDS further indicated Resident #7 had diagnoses of diabetes mellitus, paraplegia (the inability to voluntarily move the lower parts of the body), and acute osteomyelitis (an infection in a bone) to the right foot and ankle. During interview on 7/12/26 at 11:58 AM Resident #7 revealed the staff leave blood on his pillows from under his legs when the dressings are changed. Observation at this time revealed several pillows, and bedding with dried reddish brown substance on them. Interview on 7/13/26 at 9:03 AM with Staff B Laundry Aide revealed bed linens are changed every time residents have a bath or shower. Staff B further revealed that she also goes throughout the day as she is cleaning, and will change things if they are needed. Staff B stated there are extra pillow cases and linens in the linen closet for staff if something needs changed. Observation on 7/13/26 at 9:08 AM revealed Resident #7's pillow cases had a dried reddish brown fluid on the same pillow cases from the day before laying on Resident #7's bed and had not been changed. Interview on 7/13/26 at 9:13 AM with Staff A Licensed Practical Nurse confirmed pillows in Resident #7's room was soiled and should have been changed. Staff A further revealed that when she sees soiled bedding she will change it. Staff A stated the sheets and the pillow cases should have been changed. Interview on 7/13/26 at 9:34 AM with the Director of Nursing (DON) revealed she would expect bedding to be changed if there is drainage or if they are soiled. Review of a facility provided policy titled, Homelike Environment with a revised date of February 2021 indicated the facility staff and management maximizes the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary, and orderly environment.

Based on clinical record review and staff interviews, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 12 residents reviewed (Residents #1, #53). The facility reported a census of 46 residents.Findings include:1. The Minimum Data Set (MDS) assessment for Resident #1 dated 5/4/26 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of hypertension (high blood pressure) and orthostatic hypotension. The MDS documented Resident #1 did not receive diuretic medication during the last 7 days.The Care Plan with a target date 9/20/26 revealed Resident #1 was on diuretic therapy and directed staff to monitor for side effects and effectiveness. The June and July 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) directed the following physician orders:A. Furosemide (diuretic medication) 20 milligrams (mg) one tablet every 24 hours as needed for weight gain greater than 3 pounds in a day. B. Daily weight- notify the physician if weight gain of 2-3 pounds (lbs) overnight or 5-6 pounds in 5 days. Review of the June 2026 TAR revealed the following weights:6/9- weight not documented6/10- 318.96/11- 324.1 (5.2 lb weight gain)6/18- 312.56/19- 318.4 (5.9 lb weight gain)6/20- 322.5 (4.1 lb weight gain in one day, 10 lb weight gain in 2 days)6/21- weight not documented6/24- 323.7Review of the July 2026 TAR revealed the following weights:7/4- 316.37/5- weight not obtained7/6- weight not obtained7/7- 322.3 (6 lb weight gain in 3 days)7/8- 323.5 (additional 1.2 lbs weight gain, 7.2 lbs in 4 days)Review of the June and July 2026 MAR revealed Furosemide was not given.The clinical record lacked documentation that the Physician was notified of the weight gain. On 7/13/26 at 3:22 PM, the Director of Nursing (DON) said she expected the staff to follow physician orders and give the Furosemide medication as directed. She said if the Furosemide was not documented on the MAR then it was not given. On 7/13/26 at 3:34 PM, the Administrator reported the facility did not have a policy on following Dr orders. She said the facility followed the standard of practice. 2. The MDS assessment for Resident #53 dated 4/27/26 identified a BIMS score of 08, which indicated moderately impaired cognition. The MDS included diagnoses of pneumonia, chronic lung disease, respiratory failure and pulmonary fibrosis (progressive lung disease where deep tissue in the lung becomes scarred and stiff).The Clinical Census revealed Resident #53 was admitted to the facility on [DATE]. The Care Plan with a target date 5/10/26 revealed Resident #53 had altered respiratory status/difficulty breathing related to pulmonary fibrosis. The Care Plan directed staff to administer medication/puffers as ordered, monitor effectiveness and side effects. The Hospital Discharge Orders dated 4/24/26 directed staff to administer the following medications:A. Budesonide 0.5 mg/2 ml, 0.5 mg nebulizer treatment two times per day for pulmonary fibrosis. B. Breztri aerosol inhaler 160-9-4.8 MCG/ACT 2 puffs in the morning and afternoon for pulmonary fibrosis. Review of the April MAR and May MAR revealed the Budesonide nebulizer treatment was not administered 4/24/26 through 5/1/26 and the Breztri inhaler was discontinued on 4/27/26.Review of the Hospital Discharge Orders on 4/24/26 revealed the Pharmacy requested clarification on whether the Provider would like Resident #53 to use the Budesonide nebulizer solution as the Breztri inhaler contained Budesonide. On 4/27/26 (3 days after admission) the Provider gave direction to discontinue the Breztri inhaler but did not provide direction on the Budesonide nebulizer treatments. Review of the April and May MAR revealed Resident #53 did not receive any Budesonide medication from 4/28 through 5/1/26 (4 days).The Clinical Record lacked documentation the facility had requested any clarification orders for the Breztri inhaler and the Budesonide nebulizer treatments on admission or on 4/27/26 when the inhaler was discontinued. The Progress Note dated 4/30/26 documented the Nurse Practitioner (NP) saw Resident #53 on rounds due to staff reporting low oxygen levels and coarse lung sounds. The Progress Note dated 5/1/26 documented the facility received signed orders from the NP with the diagnosis of rhonchi (abnormal lung sounds), hypoxia (low oxygen levels) and pulmonary fibrosis:1. Duonebs four times daily for 7 days.2. Budesonide nebulizer treatments twice a day and rinse mouth after use3. Levaquien (ATB) 750 mg every day for 7 [NAME] 7/14/26 at 1:44 PM, the Director of Nursing (DON) said she completed Resident #53's admission. She said the pharmacy would not send both the Breztri inhaler and the Budesonide nebulizer treatments. She said the pharmacy reported the Breztri inhaler was the better choice of the two medications. The DON reported the Budesonide nebulizer treatments were put on hold until the order was clarified. She said the NP discontinued the Breztri inhaler on 4/27/26 but did not say anything about the Budesonide nebulizer treatments. She said the NP ordered the Budesonide nebulizers on 5/1/26. On 7/14/26 at 3:35 PM, the NP she would have liked to have more communication from the pharmacy regarding the admission orders. She said she would have preferred a phone call instead of a fax so the orders could have been clarified in a timely manner. The NP verified the request for clarification orders on the hospital discharge orders was documented from the pharmacy.

Based on observation, clinical record review, staff interview, and policy review the facility failed to use universal infection control measures while completing wound care for 1 of 3 residents (Resident #7) reviewed. The facility reported a census of 46 residents. Findings include:Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a readmission to the facility on 8/28/24 from a short-term general hospital stay. The MDS indicated Resident #7 had one or more unhealed pressure ulcers. The MDS further indicated Resident #7 had diagnoses of diabetes mellitus, paraplegia (the inability to voluntarily move the lower parts of the body), and acute osteomyelitis (an infection in a bone) to the right foot and ankle. Review of Resident #7's Electronic Health Record page titled, Clinical Physician Orders revealed an order for a treatment to the left heel as well as a treatment to left calf with order dates of 6/27/26. Observation on 7/13/26 at 1:22 PM Staff A Licensed Practical Nurse completed hand hygiene and donned gown, gloves, and a gown. Staff A then placed a barrier under Resident #7's legs. Staff A removed the dressing to the left leg and foot while wearing the same gloves. Staff A then doffed the gloves and utilized hand sanitizer from under the gown being worn. Staff A donned new gloves. Staff A then completed the dressing to the left calf of Resident #7. Staff A doffed the gloves being worn and again utilized the hand sanitizer from under the gown being worn. Staff A donned new gloves and reached under the gown being worn to obtain scissors to remove the rest of the dressing from the left foot. Staff A completed the dressing to the left foot of Resident #7. Staff A again doffed the gloves being worn and again utilized the hand sanitizer from under the gown being worn. Staff A was observed multiple times touching the front of the gown being worn without gloves to obtain scissors and hand sanitizer from under the gown being worn while the treatment was being completed for Resident #7. Interview on 7/13/26 at 1:59 PM with Staff A revealed that she missed a couple opportunities for hand hygiene as well as glove changes during the completion of the treatment for Resident #7. Interview on 7/14/26 11:09 AM with the Director of Nursing (DON) revealed that she would expect hand hygiene to be completed at the appropriate times as well as changing gloves at the appropriate times.The DON further revealed she would like to see staff not obtaining items from under their gowns during treatments. Review of a facility provided policy titled, Handwashing/Hand Hygiene with a revision date of August 2019 indicated staff should complete hand hygiene:a. Before handling clean or soiled dressings.b. Before moving from a contaminated body site to a clean body site.c. After contact with blood or bodily fluids.d. After removing gloves.

Based on observations,resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 44 residents. Finding Include: 1. Observation on 5/20/25 at 12:17 p.m., of the meal service showed the lunch meal consisted of Salisbury steak, mashed potatoes, carrots, roll and butter and ice cream sandwiches. The test tray was temped after the last resident was served their room lunch tray and temperatures were as follows: a. Salisbury Steak- 133.5 degrees Fahrenheit (F) b. Carrots- 131 degrees F c. Ice cream sandwich was soft and melted d. Roll was noted to have black bottom and hard 2. Observation on 5/20/25 at 12:34 p.m., with items still in the steam table in the kitchen. Food temperatures were as follows: a. Ground Salisbury Steak- 114.9 degrees F b. Carrots 131.9 degrees F Interview on 5/20/25 at 12:36 p.m., with the Dietary Manager confirmed the carrots and ground meat were not at a safe holding temperature and they should have been. 3. Observation on 5/21/25 at 12:09 p.m., of the meal service showed the lunch meal consisted of Turkey Ala King with a biscuit, broccoli and blushing pears. The test tray was temped after the last resident was served their room lunch tray and temperatures were as follows: a. Turkey Ala King- 132.7 degrees F b. Broccoli- 113.6 degrees F Review of the facility provided policy titled Food Preparation and Service with a revision date of April 2019 revealed the following information: a. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds. b. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. c. Proper hot and cold temperatures are maintained during food service. Interview on 5/21/25 at 1:17 p.m., with the Dietary Manager revealed the food should be served hot and at a safe temperature and the facility has been working on it.

Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in the comprehensive care plans for 2 of 2 residents reviewed (Resident #24 and #31). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of diabetes mellitus and type 2 diabetes mellitus with hyperglycemia.The MDS showed the Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of the Order Summary Report dated 4/7/25 revealed the following orders: a. Lantus Subcutaneous Solution (insulin/Diabetic medication) b. Humalog Injection Solution (insulin/Diabetic medication) Review of the Care Plan with an initiated date of 4/11/25 revealed a focus area of I have Diabetes Mellitus. The Care Plan lacked specific side effects to watch for with the usage of diabetic medication. 2. The MDS assessment dated [DATE] for Resident #31 documented diagnosis of diabetes mellitus and type 2 diabetes. The MDS showed the BIMS score of 00, indicating severe cognitive impairment. Review of the Order Summary Report dated 4/24/25 revealed an order for hydrocodone-actaminophen oral tablet (opioid medication). Review of the Care Plan included a focus area with an initiated date of 2/24/25 of I use opioid medications related to age related pain that lacked non pharmacological interventions to use for pain management prior to medication usage. Review of the facility policy titled Care Plans, Comprehensive Person- Centered with a revision date of December 2016 revealed the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Interview on 5/22/25 at 9:14 a.m., with the Administrator revealed non pharmacological interventions and side effects for medications should be listed on the care plan.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents reviewed for PASRR requirements, (Resident #38). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #38 documented diagnoses of depression, anxiety, bipolar disorder, dementia, and other personality and behavioral disorders due to known psychological conditions. The MDS included a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the Care Plan for Resident #38 revealed the following diagnosis: a. Bipolar Disorder, b. Anxiety, c. Dementia, d. Other personality and behavioral disorders due to known psychological conditions. Review of the consultation Behavioral Health notes for Resident #38 dated 4/3/25 showed consultation took place for outpatient psychiatric services. Review of the PASRR dated 4/14/2023 showed the facility failed to resubmit an updated PASRR screening to include mental health diagnoses, dementia and psychiatric services. In an interview on 5/22/24 at 8:46 AM, the DON reported that she expected the PASRR for Resident #38 to be resubmitted when diagnosed with mental health diagnoses and initiation of psychiatric services. The DON reported the facility failed to have a policy related to PASRR Screenings.

Based on clinical record review, staff interview, facility photographs, and facility education, the facility failed to secure a hot cup of coffee, monitor a resident known to drink hot coffee all hours of the day and night, test coffee temperatures, follow physicians orders for which resulted in a 2nd degree burn to the groin region that progressively worsened and caused substantial pain for 1 of 3 resident reviewed. (Resident #1) The facility identified the census of 46 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with diagnoses Coronary Artery Disease, Renal Failure, Non-Alzheimer Dementia, anxiety, depression, malnutrition and abnormalities of gait and mobility. The Brief Interview for Mental Status (BIMS) showed the resident scored a 9 which indicated moderate impaired decision making abilities, was able to be understood and has the ability to understand others and has adequate vision. The MDS documented the resident frequently incontinent of urine and a wheelchair was used for mobility. The MDS documented the resident denied pain, no skin issues and received Hospice services. The Plan of Care with focus areas of I have been provided with a diet order for regular diet, (initiated 12/12/22), I am/have a potential to be verbally aggressive (towards residents and staff) related to dementia, and poor impulse control (initiated: 8/12/24) I have a burn of the (inner thighs) related to coffee spill (initiated 9/7/24). Interventions include: *Resident to use sippy cups to prevent skin injuries. (Initiated 9/7/24) *I am noted to be noncompliant with transfer assistance. Redirect as able. (Initiated 8/30/24) *Place me in area where frequent observation is possible. (Initiated 8/30/24) *Adjust my treatment plan if no healing within 2-4 weeks. (Initiated 9/12/24) *Avoid scratching and keep hands and body parts from excessive moisture.(Initiated 9/7/24) *Cover my arms to prevent me from scratching. (Initiated 9/12/24) *Give anti-pruritic (itching cream) medication as ordered by physician. Monitor and document side effects and effectiveness. (Initiated 9/12/24) *I have a tendency to pick at my bandages and pull them off. Please kindly remind me to not do this as it may cause an infection/worsen the wounded area.(Initiated 9/11/24) *I need a full skin evaluation weekly with bath/shower. (Initiated 9/12/24) *Monitor me for signs and symptoms of infection or spreading. (Initiated 9/12/24) *Monitor skin rashes for increased spread or signs of infection. (Initiated: 9/7/24) *Provide my progress report to me/my family on healing status. (Initiated: 9/7/24) The Progress Notes documented on these dates and times the following: *9/7/24 at 6:41 a.m., Incident, Accident, Unusual Occurrence Note Late Entry Text: Resident found to have burn marks on his inner thighs (spilled coffee on his lap), Night shift gave coffee per his request. Resident known to be terminally restless. Accidentally spilled in his lap. Placed calmoseptine on burns and called on call hospice and primary care provider. Also gave as needed morphine for pain. *9/7/24 at 6:46 a.m., Morphine Sulfate (medicine to treat moderate to severe pain)(Concentrate) Solution 20 milligram (MG)/milliliter (ML) Give 0.5 ml by mouth every 1 hours as needed for severe bilateral thigh pain. *9/7/24 at 12:29 p.m., Resident sleeping after being up all night and receiving as needed pain medication. *9/7/24 at 5:37 p.m., Give 0.5 ml of morphine by mouth every 1 hours as needed for severe pain, burns on thighs hurt *9/7/24 at 5:42 p.m., Hospice Nurse visit completed. Continuity of Care (COC) with Facility Staff Nurse (FSN), Staff E, Licensed Practical Nurse (LPN) *9/7/24 at 6:07 p.m., Hospice Verbal Order Obtained: To burns to bilateral thighs apply Silvadene cream and cover with Mepilex (absorbent foam dressing designed for low to medium exudates (fluid that leaks out of blood vessels into surrounding tissues) change every day and as needed (PRN). May use Triad (used to treat light to moderate levels of wound leakage) cream until Silvadene (a cream used to treat wound infections in patients with second and third degree burns) until obtained from pharmacy. Prescribed by physician. Facility Nurse Notified. *9/9/24 at 6:50 a.m. Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain legs and back pain. *9/10/24 at 6:42 a.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, leg burns. *9/10/24 at 3:28 p.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, burn pain. *9/10/2024 at 6:46 p.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, pain from burns. *9/12/24 at 8:22 p.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, leg pain. *9/13/24 at 4:37 p.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, Requested for pain in hand and legs. *9/14/2024 at 9:15 p.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, Resident requested PRN morphine due to the burns on his legs really bothering him. *9/15/2024 at 7:34 a.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, wounds. *9/15/2024 at 8:35 a.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours for pain. *9/15/2024 at 9:53 a.m., Hospice Note Text: Can we change residents morphine order to be able to have 0.5 ml to 1 ml PRN? It's currently just 0.5 ml. *9/16/2024 at 11:30 a.m., Hospice Note Text: Received verbal order signed by Hospice Nurse to start Morphine 0.5 ml to 1.0 ml PRN every 1 hour and discontinue previous 0.5 ml order. *9/16/2024 at 2:41 p.m., Physician Note Text: Received signed verbal orders for treatment to bilateral inner thighs. *9/17/2024 at 7:48 a.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, Resident requested for pain. *9/17/2024 at 5:28 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, dressing change was done. *9/18/2024 at 2:49 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe. *9/19/2024 at 4:50 p.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, was given for pain in legs. *9/20/2024 at 3:20 a.m. Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, Resident yelling out ouch, help me. Noted resident removing bandages to bilateral thighs. Administered medication and changed dressing at this time. *9/20/2024 at 8:39 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, for pain in resident's legs. *9/20/2024 at 1:18 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed severe leg pain. *9/20/2024 at 1:33 p.m., Monitor target behaviors and side effects every shift every day and evening shift restless, pulling apart brief and trying to take bandages off. *9/20/2024 at 7:05 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for pain. *9/21/2024 at 2:49 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, resident restless, in pain *9/22/2024 at 6:16 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain-Severe, Resident repeatedly yelling out 'help', admits to pain to legs. *9/22/2024 at 10:17 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain-Severe, resident in increased pain during dressing change to burn to thighs. *9/22/2024 at 11:38 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, PRN Administration was: Ineffective, Follow-up Pain Scale was: 8 *9/22/2024 at 11:39 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, Resident has pain due to burns on thighs. *9/22/2024 at 1:21 p.m., Monitor target behaviors and side effects every shift, every day and evening shift. Resident yelling out in pain frequently throughout this nurse's shift. PRN morphine utilized. *9/22/2024 at 4:01 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, resident yelling out in pain during cares. *9/22/2024 at 7:45 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe, crying out during cares. *9/23/2024 at 7:53 a.m., Morphine Sulfate Solution, Gave 0.75 ml by mouth every 1 hours as needed for severe pain. *9/24/2024 at 9:05 a.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe *9/24/2024 at 2:04 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe *9/24/2024 at 7:59 p.m., Morphine Sulfate Solution, Gave 1 ml by mouth every 1 hours as needed for Pain - Severe *9/24/2024 at 8:06 p.m., resident is not swallowing water, did not feel it safe to administer morphine. *9/25/2024 at 10:09 a.m., Morphine Sulfate Solution, Gave 0.5 ml by mouth every 1 hours as needed for severe pain, Was given for pain in legs. *9/26/2024 at 9:37 a.m., Atropine Sulfate Ophthalmic Solution 1 %, Give 4 drop by mouth every 1 hours as needed for secretions. *9/27/2024 at 9:02 a.m., Morphine Sulfate Solution, Give 1 ml by mouth every 1 hours as needed for Pain - Severe, labored breathing, unresponsive. *9/27/2024 at 9:46 a.m., Atropine Sulfate Ophthalmic Solution 1 %, Give 4 drop by mouth every 1 hours as needed for secretions, gurgly and secretions. *9/27/2024 at 2:33 p.m., Morphine Sulfate Solution, Give 1 ml by mouth every 1 hours as needed for Pain - Severe *9/27/2024 at 7:13 p.m., Morphine Sulfate Solution, Give 1 ml by mouth every 1 hours as needed for Pain - Severe *9/28/2024 at 11:48 p.m., On 9/28/2024, during morning rounds at 6:00 a.m., This nurse discovered Resident unresponsive, not breathing, with no pulse or respiration. The resident's skin was cold to touch, indicating death had occurred. This nurse announced resident death at 6:03 a.m. Review of the Hospice Skilled Nursing Visit Note dated 9/7/24 at 5:01 p.m., documented the following: *Left inner leg thigh/burn second degree (a burn that affects the epidermis (outer layer of skin) and dermis (the thick layer below the epidermis) with wound bed as slough, (the white/yellow material in the wound bed) length 11 cm by width 8 cm, cleanse with soap and water and apply silvadene, cover with mepilex (dressing). *Right inner leg thigh/burn second degree with wound bed as slough, length 10 cm by width 3 cm, cleanse with soap and water and apply silvadene and cover with mepilex. *Narrative notes: Received call from facility staff nurse, Staff E, LPN. Patient spilled hot coffee in his lap this am. Patient has blistered/open areas to bilateral upper, inner thighs. Patient denies pain unless touch area. New orders for Silvadene per Physician. Triad wound cream applied until Silvadene arrives from pharmacy. Patient tells this nurse Thank you that feels much better. Facility photos of the wound evaluation documented on 9/7/24 at 6:34 a.m., revealed: Left Medial thigh, First degree Burn, in-house acquired. *Dimensions= length 12.2 cm by width 4.7 cm *Wound Bed (the underlying surface of a wound, consisting of various tissues that contribute to the healing process)= 100% granulation (the development of new tissue and blood vessels in a wound during the healing process), increased pain and warmth with pink or red wound bed *Pain= cognitively impaired-yes, sad/frightened/frown, and tense body language *Treatment= calmoseptine (moisture barrier that helps protect and heal skin irritations), morphine Facility Photos of the wound evaluation documented on 9/13/24 at 8:17 a.m., revealed: Left Medial Thigh, first degree burn, in house acquired *Dimensions=8.2 cm by 5.2 cm *Wound Bed= 20% epithelial (helps to protect or enclose organs), with 30 % granulation and 50% slough and bleeding with pink/red surface area. *Exudates (mass of cells and fluid that has seeped out of blood vessels) = moderate amount of serosanguineous (a fluid that contains both blood and serum) drainage *Pain=7 at dressing *Progress=deteriorating, new treatment. Facility Photos of the wound evaluation documented on 9/20/24 at 3:27 a.m., revealed: Left Medial thigh, first degree burn, in house acquired *Dimensions= 8.3 cm by 2.8 cm *Wound Bed= 10 % epithelial tissue, 30% granulation tissues, 20% slough, 40% eschar (dead tissue that eventually sloughs off healthy skin after an injury) and area is bleeding, islands of epithelium and pink/red surface area. *Exudate= light serosanguineous drainage *Peri Wound (the skin surrounding a wound) = 1.5 cm of attached erythema (superficial reddening of the skin) tissue and temperature is warm. *Progress=stable, no new treatment. Facility photos of the wound evaluation documented on 9/7/24 at 6:34 a.m., revealed: Right Medial thigh, first degree burn, in house acquired. *Dimensions=length 5.8 cm by 3.6 cm *Wound Bed=100% epithelial and pink/red wound bed *Pain=score of 8, with sad/frightened/frown facial expressions and cognitively impaired. Facility Photos of the wound evaluation documented on 9/13/24 at 8:17 a.m., revealed: Right Medial Thigh, first degree burn, in house acquired *Dimensions=1.4 cm by 6.8 cm *Wound Bed= 30% epithelial, and 70% granulation and pink/red surface area *Exudate= light, serosanguineous drainage *Peri-Wound= excoriated surrounding the tissue, 2.5 cm and warm *Pain= 7 at dressing change *Progress=deteriorating, new treatment Facility Photos of the wound evaluation documented on 9/20/24 at 3:27 a.m., revealed: Right Medial thigh, first degree burn, in house acquired *Dimensions= 1.7 cm by 3.0 cm *Wound Bed= 30% of epithelial tissue, 70% of granulation tissue and area is pink/red surface area *Exudate= light serosanguineous drainage *Peri Wound= 1.5 erythema with attached edges and temperature is warm *Progress=stable with no new orders Review of the Facility Skin and Wound Evaluation form dated 9/7/24 at 12:45 p.m., revealed a first degree burn of the left medial thigh, from a coffee spill, area measures 46.2 cm by 12.3 cm by 4.8 cm, with 100% of wound filled with granulation, increased pain, warmth, with no dressing applied, resident with wound pain by loud moaning or groaning and crying, pulling and pushing away, appears frightened. Review of the Facility Skin and Wound Evaluation form dated 9/20/24 at 4:09 a.m., revealed a first degree burn on the right medial thigh, from a coffee spill, with start date 9/7/24, area measures 2.6 centimeters (cm) by 1.8 cm by 3.1 cm., with 30 % of wound covered with granulation, with light amount of exudate, of serosanguineous type, resident with wound pain by loud moaning or groaning and crying, pulling and pushing away, appears frightened. Interview on 1/29/24 at 2:45 p.m., The Senior Director of Nursing (DON), confirmed and verified that the Silvadene order was not on the September Medication Administration Record (MAR) or the September Treatment Administration Record (TAR) and it is the expectation of the nurses to follow the physician orders and note orders per the State and Federal Rules and Regulations and that the facility failed to follow the orders. Interview on 1/29/25 at 3:00 p.m., Staff B, Certified Nursing Assistant (CNA), stated that Resident #1 would like to always have a cup of coffee with him and that there was no directive to put a lid on the mug. Resident #1 would be impulsive and want to transfer themselves unexpectedly. The directive now is that any resident that wants coffee out of the dining room will have a tumbler with a lid. Interview on 1/29/25 at 4:00 p.m., Staff E, LPN, confirmed and verified that the order for the Silvadene was not noted on the September MAR or TAR, Staff E stated that they did not see the burn until later on 9/7/24, when the Hospice Nurse came to evaluate the burns and the burns were blistered and peeling. Staff E, stated that it was not uncommon for Resident #1 to always have a cup of coffee with them at all times and there was not a directive to have a lid on the mug and that the resident was impulsive with transferring and would unexpectedly stand up. Interview on 1/29/25 at 4:15 p.m., the DON stated that after this incident with the coffee spill and burn the facility had put in place that if a resident wants coffee out of the dining room they will have a small tumbler with a lid at all times. The DON failed to admit or deny that they had seen the burn on the morning of 9/7/24. Interview on 1/30/25 at 11:15 a.m., the facility Assistant Director of Nursing (ADON) confirmed and verified that the order for the Silvadene cream failed to get noted on the September MAR/TAR. The ADON stated that they took the pictures of the resident burn on 9/7/24 and that the DON gave the directive to put calmoseptine on them until the Hospice nurse comes to see them. The ADON stated that the resident had a cup of coffee with them at all times and that there was no directive to have a lid on the mug and that the resident would be impulsive with wanting to transfer by themselves and stand up unexpectedly. Interview on 1/30/25 at 8:15 a.m., the Dietary Manager stated the kitchen staff follow the Federal and State rules and regulations for temperature of the food and that the food and liquids are to be at 135 degrees Fahrenheit or above. The Dietary Manger stated that no records are kept of the food temperatures of the coffee and that staff will randomly take a coffee temperature, but is not written down anywhere. An In-Service Form dated 1/29/25 with no time, revealed, Educations Description: Nurse Education regarding 1. Processing Hospice Orders and Noting them. 2. Time line for Completing assessments after risk management; Nursing focus Evaluation (incident/accident/unusual occurrence follow up charting). option B a. Time Line for Completing assessments after risk management: *This Hot Charting is related to an Incident/Accident/Unusual Occurrence (example=resident had a recent fall or an injury and a Risk Management has been completed and now you are following up every shift. *This charting is expected to be completed at least every shift for 24 hours or until stable. *If the injury is a burn, it will be expected that this chart will stay a Hot Chart and be completed every day until healed. 3. Following orders for treatments; a. All skin that is identified as impaired due to an injury is to have *Risk management completed. *Skin evaluation completed with weekly/as needed follow up evaluations completed until healed. *Doctor notification completed. *An order for treatment will be put into place and initiated immediately. This treatment will continue until the area is healed or the treatment needs to be changed due to a change in condition. *The nurse will sign the treatment off when completed. *If wound show a decline in treatment after 1-2 weeks, physician is to be notified and a new treatment to be initiated. 4. Follow documentation for burns. A Hospice Verbal Order Process with a revision dated 4/1/24, purpose is to provide direction for entry of documentation into Point Click Care (PCC). For guidance on clinical documentation expectations please refer to appropriate procedures. 1. When a Hospice Nurse obtains a verbal order for a resident, they will notify the facility nurse and complete the Hospice Verbal Order Evaluation. a. The hospice nurse will document the date/time the order was obtained, verbal order details, prescribing physician and who at the facility was notified. b. The Hospice Nurse Verbal Order Evaluation will display on the Clinical Dashboard > Clinical Alerts and on the 24 hour Summary Report. 2. The facility nurse will then enter the verbal order into PCC and obtain signature from physician. 3. Facility nurse will fax the pharmacy if needed. 4. The hospice nurse will enter the verbal order into their software and obtain signature. 5. The hospice office will scan their signed verbal order into PCC< into the residents miscellaneous tab (there will be two signed orders).

Based on clinical record review, admission agreement, resident bill of rights, facility document manager process, resident council meeting minutes, staff and family interview the facility failed to provide the resident/resident representative in writing the resident rights, rules and regulations and responsibility during the stay in the facility or upon admit for 1 of 3 residents reviewed. (Resident #4). The facility identified a census of 46 residents. Findings include: The Clinical Census report dated [DATE] at 5:18 p.m., documented Resident #4 admitted on [DATE]. The Progress Notes dated [DATE] at 12:18 p.m., documented with Physician Note Text: Resident admits to facility this morning 11:30 a.m., via family vehicle with daughter. Resident is weak when transferring. No complaints. No current illness suspected. Please review orders and advise. On [DATE], the Resident/Power of Attorney (POA) signed and dated the Admission Care Plan which indicated acknowledgement of the said form. The POA e-signed the Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitation (DNR) order Declaration Form on [DATE] at 12:01 p.m. Review of the Admission Agreement form page 13 date [DATE] in Point Click Care (PCC), revealed the Durable Power of Attorney (DPOA) for Health Care Decision marked the form with an X followed by a facility Representative to have signed the form on [DATE] with no time. Interview on [DATE] at 12:30 p.m., with the Social Service Director, no one in the facility knew who signed the form with an X and he/she failed to confirm or deny the X as her/his mark although he/she had been present on admit. Review of the printed Admission Agreement form on page 13, revealed the DPOA checked the box that represented No for DPOA and the box that represented a Yes for the resident representative e-signed by the POA on [DATE] at 11:46 a.m. Review of an Arbitration Procedure form revealed the POA e-signed the form [DATE] at 11:46 a.m. and the facility representative on [DATE] at 11:16 a.m. An Explanation of Medicare Benefits form revealed the Resident/Guardian/Legal Representative e-signed the form on [DATE] at 11:47 a.m. Interview on [DATE] at 2:38 p.m., POA, stated that the admission paperwork was not completed with them on [DATE], when Resident #4 was admitted to the facility. The POA asked for a copy of the admission paperwork during a careplan conference and noticed that the e-signature was on [DATE]. The POA confirmed and verified that they were not in the facility on [DATE]. Interview on [DATE] at 12:30 p.m , the Social Service Director, confirmed as well as the DPOA/POA had been present with the review of the admission forms and clicked on the e-signature on the form however there was no explanations as to why the date on the computer failed to automatically time stamp per normal routine with any e-signature on a computer system. The Social Service Director confirmed and verified that the facility failed to give a written admission paperwork to the POA or the Resident on [DATE]. Interview on [DATE] at 1:30 p.m., the Regional Director of Human Resources, confirmed and verified that the facility has changed their admission process and revised the Process: Document Manger on [DATE]. The Resident Council Meeting Minutes dated [DATE] at 10:30 a.m., revealed, a Resident and /or resident request to review the admission packet with all the information in it including an activity calendar for the month. The Resident [NAME] of Rights dated ,d+[DATE], stated that the resident has the 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. *The right to be fully informed in language that her or she can understand of his or her total health status including but not limited to his or her medical condition. *The resident has the right to receive notices orally (meaning spoken) and in writing in a format and a language he or she understands. *Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights. The Process: Document Manager revised on [DATE] and [DATE], documented the purpose is to provide direction for entry of documentation into the PCC. For guidance on clinical documentation expectations please refer to appropriate facility procedures. Document Manager in PCC allows staff, resident and/or resident responsible parties to sign documents electronically. Signatures can be obtained in person or remotely. When a user is signing in person they will use the facility chromebook (is a lap-top or tablet that runs on Google's operating system). When a user is signing remotely they do need to provide a mobile phone number and email and then will be able to sign on their own personal device. Documents can still be printed and signed on paper if requested.

Based on resident and staff interviews, resident council minutes and the facility assessment, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 2 of 3 residents (Resident #2, and #3). The facility identified a census of 46 residents. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 11/18/24 documented Resident #2 had diagnosis that included anemia, hypertension, diabetes mellitus, neurogenic bladder, paraplegia, depression and anxiety. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired decision making abilities. The assessment documented the resident as dependent with all activities of daily living and was able to be understood and understands others. Interview on 1/27/25 at 3:30 p.m., Resident #2 stated that it will take the staff over a half hour and up to an hour to answer the call light. 2. The MDS assessment form dated 7/4/24, documented Resident #3, had diagnosis of anemia, coronary heart disease, hypertension, anxiety, depression and chronic pain. The MDS revealed the resident with a BIMS score of 15 which indicated no cognitive impairment, able to make self understood and has the ability to understand others, and dependent with shower/bathing. Interview on 1/28/25 at 8:45 a.m., Resident #3 confirmed and verified that the call light is on for longer than 15 minutes, sometimes over 45 minutes. Interview on 1/29/25 at 3:00 p.m., Staff B, Certified Nursing Assistant (CNA) confirmed and verified that it will take longer than 15 minutes to answer a call light and that the facility needs more staff. Interview on 1/29/25 at 4:30 p.m., Staff C, CNA, confirmed and verified that it will take over 15 minutes to answer a call light especially if two staff are in a resident room using a mechanical lift. Interview on 1/30/25 at 11:55 a.m., the facility Director of Nursing confirmed and verified that the facility needs more staffing and that it could take over 15 minutes to answer a call light and that the expectation of the staff are to follow the guidelines of answering the call lights within the 15 minutes. The Resident Council Meeting Minutes dated 9/27/24, documented that residents feel call lights are not being answered timely. The Facility assessment dated [DATE], instructed that the Daily Staffing Pattern to be per day: Nurse Aides=4-7 on 1st shift 4-5 on 2nd shift 2 on 3rd shift Restorative aide included in the above staffing. The Two Week Work Schedule dated 1/23/25-2/5/25, revealed: 1/27/25=2 CNA for the 2:00 p.m.-10:00 p.m. shift with 1 CNA scheduled from 6:00 p.m.-6:00 a.m. 1/28/25=3 CNA for the 2:00 p.m.-10:00 p.m. shift with 1 CNA scheduled from 6:00 p.m.-6:00 a.m. 1/29/25=2 CNA for the 2:00 p.m.-10:00 p.m. shift with 2 CNA scheduled from 6:00 p.m.-6:00 a.m. 1/30/25=2 CNA for the 2:00 p.m.-10:00 p.m., shift with 2 CNA scheduled from 6:00 p.m.-6:00 a.m.

Based on clinical record review, observation, resident and staff interview the facility failed to provide profession standards according to the plan of care to have the residents colostomy checked every 3 hours for 1 of 1 resident reviewed (Resident #2). The facility identified a census of 46 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 11/18/24 documented Resident #2 had diagnosis of anemia, hypertension, diabetes mellitus, neurogenic bladder, paraplegia, depression and anxiety. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired decision making abilities, is understood and has the ability to understand others. The assessment documented the resident as dependent with all activities of daily living and has an colostomy. The Plan of Care with an initiated dated 8/14/24, had a focus area of, I use colostomy. Interventions include: *Staff to check colostomy bag every 3 hours and empty as needed. The Point of Care Response History dated 1/27/25 at 4:47 p.m., revealed the task segment instructed staff to check colostomy bag every 3 hours, empty if needed. The following dates and times revealed the colostomy bag checked: 1/20/25 at 3:02 a.m. and 10:30 a.m. 1/21/25 at 00:57 a.m., and 5:00 a.m. 1/22/25 at 00:26 a.m., and 5:18 a.m. 1/24/25 at 12:00 p.m., and 9:19 p.m. 1/25/25 at 2:40 a.m., and 8:12 a.m. 1/26/25 at 2:06 a.m., and 6:00 a.m., 12:00 p.m., and 9:53 p.m. The Clinical Record lacked any documentation of the colostomy bag being checked every 3 hours per the Plan of Care. Interview on 1/27/25 at 3:30 p.m., Resident #2, stated that staff fail to check the colostomy bag every 3 hours as requested and sometimes the colostomy bag is really full of air and needs to be burped and it bothered him. Observation on 1/28/25 at 12:15 p.m., Staff D, Certified Nursing Assistant (CNA) went into Resident #2's room to burp the colostomy. Staff D stated that the colostomy was full of air and burped the bag. Staff D confirmed and verified that the colostomy bag is to be checked every 3 hours but admitted that the bag does not get burped every 3 hours per the plan of care due to staffing. Interview on 1/30/25 at 11:15 a.m., the facility Director of Nursing stated that the facility has no policy/procedure on colostomy bags and that the facility follows the State and Federal guidelines for colostomy cares and that it is the expectation of the staff to check the colostomy every 3 hours per the task on the Point of Care segment.

Based on clinical record review, resident bill of rights, facility policy/process, and staff interviews, the facility staff failed to investigate Resident #3 and Resident #1 missing Fentanyl (a topical opioid pain medications) patches. The facility reported a census of 46 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired decision making abilities, was able to be understood and ability to understand others and has adequate vision. The MDS also documented the resident as required partial/moderate assistance with showering/bathing and independent with other activities of daily living and diagnosis included anemia, coronary artery disease, hypertension, anxiety, depression and chronic pain. The MDS documented the resident had pain frequently over the last 5 days and described the pain as moderate and receiving an opioid medication daily in the last 7 days. The Plan of Care with an initiated dated 8/16/23, identified a focus area of I am on pain medication therapy (Fentanyl) related to disease process (Chronic pain). Interventions include: *Fentanyl exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient's risk prior to prescribing fentanyl, and monitor all patients regularly for the development of these behaviors or conditions. *Accidental exposure of even one dose of fentanyl, especially by children, can result in a fatal overdose of fentanyl. Deaths due to an overdose of fentanyl have occurred when children and adults were accidentally exposed to fentanyl transdermal patch. Strict adherence to the recommended handling and disposal instructions is of the utmost importance to prevent accidental exposure. The Progress Notes dated 12/15/24 at 8:03 a.m., documented Administration Note Text: Fentanyl Patch 72 Hour 50 micrograms/hour Apply 1 patch transdermally one time a day every 3 day(s) for pain and remove per schedule. No patch found to remove. The Progress Notes dated 12/15/24 at 8:05 a.m., documented Administration Note Late Entry: Note Text: Entered resident's room to administer scheduled medications and a fentanyl patch as scheduled. Upon assessing the resident no patch from previous administration was found in the location listed. This nurse then proceeded to check the resident's entire back by lifting up his shirt and still no patch was found. This nurse asked the resident to remove his shirt to assess his entire upper half for the previous patch. After complete assessment of resident, no patch was found on him. Resident's bed and floor also checked and no patch was found. Resident was asked if he knew what had happened to the patch and if it had fallen off at some time and resident stated that he had no idea what had happened to it. During interview on 1/28/25 at 3:00 p.m., the facility Director of Nursing, stated that no investigation was completed on the missing Fentanyl patch and that it is the expectation of the nurses to make sure that the patch is on every shift and if not able to find the patch then to start an investigation immediately. During interview on 1/29/25 at 12:00 p.m., the facility Director of Nursing, confirmed and verified that the facility failed to do an investigation into the missing fentanyl patch and failed to notify DIAL of the missing patch. 2. The MDS assessment dated [DATE], documented Resident #1 with a BIMS score of 9 for which indicated moderate impaired decision making abilities, was able to be understood and ability to understand others and has adequate vision. The MDS also documented the resident as required substantial/maximum assistance with showering/bathing and independent with other activities of daily living and diagnosis included coronary artery disease, renal failure, Non-Alzheimer Dementia, anxiety, depression and chronic pain. The MDS documented the resident denied pain. The Physician Order dated 8/27/24 at 2:00 p.m., instructed staff to place a Fentanyl Patch 72 Hour 25 micrograms/hour and change every 3 days. The Plan of Care with a revision dated 8/6/24, had a focus area of I take opioid pain medication. Interventions include: *To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse. Under the requirements of the drug companies with approved opioid analgesic products-compliant education programs available to health care providers. *Health care providers are strongly encouraged to complete a compliant education program and counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products, emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist, and consider other tools to improve patient, household, and community safety. The Progress Note dated 8/30/24 at 1:48 p.m., documented Administration Note Text: Fentanyl Patch 72 Hour 25 micrograms/hour Apply 1 patch transdermally one time a day every 3 day(s) for pain and remove per schedule patch not found. Interview on 1/29/25 at 12:00 p.m., the facility Director of Nursing confirmed and verified that the facility failed to do an investigation into the missing Fentanyl patch. The Dependent Adult Abuse Policy dated 11/19, documented the policy is that all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and nay physical or chemical restraint not required to treat the resident medical symptoms. Residents 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. It shall be the policy of this facility to implement written procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. The Resident [NAME] of Rights dated 1/2017, stated that the resident has the 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. *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 residents individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, resident bill of rights, facility investigation, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents (Resident #3) were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hour and the facility also failed to report potential abuse for missing Fentanyl (a topical opioid pain medication) patches were reported to the DIAL within 24 hours. (Resident #3 and Resident #1). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired decision making abilities, no physical or verbal behavior symptoms directed towards others, was able to be understood and ability to understand others and had adequate vision. The MDS also documented the resident as required partial/moderate assistance with showering/bathing and independent with other activities of daily living and diagnosis included anemia, coronary artery disease, hypertension, anxiety, depression and chronic pain. The Plan of Care with an initiated date 12/18/22, documented Resident #3 has a behavior problem, for which has negative outcome from my behaviors. Interventions include: *Anticipate and meet my needs. *Approach me and speak to me in a calm manner. *Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. *Intervene as necessary to protect the rights and safety of others. *Social Services to evaluate and visit with me. *I ambulate independently without the use of an assistive device, but do use a walker at request as needed. A Grievance/Concern Investigation Form dated 8/26/24, documented Resident #3 reported to the facility, Can't remember when, but Staff A, CNA backed me up against the dining room wall, bitching at me about cleaning up my room and have stuff under bed. I will call my attorney if this keeps happening. Follow-up from facility, Staff A, CNA had removed numerous boxes of gloves from under Resident #3's bed and resident was upset. Staff A never backed up resident against a wall. A Police Department Call for Service Record dated 8/29/24 at 9:32 a.m., recorded a Resident advised Nurses Aide pushed him up against the wall. Resident would like to speak with an officer. At 10:08 a.m., Officer unable to confirm at this time, will speak with other residents. A written comment on the investigation note dated 9/4/24, documented, Staff A, stay totally away from Resident #3, no cares, not in his room, no smoking outside together, Stay away! The Progress Notes dated 9/4/24 at 9:16 a.m., documented Behavior Note Text: Resident called this nurse over to him at the dining room table. Asked resident how things were going. Resident stated that his elbow was hurting. When asked what happened. Resident stated that it was stemming from the incident he previously reported. This nurse then asked the resident I thought it was your head that was hurt. He replied yeah it was but now my elbow hurts. This nurse asked resident if Range of Motion (ROM) was intact and everything was fully functional. Resident responded yes. Resident informed and educated on the use of pain medications as needed. The Progress Notes dated 9/4/24 at 2:10 p.m., documented Administration Note Text: Monitor target behaviors and side effects every shift every day and evening shift. CNA witnessed resident saying he was going to get staff in trouble again. I also saw him walk up the hall and try to look around the corner for that same staff member. The Progress Notes dated 9/4/24 at 4:29 p.m., documented Note Text: Director of Nursing (DON) and Administrator visited with this resident regarding a recent incident in which himself and staff member were in a disagreement. Resident states staff member is still his friend and eventually will come around and speak with her again as they used to. States he does not have any issues with her currently. DON and Administrator offered other living solution in an assisted living in another town. States he does like the idea but will think about it for a while and let us know if decides this would be a good idea. Resident states he has a headache. Educated on medications he can use and encouraged fluid intake to prevent dehydration which can cause headaches. No further concerns from administration or resident. Will follow as needed A Police Department Call for Service Report dated 9/27/24 at 2:48 p.m., Resident wants to speak to an officer about him being assaulted at the facility. At 3:00 p.m., Resident has already spoken with the officer about the assault, it has been unfounded. A written comment on the Investigation Note dated 10/24/24, still upset with Staff A on 9/4/24 incident. Interview on 1/28/25 at 8:45 a.m., Resident #3 was not able to recall the exact date and time with Staff A, treating him rough and threw him up against a wall, did state the facility Administrator was told about the incident. Interview on 1/28/25 at 11:30 a.m., the facility Administrator did an internal investigation and felt that Staff A, was not capable of backing Resident #3 up against a wall in the dining room as alleged by Resident #3 and allowed Staff A to continue to work in the facility with the directive to not work with Resident #3. Interview on 1/28/25 at 1:00 p.m., Staff A, CNA, explained that on 8/26/24, she was cleaning under Resident #3's bed while he was outside smoking, sometime around lunch, and found a box of gloves and Kleenex. Resident #3's roommate told Resident #3 that Staff A had taken some things from underneath his bed and then accused me of backing him up against the dining room wall and yelling at him for all the stuff that was found. The facility asked me to go to my car until they determined for me to come back into work. I came back into work and finished my shift, I am not sure of the time I punched out or in. Interview on 1/29/25 at 11:30 a.m., the facility Administrator confirmed and verified that the facility failed to notify DIAL of the incident between Resident #3 and Staff A within the 2 hour time frame. 2. The MDS assessment dated [DATE], documented Resident #3 with a BIMS score of 15 for which indicated no impaired decision making abilities, was able to be understood and ability to understand others and had adequate vision. The MDS also documented the resident as required partial/moderate assistance with showering/bathing and independent with other activities of daily living and diagnosis included anemia, coronary artery disease, hypertension, anxiety, depression and chronic pain. The MDS documented the resident had pain frequently over the last 5 days and described the pain as moderate and receiving an opioid medication daily in the last 7 days. The Plan of Care with an initiated date 8/16/23, identified a focus area of I am on pain medication therapy (Fentanyl) related to disease process (Chronic pain). Interventions include: *Fentanyl exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient's risk prior to prescribing fentanyl, and monitor all patients regularly for the development of these behaviors or conditions. *Accidental exposure of even one dose of fentanyl, especially by children, can result in a fatal overdose of fentanyl. Deaths due to an overdose of fentanyl have occurred when children and adults were accidentally exposed to fentanyl transdermal patch. Strict adherence to the recommended handling and disposal instructions is of the utmost importance to prevent accidental exposure. The Progress Notes dated 12/15/24 at 8:03 a.m., documented Administration Note Text: Fentanyl Patch 72 Hour 50 micrograms/hour Apply 1 patch transdermally one time a day every 3 day (s) for pain and remove per schedule. No patch found to remove. The Progress Notes dated 12/15/24 at 8:05 a.m., documented Administration Note Late Entry: Note Text: Entered resident's room to administer scheduled medications and a fentanyl patch as scheduled. Upon assessing the resident no patch from previous administration was found in the location listed. This nurse then proceeded to check the resident's entire back by lifting up his shirt and still no patch was found. This nurse asked the resident to remove his shirt to assess his entire upper half for the previous patch. After complete assessment of resident, no patch was found on him. Resident's bed and floor also checked and no patch was found. Resident was asked if he knew what had happened to the patch and if it had fallen off at some time and resident stated that he had no idea what had happened to it. Interview on 1/28/25 at 3:00 p.m., the facility Director of Nursing, stated that no investigation was completed on the missing Fentanyl patch and that it is the expectation of the nurses to make sure that the patch is on every shift and if not able to find the patch then to start an investigation immediately. Interview on 1/29/25 at 12:00 p.m , the facility Director of Nursing, confirmed and verified that the facility failed to do an investigation into the missing fentanyl patch and failed to notify DIAL of the missing patch. 3. The MDS assessment dated [DATE], documented Resident #1 with a BIMS score of 9 for which indicated moderate impaired decision making abilities, was able to be understood and ability to understand others and has adequate vision. The MDS also documented the resident as required substantial/maximum assistance with showering/bathing and independent with other activities of daily living and diagnosis included coronary artery disease, renal failure, Non-Alzheimer Dementia, anxiety, depression and chronic pain. The MDS documented the resident denied pain. The Physician Order dated 8/27/24 at 2:00 p.m., instructed staff to place a Fentanyl Patch 72 Hour 25 micrograms/hour and change every 3 days. The Plan of Care with an revision dated 8/6/24, had a focus area of I take opioid pain medication. Interventions include: *To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse. Under the requirements of the drug companies with approved opioid analgesic products-compliant education programs available to health care providers. *Health care providers are strongly encouraged to complete a compliant education program and counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products, emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist, and consider other tools to improve patient, household, and community safety. The Progress Note dated 8/30/24 at 1:48 p.m., documented Administration Note Text: Fentanyl Patch 72 Hour 25 micrograms/hour Apply 1 patch transdermally one time a day every 3 day (s) for pain and remove per schedule patch not found. Interview on 1/29/25 at 12:00 p.m., the facility DON, stated that the facility failed to report the missing Fentanyl to DIAL as per policy/procedure. The Dependent Adult Abuse Policy dated 11/19, documented the policy is that all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the resident medical symptoms. Residents 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. It shall be the policy of this facility to implement written procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. Timely Abuse Reporting dated 11/19, documented all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to DIAL no later 2 hours after the allegation is made. The Resident [NAME] of Rights dated 1/2017, stated that the resident has the 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. *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 residents individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, facility investigation, resident bill of rights, facility policy/procedures, and staff interviews the facility failed to provide a supportive and safe environment for Resident #3. On 8/26/24, the facility staff learned of a Certified Nurse Aide (CNA) being accused of backing Resident #3 into a wall and bitching at them. After learning of this allegation of abuse, the facility staff told the CNA not to help Resident #3, but allowed them to work with other residents. The facility identified a census of 46 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired decision making abilities, no physical or verbal behavior symptoms directed towards others, was able to be understood and ability to understand others and had adequate vision. The MDS also documented the resident as required partial/moderate assistance with showering/bathing and independent with other activities of daily living and diagnosis for which included anemia, coronary artery disease, hypertension, anxiety, depression and chronic pain. The Plan of Care with an initiated date 12/18/22, documented Resident #3 has a behavior problem, for which has negative outcome from my behaviors. Interventions include: *Anticipate and meet my needs. *Approach me and speak to me in a calm manner. *Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. *Intervene as necessary to protect the rights and safety of others. *Social Services to evaluate and visit with me. *I ambulate independently without the use of an assistive device, but do use a walker at request as needed. A Grievance/Concern Investigation Form dated 8/26/24, documented Resident #3 reported to the facility, Can't remember when, but Staff A, CNA backed me up against the dining room wall, bitching at me about cleaning up my room and have stuff under bed. I will call my attorney if this keeps happening. Follow-up from facility, Staff A, CNA had removed numerous boxes of gloves from under Resident #3's bed and resident was upset. Staff A, never backed up resident against a wall. A Police Department Call for Service Record dated 8/29/24 at 9:32 a.m., recorded a Resident advised Nurses Aide pushed him up against the wall. Resident would like to speak with an officer. At 10:08 a.m., Officer unable to confirm at this time, will speak with other residents. A written comment on the Investigation Note dated 9/4/24, documented, Staff A, stay totally away from Resident #3, no cares, not in his room, no smoking outside together, Stay away! The Progress Notes dated 9/4/24 at 9:16 a.m., documented Behavior Note Text: Resident called this nurse over to him at the dining room table. Asked resident how things were going. Resident stated that his elbow was hurting. When asked what happened. Resident stated that it was stemming from the incident he previously reported. This nurse then asked the resident I thought it was your head that was hurt. He replied yeah it was but now my elbow hurts. This nurse asked resident if Range of Motion (ROM) was intact and everything was fully functional. Resident responded yes. Resident informed and educated on the use of pain medications as needed. The Progress Notes dated 9/4/24 at 2:10 p.m., documented Administration Note Text: Monitor target behaviors and side effects every shift every day and evening shift. CNA witnessed resident saying he was going to get staff in trouble again. I also saw him walk up the hall and try to look around the corner for that same staff member. The Progress Notes dated 9/4/24 at 4:29 p.m., documented Note Text: Director of Nursing (DON) and Administrator visited with this resident regarding a recent incident in which himself and staff member were in a disagreement. Resident states staff member is still his friend and eventually will come around and speak with her again as they used to. States he does not have any issues with her currently. DON and Administrator offered other living solution in an assisted living in another town. States he does like the idea but will think about it for a while and let us know if decides this would be a good idea. Resident states he has a headache. Educated on medications he can use and encouraged fluid intake to prevent dehydration which can cause headaches. No further concerns from administration or resident. Will follow as needed A Police Department Call for Service Report dated 9/27/24 at 2:48 p.m., Resident wants to speak to an officer about him being assaulted at the facility. At 3:00 p.m., Resident has already spoken with the officer about the assault, it has been unfounded. A written comment on the investigation noted dated 10/24/24, still upset with Staff A on 9/4/24 incident. Review of the Employee Punch Report with a run dated 1/30/25 at 11:55 a.m., revealed Staff A worked on 8/26/24 from 6:28 a.m., to 8:40 a.m., then from 9:04 a.m., to 10:36 a.m., and 11:00 a.m., to 2:51 p.m. Interview on 1/28/25 at 8:45 a.m., Resident #3 was not able to recall the exact date and time with Staff A, treating him rough and threw him up against a wall, did state the facility Administrator was told about the incident. Interview on 1/28/25 at 11:30 a.m., the facility Administrator did an internal investigation and felt that Staff A, was not capable of backing Resident #3 up against a wall in the dining room as alleged by Resident #3 and allowed Staff A to continue to work in the facility with the directive to not work with Resident #3. Interview on 1/28/25 at 1:00 p.m., Staff A, CNA, explained that on 8/26/24, she was cleaning under Resident #3's bed while he was outside smoking, sometime around lunch, and found a box of gloves and Kleenex. Resident #3's roommate told Resident #3 that Staff A had taken some things from underneath his bed and then accused me of backing him up against the dining room wall and yelling at him for all the stuff that was found. The facility asked me to go to my car until they determined for me to come back into work. I came back into work and finished my shift, I am not sure of the time I punched out or in. The Dependent Adult Abuse Policy dated 11/19, documented the policy is that 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 medical symptoms. Residents 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. It shall be the policy of this facility to implement written procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. The Resident [NAME] of Rights dated 1/2017, stated that the resident has the 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. *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 residents individuality. The facility must protect and promote the rights of the resident.

Based on record review, interview, and facility policy the facility failed to have the Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 53 residents. Findings include: The following Quality Assurance Committee Meeting Sign-In showed the Director of Nursing (DON) as the Infection Preventionist that attended the quarterly meetings for the following dates: a. 12/15/23 b. 3/8/24 c. 5/31/24 The Quality Assurance and Performance Improvement (QAPI) Program policy dated March 2020 identified the Infection Preventionist served on the committee. In an interview on 7/18/24 at 8:40 AM, Staff D, Registered Nurse (RN) reported she obtained certification as an infection preventionist. When asked if she attended QAPI meetings, Staff D replied, no. In an interview on 7/18/24 at 8:58 PM, the DON reported she completed the infection preventionist course but failed to realize the infection preventionist certification required succession completion of the infection preventionist certification test.

Based on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 4 of 15 residents reviewed (Residents #1, #5, #35, and #39). The facility reported a census of 53 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. In an interview on 7/15/24 at 11:37 AM Resident #1 revealed the food is cold when it should be hot. Resident #1 further revealed that room trays are not delivered until everyone in the dining room has been fed. 2. Review of Resident #5's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. In an interview on 7/15/24 at 1:48 PM Resident #5 revealed foods are often cold when they should be hot. 3. Review of Resident #35's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. In an interview on 7/15/24 at 11:56 AM Resident #35 revealed he has been here for four years and the food has been bad the entire time. Resident #35 further revealed the food is often cold when it should be hot. 4. Review of Resident #39's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. In an interview on 7/15/24 at 1:09 PM Resident #39 revealed the food is often burnt and then served cold. Continuous observation on 7/16/24 from 11:45 AM until 12:48 PM dining service was completed in the dining room. Post meal temperature was obtained on the food items in the steam table before room trays were sent to Residents. Post temperatures revealed Chicken and dumplings were 156 degrees, green beans were 146 degrees, chicken tenders were 138.6 degrees, cheese sauce was 123 degrees, and mashed potatoes were 118 degrees. During observations on 7/16/24 at 12:47 PM the first room tray was placed onto the meal cart for room service and was sent out to be delivered to Resident rooms after the meal tray was filled with trays. A sample room tray was obtained, and a temp check at 1:09 PM was completed revealing chicken and dumplings to be 113.9 degrees, and green beans were 86.4 degrees. In an interview on 7/16/24 at 12:57 PM with Staff C Dietary Service Manager revealed her expectations would be for food temperatures to be at the appropriate temps when served. In an interview on 7/16/24 at 1:12 PM with the Administrator revealed that her expectation would be for food served to be at appropriate temperatures. Review of a facility provided policy titled, Food Preparation and Service, with a revision date of April 2019 documented: a. Food service/distribution - Proper hot and cold temperatures are maintained during food service.

Based on record review and staff interview, the facility failed to immediately notify the physician and resident representative of a fall with an injury for 1 of 5 residents reviewed (Resident #32). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes and hypoglycemia. The Care Plan identified the resident had an actual fall related to unsteady gait initiated 10/16/2023. The Progress Notes documented the following: a. On 4/11/24 at 10:21 p.m. documented the resident received Hydrocodone (narcotic)-Acetaminophen 5-325 mg for pain in the right leg. b. On 4/12/24 at 10:06 a.m. the resident received Acetaminophen 325 mg for pain in her right ankle. She rated her pain a 6/10. c. On 4/12/24 at 5:16 p.m. the resident received Acetaminophen 325 mg for complaints of pain in her right ankle. The resident rated her pain a 6/10. d. On 4/12/24 at 5:31 p.m. the resident was on focused charting following an unwitnessed fall on 4/9. The resident denied injuries related to that fall but complained of a sore ankle related to a fall that occurred when out with family on 4/11. Acetaminophen administered and effective. Would continue to monitor and update as needed. Plan of care ongoing. e. On 4/12/24 at 6:28 p.m. the administration of Acetaminophen was ineffective, the follow up pain was 8 (of 10). f. On 4/12/24 at 9:50 p.m. the resident received Hydrocodone-Acetaminophen per request for pain in her right leg and ankle. g. On 4/13/24 at 3:25 a.m. the resident remained on focused charting related to an unwitnessed fall in the dining room. No injuries. Range of motion (ROM) intact, neuros intact. No concerns at that time. h. On 4/13/24 at 4:16 p.m. the resident received Hydrocodone-Acetaminophen per resident request for pain rated 6 out of 10 in ankle. No signs of distress. Plan of care on going. i. On 4/14/24 at 6:43 a.m. the resident received Hydrocodone-Acetaminophen per resident request for pain in right ankle due to previous fall. The ankle appeared swollen with minimal bruising. No signs of distress. Plan of care on going. On 4/14/24 at 2:10 p.m. Communication with the Physician documented while giving medication to the resident in the a.m. the nurse noticed increased swelling with bruising noted to the outer right foot. The resident stated the injury occurred due to fall in the dining room. The resident complained of pain upon movement of the foot, and stated she could walk on it but it was painful. As needed Hydrocodone and an ice pack given for pain. At 4:09 p.m. the resident received Hydrocodone-Acetaminophen per resident request for pain in the right ankle rated 6 out of 10. No signs of distress. The ankle appeared swollen, and ice pack applied. At 4:57 p.m. clarification to the physician the resident stated she fell while on a home visit Thursday 4/11. The Progress Notes on 4/15/24 documented the resident seen for fall when out with family and she stepped in a hole in the ground and fell . She didn't tell anyone at the facility she fell initially but over the weekend her foot was noted to be swollen and bruised. She had been ambulating to go outside to smoke but had a lot of pain to her foot and her ankle was quite swollen and bruised. The provider would send the resident for x-ray of her foot to rule out fracture. The resident was taking Hydrocodone for pain which she said helped a little bit. The resident rested in bed on exam. The x-ray showed acute spiral fracture of the distal fibula. Ordered to send the resident to the emergency room (ER) for evaluation. They placed the resident's foot in a splint and she would be following with orthopedic surgery. The resident was ordered to be strict non weight bearing and keep the foot elevated. The Progress Notes dated 4/15/24 at 7:38 p.m. documented the responsible party phoned. Despite the resident telling staff on 4/12/24 about the fall while out with family, the facility failed to notify the physician until 4/14/24, or the resident representative until 4/15/24. On 7/17/24 at 8:30 a.m. the Assistant Director of Nursing (ADON) stated Staff D wasn't aware she needed to do an incident report for an incident that occurred somewhere else. They had her fill out a report 4/15/24 and date it 4/12/24. Staff were giving the resident pain medication and notified the provider the 14th. The facility policy, Change in a Resident's Condition or Status revised February 2021, documented the facility promptly notified the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call the resident, when there has been an accident or incident. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when the resident was involved in any accident or incident that results in any injury including injuries of an unknown source. Except in medical emergencies, notifications would be made within 24 hours.

Based on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 47 residents. Findings include: During continuous observation on 7/16/24 from 12:15 PM to 12:45 PM Staff B dietary cook was observed wearing no gloves or hand hygiene completed when Staff B opened the freezer and obtained a box of frozen hamburger patties. Staff B then opened the box after cooking with a spatula and used the same hand to obtain a frozen hamburger patty. Staff B was observed to do this three times with no hand hygiene being completed. Staff B then proceeded to touch multiple items (lids for bowls, cabinet handles, spatulas, freezer door handles) in the kitchen with no hand hygiene being completed. In an interview on 7/16/24 at 12:57 PM with Staff C Dietary Service Manager revealed her expectations were for staff to wash hands at appropriate times while in the kitchen. In an interview on 7/16/24 at 1:12 PM with the Administrator revealed that her expectation would be staff complete hand hygiene at appropriate times while in the kitchen preparing foods. Review of a facility provided policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated October 2017 documented: a. Employees must wash their hands before coming in contact with any food surfaces, after handling raw meat, and after handling soiled equipment or utensils.

Based on observation, record review and staff interview, the facility failed to assure a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for 1 resident reviewed (Resident #38). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #38 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had frequent incontinence of bladder, and a urinary toileting program had not been attempted. The resident had diagnoses including a stroke, a seizure disorder, and chronic obsrtuctive pulmonary disease (COPD). The MDS history of the resident's urinary incontinence showed she was occasionally incontinent of bladder on the admission MDS and she had been consistently, frequently incontinent since 2/13/23, and the MDS history of a toileting program documented no urinary toileting program had been attempted while in the facility. The Care Plan revised 6/3/22 identified the resident had occasional bladder incontinence. The interventions included assisting the resident to the bathroom or commode as needed, and assisting with perineal cleansing as needed. On 7/15/24 at 11:34 a.m. the resident stated she had a problem with incontinence. On 7/16/24 at 9:45 a.m. the resident was in the hall with staff. The resident was trying to say something, but the words were not making sense. After listening for a short time, staff asked the resident if she needed the bathroom and she said that too. Staff told her they would assist her. On 7/17/24 at 8:33 a.m. the Assistant Director of Nursing (ADON) stated the resident had been incontinent frequently on the look back time frames. She said the care plan should show she was incontinent, not the occasional (incontinence). She also said they had not tried her on a toileting plan. On 7/17/24 at 9:37 a.m. Staff E Certified Nursing Assistant (CNA) took the resident to the bathroom. She removed her wet incontinent pad. Staff E stated the resident sometimes took herself to the bathroom, but she needed 1 assist. She had difficulty verbally expressing her needs that day. The facility policy Urinary Continence and Incontinence - Assessment and Management revised September 2010 documented the staff and practitioner when appropriate, would screen for, and manage, individuals with urinary incontinence. Management of incontinence would follow relevant clinical guidelines. The physician when appropriate, and staff would provide appropriate services and treatment to help residents restore or improve bladder function. If the individual remained incontinent despite treating transient causes of incontinence, the staff would initiate a toileting plan.

Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for a resident with a change of condition for 1 of 5 residents reviewed (Resident #32). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes and hypoglycemia. The Care Plan identified the resident had an actual fall related to unsteady gait initiated 10/16/2023. The Progress Notes documented the following: a. On 4/11/24 at 10:21 p.m. the resident received Hydrocodone (narcotic)-Acetaminophen 5-325 mg for pain in the right leg. b. On 4/12/24 at 10:06 a.m. the resident received Acetaminophen 325 mg 2 tablets for pain in her right ankle. She rated her pain a 6/10. c. On 4/12/24 at 5:16 p.m. the resident received Acetaminophen 325 mg for complaints of pain in her right ankle. The resident rated her pain a 6/10. d. On 4/12/24 at 5:31 p.m. the resident was on focused charting following an unwitnessed fall on 4/9. The resident denied injuries related to that fall but complained of a sore ankle related to a fall that occurred when out with family on 4/11. Acetaminophen administered and effective. Would continue to monitor and update as needed. Plan of care ongoing. e. On 4/12/24 at 6:28 p.m. the administration of Acetaminophen was ineffective, the follow up pain was 8 (of 10). f. On 4/12/24 at 9:50 p.m. the resident received Hydrocodone-Acetaminophen per request for pain in her right leg and ankle. g. On 4/13/24 at 3:25 a.m. the resident remained on focused charting related to an unwitnessed fall in the dining room. No injuries. Range of motion (ROM) intact, neuros intact. No concerns at that time. h. On 4/13/24 at 4:16 p.m. the resident received Hydrocodone-Acetaminophen per resident request for pain rated 6 out of 10 in her ankle. No signs of distress. Plan of care on going. i. On 4/14/24 at 6:43 a.m. the resident received Hydrocodone-Acetaminophen per resident request for pain in her right ankle due to a previous fall. The ankle appeared swollen with minimal bruising. No signs of distress. Plan of care on going. On 4/14/24 at 2:10 p.m. Communication with the Physician documented while giving medication to the resident in the a.m. the nurse noticed increased swelling with bruising noted to the outer right foot. The resident stated the injury occurred due to a fall in the dining room. The resident complained of pain upon movement of the foot, and stated she could walk on it but it was painful. As needed Hydrocodone and an ice pack given for pain. At 4:09 p.m. the resident received Hydrocodone-Acetaminophen per resident request for pain in the right ankle rated 6 out of 10. No signs of distress. The ankle appeared swollen, and ice pack applied. At 4:57 p.m. clarification to the physician the resident stated she fell while on a home visit Thursday 4/11. The Progress Notes on 4/15/24 documented the resident seen for a fall when out with family and she stepped in a hole in the ground and fell . She didn't tell anyone at the facility she fell initially but over the weekend her foot was noted to be swollen and bruised. She had been ambulating to go outside to smoke but had a lot of pain to her foot and her ankle was quite swollen and bruised. The provider would send the resident for x-ray of her foot to rule out fracture. The resident was taking Hydrocodone for pain which she said helped a little bit. The resident rested in bed on exam. The x-ray showed acute spiral fracture of the distal fibula. Ordered to send the resident to the emergency room (ER) for evaluation. They placed the resident's foot in a splint and she would be following with orthopedic surgery. The resident was ordered to be strict non weight bearing and to keep the foot elevated. The Progress Notes dated 4/15/24 at 7:38 p.m. documented the results of the x-ray showed an acute spiral fracture of the distal fibula. The resident sent to ER for splinting. The responsible party phoned. Despite the resident telling staff on 4/12/24 about the fall while out with family, and the resident complaining of pain to her ankle the facility failed to adequately assess the ankle and notify the provider for treatment until 4/14/24. The Care Plan added a fall at a family member's house on 4/11/24 due to unsteady grounds outside. Interventions included on 4/15/24 an x-ray and Ice pack for swelling, as needed pain medications, non weight bearing (NWB) to right foot. On 4/16/24 may bear weight with boot starting 5/29/24. Major injury form signed stating resident should make a full recovery after treatment. On 7/16/24 at 1:49 p.m. Staff D Registered Nurse (RN) stated she kind of remembered it. The resident had fallen while out with family and ended up with a fracture. The resident didn't tell them she fell for awhile. Staff D said she didn't know you needed an incident report if the incident happened somewhere else. On 7/17/24 at 8:30 a.m. the Assistant Director of Nursing (ADON) stated Staff D wasn't aware she needed to do an incident report for an incident that occurred somewhere else. They had her fill out a report 4/15/24 and date it 4/12/24 (the day the resident told staff about the incident). Staff were giving the resident pain medication and notified the provider the 14th (of the incident). They had been doing fall follow ups from a fall that occurred 4/9/24. The facility policy, Change in a Resident's Condition or Status revised February 2021, documented the facility promptly notified the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there had been an accident or incident involving the resident. Prior to notifying the physician or health care provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications would be made within 24 hours.

Based on record review and staff interview, the facility failed to review and revise the comprehensive care plan for 1 of 18 residents reviewed (Resident #38). The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #38 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had frequent incontinence of bladder, and a urinary toileting program had not been attempted. The resident had diagnoses including a stroke, a seizure disorder, and chronic obsrtuctive pulmonary disease (COPD). The MDS history of the resident's urinary incontinence showed she had been frequently incontinent since 2/13/23, and no urinary toileting program had been attempted while in the facility. The Care Plan revised 6/3/22 identified the resident had occasional bladder incontinence. The interventions included assisting the resident to the bathroom or commode as needed, and assisting with perineal cleansing as needed. On 7/17/24 at 8:33 a.m. the Assistant Director of Nursing (ADON) stated the resident had been incontinent frequently on the (MDS) look back time frames. She said the care plan should show she was incontinent, not the occasional (incontinence).

Based on clinical record review, facility policy, resident interview, Pharmacy staff interview, staff interviews, and Nurse Practitioner interview, the facility failed to assure that staff administered the correct type of insulin (long acting instead of short acting) 1 of 26 residents (Resident #3). The facility identified a census of 49 residents. Findings Include: The Minimum Data Set (MDS) for Resident #3 dated 4/20/23 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had a diagnosis of diabetes mellitus and received insulin injections. The resident was admitted to the facility 4/17/23. The Discharge Summary dated 4/5/23 revealed that the resident had orders for: Insulin aspart (short acting insulin) 100 units/milliliter (mL) injection - vial. Inject 120 units into the skin 3 (three) times daily before meals. 30-50 units with meals. The word clarify was handwritten next to this order. Tresiba FlexTouch (long acting insulin) 200 units/mL Sopn (solution pen injector) injection pen. Inject 180 (one hundred eighty) units into the skin daily. The Communication with Physician on 4/17/23 at 3:14 PM written by the Director of Nursing (DON) revealed received discharge orders over fax machine from hospital. Clarification sent to physician/nurse at sending hospital for orders for insulin aspart 100unit/mL 120 units in skin TID (3 times per day) before meals. 30-50 units with meals. No scale to go on. Awaiting call back. The Clinical Record lacked documentation of the response from the fax sent to the physician to clarify the insulin aspart order. The Reconciliation of Medications on Admission policy revised 7/17 revealed: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident ' s medications, routes, and dosages upon admission or readmission to the facility. If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. If the discrepancy was resolved, document how the discrepancy was resolved. The Order Summary Report on 4/17/23 at 5:56 PM signed by Staff B, Advanced ARNP listed: Order for Tresiba FlexTouch subcutaneous solution pen injector 200 units/mL (insulin degludec). Inject 180 units subcutaneously in the morning. No order for insulin aspart was listed. In an interview on 7/6/23 at 2:43 PM, Staff D, Pharmacist Technician, reported that both insulin aspart and Tresiba were delivered to the facility the evening of 4/17/23. The Encounter Note on 4/18/23 by Staff B revealed diabetes mellitus: Continue with Tresiba 180 Units daily. In an interview on 7/6/23 at 3:16 PM, Staff B reported that she could not remember why she only listed Tresiba orders in her Encounter Note on 4/18/23. Staff B reported that her usual practice with visits for resident admissions were to review hospital discharge orders and continue those orders before making medication changes. In an interview on 7/6/23 at 12:47 PM, the DON reported that the insulin aspart order was clarified with Staff B ' s visit with the resident on 4/18/23 and that the insulin aspart pen was just not taken out of the medication cart after the order was discontinued. The Incident, Accident, Unusual Occurence Note on 4/28/2023 at 8:45 AM written by Staff A, Registered Nurse (RN), revealed that during morning med pass this nurse administered residents medications. Resident was also to receive 180 units of Tresiba. Nursing pulled insulin from drawer only one pen in residents bag. Nursing administered 180 units. Upon nursing's return to the cart nursing realized that resident was given Novolog instead of Tresiba. Immediately notified management and initiated every 15 minute blood sugar checks. Doctor notified and ordered glucagon and 15 minute checks and to be not alone for next 6 hours. Resident was seated by nurses station. Resident had just finished breakfast. Resident was also given couple glasses of orange juice, toast with peanut butter, milk, pudding, fruit snacks, honey, brownie, crackers over the next hour and half. Resident was sent out to hospital around 11:00 AM as her blood sugar was down to 105. Husband informed. In an interview on 7/6/23 at 10:20 AM, Staff A reported that the date of the incident was her first shift at the facility, she assumed that since the resident only had 1 insulin ordered that the 1 insulin pen in the medication cart for the resident was for that insulin and did not verify the type of insulin prior to administration. Staff A reported that she did not understand why a medication a resident did not have orders for would be in the medication cart. Staff A reported that she doubled checked insulin orders by looking at the original order as she felt as though the insulin dose ordered was high. The Insulin Administration policy revised 9/14 revealed: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. The type of insulin, dosage requirements, strength, and method of administration must be verified before the administration, to assure that it corresponds with the order on the medication sheet and the physician ' s order. The nurse should notify the Director of Nursing (DON) and Attending Physician of any discrepancies, before giving the insulin. Steps in the procedure: Check and re-check that the type of insulin on the vial matches the type of insulin ordered. In an interview on 7/5/23 at 4:23 PM, the resident reported that she was eating breakfast when her insulin was administered. Within 5 minutes, the nurse told her that the wrong type of insulin was administered. The resident reported that both the facility and herself called the physician and she was sent to the Emergency Department (ED) where her blood sugar level got down to 70 and she was given medication to bring it back up. The resident reported she felt tired the rest of the day, but did not have the classic hypoglycemic signs or symptoms. The ED Provider Note on 4/28/23 at 11:04 AM signed by Staff C, ARNP, revealed: The chief complaint for the visit was receiving the wrong insulin. The patient arrives at the emergency room by ambulance from the nursing home after the patient had received fast acting insulin 180 units at 8:45 AM when she was to have received Tresiba 180 units. Blood sugar on arrival is 99, the patient states she has been feeling well. The POCT (Point of Care Test) Glucose readings that were taken in the ED revealed a reading of 65 mg (milligrams)/dL (deciliter). Intravenous D5 (dextrose 5%) half normal saline (fluid administered through the bloodstream that contains sugar) was administered at 50 cc (cubic centimeters) and was increased to 75 cc when her blood glucose level dropped. The resident was discharged back to the facility the same day.

Based on observations, interviews and record review the facility failed to provide professional standards of care for 2 of 4 residents reviewed, (Resident #35 and #10). Registered Nurse (RN) Staff C left a cup of medications on the bedside table unsupervised and Resident #35 ingested his roommate's medications. Resident #10 was found to have an open area on his bottom and it was not reported to the next shift or communicated to the physician. The facility reported a census of 47 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required limited assistance with the help of one staff for bed mobility, transfer and toileting. According to the MDS dated [DATE], the resident had a BIMS score of 14 and required set up only for bed mobility transfer and toileting. According to an untimed Incident Report dated 11/05/2021, Resident #35 took his roommate's medications. The report documented RN Staff C gathered the medications for Resident #35 and Resident #40 at the same time. Resident #40 told her to set them down and that he would take them. The nurse sat the medications down on the roommate's bedside table and walked out of the room. Resident #35 saw the medications sitting there and thought they were his and took them. His roommate's name was written on the med cup. Resident #35 saw that his roommate's name was on the medication cup after he took the medicine and told the nurse that he thought he took someone else's medications. Medications Resident #35 took include the following: 1. Atrovastatin Calcium 40 milligrams (mg) 2. [MEDICATION(S)] 300mg 3. [MEDICATION(S)] 2mg 4. [MEDICATION(S)] 500mg 5. [MEDICATION(S)] 25mg Medication that Resident #35 should have received but were held: 1. [MEDICATION(S)] 3mg 2. [MEDICATION(S)] 20mg 3. Tamsulosin 0.4mg 4. Senna-[MEDICATION(S)] 8.6-50mg The Incident Report stated Resident #35 complained of feeling dizzy, was assisted into a wheelchair by staff and 1:1 supervision with nurse was provided. Vital signs, blood sugar, and physical assessment completed by a nurse. Vital signs at that time were as follows: Temperature 98.4, Pulse 30 beats per minutes Respirations 18/minute, blood pressure 108/40 from lying position in right arm, oxygen saturation was 95%. The Hospital Report dated 11/5/22 at 8:45 PM showed the resident came into the emergency room after ingesting the roommate's medications which resulted in [CONDITION(S)] (low heart rate). He was experiencing dizziness and was given [MEDICATION(S)] and monitored in the hospital overnight. The resident was asymptomatic for over 12 hours before being discharged back to the facility. An untimed statement dated 11/6/21 by Staff C showed she first brought medication to Resident #35 and watched him take them. She then got the medications for Resident #40 who was sitting in his recliner with the laptop in his lap. She stated he pointed to the bedside table, indicating she should set the medications on the table so she did. She then asked him if he was going to take the medications and he said yes and reached toward the table. She then left the room. According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for Resident #40 showed that his evening pills were not taken until 9:30 PM by the overnight nurse. A corrective Action Form dated 11/5/21 indicated RN Staff C was hired on 10/20/21 and was issued a written warning. The document indicated Staff C walked away from the resident and left medication on the bedside table unattended. The document was signed on 11/6/21. On 5/18/22 at 10:35 AM, RN Staff C said she had been in training for a couple of days before the medication error occurred. She said the facility provided 3 days of orientation and she followed RN Staff D. On the 2nd day of training Staff C was putting the medications in the cups and had popped the pills for Resident #40. She pulled the medication cards and checked the MAR. She said Staff D was not with her at the time she put them in the cup because she was putting her foot up because she had a sore ankle and she was sitting with an anxious resident. She said Staff D had observed her prepare the pills the day before. Staff C prepared the medication and wrote the name of Resident #40 on the cup and took it to his room. She said he told her to just set them down. She knew he was an independent resident so she decided to leave them on the table without supervising the ingestion. She said the night stand she put the pills on was sitting between the recliner chairs between the residents. She said the bedside table for Resident #35 was over his bed and it was the nightstand for Resident #40 where she placed the cups of medications. Staff C said that she had given Resident #35 his pills earlier that evening and watched him take those medications one at a time. This was at the end of an evening shift 6a-6p and she didn't have any other medications to give after that. She said that she hadn't ever set down pills and walked away before. Staff C said that she continued to be in training for a while thereafter and she did not know of any residents at the facility that had been assessed to safely take their own medications. On 5/18/22 at 11:12 AM, RN Staff D said she had been training Staff C and was on the 2nd or 3rd day of training when she had to sit with an agitated resident in the nurses' station with a resident while Staff C passed the pills. She said the routine for orientation was for the 1st day to do the medications with the trainee observing, the 2nd day she would observe and help the trainee and on the 3rd day observe only. It was the evening medication pass and she had observed other medication passes earlier in the day. Staff D did not see Staff C prepare or administer either of the residents' medications but had observed other med passes that evening. Staff D was not aware of the mistake until later that evening after the overnight nurse had discovered the error. Staff D said they use an orientation checklist with trainees. Staff D said she did not have any knowledge of residents telling nurses to leave medications but some do not want the nurse to stay in the room and watch them take the medications. On 5/19/22 at 9:15 AM Resident #40 (According to MDS dated [DATE] had a BIMS score of 15; intact cognitive ability) said he saw the nurse bring in the cup of pills the night his roommate took them. He said he was sitting at his bedside table near the window and on his lap top when the nurse came in with the cup of pills, she set them on the roommates table and did not say anything. He said she just walked out the door. Resident #40 said he saw his roommate take the pills but did not realize they were meant for him. Later that evening his roommate started feeling bad and the nurse came in and took his vitals. He said one of the girls came in and took his vitals and the pulse was low. They then came back and put him in a wheel chair and said he was going to the hospital. Resident #40 knew that he hadn't had his pills that night but didn't ask for them because it varied as to when he would get them. Resident #40 said he thought the nurse that set the pills down wasn't working at the facility any longer because he hadn't seen her again. Resident #40 said that sometimes the nurses will still set down a cup of pills on the bedside table between the two recliners. If his roommate is in the rest room, they will leave them and tell Resident #40 to let Resident #35 know the pills are for him. He said the nurses will usually come back and check to see if the pills had been taken. On 5/19/22 at 10:53 AM, Resident #35 said he remembered when he took the wrong medications. He said the nurse had either set them on his bedside table or on the bed next to him. He said he usually dumps them out on the bed and takes them one at a time. He said he noticed after he took them that his roommates' name was on the cup, then they took me to the hospital. On 5/18/22 at 8:03 AM Resident #10 and his wife (who was visiting) said the nurses will set the medications down and walk away. He said it's more than one nurse that will do this. His wife said she watched to make sure he takes them and doesn't choke. On 5/19/22 at 9:15 AM, Resident #38 (MDS dated [DATE] showed a BIMS score of 15, intact cognitive ability) said sometimes the nurses will set the medications down in her room and walk away but they usually come back later to see if she had taken them. On 5/24/22 at 11:55 AM, the Director of Nursing (DON) said she expected the nurses to put the medications in a cup for the resident and document as given once the resident had taken them. She said she expected the nurses to verify a residents name before giving medications and to stay with them in the room while they take all the medications and not leave the room until that is completed. She was not aware that some nurses may still be setting the medication cup down and leaving the room returning later to see if the meds have been taken. According to the Administration of Medications policy dated October 2010 staff were directed to confirm the identity of the resident and to remain with the resident until all medications were taken. According to the Documentation of Medication Administration dated April 2007 administering of medication must be documented immediately after it is given. 2. According to the MDS dated [DATE], Resident #10 had a BIMS score of 12 (moderate cognitive deficit). He required extensive assistance with the help of two staff for bed mobility, transfers, dressing and toileting. The Care Plan updated on 4/7/21 showed Resident #10 was at risk for skin breakdown due to bowel and bladder incontinence. There were no skin issues noted on the Care Plan. On 5/18/22 at 8:03 AM Resident #10 stated the incontinence briefs he was wearing was too small for him and he was having pain the groin area. He stated he had asked a nurse earlier that morning to address the issue but she hadn't come back to deal with the pain. On 5/18/22 at 8:45 AM Certified Nursing Aide (CNA) Staff J and Licensed Practicing Nurse (LPN) Staff G transferred the resident to bed and applied moisture barrier to his testicles and bottom. They noted that his left buttocks was red with a small open area. The resident said that it hurt. On 05/19/22 at 9:17 AM RN Staff D was assigned the treatment nurse for the day. When asked if there were any areas that she would be treating for Resident #10 she said he had a spot on his bottom a while ago but it had healed out 2 months prior. On 5/19/22 at 11:16 AM Staff G and Staff D looked at the spot on the resident's left buttocks and agreed that it should be addressed. They then took a picture of the spot and said they would contact the doctor for treatment orders. On 5/19/22 at 11:45 AM Staff F said she told the treatment nurse the previous day about the open spot but did not know if there was any follow up. On 5/24/22 at 12:05 PM the DON said she expects that when there is a new skin issue discovered the aides would send an alert to the nurses in the electronic charting. The nurses were supposed to clear the dashboard daily so they were up to date on notifications. Once the alert is triggered, the nurses were to follow up with assessment and treatments.

Based on observations, record review and interviews the facility failed to provide adequate monitoring and timely interventions to prevent the development of pressure ulcers for 1 of 3 residents reviewed, (Resident #26). Resident #26 was admitted to the facility in February 2022 with no identified skin issues, in March 2022 a large, open pressure ulcer was discovered on his left heel. The facility reported a census of 47 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. According to the Minimum Data Set (MDS) dated [DATE], Resident #26 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficient). The resident required extensive assistance with the help of one staff for bed mobility, transfers, dressing, toileting and hygiene. The MDS dated [DATE] showed the same status in all areas of care. An admission assessment dated [DATE] at 11:34 AM showed the resident was admitted to the facility with no skin issues or pressure sores. According to a Braden Assessment (determines risk of developing pressure ulcers) completed on 2/2/22 at 8:34, Resident #26 was at risk for pressure ulcers. On 3/1/22 at 2:09 PM a Nursing Note showed a new wound was discovered on the residents left heel. The total area measured 10.2 centimeters (cm) with a length of 3.5 cm and a width of 4.0 cm. The Care Plan for Resident #26 was updated on 3/1/22 that indicated he was at risk for diabetic pressure ulcers with a pressure on the left heel. Staff were instructed to float heels in bed and apply protective boots while in bed at all times. The resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan did not include a focus area of risk for pressure sores until 3/1/22. On 5/19/22 at 1:19 PM Registered Nurse (RN) Staff D said she thought Resident #26 had come into the facility with a spot on his heel and they had been treating it ever since admission. She said when he first came in he was refusing cares and they were having difficulty getting him to change his clothes. She thought he may have kept his socks on all the time. The following information was included in the nursing documentation: a. On 2/4/22 at 1:40 PM cooperative with cares. b. On 2/6/22 at 6:18 PM resident pleasant and cooperative. c. On 2/8/22 at 2:33 PM pleasant and cooperative. d. On 2/11/22 at 11:38 AM free from pressure injury. Nursing documentation indicated the skin was intact with no new concerns on the following dates: a.On 2/25 at 4:35 AM b. On 2/17/22 at 4:45 AM c. On 2/19/22 at 4:39 AM d. On 2/20/22 at 4:09 AM e. On 2/22/22 1:04 PM f. On 2/23/22 at 2:22 AM g. On 2/24/22 at 4:20 AM h. On 2/25/22 at 2:57 AM i. On 2/26/22 at 4:25 AM j. On 2/27/22 at 9:52 AM k. On 2/28/22 at 4:15 AM The daily electronic charting documentation completed by the Certified Nursing Aides (CNA) from 2/1/22 at 12:38 PM, through 2/28/22 at 7:58 PM, showed on 53 occasions, the resident had no skin injuries. On 2/11/22 at 1:59 PM a red area was noted with no specified location. On 2/23/22 at 8:43 AM a bruise and scratch was noted, and on 2/25/22 at 1:59 PM a scratch was mentioned. The CNAs were directed to check the resident skin and notify a nurse of any new injuries/skin conditions. A Nursing Note on 3/1/22 at 2:09 PM revealed wound type: diabetic left heel area 10.2 centimeters (cm) with length of 3.5 and width 4.0. On 3/28/22 at 1:39 PM a Wound Ostomy and Continence Nurse (WOCN) documented Resident #26 had an ulcer of the left heel, and identified it as an unstageable pressure injury. She documented the length to be 3.8 cm and width 5.0 cm. The calculated wound size was 19 cm. with serosanquineous drainage. A report from 5/9/22 and signed on 5/12/22 at 1:44 PM by a nurse practitioner showed the resident had a stage 2 pressure injury to the left heel. According to a Nursing Note dated 5/16/22 at 10:15 AM, the total area was 6.5 cm, length 2.9 cm and width 2.9 cm. The skin was pink to purple tissue and shiny skin tissue. In an observation on 5/18/22 at 9:45 AM, RN Staff D provided a dressing change to left heel. The wound had seriosanquanous drainage on the previous dressing and the resident did not complain of pain. On 5/23/22 at 10:08 AM Certified Nursing Aide (CNA) Staff F stated she had provided cares for Resident #26 and hadn't ever known him to be resistive to cares. She said he will sleep in his bed at night and liked to sleep in the recliner during the day. She said they would put pillows under his legs to keep the heel up. She had given him showers before the ulcer was discovered and she hadn't noticed any areas on his heels. She said she thought he had come back from the hospital with that sore on his heel. On 5/23/22 at 10:41 AM CNA Staff E said she was very familiar with Resident #26 and didn't ever know him to be resistive to cares or refuse to get dressed in the morning. She thought she had given him one or two showers and didn't remember ever seeing any skin issues. She said the first time she became aware of the pressure on his heel was after the treatments had been started. She said he did like to sleep with his socks on because he would get cold, but they would change his socks every morning. On 5/23/22 at 10:49 AM CNA Staff F said she was very familiar with Resident #26 and did not remember a time when he was resistive to cares. He would allow staff to change him without incident. She said he liked to sleep with his socks on because he would get cold. They would change his socks every morning. Staff F said she was not aware of the pressure on his heel until after the treatments started. She did give him baths in the past and would report to the nurses if she had seen any new skin issues. She said they put the protective boots on him now and elevate his feet. According to a pressure injury risk assessment policy revised March of 2020, once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan would be created to address the modifiable risks for pressure injuries. A comprehensive skin assessment would be completed with every risk assessment. On 5/24/22 at 12:03 PM, the Director of Nursing (DON) said she did not know how the skin issues on the resident's heel went so long without being discovered. She expected the nurses and aides to do regular skin checks. She didn't know why no one looked under his heel during or after showers.

Based on record review and staff interviews, the facility failed to provide Resident #4 with adequate supervision and assistive devices to prevent an accident which resulted in a fractured hip. The sample consisted of 5 residents and the facility reported a census of 45 residents. Findings include: Resident #4 had a Minimum Data Set (MDS) assessment, with a reference date of 3/23/16. The MDS indicated the resident had short and long term memory problems and severely impaired cognitively. The MDS indicated the resident experienced signs and symptoms of inattention and disorganized thinking. The resident required extensive assistance of one staff for mobility, dressing, toileting and hygiene. A balance during transitions and walking test identified the resident as not steady and only to stabilize with staff assistance when walking, moving from seated to standing position, and surface to surface transfers. The clinical record Face Sheet identified the resident had [DIAGNOSES REDACTED]. The resident had 1 fall with no injury since the prior assessment. Review of the Fall Risk assessment dated [DATE] identified the resident scored a 16 on the assessment scale. A score of 10 or above represented the resident at a high risk for falling. The Care Plan, target date 6/12/16, identified the resident at risk for falls with interventions that included: utilize a bed alarm, chair alarm, and baby monitor. The alarms were to be placed up and out of reach so audible. The falls Care Plan directed both top side rails up and one lower rail up while in bed. The Care Plan did not indicate which lower side rail to be in a raised position. The Side Rail Rationale Screen, dated 3/23/16, indicated three (3) side rails were used, two top rails and one bottom rail. A fall incident report dated 6/9/16 at 10:50 p.m. reflected Staff G, certified nursing assistant (CNA), discovered Resident #4 lying on the floor between his/her roommate's walker. A Fall Investigation for CNAs, dated 6/9/16, indicated at the time of the fall, the left side rail was up instead of the right side rail. The contributing factors could have been hallucinations and wearing no gripper socks. At 11:25 a.m. on 6/9/16, the nurse notified the physician. The physician informed the nurse to call him if pain worsens to the right leg or if the resident would stop weight bearing on the right leg for a new order. The Nurse ' s Notes dated 6/10/16 at 2:15 a.m. indicated the staff attempted to stand the resident and the resident had no weight bearing on the right leg. The note indicated the resident had vocalized pain since 11:00 p.m. with attempts to stand or roll the resident. The resident cried but no tears. The nurse administered antianxiety medication. The physician was notified and ordered the resident sent to the emergency room for an evaluation. The Nurse ' s Notes indicated the resident returned to the facility at 5:10 a.m. on 6/10/16. The hospital discharge instructions indicated an x-ray of the right hip, femur and pelvis indicated no fractures seen. At 8:35 a.m. on 6/10/16, the physician notified the facility that the resident had a fractured hip and to transfer back to the hospital. The ambulance arrived at 8:45 a.m. and transported the resident to the hospital. The note indicated the resident had not had pain until moved. An x-ray report dated 6/10/16 reflected the resident sustained [REDACTED]. The Resident Assessment Data Collection/initial Care Plan indicated the resident returned from the hospital on [DATE] at 2:30 p.m. The note indicated the resident had a dressing on the incision (repair of hip) along the lateral side of the right hip. On 6/21/16 at 1:44 p.m. Staff G, CNA, was interviewed and stated she walked by Resident #4's room and observed him/her standing beside a walker. She did not hear an alarm, and then observed the alarm stuffed under blankets. She encouraged the resident lie down in bed and did not toilet the resident. Staff G stated she observed three side rails up, the upper side rails and the lower side rail. Staff G indicated the lower side rail near the door was up, and then indicated it was the lower side rail near the window. Staff G was aware Resident #4 climbed out both sides of the end of the bed. Staff G stated when the resident fell , she noted the alarms were placed under blankets again. On 6/23/16 at 1:00 p.m. Staff H, CNA was interviewed and stated he assisted Resident #4 to bed prior to the fall. Staff H stated he put the top two side rails up and the left, lower side rail up (door side) on the bed. Staff H stated he was not aware the right lower side rail (window side) was to be up. Staff H stated he went to break at approximately 12:00 a.m. and noted Resident #4 was awake and lying in bed. Upon return from break he observed the resident sitting beside the walker and complained of leg pain. Staff B, licensed practical nurse (LPN), informed him the right lower side rail (window side) was to be up because Resident #4 tried to climb out of the right side of bed. Staff H stated the head set directed three side rails were used but did not indicate which three. Facility staff now places a piece of paper on the head of the bed to indicate which specific side rails are to be up. On 6/22/16 at 3:13 p.m. Staff B, LPN, observed Staff G exit Resident #4's room approximately 10 minutes prior to the fall. Staff B heard the resident's alarm sound, but thought Staff G was with Resident #4 because typically, she doesn't turn off the alarm while in the room with the resident. She heard Staff G ask the resident why he/she was on the floor. Upon entry to the resident's room, she observed Resident #4 on the floor between his/her roommates walker. The side rails at the head of the bed were up and the left lower side rail (near the door) was up rather than the lower side rail near the window. Initially, the resident did not complain of pain, however upon rising he/she was not able to bear weight. Staff B stated Resident #4 fell between his/her bed and window and always attempted to climb out of bed on that side. The intervention implemented was to raise the lower side rail near the window because that was the side Resident #4 attempted to climb out of. Staff B had observed Resident #4 attempt to climb out of bed between the upper and lower side rail before. On 6/21/16 at 1:35 p.m. the Director of Nursing stated three side rails were to be up, two on top and the lower side rail near the window. The lower side rail provided a boundary after Resident #4 fell between the bed and window. The raised side rail was effective because he/she did not try to climb out after raised.