Every finding on record at Clarksville Skilled Nursing & Rehab Center

Based on the electronic health record review, the Notice of Transfer Form to Long Term Care Ombudsman form review and staff interviews, the facility failed to include 1 out of 3 residents reviewed for Ombudsman Notification (Resident #1). In addition, the facility failed to complete a recapitulation of resident's stay (discharge summary) for 1 of 1 residents reviewed (Resident #41). The facility reported a census of 36 residents.Findings include: 1. Resident #1's Census documented discharged to the hospital on 2/28/26 and returned to the facility on 3/3/26. The February 2026 Notice of Transfer Form to Long Term Care Ombudsman (LTCO) form didn't include Resident #1. On 4/8/26 at 2:13 PM, Staff A, Office Assistant (OA) stated she pulled February's LTCO report after the Administrator asked her about it. Resident #1's name now appeared on the list. She stated she had no idea the original list she'd sent to the LTCO office didn't have Resident #1's name. She stated she didn't input the names of the residents discharged monthly, as the facility's Electronic Health Records (EHR) system pulled the names. Staff A didn't know why the name didn't pull up right away. Staff A runs the LTCO reports early in the month and stated she ran the February one early. Staff A said she'd resend the February report to the LTCO with Resident #1's name on it today. On 4/8/26 at 4:25 PM, the Administrator stated she didn't know why the facility's system didn't pull Resident #1's name on the report. She stated they've come up with a work around to ensure all names appear on the LTCO reports. The undated Transfer Discharge policy directed staff to submit all transfers and discharges including involuntary discharge notices to the LTCO office monthly. 2. Resident #41's Census identified they discharged on 2/17/26 at 1:07 PM. Resident #41's Electronic Health Record (EHR) lacked documentation of a discharge summary. In an interview on 4/9/26 at 10:58 AM, the Director of Nursing (DON) acknowledged no one completed a discharge summary with recapitulation of the resident's stay (a concise summary of the resident's stay and course of treatment in the facility) for Resident #41. The DON indicated they should have completed a discharge summary. The undated Expected/Planned Discharge policy directed when the facility anticipated a discharge, a resident must have a discharge summary that included, but isn't limited to: a recapitalization of the resident's stay including diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. The policy also required a final summary of the resident's status at the time of discharge for release to authorized persons and agencies, with the consent of the resident or Resident #41 Representative. Additionally, the post-discharge plan of care must indicate where the individual plans to reside, any arrangements made for the resident's follow-up care, and any post-discharge medical and non-medical services. When the Interdisciplinary Team (IDT) determines a planned discharge date , the members of the IDT and the resident or Resident #41 Representative will complete a Discharge Summary observation in its entirety.

Based on observations, interviews, and record review, the facility failed to follow Doctor's Orders for 2 out of 3 residents reviewed (Resident #2 and Resident #3). Resident #2 had an order for a mechanical soft diet with ground meat. Resident #2 received cut up sausage links instead of ground up sausage for breakfast. Resident #2 had a coughing/choking spell and five days later they admitted to the hospital with aspiration pneumonia. Resident #3 had an order for cut up meat. The kitchen staff prepared to serve Resident #3 a cheeseburger without cutting the meat cut up, as ordered by the Doctor. The facility reported a census of 34 residents.Findings include:1. Resident #2's Minimum Date Sheet (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS), score of 7, indicating severely impaired cognition. Resident #2 ate independently. The MDS included a diagnosis of heart failure. The MDS reflected Resident #2 had a mechanically altered diet (required change in texture of food or liquids). The Care Plan Problem reviewed 7/7/25 indicated Resident #2 had difficulty chewing and swallowing related to dysphagia (swallowing difficulties), having 2 teeth pulled, and unable to wear his lower denture. The Care Plan included the following approaches:a. 3/25/25: Mechanical soft diet with ground meats. b. 6/26/25: Nectar thickened liquids. A Progress Note authored by Staff A, Licensed Practical Nurse (LPN), dated 6/12/25 at 8:55 AM, documented Staff A in the dining room giving a resident their medication at approximately 7:55 AM and overheard a kitchen aide ask Resident #2 if he was okay. Staff A turned and noted he had a red face, he couldn't speak, he didn't make the universal choking signal with his hands but attempted to cough up food. Resident #2 had some air exchange and continued to attempt to cough. He had a small emesis (vomit) of undigested food and liquid into the garbage at table. The staff assisted Resident #2 back to his room. While in his room, noted redness left his face, and he became pale. Once in his room Resident #2 had a more effective cough and had a moderate emesis of undigested food and liquid. He continued to cough and threw up 2 cut chunks of sausage. Resident #2 spit up phlegm but could talk to the nurse and to the Assistant Director of Nursing (ADON) with clear and appropriate speech. No staff intervention beyond forward positioning and patting on his back to promote coughing required. Resident #2 stated that never happened before and reported being fine. The nurse obtained the following vital signs (VS):a. Blood Pressure (BP) 170/72 (Measuring standard 120/80)b. Temperature (T) 97.1 Fahrenheit (F) (Measuring standard 98.6)c. Oxygen saturation (PO2) 96% on room air (RA) (Measuring standard greater than 90%)d. Pulse (P) 64 (Measuring standard 60 - 100)e. Respirations (R) 18 (Measuring standard 12 - 20)Resident #2 told the nurse as he winked, they are reason his blood pressure is up. The assessment revealed lung sounds (LS) with course crackles (short popping noises in the lungs) and wheezes (high pitched lung sounds) throughout all anterior (front) et posterior (back) lung fields. The nurse provided him with an as needed (PRN) nebulizer (delivers medicine through a mist to the lungs) was given at this time. At 8:15 AM, this writer returned to resident's room following the nebulizer treatment et noted resident had some audible wheezes (could hear without a stethoscope), LS assessed and noted no course crackles, but he did have occasional expiratory (breathe out) wheezes to posterior bases (bottom of the lungs). His VS measured the following:a. BP 132/62,b. P 55c. R 18d. T 97.5 F e. PO2 94% RA. At 8:25 AM, the nurse placed a telephone call (TC) to the Primary Care Provider (PCP)'s office, spoke with receptionist and reported they needed to speak with the PCP's nurse. The receptionist transferred the facility nurse to the PCP nurse's voicemail. The facility nurse left a message regarding the incident that morning and Resident #2's condition since the incident. The nurse asked about a new order from the PCP for emergency room (ER) evaluation or STAT (without delay) portable x-ray. The nurse requested a TC back as soon as possible. The facility expected the PCP for rounds that afternoon. At 8:50 AM, the nurse made a TC to Resident #2's son and updated him on the incident that morning and his condition since. The nurse reported she waited for a TC back from PCP and they expected the PCP to come to the facility for rounds that afternoon. He asked how Resident #2 did the previous night and noted he didn't have notes in the nurses' notes. He reported his brother got a phone call from Resident #2 and told him This is the end. The nurse reported Resident #2 didn't make any no statements like that that morning, and other than the incident he appeared in a pleasant mood. The nurse reported she would continue to assess Resident #2 and notify his son of any new orders from the PCP or if he had any change in condition. He verbalized understanding and satisfaction with the plan of care.A Progress Note dated 6/17/25 at 6:44 PM, documented that at 5:10 PM a CNA called the nurse into Resident #2's room, due to him being pale with respirations of 22. The note described Resident #2 as hard to wake and with audible (heard without a stethoscope) wheezes. The nurse's assessment revealed Resident #2's lungs as very coarse throughout. At 5:17 PM, the nurse called Resident #2's son who gave the okay to send his father to the ER. At 5:29 PM, the nurse got an order from the Doctor to send Resident #2 to the ER. At 5:45 PM, the transportation specialist arrived to take Resident #2 to the ER. The nurse notified the son, who said he would meet them there. At 5:50 PM, called ER to give nurse to nurse report.An ED General/Miscellaneous Note dated 6/17/25 at 6:20 PM, reflected Resident #2's chief complaint as shortness of breath. Resident #2 didn't provide much information personally. The facility reported he choked. The note included a diagnosis of aspiration pneumonia. An impression from a Radiology final report interpretation for a 1 view chest x-ray dated 6/17/25 at 6:22 PM, Resident #2 had pneumonia in his medial (middle) left lung base and directed to follow up to ensure clearing. The findings included patchy opacities (white patches on x-ray) of the medial left lung base.The Progress Note dated 6/17/25 at 8:35 PM, reflected the nurse called the ER. The hospital staff reported they planned to admit Resident #2 for a few days with antibiotics due to pneumonia. The nurse called and notified the DON.The Progress Note dated 6/19/25 at 10:27 AM, the nurse received a call from the hospital. They reported the Speech Therapist would evaluate Resident #2 that day, and he would likely discharge the next day. The Progress Note dated 6/20/25 at 10:44 AM, the nurse received a call from the hospital's Social Worker (SW). They reported Resident #2 would stay another night due to increase in BNP (blood test that indicates heart failure when elevated), and he had a swallow study that day at 1 PM. The Progress Note dated 6/22/25 at 10:29 AM, indicated the facility nurse spoke to the hospital Registered Nurse (RN) about an update on Resident #2. They wanted to watch Resident #2's lab work for another night. They planned to discharge Resident #2 back to the facility for skilled care the next day. The Progress Note dated 6/23/25 at 10:23 AM, identified the nurse received a call from the hospital's SW. Resident #2 had blood in his stool and they would keep another day for monitoring.The Progress Note dated 6/24/25 at 10:00 AM, reflected the nurse received a call from a hospital RN with report. Resident #2 had a nectar thickened, mechanical soft diet. He had an order to use the incentive spirometry (technique used using a handheld device to improve lung function during recovery from lung illness) usage 2500 (level reached by the resident). He had crackles in his left lower base. They obtained his weight and took him to lunch. Resident #2 had a new order for nectar thick liquids. He returned to the facility on a skilled care level for aspiration pneumonia (a bacterial infection in your lungs caused by inhaling something other than air) and exacerbation (worsening) of CHF (Congestive Heart Failure). He would work with PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy). The nurse notified the staff to monitor and record his output every shift, do daily weights, and give him thickened liquids. On 7/7/25 at 3:40 PM, a pleasant Resident #2 stated he remembered the morning he started coughing. He reported he had a sausage that morning, but he didn't feel the pieces were too big. He thought it was just a weird coughing episode. He acknowledged he went to the hospital a few days later and was treated for pneumonia. On 7/7/25 at 3:02 PM, Staff B, Cook, stated that morning went by pretty quickly as they were a little behind on passing out drinks. Staff B stood by the steam table, and she noticed Resident #2 turning red. Staff B saw Staff A get up out of her chair and went to Resident #2. Staff B directed to grab a garbage, and then Resident #2 threw up some. Staff A saw the pieces of sausage that were on his plate which he didn't eat and weren't very ground up. Staff B reported Staff C as the cook that day. Staff B stated she usually didn't give the residents on mechanical soft diets hot dogs or sausages as they don't grind up very well, in her opinion. They asked Staff B to write a statement, so she didn't talk with Staff C right away. They had the steam table out in the dining room by the bird cage with Staff C and Staff B both serving food. Staff B stated she didn't remember giving Resident #2 his food as she focused on passing out the drinks because the residents started coming out to the dining room and They didn't have their drinks yet. Resident #2 had the rest of the food almost gone off of his plate and everything else on that plate would have fit in with his diet. Staff C got quiet after that incident that day and she didn't really talk to Staff B after that. Staff B stated everyone in the kitchen knows Resident #2 is on a mechanically soft diet with ground meats. Staff C had served him ground meat before this happened, so Staff B knew that Staff C knew (Resident #2's diet) too. When asked what size the chunks of sausage were, she showed a distance between her thumb and index finger. When asked if the pieces of sausage she saw were appropriate sized for ground meat, she said no. It appeared that the size she indicated as about the size of a star on a small decorative flag on the table. She nodded and said that the star was about the right size. The star measured on the ruler application on a cell phone, as 0.56 centimeters (cm). On 7/8/25 at 10:57 AM, Staff A stated that morning their floor nurse called in, so between Staff A and the ADON they covered the floor. Staff A gave medications to another resident who sat in the dining room. Staff A thought Staff B stated Resident #2 was coughing. Staff A stated Resident #2 did have an ineffective cough and had a small emesis. Staff A pushed Resident #2 down to his room in his wheelchair where he proceeded to have another emesis and continued coughing. He brought up 2 pieces of sausage. When asked if the sausage pieces were ground Staff A said no. Staff A stated she didn't see what he had on his plate in the dining room. They served sausage links that morning. She only saw the pieces of sausage he vomited. Staff A described it as the full diameter of the link; she indicated with her thumb and index finger (approximately 1 1/2 cm) but the width of the sausage piece as maybe the width of the white stripe on the flag. The white stripe on the flag measured 0.58 cm. Staff A added the ADON came in the room as well. Staff A described Resident #2's color as red during the coughing episode and then became pale after that, but then his color returned. He did have some audible wheezing, but had clear speech and he acted normal. Staff A and the ADON discussed the diet compared to the piece of sausage Staff A saw. Staff A didn't know if the ADON looked at the sausage at that time. They looked into Resident #2's diet order. Staff A stated the pieces of sausage she saw Resident #2 cough up were too big for his mechanical soft diet with ground meat. The ADON went to talk with the cook and Staff A called the PCP and Resident #2's family. On 7/8/25 at 11:13 AM, the ADON, Licensed Practical Nurse (LPN), stated Staff A asked her over the walkie talkie to go to Resident #2's room. When she got there Resident #2 had pretty much coughed everything up. The ADON said Resident #2 could talk but had his face a little flushed. This ADON stated she didn't see the sausage. She did see some phlegm come up, but she didn't see the sausage. The ADON stated talked with Staff C but didn't remember Staff C's response. The ADON reported she knew Staff C said Resident #1 had sausage that morning but couldn't remember if Staff C said it was ground or not. On 7/8/25 at 11:30 AM, lunch service began, observed the CDM stood next to the steam table, and Staff C plated the food. Staff C served Resident #2 first with a loose meat hamburger on a bun with cheese, 4 cheesy tater tots, and a small bowl of salad. The CDM described the lettuce as shredded and tater tots soft because they had cheese in them, making them appropriate for a mechanical soft diet. On 7/8/25 at 12:09 PM, the Certified Dietary Manager (CDM), stated she worked at the facility since 2013. She worked as a cook for the majority of her time and then became the Dietary Manager about 3 years ago. The CDM stated she arrived at the facility a few minutes after it happened. She stated her shift started at 8:00 AM. She stated right when she got in to work, they told her what happened. The CDM stated she didn't see the food left on Resident #2's plate. Another staff member told her Staff C threw it away. The CDM stated that when she asked Staff C about it, they didn't remember throwing his food away. When the CDM asked Staff C if she ground up the sausage, the cook said she finely chopped the sausage. The CDM found out she didn't grind any meat that morning for the breakfast buffet. The CDM said only 1 other resident at that time had a diet order for ground meat and that resident didn't like breakfast meats.On 7/8/25 at 12:45 PM, Staff C stated she didn't have any ground sausage on the breakfast buffet that morning, and Resident #2 wanted bacon. She stated she wouldn't serve Resident #2 bacon, so Staff C took a piece of sausage link and cut it up into fine pieces. Staff C stated she normally ground the sausage. They had their kitchen closed due to construction, so she would have had to run all the way down to the other end of the building to get him ground sausage. Staff C stated at that time they only had 1 resident had a diet order for ground meat. When asked if the facility had another resident with a mechanical soft diet with ground meats, Staff C said yes but that resident didn't like breakfast meats. Staff C stated she wouldn't give the resident any meat that morning, but then he asked for bacon, and she told him no bacon. When told the reported size of the sausage noted on his plate and what he vomited measured the full diameter of the sausage link and about 1/2 a cm thick. Staff C reported no way the sausage could measure that big of pieces. Staff C stated she normally cut the sausage links in half-length wise and then chopped it up so it couldn't have been the whole diameter of the link. Staff C stated the residents don't submit a breakfast menu as breakfast is always a buffet, so the resident wouldn't have choose which items they wanted like they do with lunch and supper. When asked why she didn't grind up some sausage for the buffet, Staff C stated that she guessed she didn't think about grinding up one portion of sausage that morning. Adding she forgot, otherwise she would have ground some. She then stated Resident #2 did like breakfast meats. She added Resident #2 had ground sausage for breakfast on the day of the interview. Staff C stated she heard Resident #2 ended up getting pneumonia. On 7/8/25 at 1:49 PM, The Registered Dietitian Consultant stated she knew of Resident #2 receiving cut up sausage links instead of ground sausage. When asked if it was okay to cut the sausage up instead, she stated that she would instruct staff to grind the meat even if staff stated they cut it into small pieces. She stated the staff should have ground the sausage. A Speech Therapy Treatment Encounter Note dated 7/8/25, documented Resident #2 had a diet order for a mechanically soft diet with nectar thick liquids. The note reflected therapy saw Resident #2 for ongoing dysphagia (difficulty in swallowing) intervention to promote safe swallow function. The Therapist saw Resident #2 in the dining room during the noon meal. Resident #2 tolerated the mechanical soft textures (shredded lettuce salad, ground meat cheeseburger, and cheesy tots) demonstrating adequate mastication (chewing), timely oral transit, timely swallow trigger, and no clinical signs/symptoms in 100% of trials. Speech Therapy recommended Resident #2 completed a follow-up video swallow study to assess any change in their swallowing function, specifically with liquids. Per the video swallow report from their hospital stay, Resident #2 previously had silent aspiration with thin liquids. The Therapist recommended to continue per their plan of care.On 7/9/25 at 9:57 AM, the Medical Director reported Resident #2 had an elevated BNP level, abnormal for their age. They explained Resident #2 likely had some left heart strain and they felt Resident #2 had some heart failure happening. They treated Resident #2 for both pneumonia and CHF (Congestive Heart Failure), as they happened at the same time. The Medical Director stated he thought the report the nurse gave the hospital colored the diagnosis of aspiration in the ER notes regarding a choking episode earlier in the week. He stated a 2-view x-ray of Resident #2's chest would be better to diagnosis them instead of the 1-view. 2. Resident #3's MDS assessment dated [DATE], identified a BIMS score of 99, indicating they rarely or never understood. The MDS indicated Resident #3 had severely impaired cognition for decision-making. The MDS listed Resident #3 as independent for eating. The MDS included a diagnosis of dysphagia.The Care Plan Problem start date 6/8/23 regarding Resident #3's nutritional status indicated they had difficulty swallowing as evidenced based on a diagnosis of dysphagia and their admission on a mechanically altered diet. The Approach dated 2/7/25, directed staff that Speech Therapy upgraded their diet from mechanical soft to general with cut meat. The approach included Resident #3 may need cueing to chew well, offer ground meat if he didn't eat the general cut meat. A goal with a long-term target date of 8/31/25, documented they would tolerate their diet without signs or symptoms of aspiration. A Speech Therapy Treatment Encounter Note dated 2/27/25, documented Therapy saw Resident #3for ongoing dysphagia intervention to promote safe swallow function and diet tolerance. They saw Resident #3 in the dining room and presented them with a regular texture snack. Resident #3 demonstrated adequate mastication (chewing), timely oral transit, timely swallow trigger, and no clinical signs/symptoms of aspiration in all trials, consuming entire packet (of shortbread cookies) without difficulty. Patient tolerated thin liquids without signs or symptoms aspiration. Speech Therapy to discharge on regular diet with cut up meats and thin liquids.The facility provided an untitled list with residents' names and diets dated 7/8/25. The observation used the list during lunch service observation. On 7/8/25 at 11:30 AM, lunch service began, observed the CDM stood next to the steam table, and Staff C plated the food. At 11:35 AM, the staff served the third resident, Resident #3. Staff C prepared a plate with a hamburger patty on a bun with cheese, tater tots, a small lettuce salad, and handed it to the CDM to deliver to Resident #3. The CDM turned to hand it to staff to take it to Resident #3. When asked if he needed his meat cut up, the CDM said yes, when asked if they planned to serve him the whole sandwich (without the meat being cut up), the CDM said yes. The CDM handed the plate back to Staff C and the CDM stated Resident #3 needed to have his meat cut up and directed Staff C to cut up the hamburger patty. At 11:48 PM, Staff C served a whole hamburger to another resident, the CDM stopped her and reminded her the resident needed their meat cut up. The CDM reminded the [NAME] again when she tried to serve a full hamburger on a bun to another resident with an order for cut up meat. The CDM stated all of the resident at that table have an order for cut up meat. She repeated this as the cook prepared another resident's hamburger.At 12:02 PM, the CDM whispered to Staff C. Staff C cut up another resident's hamburger. At 12:05 PM, the CDM whispered to Staff C again. Staff C cut up another resident's hamburger. The Resident Diet Order List included 9 residents with direction to cut meat. Of these 9 residents, 6 of them received hamburgers (not the alternative of chef salad). The CDM had to remind Staff C to cut the meat for all 6 of the residents served hamburgers with cut meat direction on the diet sheet. On 7/8/25 at 12:09 PM, the CDM confirmed Staff C wasn't going to cut up any of the hamburgers that day. After the first one, she needed to remind her for each resident who required cut up meat. She reported it as frustrating, as the cooks have all of the residents' names and their orders right there to look at, so they know what to serve. On 7/8/25 at 12:45 PM, Staff C stated because they had hamburger that day for lunch, she didn't think she had to cut it up. Staff C stated if it were a pork chop, Swiss steak, chicken, turkey, roast beef, pork loin, or anything like that she would have cut the meat. Staff C added she cut everybody's meat. Staff C stated nobody ever told her she needed to cut up hamburger, she stated she never knew that. On 7/8/25 at 1:49 PM, when asked about the meal that day that Staff C didn't cut up the cheeseburgers for residents with orders to cut up meat as written on the diet sheet, the Registered Dietitian Consultant responded it depended on if they needed the cut meat for a set up assist or if Speech Therapy recommended, they needed all meat cut up. The Registered Dietitian received a list of the residents observed that day that Staff C gave a whole hamburger with instruction to cut up meat on the diet list provided by the CDM. She stated she would look over the residents and call back. The list included Resident #3. On 7/8/25 at 2:14 PM, the Registered Dietitian stated she viewed the notes. She reported the list included Resident #3 as the only resident with a ST recommendation. She explained they needed to cut up Resident #3's meats due to swallowing difficulties/dysphagia. The Dietitian reported the other residents on the list, had orders as they needed set up assistance as they have difficulty cutting their food. She stated they should have cut up Resident #3's hamburger. On 7/8/25 at 4:15 PM, the Director of Nursing and the Administrator acknowledged the concern with Resident #2 receiving the wrong diet, choking, and required going to the hospital a few days later. They acknowledged the concern of Resident #3 planned to be served a hamburger patty not cut up. They stated they understood the Registered Dietitian stated Resident #2 should have received ground sausage, not cut up sausage, and someone should have cut up Resident #3's hamburger cut up per his diet order as he had swallowing difficulties/dysphagia. They acknowledged the CDM did give the plate back to Staff C after being questioned if the meat needed to be cut up and acknowledged the CDM admitted they were going to serve Resident #3 the whole hamburger without cutting it up. An undated Dietary Services policy directed the facility provide residents nutrition within the diets as ordered by their physician. The policy instructed to plan and follow menus to meet the nutritional needs of residents according to their physicians' orders. In addition, provide diets as directed by the consultant dietician.

Based on interviews, observations, record and policy review, after the facility identified a change in a resident's condition, the facility failed to notify a resident's family or responsible party for 1 of 3 residents reviewed (Resident #1). After staff heard the door alarm sound, they found Resident #1 attempted to exit the building, opened a door and was outside on the sidewalk. The facility didn't notify Resident #3's wife of the incident until days later. The facility reported a census of 34 residents.Findings include: Resident #1's Minimum Data Set, dated [DATE], identified a Brief Interview for Mental Status documented a score of 11 out of 15, indicating moderately impaired cognition. Resident #1 used a wheelchair for mobility. The MDS included diagnoses of unspecified dementia and depression.A Doctor's Order dated 5/28/25, directed to apply a wander management device to the right side of Resident #1's wheelchair every day, evening, and night shift. A Care Plan Problem dated 5/28/25, documented Resident #1 had a risk for elopement. The approaches directed the staff the following:a. Check battery life on wander-management device every week.b. Check location of wander-management each shift.c. A wander-management device applied to the right side of his wheelchair. A Progress Note dated 5/17/25 at 5:42 AM recorded as a late entry on 5/18/25 at 5:42 AM, authored by Staff E, Registered Nurse (RN). After the employee door alarm sounded, a Certified Nurse Aide (CNA) went to investigate and found Resident #1 pushed open the door. When the CNA asked Resident #1 what he was doing, he replied I'm trying to get out of here. The CNA returned Resident #1 to the 200-hallway. A Progress Note dated 5/28/25 at 12:30 PM, documented the staff applied a wander management device to Resident #1's wheelchair. A Progress Note dated 5/28/25 at 2:41 PM, documented the staff notified the Primary Care Provider of Resident #1's wander management and potential elopement. In the Internal Investigation Notes, the Director of Nursing (DON), documented on 5/19/25 she received report from Staff E. Staff E reported Resident #1 pushed open the door to the employee entrance. The DON asked Staff E if they put on wander device on Resident #1. Staff E replied no, because he didn't exit the building. On 5/27/25 another nurse reported to the DON they found Resident #1 outside on 5/17/25. The DON started an internal investigation and notified the Administrator. On 5/25/25 at 12:00 PM, the DON notified Resident #1's Spouse in person of the incident. On 7/7/25 at 3:55 PM, when asked if he remembered going out a door in the building, Resident #1 responded he didn't actually live at the facility. He encouraged to ask his roommate, (the guy over there and pointed at the curtain), as he actually lived at the facility. Resident #1 responded pleasant as he sat in his recliner in his room. On 7/8/25 at 10:43 AM, witnessed Resident #1's spouse sitting on his bed in his room. Resident #1 sat in his wheelchair using an electric razor to shave. The wife stated she really didn't believe Resident #1 opened the door. She acknowledged he had memory issues but said that just isn't something he would do. She said the facility didn't have video or anything showing him trying to go out the door. She said she felt he is absolutely safe, and she had no concerns about his safety. She stated they put a wander device on him after they said he tried to go out the door. She pointed to the wander device on his wheelchair. He never tried anything like that before, she said, so's why it's so hard to believe it. She stated she didn't get notified until days after the incident happened.On 7/8/25 at 3:14 PM, Staff D, CNA, stated when she came into work the night of the incident and when everybody finished up after supper. She started her shift at 6 PM. At that time, she saw Resident #1 and he wheeled himself back to his room using his hands and his feet to propel himself in the wheelchair. At that time, the door alarm went off and it sounded the same as a call light. The door alarms didn't go off very often at all. Staff D stated she didn't see it come across her pager, as she assisted another resident transfer to a chair. Then when she walked to the nurses' station to see the computer panel, it showed the employee door alarmed and 6 minutes passed since the alarm went off. At the time, Staff D asked other staff member through her walkie talkie if anyone went out the door or checked the door. Staff D thought one person may have answered it, but added they were with another resident. Staff D went to the employee door immediately after and found Resident #1 with the right rear wheel of his wheelchair propping the door open. Staff D stated he had his left front wheel off of the sidewalk. The sky was still light outside it without rain or anything. It was probably close to the temperature inside, probably around 70 degrees. Staff D stated after she wheeled him back, probably a minute or two later, Staff E came out and she told her what happened. Staff E only asked Staff D what Resident #1 said. When Staff D him where he was going, he replied he was going home. Staff D didn't believe Staff E asked any further questions. Staff D remembered telling Staff E about Resident #1 being outside. Staff E really didn't ask Staff D any other questions. Staff D remembered being really worried about him being stuck on the lip of the sidewalk and pretty sure she told Staff E about it. On 7/8/25 at 3:42 PM, the Director of Nursing (DON), stated she found out about the incident a week or two after it happened. The DON stated Staff D told another nurse about the incident. The DON stated Staff E didn't know Resident #1 went outside. The DON reported she expected Staff E to ask Staff D to make sure she heard correctly. Staff E viewed the incident as he didn't go outside as he just kind of pushed the door open. The DON stated Resident #1 never showed any exit seeking behaviors. The DON described Resident #1 as non-ambulatory when he admitted to the facility because of a fracture. She added he didn't show any exit seeking behaviors since the incident. On 7/9/25 at 10:58 AM, Staff E stated she apparently misheard over the walkie he attempted to get out but didn't. Staff E thought he was in the process of trying to get out. Staff E stated she should have done more. Staff E said she didn't know he actually got the door open or got completely outside at all. Staff E thought he attempted to get out. Staff E reported Resident #1 attempting to get out a door as new to him. Staff E stated she didn't tell his wife, and she should have. Staff E clarified she meant calling the wife as what she should have done more. Staff E stated they didn't really talk much about it after it happened that night due to the chaos of the night. On 7/9/25 at 11:50 AM, the DON acknowledged the concern regarding Resident #1's exit seeking behavior being new and the facility should have notified the family the day the incident occurred. An undated Change in Condition policy directed the following:Purpose: To monitor and report changes of residents' conditions.The facility will make every effort to inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when they need to alter treatment significantly, discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.An undated Missing Resident/Tenant Information report directed staff to identify the next of kin and relationship, their address, and their telephone number.

Based on record review, staff interviews and Resident Assessment Instrument (RAI) Manual the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) assessments for 2 of 12 residents reviewed (Resident #15 and Resident #18). The facility reported a census of 35 Residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), diabetes, and anemia (low blood iron). The MDS lacked documentation of Resident #15's new diagnosis of atrial fibrillation (abnormal heart rate that affects breathing and clotting of the blood) and lacked documentation that she received an anticoagulant during the lookback period. Resident #15's Hospital Discharge Summary dated 2/26/25 documented the principal problem for the hospitalization as atrial fibrillation. In addition, the summary included an order for Eliquis (an anticoagulant medication used to thin the blood to prevent blood clots) to give twice daily. Resident #15's February and March 2025's Medication Administration Record (MAR) reflected they received Eliquis during the seven-day lookback period. During an interview on 4/2/25, the Director of Nursing (DON) reported she reviews the order sheets to determine what medications residents take to code on the MDS. She reported the MDS should have Eliquis coded. She reported the facility didn't have a policy for MDS the facility followed the RAI Manual. The RAI Manual instructed to coded diagnoses in the last 60 days from sources which included hospital discharge summaries. The RAI Manual instructed to code any high-risk medications received during the 7 day lookback period. The RAI listed an anticoagulant as a high-risk medication. 2. Resident #18's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of hypertension, hemiplegia (the inability to move one-side of the body or severe weakness on one-side of the body) and Rheumatoid arthritis (a long-term connective tissue disorder that affects movement and comfort). The MDS reflected Resident #18 used bed rails as a restraint (any manual method, physical, or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). The Care Plan Problem revised 1/29/25 documented Resident #18 couldn't complete bed mobility by herself. The Interventions directed she had bilateral short side rails to the upper half of her bed. She used them to assist with repositioning side to side, and when staff provide care. During an interview on 4/2/25 at 11:20 AM, the DON reported they're not to code side rails on the MDS as a restraint for Resident #18. She added it happened in error. The RAI Manual documented to evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to their body. If the resident cannot easily and voluntarily do this, continue with the assessment to determine whether or not the manual method or physical or mechanical device, material or equipment restrict freedom of movement or restrict the resident's access to their own body. If it does then to code as a restraint.

Based on record review, policy review, and staff interviews, the facility failed to follow physician orders. In addition, the facility failed to notify the physician of medication error for 1 of 1 residents reviewed (Resident #36). The facility reported a census of 35 residents. Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified him with severe impaired cognitive skills for daily decision making. The MDS reflected he had a short- and long-term memory problem. The MDS included diagnoses of cancer, dementia, anxiety, and depression. The MDS listed Resident #36 received hospice level of care. Resident #36's Hospice Admission Orders dated 3/5/25, directed to discontinue the following medications: gabapentin (anticonvulsant and nerve pain medication) and Seroquel (antipsychotic medication). Resident #36's March 2025 Medication Administration record included documentation that reflected he received the following medications: a. Start date 3/7/25 - open ended (indicating no end date): Gabapentin tablet 600 milligrams (MG). Give 1 tablet at bedtime. - Staff documented giving him this medication on 3/7/25 and 3/8/25. b. Start date 3/7/25 - open ended: quetiapine (Seroquel) tablet 25 MG. Give 1 tablet twice a day. - Staff documented giving him this medication in the evening of 3/7/25, and both shifts for 3/8/25 and 3/9/25. The clinical record lacked documentation of communication with the physician on error in giving Seroquel and Gabapentin. During an interview on 4/2/25 at 2:15 PM, the Director of Nursing (DON) reported the Assistant Director of Nursing put the orders in and a second nurse verified the orders. The facility sent the provider the orders to review. The DON reported the staff didn't notice until after Resident #36 discharged from the facility the medication discrepancy when they reviewed his chart. She reported no one notified the physician of the error since Resident #36 no longer resided in the building. During an interview on 4/2/25 at 2:40 PM the Physician reported he didn't know of Resident #36's medication errors. He reported he didn't see the patient at the facility and so he didn't know when he signed the orders on 3/11/25 that the facility put the wrong transcription in the system. He reported Resident #36 recently took the medications so it wouldn't have harm concerns since he used it for a long period of time. The undated facility policy titled Physician Order Transcription Policy and Procedure Sample for Skilled Nursing Facility directed the facility to accurately document physician orders into the electronic medical records system. The undated facility policy titled Medication Errors directed staff to notify the physician or health care practitioner as soon as possible. Staff are to document actions taken in the medical record.

Based on record review, policy review and staff interviews, the facility pharmacist failed to provide pharmaceutical services to meet each resident needs by dispensing discontinued medications for 1 of 1 resident reviewed (Resident #36). The facility reported a census of 35 residents. Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified him with severe impaired cognitive skills for daily decision making. The MDS reflected he had a short- and long-term memory problem. The MDS included diagnoses of cancer, dementia, anxiety, and depression. The MDS listed Resident #36 received hospice level of care. Resident #36's Hospice Admission Orders dated 3/5/25, directed to discontinue the following medications: gabapentin (anticonvulsant and nerve pain medication) and Seroquel (antipsychotic medication). The Pharmacy Facility Delivery Log reflected the pharmacy delivered on 3/6/25 Gabapentin and Seroquel for Resident #19. During an interview on 4/2/25 at 3:00 PM, the facility Pharmacist reported the pharmacy has access to the facility's electronic health record (facilities system for electronic charting). The Pharmacist reported he cross referenced the hospice admission orders to the electronic health record and noted the admission orders didn't have an order to continue the Seroquel and gabapentin. The Pharmacist reported he thought they were new orders again since Resident #36 had recently been on them prior to coming to the facility with review of his prior records from the hospital. He reported to not delay Resident #36 receiving his medications so he filled and sent them to the facility. The undated facility policy titled Ordering and Receiving Medications instructed prior to filling any medications, the pharmacist reviews the order and clarified any concerns with the attending physician prior to dispensing.

Based on record review, policy review and staff interviews, the facility failed to prevent significant medication error for 1 of 1 residents reviewed (Resident #36). The facility reported a census of 35 residents. Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified him with severe impaired cognitive skills for daily decision making. The MDS reflected he had a short- and long-term memory problem. The MDS included diagnoses of cancer, dementia, anxiety, and depression. The MDS listed Resident #36 received hospice level of care. Resident #36's Hospice Admission Orders dated 3/5/25, directed to discontinue the following medications: gabapentin (anticonvulsant and nerve pain medication) and Seroquel (antipsychotic medication). Resident #36's March 2025 Medication Administration record included documentation that reflected he received the following medications: a. Start date 3/7/25 - open ended (indicating no end date): Gabapentin tablet 600 milligrams (MG). Give 1 tablet at bedtime. - Staff documented giving him this medication on 3/7/25 and 3/8/25. b. Start date 3/7/25 - open ended: quetiapine (Seroquel) tablet 25 MG. Give 1 tablet twice a day. - Staff documented giving him this medication in the evening of 3/7/25, and both shifts for 3/8/25 and 3/9/25. During an interview on 4/2/25 at 2:00 PM, the Hospice Nurse reported Resident #36's family called her due to Resident #36 sitting slumped over and very sleepy when they came in the evening on 3/9/25. She reported asking the nurse to review the medication list with her. At that time, they noted the facility gave Resident #36's Seroquel and gabapentin. The Hospice nurse questioned the facility nurse about the discontinued medications but the nurse didn't know a medication error occurred or knew of any concerns of a medication error. Review of the progress notes for Resident #36 lacked documentation of medication errors, an assessment at the time, or any notifications completed after they identified the error. During an interview on 4/2/25 at 2:15 PM, the Director of Nursing (DON) reported the Assistant Director of Nursing put in the orders and a second nurse verified the orders. The facility sent the provider the orders to review. The DON reported the staff didn't notice the medication discrepancy until after Resident #36 discharged from the facility they review his clinical record. The undated facility policy titled Physician Order Transcription Policy and Procedure Sample for Skilled Nursing Facility directed the facility is to accurately document physician orders into the electronic medical records system. The undated facility policy titled Medication Errors directed to document actions taken in the medical record.

Based on observation, record review and staff interview the facility failed to utilize proper food handling to prevent potential cross contamination of food to prevent food borne illness for 1 meal service observed. The facility reported of census 35 residents. Findings include: The menu for Tuesday, 4/1/25 consisted of the following: a. Chicken dumpling Soup with a buttered croissant b. Pork chop, au gratin potato, creamed peas c. Apple cranberry crunch, peaches and milk. During an observation of the meal service on 4/1/25 at 11:48 AM, Staff A, Dietary Cook, used tongs to place a buttered croissant on a plate. Then used a ladle to place soup into a bowl. They placed the bowl of soup on the plate with the buttered croissant. Staff A used tongs to place four saltine crackers on the plate to the right of the soup bowl. Staff A used her right ungloved hand to place a soup spoon on the plate to the right of the soup bowl on the saltine crackers. Staff A adjusted the soup spoon and saltine crackers with her bare ungloved right hand touching the saltine crackers. At 11:50 AM, Staff A used tongs to place a buttered croissant on a plate. Staff A used a ladle to place soup into a soup bowl and placed the bowl on the plate with the buttered croissant. Staff A, Dietary [NAME] used tongs to remove saltine crackers from a plastic container and placed them to the right of the soup bowl. Staff A, Dietary [NAME] held the tongs in her right ungloved hand and used her ungloved left hand to lift two saltine crackers off the plate. Staff A placed her ungloved middle finger and index finger of her left hand on the edges of the saltine crackers. Staff A grasped the saltine crackers with her left hand and placed them in the plastic tub of ready to eat saltine crackers. During an interview on 4/1/25 at 11:57 AM Staff A acknowledged she touched the saltine crackers with her bare hands and placed them back into the plastic container that held the ready to serve saltine crackers. During an interview on 4/1/25 at 11:59 AM Staff B, Dietary Manager, acknowledged she observed two occasions when Staff A touched the saltine crackers with her bare hands. Staff B reported Staff A should have used tongs to handle the saltine crackers and should have thrown out the saltine cracker instead of placing them back in the plastic container of ready to eat saltine crackers. The undated facility policy titled Food Handling Policy instructed staff to always use a clean, appropriate serving utensil to serve food never use your hand. If hands must be used (i.e. for sandwiches, cookies, etc.), wear clean, disposable gloves.

Based on observations, interviews, and record review, the facility failed to revise and update care plans for 3 out of 16 residents reviewed (Residents #8, #13, and #30). Resident #8's care plan did not address that she had actual pressure ulcers. Resident #13's care plan did not address that she was on a diuretic medication. Resident #30's care plan did not address that she was on an antipsychotic medication. The facility reported a census of 35 residents. Findings include: 1. A Wound Management Detail Report, documented that Resident #8 had a pressure ulcer on her right ankle. It documented that the wound was identified on 2/13/24 and it documented that the wound had not been healed on 4/5/24. This management report documented that Resident #8 had a pressure ulcer on her right buttock. It documented that the wound was identified on 1/29/24. It documented that the wound was not healed on 4/5/24. A Care Plan Problem dated 1/29/24, documented that Resident #8 was at risk for pressure ulcers. The goal was Resident #8's skin would remain intact within the next 90 days. On 04/10/24 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) acknowledged that the Care Plan addressed potential pressure ulcers and did not address that this resident actually had a pressure ulcer. 2. A doctor's order dated 10/27/23, documented that Resident #13 received nursemaid (a diuretic medication) 20 mg (milligrams) orally once a day. Review of this resident's Care Plan revealed that diuretic medication was not addressed. 3. A doctor's order dated 2/20/24, documented that Resident #30 received Seroquel (an antipsychotic medication), 25 mg (milligrams) orally twice a day. Review of resident's Care Plan revealed that antipsychotic medication was not addressed. 4/9/24 at 4:10 PM, the LNHA stated they did not address antipsychotic in Resident #30's Care Plan. She stated they are going through all of the Care Plans to be sure all medications are addressed. She stated they did not address the diuretic on Resident #13's Care Plan either. She stated so far those are the only 2 residents that they have found whom didn't have medications addressed. An undated Comprehensive Care Plan Policy directed staff that revision of Care Plan: should be based on the assessment and review of the current care plan, revise the care plan as needed to reflect any changes in the resident's health status or care needs. The revised care plan should include specific goals and interventions to address the resident's physical, emotional, and social needs.

Based on interview and record review, the facility failed to issue a bed hold notice to 1 of 1 residents reviewed for hospitalization s (Resident #13). The facility was unable to provide documentation that a notice of a bed hold policy was given to Resident #13 and/or her representative for 3 separate hospital stays. The facility reported a census of 35 residents. Findings include: A Resident Census for Resident #13 documented that this resident had been hospitalized on [DATE] to 5/26/23, 5/28/23 to 5/31/23 and 9/1/23 to 9/7/23. The facility was not able to provide documentation that a notice of bed hold policy was given for these hospitalization s. An email sent to the Licensed Home Administrator on 4/11/24 at 11:51 a.m., requested verification that the facility did not have bed hold policy for the above hospitalization s for Resident #13. Requested the Bed Hold Policy be sent via email if the facility did not have the documentation for the bed hold policy on those dates. The Licensed Home Administrator on 4/11/24 at 11:57 a.m., returned the email with the Bed Hold Policy. The facility did not have the documentation to support that the bed hold policy was given on the above dates. An undated Notice of Bed-Hold policy, directed that the notice of bed-hold policy would be given to ensure that resident or resident's representative is aware of the facility's bed-hold and reserve bed payment policy the initial discussion and disclosure of this policy is discussed with the resident and/or resident's representative upon admission. A description of this policy is located within the admission agreement.

Based on observation, policy review and staff interview the facility failed to measure total volume of prepared pureed food to determine an appropriate serving size for 2 of 2 residents (Resident #3 and #16), failed to perform temperature check on food served to Resident #18 and #25, failed to properly reheat food to 165 degrees Fahrenheit (F) that was served out to 1 of 2 resident (Resident #16) and failed to prevent bare hands from coming into contact with food. The facility identified a census of 29 residents. Finding include: During an interview on 12/29/22 at 10:26 a.m. Staff A, Dietary Cook, reported they had two residents on pureed diets and she would be preparing three servings of puree for each menu item. A Fall/Winter 2021-2022 Week 3 Dinner general pureed menu: a. Chicken Kiev 4 ounces b. 1 cookie, pureed A Diet List provided to the facility on [DATE] showed Resident #3 and #16 on general diet, pureed texture with nectar thickened liquids. During an observation on 12/29/22 at 10:27 a.m. Staff A using tongs placed three 4-ounce (oz.) servings of Chicken Kiev into the Extreme mixer. Staff A added broth to the Extreme mixer, placed top on the mixer and started to blend. At 10:29 a.m. Staff A opened a bag of bread reaching in to remove two slices of bread with her bare hands, laying the two slices of bread on top of the employee dinner sign up list. The Dinner Sign Up list had multiple different writings and signatures on the sheet with a half inch by half inch faint orange stain on the lower right hand side of the paper. Staff A then picked up the two slices of bread with her bare hands and placed in the mixer with the chicken and started to blend the bread into the chicken mixture. Staff A scraped down the chicken mixture from inside the blender and using a 4 oz. scoop placed two servings into two separate bowls. The remaining amount of the mixture was scooped up with the scoop and placed in a third bowl. All three bowls were moved to the steam table. Staff A failed to measure the total volume of the puree mixture to obtain a correct serving size. During an observation on 12/29/22 at 10:42 a.m. Staff A, placed three cookies and approximately 2-3 oz. of reduced fat milk into the Extreme mixer and proceeded to blend. Staff A scraped the mixture from the inside of the blender and emptied the contents into a measuring cup. Staff A failed to actually measure any volume of the mixture and proceeded using a 2 oz. scoop separated the mixture into three small plastic cups without checking chart for total volume of mixture and number of servings. During an observation on 12/29/22 at 11:25 a.m. three serving bowls of pureed Chicken Kiev temped by Staff A, Cook, revealed a temperature of 121 degrees Fahrenheit (F), 122 degrees and 140 degrees. All three bowls of the pureed Chicken Kiev were placed back in the steam pan on the steam table. During an interview on 11/29/22 at 11:28 a.m. Staff A reported she would re-warm the pureed Chicken Kiev as she placed the three bowls of Chicken Kiev in the microwave. At 11:30 a.m. Staff A performed a temperature check on the three dishes of Chicken Kiev after reheating with the following temperatures 151 degrees, 162 degrees and 165 degrees. The two bowls of Chicken Kiev that failed to be brought up to 165 degrees were placed back in the steam pan on the steam table on the left side of the steam pan. Staff A failed to properly reheat the two bowls of Chicken Kiev that were below 165 degrees. During an observation on 12/29/22 at 11:29 a.m. Staff A failed to perform a temperature check on soup she removed from the microwave and set up on a room tray to be delivered to Resident #18. During an observation on 12/29/22 at 11:44 a.m. Staff A removed a bowl of regular cut up chicken from the steam table and served out to Resident #25 without performing a temperature on the chicken to ascertain a safe food temperature prior to serving. During an observation on 12/29/22 at 11:47 a.m. Staff A served Resident #16 the bowl of Chicken Kiev sitting on top of another bowl of Chicken Kiev on the left side of the steam table that had failed to temp at 165 degrees or higher after re-heat. During an observation on 12/29/22 at 11:54 a.m. Staff A checked a post meal temperature on the small bowl of pureed Chicken Kiev that had been put back into the left side bottom of the steam pan that had temped at 162 degrees after re-heat. The bowl of Chicken Kiev had improperly reached serving temperature from the steam table at 167.5 degrees. During an observation on 12/29/22 at 12:10 p.m. Resident #3 had eaten all of her pureed Chicken Kiev that had been served to her. Resident #16's bowl of pureed Chicken Kiev had one spoonful out of the bowl. During an interview on 12/29/22 at 12:15 p.m. the Dietary Manager stated she expected staff to use gloves to handle ready to eat foods. Food should not be touched with bare hands. All food is to be temped to assure proper temperature before food is served out to residents. She reported Staff A had been taught the volume method for preparing pureed food and had been audited. She should have measured the pureed volume for each pureed food item and then used the chart to find the correct serving size. She stated she expects all reheated food items to be above 165 degrees to be served out or the food item should not be served out. She stated she had observed the pureed Chicken Kiev had not been reheated to the appropriate temperature prior to serving. During an interview on 12/29/22 at 1:03 p.m. the Consulting Dietician reported she would expect all food to be temped to ensure a safe food temperature prior to serving. She would have expected the pureed Chicken Kiev to be reheated to 165 degrees prior to being served out for safe food temperature. She teaches the puree volume method. The Consulting Dietician reported unless there is a pureed standardized recipe for the Chicken Kiev she would expect the staff to use the puree volume method to get a correct serving size. She reported staff should not touch food with bare hands. During an interview on 12/29/22 at 1:08 p.m. the Dietary Manager reported the Chicken Kiev comes frozen from their supplier ready to cook. The kitchen did not have a pureed standardized menu for that food item. A Pureed Technique Policy, undated, provided by the facility directed the following: 1. Review menu for the food items that need to be pureed. Follow the menu exactly as planned. 2. Correct number of portions plus 1-3 are added into the blender. 3. Liquids of nutritive value are added when pureeing: meat broth, gravy, milk, sauces, juice. No water. 4. If bread and butter are on the menu these may be added to the entree for the day or half in the meat and half in the vegetable. Do not forget the butter/margarine if this is on the menu. 5. Puree food to an applesauce or smooth pudding consistency. 6. Pureed food is scraped from the blender or Robo Coupe into a measuring device to determine total volume. 7. Volume is divided by the total number of potions (including extra servings). 8. A chart is also available for assistance. If a portion is between scoop sizes, use the scoop of larger volume. 9. It is recommended to puree no more than 15 servings at a time. 10. Pureed food is placed into a serving pan and the temperature is taken. 11. Hot pureed food is reheated to 165 degrees or greater if the temperature dropped below 140 degrees. The Food Preparation and Service Policy, undated, provided by the facility listed a procedure that included food would be served at acceptable temperatures, assuring safety and quality. Hot foods would be served hot. The Policy further directed food would be placed on the steam table to maintain acceptable temperatures during the meal service and resident requiring assistance would be assisted with the meal while the food is at an appropriate temperature. A Reheating Food chart, undated, provided by the facility directed a temperature of 165 degrees (F) for leftovers and re-heating of food and holding of hot foods at 135 degrees or above. The Monitoring, Recording and Beverage Temperatures procedure, undated, provided by the facility documented the Cook will monitor food temperatures during the process of preparing and cooking meals by the use of steam/steam table thermometer. The Cook will check and record food temperatures before the service of each meal. All perishable or potentially hazardous food shall be cooked to recommended temperatures and held at a safe food temperature of 41 degrees Fahrenheit or below, or 135 degrees Fahrenheit or above. If the temperature is not within the appropriate temperature range, the food item is not to be served. The When to Wear Gloves Policy, undated, provided by the facility directed gloves must be worn when handling ready to eat foods. The 2017 Food Code specified the following: 1. Temperature control for safety-food that is cooked to a temperature and for a time received hot shall be at a temperature of 135 degrees (F) or above; 2. Except when washing fruits and vegetables, food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissues, spatulas, tongs, single-use gloves or dispensing equipment. 3. Food employees shall minimize bare hand and arm contact with exposed food that is not in ready to eat form. 4. Temperature control for safety food reheated in a microwave oven for hot holding shall be reheated to that all parts of the food reach a temperature of at least 165 degrees (F) for 15 seconds. 5. Temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating.

Based on clinical record review and staff interview, the facility failed to update the advanced directive status for one of 16 residents reviewed. (Resident #13) The facility census was 31 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #13 had [DIAGNOSES REDACTED]. During clinical record review of the electronic health records (EHR) and the face sheet the resident was a Do Not Resuscitate (DNR) code status. A document labeled Guidelines for Life sustaining Procedures signed on 5/3/16, documented the resident as DNR. A Iowa Physician order [REDACTED]. The report sheet dated 10/14/19, did not have the resident listed as full code status. During interview on 10/21/19 at 3:50 p.m., the Director of Nursing (DON) reported staff was to look for the resident's code status in the EHR, report sheet or on a sheet hanging in the medication room for advanced directives status. The DON reports the 3rd shift nurse updated these weekly and she would expect it to be correct for residents advanced directives.

Based on observation, clinical record review and staff interview, the facility failed to follow proper infection control measures for three of four residents utilizing oxygen (Resident #12, #20 & #25) and failed to ensure proper hand washing after personal cares for one of six residents reviewed.(Resident #12) The facility census was 31 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #12 had [DIAGNOSES REDACTED]. Observation on 10/22/19 at 11:40 a.m., revealed the resident was using a portable oxygen tank while in the dining room. Observation of her room revealed an oxygen concentrator with humidification, extra-long oxygen tubing attached to the concentrator, and a nebulizer machine (used for giving breathing treatments) with a mask on her dresser. There was no date on the humidification bottle, nebulizer mask or the oxygen tubing to indicate when it was last replaced. During observation on 10/22/19 at 1:00 p.m., the oxygen tubing, nebulizer mask, and humidification bottle remained without a date to indicate when last changed. A brand new nebulizer mask and extra-long oxygen tubing was laying on top of the dresser, unopened and undated. The facility policy for Changing and Replacement of Oxygen Delivery Equipment dated (MONTH) (YEAR), documented All nasal cannula's shall be replaced on a minimum of every seven days and as needed. All humidifiers/bubblers shall be replaced on a minimum of every 7 days and as needed. All other tubing in a non-humidified system shall be changed on a minimum of every 30 days. All other tubing in a humidified system shall be replaced on a minimum of every 7 days. All oxygen delivery supplies will be tagged with the date of the change and the initials of the staff member changing the equipment. During observation on 10/22/19 at 11:40 a.m., Staff A, certified nurse aide, CNA Staff B, CNA completed perineal care for the resident and removed their gloves but failed to complete hand hygiene. Staff A and Staff B assisted the resident to ambulate out of the room with staff hanging on to the gait belt and assisting the resident with the walker from time to time to the dining room. Review of a document labeled Infection Control Program documented staff will be educated, trained, and monitored for proper handwashing as follows. Bullet points emphasized handwashing will be monitored before and after assisting a resident with toileting (hand washing with soap and water), and after removing gloves or aprons. During interview on 10/22/19 at 11:50 a.m., Staff A stated he should have washed his hands as soon as he removed the gloves and before he started to ambulate the resident. 2. The MDS assessment dated [DATE], documented Resident #25 had [DIAGNOSES REDACTED]. Observation on 10/21/19 at 11:48 a.m., revealed the resident was using oxygen via a portable tank in the dining room. There was no visible date on the tubing as to when it was last changed. During observation on 10/23/19 at 8:20 a.m., new oxygen tubing laying coiled up in the plastic wrapper it came in with piece of tape on the tubing dated 10/22/19. The oxygen tubing currently in use on the oxygen concentrator had no date on it to indicate when last changed. During interview on 10/23/19 at 11:00 a.m., the Director of Nursing (DON) stated her expectation was oxygen equipment-humidification bottles, tubing, nebulizer masks- be changed out weekly, dated with the day they were changed, and signed for as being changed. The DON stated it was her expectation staff wash their hands or use hand sanitizer after gloves were removed. 3. The MDS assessment dated [DATE], documented Resident #20 had [DIAGNOSES REDACTED]. Residents current physicians orders include an order for [REDACTED]. Observation on 10/23/19 at 10:50 a.m., revealed the residents nasal cannula had no markings to show when it had been changed last.

Based on clinical record review and staff interview, the facility failed to complete a recapitulation if the resident stay for one of one closed record reviewed. (Resident #31) The facility census was 31 residents. Findings include: 1. Clinical record review revealed Resident #31 was discharged [DATE]. The clinical record lacked evidence a recapitulation or documentation of a summary of services provided was completed at discharge. During interview on 10/23/19 at 11:15 a.m., the Director of Nursing reviewed the closed record and confirmed no recapitulation was completed as required.

Based on observation, clinical record review and staff interview, the facility failed to notify the residents physician of a condition change for two of two residents reviewed. (Resident #3 & #26) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. Nurse notes dated 6/18/18 at 1:30 p.m., documented the resident had 3+ [MEDICAL CONDITION] to the left lower extremity with lungs sounds diminished but clear. On 6/19/18 at 11:40 p.m., the nurse note documented the residents temperature was 99.5, Tylenol given. On 6/19/18 at 2:00 a.m., the resident's temperature was 101.7 ice packs placed bilaterally axilla (armpit). At 2:45 a.m., the resident's temperature was 99.8 and at 5:17 a.m., the temperature was 100.2. On 6/20/18 at 7:35 p.m., the resident complained of shortness of breath and oxygen saturation was at 85% on room air, 3 liters of oxygen was administered and oxygen saturation was 93%. At 8:38 p.m., the resident was having additional episodes of dyspnea (difficulty breathing), temperature was 99.7, heart rate was 116 beats per minute, and respirations were 28 per minute. T At 8:59 p.m., an order was received to send resident to the emergency room . It included documentation the physician was upset he was not notified of the resident's intermittent temperature as he may have been able to prevent the emergency room visit. During interview on 8/9/18 at 11:00 a.m., Staff A, Licensed Practical Nurse, LPN reported the assessed health changes with any resident should be reported to the physician as soon as they were discovered. 2. The MDS assessment dated [DATE], documented Resident #26 had [DIAGNOSES REDACTED]. Review of the Care Plan showed a documented approach/ intervention that resident needed nursing staff to complete wound care and report any signs of infection and [MEDICAL CONDITION], increased redness, swelling, warmth, tenderness, and purulent drainage to primary care physician. During observation on 8/8/18 at 7:45 a.m., the two open areas had yellow slough in the wound bed, bright reddened skin surrounded the wounds and ran down the shin to the resident's ankle. Nurse notes dated 8/3/18, documented large amounts of cloudy yellow drainage observed on the lower left leg. Dressing was saturated with drainage prior to change. Patient complains of feeling discomfort around wound. Oncoming nurse to notified, she will follow up with primary care physician. During interview on 8/8/18 at 8:18 a.m., Staff D, registered nurse reported there was no evidence of physician notification of the drainage from the wound and she would expect them to notify the primary care physician with changes.

Based on clinical record review and staff interview, the facility failed to refer three of four residents reviewed with a newly evident qualifying mental illness [DIAGNOSES REDACTED]. (Resident #27, #12 & #31) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #27 had [DIAGNOSES REDACTED]. Clinical record review revealed a negative level 1 screen outcome dated 4/8/13, which documented the resident had no major mental illnesses to include major [MEDICAL CONDITION] and psychotic/delusional disorder. A [DIAGNOSES REDACTED]. Clinical record review revealed no re-submission of information for a PASRR which included the [DIAGNOSES REDACTED]. During interview on 8/7/18 at 2:00 p.m., Staff A, Licensed Practical Nurse, LPN stated there was no re-submission of information completed and they did not know why. 2. The MDS assessment dated [DATE], documented Resident #12 had [DIAGNOSES REDACTED]. The current PASARR dated 12/23/18, was a negative level 1 and documented only [MEDICAL CONDITION] diagnosis. 3. The MDS assessment dated [DATE], documented Resident #31 had [DIAGNOSES REDACTED]. The preadmission PASARR dated 1/4/18 was a negative level 1 and included [DIAGNOSES REDACTED]. During interview on 8/9/18 at 1:27 p.m., the administrator reported they have multiple users for completing the preadmission screening but do not have a good system for monitoring the new [DIAGNOSES REDACTED].

Based on observation, clinical record review and staff interview, the facility failed to provide toileting in a timely manner for one of six residents observed. (Resident #27) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #27 had [DIAGNOSES REDACTED]. The care plan dated 10/11/13, included an intervention to ensure toileting prior to each meal. On 8/8/18 at 6:30 a.m., the resident sat in their room in a wheel chair. At 8:45 a.m., the resident sat in their room in a wheel chair. At 9:30 a.m., the resident sat in their room in a wheel chair. At that time the surveyor asked Staff B, Certified Nurse Aide, CNA if they had provided any cares for the resident since first observed at 6:30 a.m. Staff B verified they had been working that hall and stated the resident had no cares since being assisted to transfer into the wheel chair and morning cares upon awaking. At 10:19 a.m., the resident sat in the wheel chair in their room. Observation revealed an odor of urine. Staff B and Staff C, CNA transferred the resident to the bed with a Hoyer lift. Staff B verified the residents brief was wet. Observation revealed the residents incontinent brief to be visibly saturated with urine. Staff B and Staff C completed incontinent cares for the resident and assisted the resident back to the wheel chair. During interview on 8/9/18 at 11:45 a.m., Staff D, Registered Nurse stated they would expect the resident to be toileted during the day with a commode before and after meals and as needed. During interview on 8/9/18 at 1:30 p.m., the Administrator stated they talked to the other staff who had worked the day shift on 8/8/18 and none had toileted the resident during the observation time.

Based on clinical record review and staff interview, the facility failed to ensure safety interventions were implemented in order to prevent further injury for one resident reviewed. (Resident #9) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. A bruise assessment dated [DATE] at 7:30 p.m., documented the resident sustained [REDACTED]. The form documented the bruise was from a sling/edging when removed from under the resident. The form included an immediate nursing intervention to prevent further injury was to measure the area. Review of the care plan included no documentation of potential interventions put in place after the incident to attempt to prevent further injury. On 8/9/19 at 2:55 p.m., Staff D, Registered Nurse stated sheepskin in the sling could possibly prevent further injury. At that time the surveyor asked the facility Administrator, also present, if anyone had reviewed the incident to discuss interventions to prevent further injury. The Administrator stated they did not know. At 11:45 a.m., the Administrator stated they had now followed up and discovered they could order a special made sheepskin for the area of the sling which caused the injury.

Based on observation, clinical record review and staff interview, the facility failed to utilize proper infection control technique during cares for two of six residents observed. (Resident #26 & #31) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 had [DIAGNOSES REDACTED]. During observation on 8/8/18 at 7:45 a.m., Staff F, Registered Nurse, RN treated two open wounds on resident's left lower leg. The open areas had yellow slough in wound bed, bright reddened skin surrounded the wound and also ran down the shin to the ankle. Staff F placed the treatment bag on the bed stand and donned gloves. Staff F cleansed the area to the residents left lower extremity with wound cleanser, removed gloves and donned new gloves. Staff F placed [MEDICATION NAME] on a gloved index finger and applied [MEDICATION NAME] to the lower smaller wound in an up and down movement, placed more [MEDICATION NAME] on same finer and applied it to the upper wound moving back and forth across the wound bed. Staff removed gloves applied gauze and covered the area with kerlix. Staff F returned supplies to the treatment bag, exited the room, opened the medication cart and placed the bag into the cart and documented on computer keyboard and then sanitized their hands with sanitizer. During interview on 8/8/18 at 8:18 a.m., Staff D, RN stated she would expect the [MEDICATION NAME] to be applied with clean gauze or a Q-tip and not with a gloved finger moving between two wounds. Staff D would expect hand sanitation to be completed with glove changes and to wash if hands were soiled or resident care had been provided. 2. The MDS assessment dated [DATE], documented Resident #31 had [DIAGNOSES REDACTED]. During observation on 8/8/18 at 7:59 a.m., Staff H, Certified Nurse Aide, CNA and Staff E, CNA assisted the resident on to the commode and donned gloves. Staff H removed a visibly soaked brief, rolled it up and placed it into the trash receptacle. Staff H removed gloves and proceeded to other side of the room. Staff H touched the divider curtain, the roommate's walker handles and the roommate's shoulder and began care for the roommate without any hand sanitization. During interview on 8/8/18 at 8:15 a.m., Staff A, Licensed Practical Nurse, LPN stated she would expect hands to be sanitized after providing cares and prior to going to give cares to another resident. During interview on 8/9/18 at 9:48 a.m., Staff A, LPN reported staff can use hand sanitizer between glove changes and it available to them in the hall way but it should not take the place of hand washing as the policy stated.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to follow standard and contact precautions for 1 of 9 residents reviewed (Resident #4). The facility census was 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #4 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The resident had a suprapubic catheter. Review of a care plan with an approach start date of 4/27/17, indicated resident currently has MRSA in the suprapubic catheter site. Interventions included please observe the facility contact precautions, apply the ordered treatments, and notify doctor with any concerns. During observation on 5/30/17 at 10:55 a.m., a Contact Isolation Precaution sign was noted hanging on the resident's room door. At 4:00 p.m., Staff G, certified nurse aide, CNA and Staff F, CNA entered the room and proceeded to assist the resident without washing their hands or applying gloves. Staff G unhooked the resident's catheter bag from the bed and placed it on the wheelchair. After getting the resident seated in the wheelchair, Staff G pushed the resident to the dining area. Staff G failed to wash or sanitize his/her hands before leaving the room. Staff F sanitized her hands in the hallway after exiting the room. After placing the resident at the table, Staff G returned to the 100 hallway and entered another resident's room with a mechanical lift. The facility Level 2 Contact Precautions identified precautions that are in addition to Standard Precautions and include the following steps: 1. Wash hands. 2. Gowns are indicated only if soiling is likely. 3. Gloves are indicated when touching infective material. Change frequently after contact. 4. Red bag contaminated linen only. 5. Red bag infectious trash only. Dispose of in biohazard container in the med room. 6. Non-contaminated garbage is to be disposed of in the standard manner. 7. Wash hands. During interview on 5/31/17 at 2:45 p.m., the Administrator and Director of Nursing (DON) stated it was an expectation staff wash their hands before caring for a resident, after caring for a resident, after removing gloves and before leaving the resident's room regardless of whether they are on contact precautions or universal precautions.

Based on observation, record review and family and staff interviews, the facility failed to ensure Resident #1 was protected against environmental hazards. The sample consisted of 4 residents and the facility reported a census of 36 residents. Resident #1 laid in a low bed and rolled out of bed and onto a baseboard heater. The resident received 2nd degree burns to the groin, abdomen and right leg. The facility immediately evaluated all beds in the facility and found Resident #1 was the only bed resting parallel to the base board heater. On 3/20/17, the Administrator provided inservices to housekeeping and nursing staff to not place a resident's bed parallel to the base board heater that is less than 36 inches. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 2/2/17. The MDS identified the resident required extensive assistance of two staff persons for bed mobility, transfers, ambulation, dressing and toilet use. The resident's functional status with balance during transitions and walking identified the resident as not steady and only able to stabilize self with staff assistance. Resident #1 used a walker and wheelchair and had impairment of both lower extremities. The BIMS (Brief Interview for Mental Status) identified the resident had a severe cognitive impairment and had [DIAGNOSES REDACTED]. The resident experienced the following falls near the resident's bed: A form titled Fall Scene Investigation Report identified a fall on 11/1/16 at 12:10 a.m. The resident's call light was activated and the staff observed the resident on the floor. The form indicated the resident rolled out of bed and onto the floor. A diagram indicated the staff found the resident lying on the floor between the recliner and bed. The recommendation to prevent this from happening again was to remind staff to ensure the left and right half side rails are in an up position. The staff placed Dycem (rubber like square item) under the incontinence pad so the resident would not slide out of bed. The Fall Scene Investigation Report, indicated on 3/19/17 at 3:50 a.m. Staff A, certified nurse aide, CNA responded to an alarm and found Resident #1 on the floor between the bed and the electric radiant baseboard heater. Both the left and right side rails were raised. Staff A called for the charge nurse who assessed the resident and found 1st and 2nd degree burns on both lower extremities and the left side of the resident's abdomen; caused by contact with the electric radiant baseboard heater. The nurse called for an ambulance and the resident was transported to the local hospital emergency room for treatment. During an interview on 3/22/17 at 2:50 p.m., Staff A, certified nursing assistant, verified they responded to the alarm for the resident and verified it was the resident's alarm since they could not reset the call light by simply pushing the reset button on the wall. Staff A had to first reset the resident alarm, then push the call light reset button on the wall - which Staff A did after the resident was pulled to a safe area away from the baseboard heater. Staff A verified the bed was placed parallel to the radiant baseboard heater and just far enough away that blankets hanging down from the bed would not rest on top of the heater and be a fire hazard. On 3/22/17 at 1:10 p.m., Staff B, registered nurse, was interviewed and verified no call light was on when Staff A went to assist another resident and when finished came into the hall seeing the call light on for the resident and went immediately to the room. Staff B heard Staff A yelling so Staff B came to assist. Staff B verified the positioning of the bed and the resident against the radiant baseboard heater with Staff A trying to hold the resident away from the heater while they assessed the resident and called the ambulance, on-call physician and family. On 3/21/17 at 2:55 p.m., a family member stated they had the room arranged with the recliner between the bed and the baseboard heater so the resident could sit and look out the window. The facility rearranged the resident's room a couple of months ago, placing the bed along the wall against the baseboard heater to make it easier to use a mechanical lift to transfer the resident in and out of bed. Review of the report from the local Emergency Department dated 3/19/17, indicated the resident was treated for [REDACTED]. The report indicated the burns were scattered on each leg and abdomen. The physician ordered Silvadene (antibacterial topical medication) to be applied with dressing changes twice a day to the burn wounds located at the left abdomen/groin and lower extremities for 2 weeks. The pain medications orders were Acetaminophen (Tylenol) 1000 milligrams every 8 hours for 2 weeks and Roxanol (morphine sulfate-narcotic) 5 milligrams every 2 hours as needed for uncontrolled pain. The physician directed to continue current other medications and treatments. During an observation and staff interview, on 3/22/17 at 9:35 a.m., the maintenance person found the electric radiant baseboard heaters used in resident rooms come on when the room temperature dropped below the temperature setting on the heater and remained on until the room temperature rose above that setting, the heaters are either on or off, when the heaters come on to warm the resident room they reach a temperature of about 135 degrees Fahrenheit (F) according to the infrared thermometer used by the maintenance person. While testing the heaters, the surveyor was only able to hold their hand on the heater for a few seconds before it became too hot to comfortably maintain contact. On 3/22/17 at 8:25 a.m., the Administrator stated after the resident rolled/fell out of bed and sustained burns from the radiant baseboard heater, the bed was moved away from the heater by maintenance personnel and they went through the facility to ensure all resident beds were away from the radiant baseboard heaters to prevent injury to other residents. Staff were educated to make sure resident beds were kept a safe distance away from the radiant baseboard heaters in the resident rooms. During observation throughout the survey days on 3/22/17 & 3/23/17, no resident beds were noted to be positioned against or near to the electric radiant baseboard heaters throughout the facility. On 3/20/17, all staff received notice that no beds were to run parallel with the baseboard heaters unless there is at the very minimum of 36 inches between the bed and the baseboard heaters. Observation of photographs of the abdomen and right thigh and lower leg, identified extensive first and second degree burns located on the right leg and left side of lower abdomen. Note: At the initial time of the complaint investigation, the complaint was coded at a J immediate and serious jeopardy. By 3/19/17, the facility had evaluated other beds to ensure of being parallel to the base board heaters and moved Resident #1's bed. On 3/20/17 the facility abated the immediate jeopardy with inservices to housekeeping and nursing staff are to not place resident's beds parallel to the base board heaters less than 36 inches. The Administrator posted the reminders to all staff.

Based on record review, staff and family interviews, the facility did not always ensure that each resident had the right to be free from verbal, sexual, physical and/or mental abuse. Concerns were noted for one of four residents in a sample of four residents. (#1). The facility reported a census of 36 residents. Findings include: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Documentation in the facility Minimum Data Set (MDS) assessment form dated 02-02-2016 indicated Resident #1 could not complete the Brief Interview for Mental Status (BIMS) and was assessed as having long term and short term memory problems and severely impaired cognitive skills for decision making. The assessment form also indicated Resident # 1 required extensive staff assistance with most activities of daily living (ADL's) including bed mobility, transfers, dressing, personal hygiene, toileting, bathing and eating Resident #1 did not ambulate. The facility's individual plan of care (dated 02/10/2016) addressed Resident #1 ADL function/rehabilitation potential and directed staff to implement the following approaches: * Utilize the mechanical sit to stand with two staff assist for all transfers. * Incontinent of bowel and bladder, wears adult pull up briefs and needs assistance with pericares after toileting. Documentation in the nurse's notes dated 02-03-2017 included an annual social service note which indicated Resident #1 was unable to complete the BIMS as Resident #1 did not answer any of the questions. The notation indicted staff interviews were completed which determined Resident #1 was severely impaired with decision making skills. The annual MDS notation, dated 02/08/2017 indicated Resident #1 was alert and able to state his/her name only. The notation also indicated Resident #1 had frequent urinary and bowel incontinence and wore adult briefs to help manage (the incontinence). The assessment also indicated Resident #1 was no longer ambulatory and required the use of the stand lift and the assistance of two staff for all transfers. Resident #1 utilized a wheelchair (for locomotion) with staff propelling to and from destinations. During an interview on 02/16/17 at 11:35 a.m., the facility administrator indicated at 8:01 p.m. on 02/06/2017 she received notification from a community member stating an employee sent a Snapchat of a staff member holding BM (bowel movement) in the palm of his/her gloved hand and a resident's buttocks. The administrator indicated she immediately went to the nursing facility and initiated an investigation. During an interview on 02/15 2017 at 2:00 p.m. Staff A stated it was her understanding that the facility policy directed staff not to have their cell phones on their person while on duty. Staff A stated cell phones were permitted in the facility break room. Staff A stated she had attended facility inservices on HIPPA and it was pretty obvious/clear that cell phones were not permitted (on their person) but Staff A added that not all staff abided by the policy. Staff A added that on the date of the incident (02-06-2017) she was getting off work (at a different job) when she received a Snapchat from Staff E. Staff A stated she opened the Snapchat and saw a photo of a gloved hand holding a pile of BM. She described it as if a resident was in the process of defecating and staff caught the feces. Staff A stated she was unable to see the resident but did see bare buttocks from the lower back to mid thigh area. Staff A stated she knew the photo was a resident and staff person. She also stated the photo included a typed message, something to the effect of, this is what I do at my job. During an interview on 02/15/2017 at 2:21 p.m. Staff B stated facility policy directed staff not to have their cell phones on their person while on duty unless it was an emergency and their supervisor was aware. Staff B stated normally cell phones were to be kept in the breakroom. Staff B also stated that taking pictures of residents (or any part of a resident (s) (body) is a no-no. Staff B stated on the evening of the incident she received a Snapchat notification but did not open it immediately. She stated later when she did open it she observed a hand with poop on it. Staff B stated she did not recall seeing any part of a resident. Staff B stated she could not recall what the accompanying text had read. She added that she didn't think it was a very professional thing to do and was shocked that a staff person would do such a thing. Staff B also stated she thought the incident should have been reported (to administration ) but admitted that she did not report it because she was a friend of Staff E. During an interview on 02/15/17 at 2:39 p.m. Staff C also stated that it was facility policy that staff did not have cell phones on their person while at work, but cell phones were allowed in the breakroom. Staff C also indicated it was against facility policy for staff to take pictures of residents or any part of a resident. Staff C stated on the day of the incident, she checked her cell phone (between 6:00 and 7:30 p.m.) and noted she had received a message from Staff E which was a picture of a hand with BM on it. Staff C stated she didn't notice any part of a resident but later learned that the photo did include part of a resident's body. Staff C also stated there was a text with the photo that mentioned something about what she (Staff E) does at her job. Staff C stated it did not cross her mind that it was wrong to take a photo and send it out on Snapchat and she did not report the incident as it also did not cross her mind that it was potential abuse. During an interview on 02/16/17 at 10:14 a.m., Staff D stated it was facility policy that staff did not have cell phones on their person during work time and staff were not allowed to take photos of residents. Staff D stated on the day of the incident she (Staff D) and Staff E were assisting Resident #1 to bed following the evening meal. Staff D stated Resident #1 was positioned in the EZ stand (for a transfer) and they had completed perineal cares. Staff D stated a clean adult brief had been placed when Resident #1 began to defecate again. Staff D stated Staff E caught the bowel movement in her gloved hand so the clean brief would not be soiled. Staff D stated she then observed Staff E take her cell phone and take a photo of what Staff D thought was Staff E's gloved hand with the bowel movement. Staff D stated then Staff E put her phone away. Staff D stated she did not report the incident, nor was she aware that Staff E had sent the picture to other individuals, and that the photo included a text message. Staff D confirmed that Resident #1 did not consent to having the photo taken and the photo included Resident #1's body (parts). During an interview on 02/16/17 at 10:58 a.m. Staff E stated the facility had zero tolerance for staff to have cell phones on their person while at work. Staff E stated she thought the day shift followed the policy more than second shift staff. Staff E stated she did have her cell phone on her person a few times a week. She stated she also saw other staff with their cell phones, but they checked/used them during down times in the cubbies where the Kiosk was located. Staff E stated it was even more unacceptable for staff to take pictures of residents. Staff E described the evening of the incident to be a usual day. She stated she was assisting in getting Resident #1 ready for bed about 7:00 p.m. Staff E stated perineal cares had been completed and as a new brief was placed, Resident #1 began to defecate again. Staff E stated she did not want Resident #1 to soil a second brief so she caught the bowel movement in her left (gloved) hand. She stated she then retrieved her cell phone with her ungloved right hand and snapped a photo, adding a text I love my job which she stated she was being sarcastic. Staff E stated Staff D was quiet while providing cares, and together they finished getting Resident #1 ready for bed. Staff E stated her actions were immature and she just wasn't' thinking. She added that she did not mean any harm by her actions. Review of the facility policy (not dated) titled Personal Blogging Social Media and Confidential Information included the following direction for staff. 1. You may not post resident, vendor or co-worker information which is otherwise prohibited from release by state or federal law. Examples include but are not limited to: * Prohibiting the use of photographs or recordings in any manner that would demean or humiliate a resident (s); including by not limited to using any type of equipment (i.e.: cameras, smart phones and other electronic devices) to take, keep or distribute photographs and recordings on social media. * Demeaning or humiliating photographs or video of nudity, exposed bodily (sic) parts, such as genitalia, breast, or of posting examples of bodily functions such as toileting, provisions of incontinence care, exposing perineal areas and/or fecal material on body parts or bedding/ furnishings.

Based on clinical record review and staff interviews, the facility failed to provide adequate supervision to protect Resident #1 during times of known increased confusion, such as during infections, with a change in psychotropic medications and during the evening hours. Resident #1 sustained a fractured hip when he/she stood up from a wheelchair unassisted and sustained a fall. The sample consisted of 4 residents and the facility reported a census of 42 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 5/7/14 which identified the resident had [DIAGNOSES REDACTED]. The MDS reported the resident required limited assistance with transfers, walking in the hall, and extensive assistance with bed mobility, walking in the bedroom, dressing, toilet use, personal hygiene and bathing. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #1 scored 10 of 15. A score of 10 revealed the resident experienced moderate cognitive impairment. The MDS also reported the resident refused or rejected care 1 to 3 days in the 7-day assessment period. The MDS reported functional limitation in range of motion/impairment of both upper and lower extremities. According to the balance test for transitions and walking the resident was not steady and was only able to stabilize with staff assistance for moving from a seated to a standing position, walking, turning around, moving on and off toilet and with surface to surface transfers. The MDS reported the resident had suffered a fall, without injury since the last assessment. Review of a psychiatrist's progress note dated 6/4/14 reported the resident's primary care provider referred Resident #1 to the psychiatrist on 5/1/14 for evaluation and treatment of [REDACTED]. When delirious the resident became aggressive, loud and uncooperative. The resident had a history of [REDACTED]. The psychiatrist reviewed the nurse's progress notes from January 2014 to June 4, 2014 and noted numerous accounts of resident transferring self out of bed or chair without assistance, yelling at or commanding spouse to do things for him/her, and transient episodes of increased confusion and anger associated with urinary tract infections. The psychiatrist called the nursing home and spoke with two registered nurses (RN). One nurse reported in the evening or during the night the resident got more confused. The agitation started late in the afternoon and the resident could get belligerent. The resident would perseverate on something, like being convinced he/she could walk without assistance. The second RN reported the resident would begin to get agitated around 7 p.m. The psychiatrist assessed Resident #1 with impaired judgment and insight and impaired short and long-term memory. The assessment also included delirium due to general medical condition, dementia with behavioral disturbance, intermittent episodes of increased confusion, forgetful and impulsive. Review of the Physical Therapist Discharge Summary dated 8/23/13 revealed the resident's strength had improved, the resident required contact guard assistance of one person for transfers for safety. The Plan of Care dated 5/8/14 noted the resident's risk for falls due to use of antidepressant medication, the need for staff assistance with completing personal care, a history of falls and history of increased confusion with urinary tract infection. The approaches instructed the staff the resident would often get up by him/herself and was often resistive to redirection. The plan of care also instructed the staff to continue to provide frequent safety reminders and education regarding the need for staff assistance with all transfers and walking. An approach dated 4/7/14 instructed the staff to provide education/redirection to utilize call light to notify staff or need for assistance with picking items off floor. The Nurse's Notes identified the following: On 3/31/14 at 12:35 a.m. the staff found the resident standing up at the bedside. The resident verbalized an intent on going home. The staff attempted to redirect the resident. The resident slugged a staff member in the stomach. Staff attempted to provide reality orientation and agitation increased. On 4/1/14 at 1:40 p.m. a housekeeper found the resident standing up by him/herself and pulling out a dresser drawer, looking for a telephone book. The resident became angry. The staff provided education regarding safety and staff assistance when he/she was up. On 4/5/14 at 3:30 p.m. the staff reported the resident fell in his/her bedroom. The resident reported he/she stood up from the wheelchair and attempted to pick something up off the floor. Four staff members assisted the resident up off the floor. The resident received education and redirection regarding the allowing of staff to assist with tasks. The incident report identified a plan. The plan consisted of redirection and providing education to the resident regarding use of the call light and allowing staff to assist. On 4/6/14 at 7:30 p.m. the staff found the resident standing in his/her room between the recliner and bed. The resident requested assistance with moving the bed. The staff provided redirection. The resident became upset and refused to sit down. The staff noted increased confusion. The resident adamant that he/she routinely walked independently and drove his/her cars daily. Staff provided reorientation, in which the resident rejected. The resident made depressive statements such as the staff never let him/her do anything and he/she might as well be dead. On 4/8/14 at 10:10 a.m. (the physician) increased the Exelon (medication for dementia) three weeks ago with little improvement noted. On 4/14/14 at 3:30 p.m. staff noted the resident with increased confusion and behavior changes. The resident arguing with staff that he/she was independent and going home. The resident attempting to transfer self from recliner and walk. On 4/14/14 at 4:30 p.m. the staff a urine specimen. At 10:00 p.m. the staff received the urine results. The Physician was paged. At 10:05 p.m. (the nurse) received a new order for an antibiotic. On 5/9/14 at 11:00 p.m. the resident ' s temperature registered 101 Fahrenheit (normal 98.6). The resident was administered Tylenol (for fever and pain control). On 5/10/14 at 2:30 a.m. the resident ' s lung sounds remain adventitious, congested. On 5/10/14 at 8:30 a.m. a portable x-ray of the resident ' s chest was taken. At 9:50 a.m. the facility received the x-ray results which were sent to the physician. On 5/10/14 at 1:30 p.m. the resident had moist crackles (abnormal) audible in both lower lungs. On 5/11/14 at 1:10 p.m. the nurse heard crackles in both lower lungs. The resident stated he/she felt good. On 5/12/14 at 2:00 p.m. the resident was confused earlier this morning, but later noted less confusion. On 5/16/14 at 1:30 p.m. the staff heard lung sounds with an occasional crackle to both lungs with occasional expiratory wheeze to the left base. The staff identified no cough and the resident denied being short of breath. The resident continues on an antibiotic. On 5/16/14 at 3:15 p.m. the staff heard a thud sound from the resident's room. The resident was found on the floor in front of the recliner. The incident report identified a plan. The staff reviewed the last six months of falls and determined the plan would be to offer toileting and walk the resident between 1:30 and 2:00. On 6/4/14 at 12:20 p.m. the resident left for an appointment with the psychiatrist. At 2:45 p.m. the resident returned with a new order for Quetiapine (Seroquel/antipsychotic medication) 12.5 milligrams (mg) as needed (prn) for anger and extreme confusion and an order to update the physician in two weeks. On 6/15/14 at 7:00 p.m. the staff found the resident and roommate lying on the floor. The resident complained of left knee discomfort. The resident reported he/she got up out of the wheelchair and walked to the back of the wheelchair to fix it. The roommate got up to assist and both fell to the floor. Staff reminded the resident of the importance to call for staff before standing. The incident report form revealed the resident complained of knee discomfort after the fall in the bedroom. On 6/16/14 at 9:45 a.m. the staff reported the resident had increased pain this morning with transfers and did not bear weight well on to the left leg. At 10:00 a.m. the nurse made a phone call to the physician's office. At 10:15 a.m. the nurse received a new order to send the resident to the emergency room . At 10:45 a.m. the resident left the facility by ambulance. At 4:40 p.m. the facility received a report that the resident had a fractured hip. Review of a hospital discharge summary report dated 6/21/14 revealed the resident had an accidental fall and suffered a left hip fracture and was admitted to the hospital. The resident underwent [REDACTED]. When interviewed on 7/14/14 at 3:30 p.m. a certified medication aide, Staff B, stated prior to falling and breaking his/her hip, Resident #1 had occasional confusion. The resident would be more confused when he/she first awoke from a nap. The resident would then get up unassisted. At the time, the resident thought he/she had used the call light, however, the light had not been triggered. The resident also had times when he/she believed his/her spouse could assist him/her. When interviewed on 7/14/14 at 3:35 p.m. a certified nursing assistant (C.N.A.) Staff C, stated Resident #1 was forgetful. The resident would get up unassisted. Staff C would catch the resident up alone and sometimes she would catch the resident at the edge of his/her chair just getting ready to get up. When interviewed on 7/14/14 at 3:40 p.m. a C.N.A., Staff D stated the resident had a history of [REDACTED]. When interviewed on 7/14/14 at 3:45 p.m. a second shift licensed practical nurse (LPN), Staff E, stated prior to the resident breaking his/her hip, she noticed the resident became more confused towards night time. The resident believed he/she was independent. The staff would tell the resident he/she needed assistance and the resident would tell them he/she did not need assistance and they could not tell him/her that he/she did. One evening the resident was under his/her bed and the resident believed the bed was a car and he/she was fixing the air conditioner. On 6/15/14, she was on duty. The resident informed her, he/she had gotten up to fix his/her wheelchair. The resident informed her the back of the wheelchair was not up right. The resident complained of pain in his/her knee all night. They did not let the resident bear any weight that night. When interviewed on 7/15/14 at 10:00 a.m. a first shift LPN, Staff F, stated prior to falling and breaking his/her hip, the resident would usually use the call light, and however, there were times when he/she was more confused. The resident would believe he/she could get up unassisted. Staff F stated the resident's confusion was not always related to an infection. When interviewed on 7/15/14 at 10:16 a.m. a C.N.A., Staff G, stated prior to the resident breaking his/her hip the resident used the call light about half of the time. Staff G would find the resident up unassisted in his/her bedroom. The resident did not retain their redirection or education to use the call light. When interviewed on 7/15/14 at 9:35 a.m. the Director of Nursing (DON) stated the staff called her every time a resident fell and they brain storm together. She stated after the resident fell on [DATE] they felt the resident's delirium was due to an infection. The DON stated their intervention was to treat the resident's infection. The DON stated the resident continued to stand up unassisted after 1/21/14. The resident then fell again on 4/5/14 at 3:15 p.m. when the resident stated he/she was picking something up off the floor. The DON stated nothing was on the floor at the time of the fall. The DON stated their intervention at that time was to provide education and redirection for the resident to use the call light. The DON stated the staff always provided education and redirection to the resident each time the resident either stood or transferred him/herself without assistance. The resident fell again on 5/16/14 at 3:15 p.m. when he/she stood up unassisted and was going home. The new intervention was for the staff to take the resident for a walk sometime between 1:30 and 2:30 p.m. The resident then fell again on 6/15/14 at 7:00 p.m. and broke his/her hip.