Every finding on record at Clay County Health and Rehabilitation

Based on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all the residents residing in the facility.Findings included:During the Entrance Conference with the Administrator on 4/27/26 at 11:02 AM, he revealed the facility's Infection Preventionist position was currently vacant and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were performing those duties. He also stated that neither the ADON or DON had completed the Statewide Program for Infection Control and Epidemiology (SPICE) training or any other specialized infection prevention and control training.An interview on 4/30/26 at 10:30 AM with the DON revealed the previous IP left the facility the first part of March 2026. She stated that currently she and the new ADON were performing the IP functions but neither of them were SPICE trained and had not had any other specialized infection prevention and control training.An interview on 4/30/26 at 12:27 PM with the Administrator revealed the facility was attempting to hire an IP.

Based on record review, staff, Pharmacist, and Medical Director interview, the facility failed to transcribe and implement orders for diabetes care according to the hospital discharge summary for a resident with diabetes. Additionally, the facility failed to transcribe and implement orders for the same resident's Coreg (used to treat heart failure and hypertension) according to the hospital discharge summary. This deficient practice occurred for 1 of 5 residents reviewed for significant medication errors (Resident #23).Findings included.Resident #23 was re-admitted to the facility on [DATE]. His diagnoses included type-2 diabetes mellitus with hyperglycemia, atherosclerotic (buildup of plaque in artery) heart disease of native coronary artery (blood vessels in the heart) without angina (chest pain), heart failure, hypertension.An admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 was cognitively intact. The MDS further documented that he had orders for insulin, received insulin injections, and hypoglycemic medication.1a. A hospital Discharge summary dated [DATE] discharge medication list included the following orders:- Insulin aspart (NovoLog) (short acting insulin) 100 units/ milliliter (ml) inject 10 units under the skin 3 times a day with meals.-Insulin aspart 100 units/ ml sliding scale insulin to be administered before meals and at bedtime. Usual correction to be used between 6:01 AM-10:59 PMBlood glucose (BG) less than 70-hypoglycemia protocol70-150-no correction insulin151-200-2 units201-250-3 units251-300-4 units301-350-6 units351-399-7 unitsGreater than 399-7 units and initiate BG greater than 399 protocol Usual correction to be used between 9:00 PM- 6:00 AMBlood glucose (BG) less than 70-hypoglycemia protocol70-200-no insulin201-250-1 units251-300-2 units301-399-3 unitsGreater than 399-3 units and initiate BG greater than 399 protocol -Insulin glargine (Lantus) (long-acting insulin) 100 units/ml inject 15 units under the skin two times a day. Resident #23's electronic record indicated his medications were entered into the electronic computer system by the Assistant Director of Nursing (ADON) when he was re-admitted on [DATE].Resident #23's electronic medical record contained active orders dated 4/14/26 for:-Insulin Aspart 100 units/ml sliding scale insulin, inject per sliding scale before meals and at bedtime.If 200-250-2 unit251-300-4 unit351-400-8 unit401-450-10 unit451-500-12 unitGreater than 500 call MD -Glargine insulin 15 units twice daily.Review of Resident #23's electronic record, active physician orders, and Medication Administration Record (MAR) for April 2026, revealed there was not an order for aspart insulin 10 units three times daily with meals that had been entered. The electronic medical record documented Resident #23's BG was monitored four times daily. His BG results were documented most frequently ranging in the 200's and 300's. From 4/14/15-4/29/26 the medical documented Resident #23's BG results were greater than 400 on 9 occasions on the following dates 4/16/26, 4/17/26, 4/18/26, 4/19/26, 4/22/26,4/25/26, and 4/26/26. Review of the April 2026 Medication Administration Record (MAR) documented Resident #23's insulin aspart sliding scale insulin and glargine insulin were administered as ordered.1b. A hospital Discharge summary dated [DATE] discharge medication list included an order for:-Carvedilol (heart medication) 12.5 mg by mouth twice daily. Review of Resident #23's active physician orders included an order dated 4/14/26 that read, Coreg (Carvedilol) oral table 12.5 mg give one table by mouth twice daily for hypertension.Review of the April 2026 Medication Administration Record (MAR) revealed Coreg was only scheduled on the MAR to be given one time a day in the morning. The MAR documented Resident #23 had only received his Coreg once daily in the morning from 4/15/26 through 4/30/26. The electronic medical record documented from 4/14/26 to 4/28/26 Resident #23's blood pressure was monitored at least daily. Resident #23's systolic blood pressure (top number in blood pressure reading, measures the maximum pressure in your arteries when the heart beats) ranged from 130-180 (normal systolic blood pressure is 120 or less). His systolic blood pressure was documented at greater than 160 on 7 occasions. Resident #23's diastolic blood (bottom number in blood pressure reading, measures pressure in your arteries when your heart is resting) pressure ranged from 68-108 (normal diastolic blood pressure is less than 80). His diastolic blood pressure was documented at greater than 90 on 4 occasions.The electronic medical record documented from 4/14/26 to 4/28/26 Resident #23's pulse was monitored at least daily. Resident #23's pulse ranged from 73-112 (normal pulse range is 60-100). His pulse was documented at greater than 100 on 7 occasions.A care plan dated 4/16/26 was in place for hypertension. The care plan goal was to remain free of complications related to hypertension. The care plan interventions included giving anti-hypertensive medications as ordered.An interview was conducted with the Assistant Director of Nursing (ADON) on 4/30/26 at 9:33AM. The ADON said he did not recall Resident #23's 4/14/26 admission orders specifically but that he had entered the orders. The ADON stated he did not verify orders from the discharge summary with the physician on admission for residents because he was not aware he needed to do so. The ADON reviewed Resident #23's hospital Discharge summary dated [DATE]. He said he had missed entering the order for routine aspart insulin 10 unit with meals. The ADON confirmed the discharge summary orders were for Coreg 12.5 mg to be given twice daily. He reviewed the Coreg order he entered in the electronic computer system. The ADON said he had entered the time code incorrectly for Resident #23's Coreg order. He explained he had entered a once a day time code instead of a twice a day time code for Resident #23's Coreg. The ADON explained that the aspart insulin sliding scale entered was the default insulin sliding scale insulin used by the facility. The ADON said it was typically the DON or the Unit Manager (UM) who did the second check on admission orders after he entered them. He did not know who had completed the second check.An interview was conducted with the UM on 4/30/26 at 10:21 AM. The UM stated she had worked at the facility for about 6 weeks. When asked about the process for new admission orders, the UM stated she did not usually do them. The UM explained that the ADON typically entered the new admission orders and then passed the admission paperwork on to her to do all the assessments when the resident arrived at the facility. The UM said she did not perform a second check of the admission orders and said she was not sure who did the second check of the orders. The UM stated she had not been told she needed to check the admission orders. The UM said she probably should have known she needed to do so but that no one had told her she needed to.An interview was conducted with the pharmacist on 4/30/26 at 3:43 PM. The pharmacist would not comment if Resident #23's missed order for routine aspart insulin was significant or if Resident #23 receiving Coreg once a day instead of twice a day as ordered was a significant medication. The Pharmacist said medications were given for a clinical reason and Resident #23 needed the medications for that clinical reason.An interview was conducted with the Director of Nursing (DON) on 4/30/26 at 9:52 AM. The DON reported the facility performed new admission audits and said reviewing the orders was part of that audit. The DON said she recalled reviewing Resident #23's orders and discharge summary in the clinical meeting. The DON stated during the morning clinical meeting they checked the discharge summary orders against the orders entered in the electronic computer system. The DON explained she printed a copy of the orders from the electronic computer system and used the paper copy to check the orders against the discharge summary but did not open each order in the electronic computer system to ensure the time codes were accurate. The DON said orders were supposed to have a second check by a nurse. She reported the UM and ADON who were supposed to check the new admission orders. The DON explained that previously she had entered the new admission orders but during the last month that had changed because the facility had filled the ADON and UM positions and she had turned that over to them to do. The DON stated the ADON and UM had been trained and told what was expected. She reported if the orders were put in by one then the other should do the second check of the admission orders. The DON explained that outside of business hours the floor nurses were responsible for verifying and entering the new admission orders, and then ADON or UM were supposed to perform the second check. The DON stated orders should be entered accurately from the discharge summary unless the provider changed something when the orders were verified. She said if the provider did change something then it should be noted on the discharge summary. She stated if the provider was not in the building, then the nurse was supposed to call and verify the orders with the provider over the phone and note on the discharge summary who the orders were verified with and the date. The DON said she was unable to locate a verified or facility provider signed copy of Resident #23's 4/14/26 discharge summary. The DON stated the ADON and UM positions were recent positions that had been filled and additional training was needed. The DON did not think the missed order for Resident #23's routine aspart insulin was a significant medication error because his blood sugars were being monitored and he had an order for sliding scale insulin. The DON did not think Resident #23 receiving Coreg once a day instead of twice daily was a significant medication error because he was still receiving the medication.An interview was conducted with the Medical Director on 4/30/26 at 12:47 PM. The Medical Director stated the facility should follow the discharge summary orders and enter them accurately. The Medical Director indicated the facility should verify discharge summary orders for new admissions with a provider. The Medical Director stated he did not want the sliding scale insulin scale on Resident #23's discharge summary used. He explained that the sliding scale insulin orders in place for Resident #23 was the default sliding scale used at the facility when sliding scale insulin was ordered and that was what he wanted to be in place. The Medical Director did not think Resident #23's order for routine aspart insulin 10 units before meals being missed was a significant medication error because he was receiving sliding scale insulin and his blood sugars were being monitored. The Medical Director stated Resident #23 not receiving his Coreg twice daily as ordered could be significant because it could affect the heart. He said Resident #23 should have received his Coreg as ordered. The Medical Director said the potential for the medication error to be significant was high because Coreg was a heart medication and by default, he would consider it a significant medication error.An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator stated admission orders should be entered accurately and according to the hospital discharge summary.

Based on record review, and staff and Registered Dietitian (RD) interviews, the facility failed to follow Registered Dietitian recommendations for nutritional supplement for a resident with significant weight loss for 1 of 5 residents reviewed for nutrition (Resident #44).The findings included:Resident #4 was admitted to the facility on [DATE]. Her diagnoses included dementia. A care plan last revised on 3/26/25 was in place indicating Resident #44 had a nutritional problem/ potential nutritional problem. The care plan goal was for her to maintain adequate nutritional status as evidenced by maintaining weight within 5% of body weight, not having symptoms of malnutrition, and consuming at least 50 % of meals daily. The care plan interventions included for the Registered Dietitian to evaluate and make diet change recommendations as needed, provide and serve diet as ordered, weight per facility guidelines, and monitor/ report symptoms of malnutrition. Resident #44's electronic medical record documented on 12/5/25 her weight was 120 poundsA quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had severe cognitive impairment. She was documented for behaviors or rejection of care. The MDS indicated she was able to feed herself after meal set up, her weight was 120 pounds, and that she did not have weight loss.Resident #44's electronic medical record documented on 1/5/26 her weight was 110 poundsAn order by the Medical Director dated 1/14/26 read, health shake (nutritional supplement) one time daily.An RD note dated 2/5/26 indicated Resident #44's current weight was 110 pounds and noted she had signification weight loss at the 30-day mark. The RD note indicated Resident #44 was started on a supplement and Remeron (antidepressant used to treat appetite) in response to the weight loss. The RD note recommended continuing the current nutritional intervention.Resident #44's electronic medical record documented on 2/11/26 her weight was 109.6 pounds and on 3/4/26 her weight was 109 pounds.A diet order dated 3/22/26 read: Regular diet, mechanical soft texture, regular/ thin liquid consistency. Resident #44's electronic medical record documented on 4/1/26 her weight was 101.8 poundsResident #44's electronic medical record under progress notes contained a significant weight change assessment progress note dated 4/14/26 by RD #1. The note indicated Resident #1 had a 6.6 % weight loss over 1 month reported for the month of April. The note stated she received health shakes daily and the RD recommended increasing her health shakes to three times a day for support of continued weight loss.Review of Resident #44's physician orders revealed there was no order for the health shakes to be increased to three times a day.An interview with Nurse #1 was conducted on 4/29/26 at 11:00 AM. Nurse #1 stated she was Resident #44's routine nurse. She reported Resident #44 only received a health shake once a day. She explained health shakes were given to residents by the nurse and were kept in the nourishment refrigerator or were sent from the kitchen.An interview was conducted with RD #2 on 4/29/26 at 9:27 AM. The RD stated Resident #1 had weight loss previously from December 2025 to January 2026. She reported her weights had remained stable from January until March and then her weight had started declining again in April. She explained she was the facility's routine RD and had been coming to the facility for 8 years. She reported she came to the facility every other week and then worked remotely every other week. RD #2 stated she did have other RDs who helped her review residents to keep up to date with assessments. RD #2 reported Resident #44 had been reviewed by RD #1 for weight loss on 4/14/26 and it was recommended to increase her health shakes to three times a day. RD #2 explained after residents were reviewed the RD recommendations were emailed to the Director of Nursing (DON) and the DON entered the new orders into the electronic computer system. RD #2 explained RD #1 had emailed his recommendations to her instead of emailing them to the facility after his review on 4/14/26. She stated RD #1's recommendations had probably gotten lost in her email, and she had missed sending them to the facility. RD #2 stated RD #1 had just started helping her and had not known he needed to email the recommendations to the facility. She reported RD #1 had been emailing his recommendations to her, but she had since corrected RD #1 and told him he needed to email the recommendations to the facility.An interview was conducted with the DON on 4/29/26 at 10:20 AM. The DON stated monthly weights were typically completed by the 5th day of the month and then reviewed by the interdisciplinary team during the clinical morning meeting. She reported that after the monthly weights were reviewed the RD was notified if a resident had weight loss and needed to be seen. The DON indicated the RD also reviewed the weights. The DON said during the morning clinical meeting they discussed if there were any concerns about a resident losing weight, not eating, or showing decline and she notified the RD to see the resident. The DON reported she had not received the RD recommendation to increase Resident #44's health shake to three times a day. The DON said there was not a process in place for reviewing the RD notes. She explained she relied on the RD sending the recommendations to her by email and then she entered the orders for whatever was recommended. The DON stated she was not aware of another RD helping RD #2 and was not sure what had happened. The DON stated Resident #44 should have received the health shakes three times a day if it was recommended by the RD but she had not been aware. An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator stated the facility had a process for RD recommendations but that something happened in the process where they had not received the RD recommendations for Resident #44.

Based on record review, and staff and Medical Director interviews, the facility failed to ensure the physician visit included a plan to address an abnormal low thyroid laboratory test from the hospital discharge summary. This deficient practice occurred for 1 of 3 residents reviewed for physician visits (Resident # 1).Findings included:A hospital Discharge summary dated [DATE] indicated Resident #1 had been hospitalized for COVID-19 pneumonia. The discharge summary documented that her thyroid stimulating hormone (TSH) level was low with a result of 0.36 (typical normal range is 0.4-4.0). The discharge summary recommended follow up with primary care provider for repeat thyroid function tests.Resident #1 was readmitted to the facility on [DATE]. Her diagnoses included pneumonia due to COVID and dementia.Resident #23's medical record did not contain a diagnosis of thyroid disease or physician order for any thyroid medication.Resident #1's medical record did not contain any information indicating she had laboratory work completed by the facility to recheck her thyroid function.A physician visit note dated 3/16/26 by the Medical Director stated she was being seen for an initial assessment and history and physical after hospitalization. The note documented TSH was suppressed. Under the section diagnosis, assessment, and plan of the note, there was not a plan included which addressed rechecking her thyroid function or addressing the abnormal thyroid laboratory test. An admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had severe cognitive impairment.An interview was conducted with the Medical Director on 4/30/26 at 12:47 PM. The Medical Director stated he mentioned in his visit note on 3/16/26 that Resident #1's TSH was suppressed but said it had gotten by him to order it to be rechecked. He stated there should have been a plan to recheck her TSH. He reported Resident #1 did not have any mention in her medical history about thyroid issues and that was probably why he missed it. He explained he used the resident's medical history to populate and create the framework for his visit notes. The Medical Director stated checking a follow up TSH for Resident #1 was warranted. He reported the facility should also be monitoring and following up on labs too. The Medical Director stated he could not say there was no adverse effect until they assessed Resident #1's thyroid function thoroughly. He explained there were different medical conditions that could cause a low thyroid level such as a benign tumor (non-cancerous tumor) or mild version of grave's disease (thyroid disease) that would not be very problematic to treat. The Medical Director stated COVID could also cause inflammatory changes in organs, but that most likely Resident #1's low thyroid level was not a result of COVID and was most likely present before her COVID illness. An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator stated he expected staff to review the discharge summary and to follow and implement the orders from the discharge summary.

Based on record review and interviews with staff, Consultant Pharmacist, and Consultant Pharmacist Supervisor, the Consultant Pharmacist failed to identify irregularities regarding laboratory monitoring for 1 of 1 resident with a diagnosis of diabetes reviewed for unnecessary medication (Resident #12).Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus. Review of Resident #12's electronic health record revealed an A1c of 7.9% dated 7/02/25. This was the last documented A1c in the medical record. (A1c is a blood test that measures your average blood sugar levels over the past 3 months). Nurse Practitioner progress note dated 10/30/25 read in part that the CBGs (capillary blood glucose) stable. The note recommended DC (discontinuation) of Accu-Cheks (finger sticks to check blood sugar) at that time and continue with routine A1c monitoring. Continue Metformin. Further review of Resident #12's electronic health record revealed there was no order for routine A1c monitoring. Review of Resident #12's medical records revealed the Consultant Pharmacist had conducted medication regimen reviews (MRRs) monthly on 11/12/25, 12/22/25, 1/15/26, 2/11/26, 3/13/26, and 4/12/26. There were no recommendations for any monitoring laboratory tests. During an interview on 4/30/26 at 3:54 PM the Consultant Pharmacist stated he had not recommended an A1c lab test for Resident #12's Metformin medication monitoring. He also stated he sometimes looked for laboratory results and sent recommendations to the Physician, but he did not catch everything. During an interview on 4/30/26 at 3:59 PM the Consultant Pharmacist Supervisor stated if a resident was taking diabetic medication such as Metformin, the Consultant Pharmacist should have reviewed laboratory test results for medication monitoring and made the necessary recommendations. She stated the Consultant Pharmacist should have recommended blood sugar level monitoring such as an A1c. An interview on 4/30/26 at 11:01 AM with the Director of Nursing (DON) revealed the Consultant Pharmacist did not make a recommendation for A1c laboratory tests for Resident #12. She stated the facility system for scheduled lab tests was after the Physician ordered the laboratory test, the nurse would write them in a calendar, and they would be drawn when they were due. The DON indicated although she reviewed the monthly medication regimen reviews, she had not identified that a recommendation for an A1c for Resident #12 was missing. An interview on 4/30/26 at 12:27 PM with the Administrator revealed he deferred to the Director of Nursing for questions about medical monitoring.

Based on record review and staff, Physician, Consultant Pharmacist, and Consultant Pharmacist Supervisor interviews, the facility failed to ensure monitoring for medication management was completed as recommended by the medical provider for 1 of 6 resident with a diagnosis of diabetes reviewed for unnecessary medications (Resident #12).Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus. Resident #12's physician's orders included an order dated 8/07/25 for Metformin (oral medication primarily used to manage type 2 diabetes) 500 milligrams (mg) by mouth every day. A Nurse Practitioner progress note dated 10/30/25 read in part that the CBGs (capillary blood glucose) stable. The note recommended DC (discontinuation) of Accu-Chek (finger sticks to check blood sugar levels) at that time and continue with routine A1c (blood test that measures your average blood sugar levels over the past 3 months) monitoring. Continue Metformin. The Nurse Practitioner was not available for interview. Review of Resident #12's Physician's orders revealed the Nurse Practitioner discontinued the finger stick blood sugars on 10/30/25. Further review of Resident #12's physician's orders showed no diagnostic lab tests ordered for diabetes monitoring. During an interview on 4/30/26 at 12:45 PM the Physician stated that Resident #12 should have had an A1c test quarterly to monitor his blood sugar levels. He acknowledged it was his fault he had missed that the testing needed to be done and had not ordered it. During an interview on 4/30/26 at 3:59 PM the Consultant Pharmacist Supervisor stated if a resident was taking diabetic medication such as Metformin, the facility should have been monitoring the resident's blood sugar levels with an A1c laboratory test. An interview on 4/30/26 at 11:01 AM with the Director of Nursing (DON) revealed Resident #12 should have had an A1c test scheduled quarterly. She stated the Physician did not order any additional monitoring of Resident #12's blood sugar and the facility staff had not recognized that it should have been done. The DON stated Resident #12's progress notes were reviewed and discussed at morning meetings so the missing A1c order should have been identified during the review.

Based on record review, observations and staff interviews, the facility failed to discard expired medication from the medication room for 1 of 1 medication room observed for medication storage and labeling. Additionally, the facility failed to keep unattended medications in a secured medication cart for 1 of 4 medication carts (300-hall medication cart) observed for medication storage. Findings included: 1. On 4/30/26 at 9:00 AM observations of the medication room were conducted with Unit Manager (UM) #1 and revealed the following: a. Three prefilled Pneumovax 23 (pneumonia vaccine) 0.5 milliliter (ml) single dose syringes were found in the refrigerator with a manufacturer's expiration date of 1/24/26. b. Two Acetaminophen 650 milligram (mg) suppositories with a manufacturer's expiration date of 3/2026. c. Four unopened 118 ml bottles of Dextromethorphan HBR Guaifenesin (cough medicine) with a manufacturer's expiration date of 2/2026. On 4/30/26 at 9:09 AM an interview was conducted with UM #1. She stated expired medications should be removed and discarded from the medication room. She was not sure who was responsible for checking the medication room for expired medications. An interview with the Pharmacist was conducted on 4/30/26 at 3:00 PM. The Pharmacist stated expired medications should be removed and discarded from the medication room. He said pharmacy performed a spot check of the medication room for expired medications but did not do an all-inclusive check of all the medications stored in the medication room. The Pharmacist reported the facility was responsible for checking the medication room for expired medication outside of the spot checks done monthly by the pharmacy. He said if he noticed a trend or issue with expired medications being found then he would let the facility know so they could do a more in-depth check. The pharmacist reported he had completed a spot check of the medication room last week on 4/16/26 and had not noticed a trend or issues with expired medications found. An interview was conducted with the Director of Nursing (DON) on 4/30/26 at 3:49 PM. The DON stated expired medication should be removed and discarded from the medication room. She reported the medication room was supposed to be checked weekly but said it was not assigned to a specific individual. She reported there was not a check list or anything staff completed or turned in when the medication room was checked. The DON further stated staff were supposed to check the expiration date anytime they took a medication out of the medication storage room. She stated it was an honor system that staff checked the medication room for expired medications. An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator stated he expected expired medications to be removed from the medication room. 2. On 4/28/26 at 10:24 AM an observation of the 300-hall medication cart revealed it was unattended in the hallway and was unlocked (a red dot was visible on the lock mechanism which indicated an unlocked position). There was one resident in a wheelchair in the hallway during this time. Medication Aide #1 returned to the cart at 10:25 AM from behind a closed resident room door. During an interview on 4/28/26 at 10:25 AM Medication Aide #1 acknowledged she did not lock the medication cart and indicated she should have pushed in the lock before leaving the cart. Medication Aide #1 reported the medication cart should have been locked for resident safety. An interview on 4/29/2026 at 12:23 PM with the Director of Nursing (DON) revealed Medication Aide #1 should not have walked away and left the medication cart unlocked. She acknowledged the medication cart was supposed to be kept locked for resident safety. During an interview on 4/30/26 at 5:29 PM the Administrator revealed medication carts should be kept locked for safety when unattended.

Based on observations, record review, and staff interviews, the facility failed to implement their policy and procedures for glucometer disinfection, standard precautions, and hand hygiene when Medication Aide #1 failed to disinfect Resident #23's assigned glucometer after performing a capillary blood glucose (CBG) test. Additionally, Medication Aide #1 failed to wear gloves when she performed the CBG test and failed to perform hand hygiene before and after performing the CBG test. This deficient practice occurred for 1 of 3 glucometer infection control observations and 1 of 3 hand hygiene observations (Medication Aide #1).The findings included: a. The facility policy dated 6/1/25 and entitled Glucometer Disinfection read in part: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to resident and employees.The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV) (blood borne virus), Hepatitis C (blood borne virus), and Hepatitis B (blood borne virus).Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. The glucometer User Instruction Manual read in part: Put on gloves, inspect for blood, debris, dust or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. To clean the meter, use a moist lint-free dampened cloth. To disinfect your meter, clean the meter surface with approved disinfecting wipe. Allow surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry or allow to air dry. A continuous observation was conducted on 4/29/26 from 11:25 AM to 11:35 AM of Medication Aide #1 performing a blood glucose test for Resident #23. Medication Aide #1 removed the glucometer from the top drawer of her medication cart. The glucometer was stored in a zippered storage bag and labeled with Resident #23's name. Medication Aide #1 gathered supplies (an alcohol pad, lancet, gauze pad, and test strips). Medication Aide #1 was accompanied as she carried the glucometer and supplies down to Resident #23's room. After entering the room, Medication Aide #1 put the glucometer and supplies down on the resident's bed. Medication Aide #1 wiped the resident's finger with an alcohol pad, used a lancet to perform a finger stick to obtain a drop of blood, and applied the blood to the test strip inserted into the glucometer. Once the blood glucose results were obtained, Medication Aide #1 discarded the trash. She exited Resident #23's room with the lancet and glucometer. As she walked back up the hallway to the medication cart, Medication Aide #1 placed the glucometer back into the zippered storage bag labeled with Resident #23's name. When she returned to the medication cart, she placed the lancet into the sharps container and returned the glucometer to the top drawer of the medication cart. There were disinfectant wipes present in the bottom drawer of the medication cart. An interview was performed with Medication Aide #1 on 4/29/26 at 11:35 PM. Medication Aide #1 said resident glucometers were for individual use and not shared. Medication Aide #1 stated glucometers were supposed to be disinfected after each use. She explained she was planning on disinfecting all three of the glucometers on the medication cart after she was done doing all the CBG checks on her hall. Medication Aide #1 reported she was taught to disinfect the glucometer using a disinfectant wipe after each use, and before placing it back into the storage bag or putting the glucometer back into the medication cart. Medication Aide #1 then reported she had just forgotten to disinfect the glucometer. An interview was conducted with the Director of Nursing (DON) on 4/29/26 at 12:23 PM. The Director of Nursing reported glucometers were not shared and were for individual use. She stated that glucometers needed to be disinfected after each use to prevent the transmission of blood borne pathogens. An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator stated that glucometers should be disinfected after each use. He said staff should follow the facility's policy for glucometer disinfection. b. A facility policy dated 6/1/25 and entitled Standard Precautions read in part: Staff must wear personal protective equipment (PPE) as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infections materials is likely. -Under Standard Precautions Infection Control Protocol section Personal Protective Equipment read in part, Gloves: for touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes, non-intact and intact resident skin. Hand Hygiene: After touching blood, body fluids, excretions, contaminated items; before and after removing PPE. A policy dated 6/1/25 entitled Hand Hygiene read in part All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in locations within the facility. -Hand hygiene is a general term for cleaning your hands by hand washing with soap and water or the use of antiseptic hand rub also known as alcohol-based hand rub.Staff will perform hand hygiene as indicated using proper technique consistent with accepted standards of practice. -Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The hand hygiene table indicated hand hygiene should be performed after handling contaminated objects, before applying and after removing PPE, including gloves. Before performing resident care procedures and after handling items potentially contaminated with blood, body fluids, secretions or excretions. A continuous observation on 4/29/26 from 11:25 AM to 11:35 PM was conducted of Medication Aide #1 performing a CBG check for Resident #23. Medication Aide #1 removed the glucometer from the medication cart; she did not perform hand-hygiene while at the medication cart. She was accompanied as she walked to Resident #23's room. She entered the room and placed the glucometer down on the bed. After entering the room Medication Aide #1 did not perform hand hygiene or put on gloves. While not wearing gloves, Medication Aide #1 wiped the resident's finger with an alcohol pad, used the lancet to perform a finger stick, gently squeezed the tip of his finger until a drop of blood formed, wiped the first drop of blood from his finger using the gauze pad, then gently squeezed his finger again until a drop of blood formed, and applied the drop of blood to the test strip. After applying the drop of blood to the test strip she held the gauze pad on his finger to stop the bleeding. After performing the CBG test, she discarded the trash and exited the room. Medication Aide #1 did not perform hand hygiene prior to exiting the room. She was accompanied as she walked back to the medication cart. At the medication cart she discarded the lancet and opened the top drawer and placed the glucometer back into the cart. She then sanitized her hands using hand-sanitizer. An interview was conducted on 4/29/26 at 11.35 AM. Medication Aide #1 first said she did not wear gloves when performing CBG checks because she did not know she was supposed to. She stated she had not performed hand-hygiene before or after doing the CBG check because she was nervous and had forgotten but said she knew that she was supposed to. Medication Aide #1 then changed her response and stated she did typically wear gloves when performing CBG checks but had gotten nervous and forgotten. An interview was conducted with the Director of Nursing (DON) on 4/29/26 at 12:23 PM. The Director of Nursing stated Medication Aide #1 should have worn gloves when doing Resident #23's CBG check and should have performed hand-hygiene before and after. An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator said staff should follow the facility's policy for hand hygiene and Medication Aide #1 should have worn gloves.

Based on record review and staff interviews, the facility failed to document a resident or Responsible Party (RP) were provided education regarding the benefits and potential side effects of the pneumococcal immunization or if the resident received the pneumococcal immunization or did not receive it due to a medical contradiction or refusal. In addition, there was no documentation the resident was offered the pneumococcal immunization. This occurred for 1 of 5 residents reviewed for immunizations (Resident #6). The findings included:A review of the facility's policy entitled Pneumococcal Vaccine' last revised 10/22/25 read in part that each resident will be assessed for pneumococcal immunization upon admission. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized in accordance with physician-approved standing orders.Resident #6 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure and chronic obstructive pulmonary disease.Review of Resident #6's electronic medical record revealed no documentation education was provided about the risks and benefits of the pneumococcal immunization, if the immunization was offered, or if the immunization was received or refused.An interview on 4/30/26 at 10:30 AM with the Director of Nursing (DON) revealed the previous Infection Preventionist (IP) left the facility the first part of March 2026. She stated that currently she and the new Assistant DON were performing the IP functions. The DON was unable to provide any documentation about Resident #6 pertaining to pneumococcal immunization.An interview on 4/30/26 at 12:27 PM with the Administrator revealed the facility was attempting to hire an IP and he was aware that resident immunizations were not up to date.

Based on record review and staff interviews, the facility failed to assess a resident for eligibility and ensure a resident was offered the COVID-19 vaccination for 1 of 5 residents reviewed for immunizations (Resident #6).Findings included:A review of the facility's policy entitled 'COVID-19 Vaccination' last revised 11/13/25 read in part that COVID-19 vaccinations will be offered to resident as per Centers for Disease Prevention and Control (CDC) guidelines unless it is medically contraindicated, the individual has already been immunized or refuses to receive the vaccine.Resident #6 was admitted to the facility on [DATE].Review of Resident #6's electronic medical record revealed no documentation the COVID-19 vaccine was offered to the resident. There was also no documentation the resident or responsible party were educated regarding the benefits and potential risks associated with the COVID-19 vaccine or if the resident consented to or refused the COVID-19 vaccine.An interview on 4/30/26 at 10:30 AM with the Director of Nursing (DON) revealed the previous Infection Preventionist (IP) left the facility the first part of March 2026. She stated that currently she and the new Assistant DON were performing the IP's functions. She stated she did not have a list of residents who had received the COVID-19 vaccine and was unable to provide information about Resident #6's COVID-19 vaccine status.An interview on 4/30/26 at 12:27 PM with the Administrator revealed the facility was attempting to hire an IP and he was aware that resident immunizations were not up to date.

Based on record review and staff and physician interviews, the facility failed to ensure physician visits were performed at least once every sixty days for 3 of 3 sampled residents reviewed for physician visits (Residents #62, #44 and #9). 1. Resident #62 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, dementia and diabetes.Resident #62's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired and was dependent on staff for most activities of daily living. A review of Resident #62's electronic health record revealed a Nurse Practitioner (NP) progress note dated 12/18/25 and a Physician's annual wellness visit dated 3/31/26. No further documentation was found to show the Physician or NP had visited or assessed the resident between 12/18/25 and 3/31/26. An interview with the Physician on 4/30/26 at 2:31 PM revealed he used scheduler software to track required resident visit dates. He explained he currently did not have an NP and was doing the best he could to stay in compliance with resident visits but acknowledged he let some visits slip by. An interview on 4/30/26 at 11:01 AM with the Director of Nursing (DON) revealed it was the Physician's responsibility to visit and assess residents as required by the regulation. She indicated the Physician was responsible for organizing and maintaining his visit schedule. During an interview with the Administrator on 4/30/2026 at 5:48 PM he revealed the Physician should have seen residents as required by regulation. 2. Resident #44 was admitted to the facility on [DATE]. Her diagnoses included dementia. A Nurse Practitioner (NP) note dated 1/29/26 indicated Resident #44 was seen for a 90 day follow up visit. A Physician visit note dated 4/20/26 indicated Resident #44 was seen for a federally mandated visit and acute visit. Resident #44's electronic medical record did not contain documentation where she was seen by the Physician or NP from 1/30/26 through 4/19/26 (80 days). An interview was conducted with the Director of Nursing (DON) on 4/30/27 at 2:00 PM. The DON was not sure how often residents were required to be seen by the Physician/ NP but said she would check. She explained the Medical Director kept up with his routine visits and when residents needed to be seen. An interview was conducted with the Medical Director on 4/30/26 at 12:47 PM. The Medical Director stated residents were supposed to be seen on admission, then 30 days after admission, 60 days after admission, 90 days after admission, and then every 60 days. He stated visits could be alternated with an NP. The Medical Director explained he currently did not have an NP to help him and said he was doing the best he could to stay in compliance with regulations. He reported he used an internal scheduler system to track and schedule resident visits but sometimes visits slipped through. He said he did not think anyone at the facility was following routine visits and when residents needed to be seen. The Medical Director stated Resident #44 should have been seen around 3/29/26 or early April and he missed it. An interview was conducted with the Administrator on 4/30/26 at 5:34 PM. The Administrator stated residents should be seen by the Physician/ NP timely and as required. The Administrator stated there had been transition in the NP role and thought it may have played a part in the missed visits. 3. Resident #9 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease and hypertension. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #9 had moderately impaired cognition and required moderate staff assistance for most activities of daily living. Review of Resident #9's electronic health record revealed a Nurse Practitioner (NP) progress note dated 12/11/25 and a Physician's federal mandated visit dated 2/10/26. No further documentation was found to indicate the Physician or NP had visited or assessed the resident after 2/10/26. An interview on 4/30/26 at 2:31 PM with the Physician revealed he used scheduler software to track required resident visit dates. He explained he currently did not have an NP and was doing the best he could to stay in compliance with resident visits but acknowledged that some visits 'slip by.' He confirmed that Resident #9's last visit occurred on 2/10/26 and she should have been seen on 4/16/26 but was not. He stated he was not at the facility on 4/16/26, so that visit had been missed. An interview on 4/30/26 at 11:01 AM with the Director of Nursing (DON) revealed it was the Physician's responsibility to visit and assess residents as required by regulation. An interview on 4/30/26 at 12:27 PM with the Administrator revealed the Physician was responsible for seeing residents as required by regulation.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of bed rails and diagnoses for 7 of 12 sampled residents reviewed for physical restraints, respiratory care and unnecessary medications (Residents #1, #51, #63, #13, #65, #24, and #47). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling, generalized muscle weakness and left shoulder pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition and required substantial/maximum assistance with bed mobility. The MDS indicated Resident #1 used a physical restraint daily and bed rail was marked as the type of restraint utilized. During an observation and interview on 02/25/25 at 9:15 AM, quarter bed rails were observed in the upright position on each side of Resident #1's bed. Resident #1 explained she used the bed rails to reposition herself when lying in bed and as an aid when pulling herself up to sit on the side of the bed. During an interview on 02/27/25 at 11:24 AM, the MDS Coordinator confirmed that the quarter bed rails used by Resident #1 were for independent bed mobility and not restraints. The MDS Coordinator explained she misunderstood the question on the MDS assessment regarding bed rail use and the quarterly MDS assessment dated [DATE] for Resident #1 was coded incorrectly. During an interview on 02/27/25 at 1:34 PM, the Administrator explained the facility did not use restraints and bed rails were used only as personal bed mobility devices. The Administrator stated he expected MDS assessments to be completed accurately. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses that included debility (physical weakness), respiratory failure and asthma with acute exacerbation (sudden worsening of symptoms). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51 had moderate impairment in cognition and required partial/moderate assistance with bed mobility. The MDS indicated Resident #51 used a physical restraint daily and bed rail was marked as the type of restraint utilized. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #51 had moderate impairment in cognition and required partial/moderate assistance with bed mobility. The MDS indicated Resident #51 used a physical restraint daily and bed rail was marked as the type of restraint utilized. During a joint interview on 02/27/25 with Med Aide #1 and Nurse Aide #1 both stated Resident #51 used quarter bed rails for independent bed mobility and repositioning. During an interview on 02/27/25 at 11:24 AM, the MDS Coordinator confirmed that the quarter bed rails used by Resident #51 were for independent bed mobility and not restraints. The MDS Coordinator explained she misunderstood the question on the MDS assessment regarding bed rail use and the quarterly MDS assessment dated [DATE] for Resident #51 was coded incorrectly. During an interview on 02/27/25 at 1:34 PM, the Administrator explained the facility did not use restraints and bed rails were used only as personal bed mobility devices. The Administrator stated he expected MDS assessments to be completed accurately. 3. Resident #63 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and generalized muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had moderate impairment in cognition and required partial/moderate assistance with bed mobility. The MDS indicated Resident #63 used a physical restraint daily and bed rail was marked as the type of restraint utilized. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had moderate impairment in cognition and required partial/moderate assistance with bed mobility. The MDS indicated Resident #63 used a physical restraint daily and bed rail was marked as the type of restraint utilized. During an interview on 02/27/25 at 11:24 AM, the MDS Coordinator confirmed that the quarter bed rails used by Resident #63 were for independent bed mobility and not restraints. The MDS Coordinator explained she misunderstood the question on the MDS assessment regarding bed rail use and the quarterly MDS assessments dated 10/11/24 and 11/12/24 for Resident #63 was coded incorrectly. During an interview on 02/27/25 at 1:34 PM, the Administrator explained the facility did not use restraints and bed rails were used only as personal bed mobility devices. The Administrator stated he expected MDS assessments to be completed accurately. 47683 4. Resident #13 was admitted to the facility on [DATE] with diagnosis that included paraplegia (a condition characterized by the loss or impairment of voluntary movement and sensation in the lower half of the body), contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity, and rigidity of joints) right hip, anxiety, major depressive disorder, dementia, abnormal posture, and cerebrovascular disease (a variety of medical conditions that affect the brain's blood vessels and blood flow). Review of the quarterly minimum data set (MDS) dated [DATE] revealed that bed rails were marked as a restraint used daily. Review of the care plan dated 2/10/25 revealed Resident #13 has an activities of daily living (ADL) self-care performance deficit related to decreased cognitive function, paraplegia, and limited mobility. Goals include Resident #13 will maintain the current level of function in ADL through the review date. Interventions for bed mobility included Resident #13 uses bilateral quarter rails to maximize independence with turning and repositioning in bed. Review of the physician's orders dated 10/6/21 revealed that the facility would maintain bilateral quarter rails to promote the highest level of independence with bed mobility, positioning, and incontinence care. An interview on 02/27/25 at 11:24 AM with the MDS Coordinator revealed that she misunderstood the question and realized she answered the question wrong. She stated that now she knows they should not have been marked under restraints and the bed rails were used for independent bed mobility and not as a restraint. An interview on 02/27/25 at 1:06 PM with the Director of Nursing (DON) revealed that her expectations with MDS accuracy were to follow the policy and procedure of the facility. An interview on 02/27/25 at 1:34 PM with the Administrator revealed that his expectation was that MDS assessments be coded accurately. He further revealed that the facility had not used restraints, and the bed rails were used as personal mobility devices. 5. Resident #65 was admitted to the facility on [DATE] with diagnosis that included muscle weakness, unsteadiness on feet, lack of coordination, and abnormalities of gait and mobility. Review of the quarterly MDS dated [DATE] revealed that bed rails were marked as a restraint used daily. Review of the care plans dated 12/10/24 revealed Resident #65 ADL self-care performance deficit related to impaired balance, Pain (low back pain). Goals included Resident # 65, will improve the current level of function through the review date. Interventions for bed mobility included Resident #65 uses bilateral quarter rails to promote independence with turning, repositioning, and mobility. Review of the physician's orders dated 11/19/24 revealed that the facility would maintain bilateral quarter rails to promote independence with bed mobility, turning, and repositioning. An interview on 02/27/25 at 11:24 AM with the MDS Coordinator revealed that she misunderstood the question and realized she answered the question wrong. She stated that now she knows they should not have been marked under restraints and the bed rails were used for independent bed mobility and not as a restraint. An interview on 02/27/25 at 1:06 PM with the Director of Nursing (DON) revealed that her expectations with MDS accuracy were to follow the policy and procedure of the facility. An interview on 02/27/25 at 1:34 PM with the Administrator revealed that his expectation was that MDS assessments be coded accurately. He further revealed that the facility had not used restraints, and the bed rails were used as personal mobility devices. 37538 6. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included dementia, Alzheimer's disease, pneumonia, and chronic obstructive pulmonary disease. A review of the Medical Doctor (MD) progress note dated 12/30/24 revealed Resident #24 was evaluated for chest congestion and cough. The MD's physical exam revealed Resident #24's lungs were clear and there was no complications related to a cough at the time of the evaluation. The MD recommended to continue monitoring and no new physician orders were provided for the treatment of pneumonia. A review of the physician orders from 12/30/24 through 1/17/25 revealed no orders for a chest x-ray or antibiotic medication for the treatment of pneumonia. A review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed pneumonia was coded as an active diagnosis. The MDS list of high risk medications revealed Resident #24 was not taking and there was no indication noted for the use of antibiotics. During an interview on 02/27/25 at 11:43 AM the MDS Coordinator confirmed she completed the quarterly MDS assessment for Resident #24 dated 1/17/25. The MDS Coordinator revealed for determining a resident's active diagnoses, she reviewed physician orders, labs and diagnostic results, and nurse progress notes. After review of Resident #24 medical records the MDS Coordinator revealed there was no documentation to support pneumonia was an active diagnosis during the MDS assessment dated [DATE] and was incorrectly coded. During an interview on 02/27/25 at 1:17 PM the Director of Nursing (DON) revealed there would need to be written documentation in the resident's medical record from a medical care provider to confirm an active diagnosis of pneumonia and if not the MDS was incorrectly coded. During an interview on 02/27/25 at 1:45 PM the Administrator revealed active diagnoses should be coded correct when completing the resident's MDS assessment. 7. Resident #47 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation and heart failure. A review of the current physician orders revealed Resident #47 was taking metoprolol 25 milligrams (mg) daily for hypertension and lisinopril 20 mg twice a day for hypertension that were started on 1/25/25. A review of Resident #47's admission MDS assessment dated [DATE] revealed hypertension was not coded as an active diagnosis. During an interview on 02/27/25 at 11:33 AM the MDS Coordinator confirmed she completed the admission MDS assessment for Resident #47 dated 1/31/25. The MDS Coordinator revealed that when coding active diagnosis, she reviewed the resident's list of medications and if they were taking medication used to treat hypertension it should be coded as an active diagnosis and if not was error. During an interview on 02/27/25 at 1:17 PM the DON revealed if current physician's orders included metoprolol or lisinopril for the treatment of hypertension it should be coded as an active diagnosis on the MDS. During an interview on 02/27/25 at 1:45 PM the Administrator revealed active diagnoses should be coded correct when completing the MDS assessment.

Based on record review and staff interviews the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 8 residents reviewed for pressure ulcers and unnecessary medications (Residents #46 and #51). Findings Included: a. Resident #46 was admitted to the facility on [DATE] with diagnoses that included diabetes, stroke and end-stage renal disease. Review of Section V (CAA Summary) from the admission Minimum Data Set (MDS) dated [DATE] revealed the care area for pressure ulcer triggered for Resident #46. The MDS Coordinator who completed the assessment did not provide any information in the analysis of findings that described the nature of Resident #46's problem, possible causes, contributing factors, and risk factors for the triggered care area. It was noted on the CAA summary that pressure ulcers would be addressed in the care plan due to Resident #46 admitting with wounds. b. Resident #51 was admitted to the facility on [DATE] with diagnoses that included debility (physical weakness), respiratory failure and asthma with acute exacerbation (sudden worsening of symptoms). Review of Section V (CAA Summary) from the annual Minimum Data Set (MDS) dated [DATE] revealed the care area for psychotropic medication use triggered for Resident #51. The MDS Coordinator who completed the assessment did not provide any information in the analysis of findings that described the nature of Resident #51's problem, possible causes, contributing factors, and risk factors for the triggered care area. It was noted on the CAA summary that psychotropic medication use would be addressed in the care plan. During an interview on 02/27/25 at 11:24 AM, the MDS Coordinator explained when she first started the position, she didn't understand the CAA or that they needed to be completed for comprehensive assessments. She stated she now understood what should be included in the analysis of findings and for the more recent MDS assessments, she had started adding more pertinent information in the CAA for the care area(s) that triggered. The MDS Coordinator confirmed the pressure ulcer care area that triggered for Resident #46 and the psychotropic medication use care area that triggered for Resident #51 did not have a comprehensive analysis of finding completed. During an interview on 02/27/25 at 1:34 PM, the Administrator stated it was his expectation for CAAs to completed and contain a comprehensive analysis of findings for the triggered care area(s).

Based on observations, record review, and staff interviews the facility failed to complete bed rail assessments to determine the need for bed rail use for 3 of 5 sampled residents (Resident #1, #51 and #13). Findings Included: 1. a. Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling, generalized muscle weakness and left shoulder pain. Review of Resident #1's electronic medical record on 02/26/25 revealed the last completed bed rail assessment was dated 11/08/23. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition and required substantial/maximum assistance with bed mobility. During an observation and interview on 02/25/25 at 9:15 AM, quarter bed rails were observed in the upright position on each side of Resident #1's bed. Resident #1 explained she used the bed rails to reposition herself when lying in bed and as an aid when pulling herself up to sit on the side of the bed. b. Resident #51 was admitted to the facility on [DATE] with diagnoses that included debility (physical weakness), respiratory failure and asthma with acute exacerbation (sudden worsening of symptoms). Review of Resident #51's electronic medical record on 02/25/25 revealed there were no bed rail assessments completed since 10/26/23, the date of the last recertification and complaint investigation survey. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #51 had moderate impairment in cognition and required partial/moderate assistance with bed mobility. During a joint interview on 02/27/25 at 10:11 AM, Med Aide #1 and Nurse Aide #1 both stated Resident #51 used quarter bed rails for independent bed mobility and repositioning. During an interview on 02/27/25 at 1:06 PM, the Director of Nursing (DON) stated the facility had a policy and procedure in place for bed rail use and it was the responsibility of administrative nursing staff to complete bed rail assessments quarterly or at the very least, annually. The DON stated it was her expectation staff would follow the facility policy to ensure bed rail assessments were completed per the facility policy. During an interview on 02/27/25 at 1:34 PM, the Administrator stated it was his expectation for bed rail assessments to be completed per the facility policy. 47683 2. Resident #13 was admitted to the facility on [DATE] with diagnosis that included paraplegia (a condition characterized by the loss or impairment of voluntary movement and sensation in the lower half of the body), contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity, and rigidity of joints) right hip, anxiety, major depressive disorder, dementia, abnormal posture, and cerebrovascular disease (a variety of medical conditions that affect the brain's blood vessels and blood flow). Review of the physician's orders dated 10/6/21 revealed that the facility would maintain bilateral quarter bed rails to promote the highest level of independence with bed mobility, positioning, and incontinence care. Review of the bed rail assessment revealed it was last completed on 12/12/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 required substantial/maximum assistance with bed mobility. An interview on 02/27/25 at 1:06 PM with the Director of Nursing (DON) revealed the breakdown in the completion of bed rail assessments fell through the cracks because there was so much change in administrative nursing staff. She further revealed it was the responsibility of administrative nursing staff to complete the bed rail assessments. She stated that her expectation was that bed rail assessments were to be completed quarterly or at the very least annually and to follow the facility's policy. An interview on 02/27/25 at 1:34 PM with the Administrator revealed that his expectation for bed rail assessments was that they be completed per the facility policy.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 4 residents reviewed for diabetes management (Resident #39). The findings included: Resident #39 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. Review of physician's orders dated 07/05/23 revealed Resident #39 had an order to receive 10 units of Humalog insulin subcutaneously 3 times daily before meals for diabetes. The order specified holding the insulin when Resident #39's capillary blood glucose (CBG) was lower than 120 milligrams per deciliter (mg/dL). The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #39 with intact cognition and indicated that she was receiving insulin daily in the 7-day assessment periods. A review of medication administration records (MARs) on 10/24/23 indicated Resident #39 had received 10 unit of Humalog insulin subcutaneously erroneously 2 times when her CBGs were below 120 mg/dl, and her insulin was held against the parameter 17 times when her CBGs were above 120 mg/dl within 112 days (from 07/05/23 through 10/24/23) on the following dates and times with the charted codes: - 07/05/23 noon when CBG = 130 mg/dL - Held per parameter. - 07/08/23 noon when CBG = 167 mg/dL - Held per parameter. - 07/11/23 evening when CBG = 146 mg/dL - Insulin not required. - 07/25/23 evening when CBG = 146 mg/dL - Insulin not required. - 08/07/23 morning when CBG = 127 mg/dL - Insulin not required. - 08/21/23 morning when CBG = 111 mg/dL - Insulin was administered - 08/29/23 morning when CBG = 139 mg/dL - Insulin not required. - 09/01/23 noon when CBG = 128 mg/dL - Held per parameter. - 09/04/23 morning when CBG = 154 mg/dL - Insulin not required. - 09.05/23 morning when CBG = 121 mg/dL - Insulin not required. - 09/11//23 morning when CBG = 98 mg/dL - Insulin was administered - 09/16/23 morning when CBG = 126 mg/dL - Insulin not required. - 09/26/23 noon when CBG = 140 mg/dL - Held per parameter. - 09/26/23 evening when CBG = 191 mg/dL - Held per parameter. - 09/28/23 morning when CBG = 140 mg/dL - Insulin not required. - 10/03/23 morning when CBG = 145 mg/dL - Insulin not required. - 10/10/23 noon when CBG = 203 mg/dL - Held per parameter. - 10/19/23 noon when CBG = 140 mg/dl - Held per parameter. - 10/24/23 morning when CBG = 170 mg/dl - Insulin not required. Review of medical records revealed Resident #39's CBGs were stable at the baselines ranged from 79 to 359 mg/dl, mostly in the high 100s or low 200s mg/dl in the past 3.5 months. Review of medical record revealed the Consultant Pharmacist had conducted monthly medication regimen reviews for Resident #39 in the past 12 months on 11/16/22, 12/27/22, 01/25/23, 02/14/23, 03/20/23, 04/15/23, 05/20/23, 06/15/23, 07/14/23, 08/09/23, 09/03/23, and 10/12/23. However, he did not identify any drug irregularities related to insulin and did not make any specified recommendations to the physician or nursing staff to correct the error. An interview was conducted with the Unit Manager (UM) on 10/24/23 at 12:09 PM. She stated that she was not aware of the incident and was shocked to learn that it had occurred numerous times in the past 3.5 months. She indicated that failure to follow the parameters set by the physician could compromise the effectiveness of diabetes management. She expected all the nurses to consult the physician before making any clinical decisions related to insulin. It was her expectation for the Consultant Pharmacist to identify the drug irregularities and notify the MD and the facility in a timely manner. A phone interview was conducted with the Consultant Pharmacist on 10/25/23 at 12:56 PM. He confirmed he had performed medication regimen reviews for Resident #39 in the past 12 months and acknowledged that he did not notice that the parameter for Resident #39's Humalog was not followed by numerous nurses repeatedly in the past 3.5 months. He added the failure of nurses to follow the parameter of Humalog order could elevate the level of hemoglobin A1C (A1C is a simple blood test that measures patient's average blood sugar levels over the past 3 months. A normal A1C level was below 5.7%, a level of 5.7% to 6.4% indicated prediabetes, and a level of 6.5% or more indicated diabetes). A subsequent phone interview was conducted with the Consultant Pharmacist on 10/25/23 at 4:45 PM. He stated that Resident #39's hemoglobin A1C was not affected by the incident. In fact, he indicated that Resident #39's hemoglobin A1C had improved from 6.6% on 07/20/23 to 6.3% on 10/18/23. He stated that he could not predict what might happen if nurses failed to follow the parameter of Resident #35's Humalog order repeatedly. During a phone interview conducted on 10/25/23 at 1:54 PM, the MD stated that the failure of nurses to follow the parameter of Resident #39's Humalog order could elevate her CBGs but not to a harmful level. He expected nurses to consult him before holding or administering the insulin outside of the set parameter. He expected the Consultant Pharmacist to identify the medication error and notify him in a timely manner as he had access to the MARs. An interview was conducted with the Director of Nursing (DON) on 10/26/23 at 10:49 AM. She stated that the above incident was a medication error. She expected nursing staff to follow physician's order and parameter when performing medication pass and contact the physician before making any changes to the order. She stated that the Consultant Pharmacist reviewed Resident #39's medications monthly and had access to all her medication records. It was her expectation for the Consultant Pharmacist to identify the medication error and notify her and the MD in a timely manner. During an interview conducted with the Administrator on 10/26/23 at 11:16 AM, he expected the Consultant Pharmacist to identify the issues and notify the MD and DON in a timely manner.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to prevent significant medication errors when 5 nurses failed to follow the physician's parameter as ordered during insulin administration. As a result, Resident #39 had received 2 doses or unnecessary Humalog insulin and her insulin had been held against the parameter 17 times within 112 days. This affected 1 of 4 residents reviewed for diabetes management (Resident #39). The findings included: Resident #39 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. The care plan initiated on 06/15/20 indicated Resident #39 had diagnosis of diabetes mellitus. The goal was to remain free of complications related to diabetes through the next review date. Intervention included administering medications as ordered. Review of physician's orders dated 07/05/23 revealed Resident #39 had an order to receive 10 units of Humalog insulin subcutaneously 3 times daily before meals for diabetes. The order specified holding the insulin when Resident #39's capillary blood glucose (CBG) was lower than 120 milligrams per deciliter (mg/dL). The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #39 with intact cognition and indicated that she was receiving insulin daily in the 7-day assessment periods. A review of medication administration records (MARs) on 10/24/23 indicated Resident #39 had received 10 unit of Humalog insulin subcutaneously erroneously 2 times when her CBGs were below 120 mg/dl, and her insulin was held against the parameter 17 times when her CBGs were above 120 mg/dl within 112 days (from 07/05/23 through 10/24/23) on the following dates and times with the charted codes: - 07/05/23 noon when CBG = 130 mg/dL - Held per parameter. - 07/08/23 noon when CBG = 167 mg/dL - Held per parameter. - 07/11/23 evening when CBG = 146 mg/dL - Insulin not required. - 07/25/23 evening when CBG = 146 mg/dL - Insulin not required. - 08/07/23 morning when CBG = 127 mg/dL - Insulin not required. - 08/21/23 morning when CBG = 111 mg/dL - Insulin was administered - 08/29/23 morning when CBG = 139 mg/dL - Insulin not required. - 09/01/23 noon when CBG = 128 mg/dL - Held per parameter. - 09/04/23 morning when CBG = 154 mg/dL - Insulin not required. - 09.05/23 morning when CBG = 121 mg/dL - Insulin not required. - 09/11//23 morning when CBG = 98 mg/dL - Insulin was administered - 09/16/23 morning when CBG = 126 mg/dL - Insulin not required. - 09/26/23 noon when CBG = 140 mg/dL - Held per parameter. - 09/26/23 evening when CBG = 191 mg/dL - Held per parameter. - 09/28/23 morning when CBG = 140 mg/dL - Insulin not required. - 10/03/23 morning when CBG = 145 mg/dL - Insulin not required. - 10/10/23 noon when CBG = 203 mg/dL - Held per parameter. - 10/19/23 noon when CBG = 140 mg/dl - Held per parameter. - 10/24/23 morning when CBG = 170 mg/dl - Insulin not required. Review of medical records revealed Resident #39's CBGs were stable at the baselines ranged from 79 to 359 mg/dl, mostly in the high 100s or low 200s mg/dl in the past 3.5 months. During an interview conducted on 10/24/23 at 11:58 AM, Nurse #2 confirmed that he had held Resident #39's Humalog several times when her CBGs were higher than 120 mg/dl and acknowledged that it was an error. He explained that those doses were held when Resident #39 was either being lethargic or not having a good meal intake before the insulin was due. He stated that he did not consult the physician before making those clinical decisions. During a phone interview conducted on 10/25/23 at 7:26 PM, Nurse #3 confirmed that he had failed to follow the parameter set by the physician for Resident #39's Humalog order numerous times and acknowledged that it was an error. He explained that the parameter for Resident #39's Humalog was previously set at 150 mg/dl and later had changed to 120 mg/dl. He added it was his oversight for failure to follow the parameter set by the physician when performing medication pass for Resident #39's Humalog order. An interview was conducted with the Unit Manager (UM) on 10/24/23 at 12:09 PM. She stated that she was not aware of the incident and was shocked to learn that it had occurred numerous times in the past 3.5 months. She indicated that failure to follow the parameters set by the physician could compromise the effectiveness of diabetes management. She expected all the nurses to consult the physician before making any clinical decisions related to insulin. She added it was a significant medication error as it involved insulin with 5 nurses for 19 times in approximately 3.5 months. During an interview conducted on 10/25/23 at 11:48 AM, Resident #39 did not know that the physician had set a parameter for her Humalog. She stated that she had received insulin as ordered in a timely manner and added her CBGs were stable in the past 3 months. A phone interview was conducted with the Consultant Pharmacist on 10/25/23 at 12:56 PM. He stated the failure of nurse to follow the parameter of Humalog order could elevate the level of hemoglobin A1C (A1C is a simple blood test that measures patient's average blood sugar levels over the past 3 months. A normal A1C level was below 5.7%, a level of 5.7% to 6.4% indicated prediabetes, and a level of 6.5% or more indicated diabetes). A subsequent phone interview was conducted with the Consultant Pharmacist on 10/25/23 at 4:45 PM. He stated that Resident #39's hemoglobin A1C was not affected by the incident. In fact, he indicated that Resident #39's hemoglobin A1C had improved from 6.6% on 07/20/23 to 6.3% on 10/18/23. He refused to comment if the above incident would be considered as a significant medication error and added he could not predict what might happen if nurses failed to follow the parameter of Resident #35's Humalog order repeatedly. During a phone interview conducted on 10/25/23 at 1:54 PM, the MD stated that the failure of nurses to follow the parameter of Resident #39's Humalog order could elevate her CBGs but not to a harmful level. He expected nurses to consult him before holding or administering the insulin outside of the set parameter. He stated it was a significant medication error as it involved insulin with 5 different nurses for 19 times within 3.5 months. An interview was conducted with the Director of Nursing (DON) on 10/26/23 at 10:49 AM. She stated that the above incident was a medication error but was not sure it was a significant medication error. She expected nursing staff to follow physician's order and parameter when performing medication pass and contact the physician before making any changes to the order. During an interview conducted with the Administrator on 10/26/23 at 11:16 AM, he denied it was a medication error. He expected the nurse to work for the best interest of the residents to hold the insulin when Resident #39 was not eating well or being lethargic. On the other hand, he expected nurses to follow the order and parameter, and consult the physician before holding or administering the Humalog outside of the parameter.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 5 wound care observations on 2 of 3 residents reviewed (Resident #53 and Resident #33). The findings included: The facility's policy entitled Dressings, Dry/Clean revised on September 2013 under Steps in the Procedure indicated the following: 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. The facility's policy entitled Handwashing/Hand Hygiene which is part of their Infection Control Policies and Procedures last revised on August 2019 under Policy Interpretation and Implementation indicated the following: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; k. After handling used dressings, contaminated equipment, etc.; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. a. An observation of wound care by Nurse #1 was made on 10/25/23 at 9:40 AM. Nurse #1 washed both hands and put on gloves. She removed the old dressing on Resident #53's wound to the back of his left leg. The old dressing had moderate amount of serosanguinous (contains or relates to both blood and the liquid part of blood) drainage. She proceeded to clean the wound with normal saline-soaked gauze and while being cleaned, the wound started to bleed. Nurse #1 removed her gloves and without doing hand hygiene, she put on a new pair of gloves to both hands. Nurse #1 applied an antiseptic solution-soaked gauze onto the wound and let it soak for about ten seconds. After ten seconds, she removed it and placed a petrolatum-based mesh gauze onto the wound bed, covered it with an abdominal gauze pad and wrapped it with a rolled gauze. Nurse #1 secured it with tape and then removed her gloves, gathered any unused supplies and washed both hands. Another observation of wound care was made for Resident #53 on 10/25/23 at 10:00 AM. Nurse #1 put gloves on after washing both hands. She removed the dressing to Resident #53's left knee which had moderate amount of clear drainage. She sprayed the wound with normal saline and patted it dry with a dry gauze. Nurse #1 removed her gloves and without performing hand hygiene, put on a new pair of gloves. She covered the wound with an adhesive border gauze, removed her gloves and washed her hands. b. An observation of wound care was made for Resident #33 on 10/25/23 at 10:07 AM. Nurse #1 washed both hands and put on gloves. Nurse #1 tried to remove the old dressing to Resident #33's right heel but it adhered to Resident #33's skin so she sprayed normal saline around the dressing edges until it came off. The old dressing was soaked with povidone iodine solution and the wound had small amount of serosanguinous drainage. Nurse #1 removed her gloves and without doing hand hygiene, put new gloves on. Nurse #1 cleaned the wound with normal saline-soaked gauze, poured povidone iodine solution onto a stack of gauze and applied it onto Resident #33's right heel. She covered it with an abdominal gauze pad, wrapped it with rolled gauze and secured it with tape. Nurse #1 repositioned Resident #33's heels, discarded unused supplies in a trash bag, removed her gloves and washed both hands. An interview with Nurse #1 on 10/25/23 at 10:37 AM revealed she was educated to wash her hands when going into the room, between dirty and clean dressings and before leaving the room after performing wound care. Nurse #1 stated she was supposed to wash her hands after removing her gloves and prior to donning another pair of gloves but she got nervous while being observed doing wound care and she forgot to do so. An interview with the Infection Preventionist (IP) on 10/25/23 at 10:57 AM revealed she recommended washing hands in between dressing changes and whenever gloves were removed during wound care. The IP stated that she had not done education specifically on hand hygiene during wound care with Nurse #1 because the old treatment nurse and the wound care provider had worked with Nurse #1 on how to do the treatments. The IP stated Nurse #1 should have performed hand hygiene whenever she removed her gloves after cleaning the wounds and prior to putting on new gloves. An interview with the Interim Director of Nursing (DON) on 10/26/23 at 11:32 AM revealed she was aware that Nurse #1 was nervous when she was observed doing wound care, but she needed to do more education with her. The Interim DON stated that she was not sure if Nurse #1 understood to perform hand hygiene after removing her gloves and prior to cleaning the wounds.

Based on observations and staff interviews, the facility failed to repair broken and splintered entrance doors to resident rooms on 2 of 4 hallways (Resident Rooms #209, #213, #215, #304, #306 and #314). The findings included: 1. The following observations were related to the facility's failure to repair broken entrance doors to resident rooms with sharp splintered edges at the lower portion of the doors: a. Observation of room [ROOM NUMBER] on 02/05/19 at 2:42 PM revealed the entrance door was broken with sharp splintered edges approximately 10 inches long at the lower portion of the door. Subsequent observations made on 02/06/19 at 2:58 PM and 02/07/19 at 11:47 AM revealed the door remained in disrepair. b. Observation of room [ROOM NUMBER] on 02/05/19 at 2:56 PM revealed the entrance door was broken with sharp splintered edges due to ripped lamination at the lower portion of the door. Subsequent observations made on 02/06/19 at 10:33 AM and 02/07/19 at 11:45 AM revealed the door remained in disrepair. c. Observation of room [ROOM NUMBER] on 02/05/19 at 3:16 PM revealed the entrance door was broken with several splintered sharp edges due to ripped lamination on the bottom 2 feet of the door. Subsequent observations made on 02/06/19 at 3:05 PM revealed the door remained in disrepair. d. Observation of room [ROOM NUMBER] on 02/05/19 at 4:21 PM revealed the entrance door was broken with sharp splintered edges due to ripped lamination at the lower right portion of the door. Subsequent observations made on 02/06/19 at 9:51 AM and 02/07/19 at 11:49 AM revealed the door remained in disrepair. e. Observation of room [ROOM NUMBER] on 02/07/19 at 12:08 PM revealed the entrance door was broken with sharp splintered edges approximately 10 inches long due to ripped lamination at the lower portion of the door. f. Observation of room [ROOM NUMBER] on 02/07/19 at 12:11 PM revealed the entrance door was broken with sharp splintered edges due to ripped lamination at the lower portion of the door. During an environmental tour conducted on 02/07/19 at 1:21 PM with the Maintenance Manager (MM) and the Administrator, the above mentioned entrance doors with sharp edges for room [ROOM NUMBER], #213, #215, #304, #306, and #314 were observed and remained in disrepair. During an interview conducted on 02/07/19 at 1:37 PM, the MM acknowledged that the sharp edges at several entrance doors were safety hazards and stated it was his oversight due to recent overwhelming workloads. According to the MM, he was the only maintenance staff in the facility. He used to have one maintenance assistant worked under him who quit about 2 weeks ago. The MM stated on a regular basis, he did walk a through of the facility at least once per week to identify maintenance needs. Otherwise, he depended on staff to report maintenance concerns via verbal reports or work orders. The MM added maintenance work was prioritized with safety concerns being addressed first, equipment issues addressed second and cosmetic issues addressed third. During an interview conducted on 02/07/19 at 2:12 PM, the Administrator stated the maintenance department was currently interviewing applicants to fill in the empty vacancy. He attributed the doors with sharp edges as an oversight in the part of MM. It was his expectation for the facility to remain free of safety hazards.

Based on record review and staff interviews, the facility failed to follow a physician order [REDACTED].#67). The findings included: Resident #67 was originally admitted to the facility on [DATE]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #67 had [MEDICAL CONDITIONS] and was taking a daily diuretic. The MDS also revealed Resident #67 weighed 191 pounds with no significant weight loss or gain in the past 6 months. Record review of the Team Health Provider Visit Form dated 11/27/18 revealed Resident #67 was refusing a prescribed diuretic (taken to reduce extra fluid in the body). A request was made from nursing staff on 11/27/18 to discontinue the medication for Resident #67 and the physician responded Ok to stop. Be sure he's weighed daily. Record review of physician's orders [REDACTED].#67 was to be weighed daily at 6:00AM. No parameters for notifying the physician for weight loss or weight gain was listed. Record review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed no weight or refusals of weight to be taken was documented on 11/29/18 for Resident #67. Record review of the MAR for (MONTH) (YEAR) revealed no weights or refusals of weights to be taken was documented on the following dates: 12/03/18, 12/07/18, 12/08/18, 12/22/18 and 12/24/18 for Resident #67. Resident #67 was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/08/19 at 12:10PM, assistance from the Director of Nursing (DON) was requested to find the missing weights from (MONTH) and (MONTH) (YEAR). The DON reviewed the weight sheets, front and back of the MAR for (MONTH) and (MONTH) of (YEAR) and nurses notes for (MONTH) and (MONTH) (YEAR). The DON was unable to find the daily weights missing or documentation of the refusal of Resident #67 to be weighed for 11/29/18/ 12/03/18, 12/07/18, 12/08/18, 12/22/18 and 12/24/18. During an interview on 02/08/19 at 12:27 PM the DON stated that daily weights were supposed to be documented on the MAR and should also be transcribed over to the weight sheet. The DON also stated the MAR was reviewed daily by the desk nurse or the Assistant Director of Nursing (ADON) and this error should have been caught. The DON stated her expectation was for physician orders [REDACTED]. During an interview on 02/08/19 at 1:34 PM with Nurse Supervisor #1 she stated if there was a doctor's order present that had not been discontinued you were supposed to follow it. During an interview on 02/08/19 at 1:40PM with Nurse Supervisor #2 she stated staff should follow physician's orders [REDACTED].

Based on record review and staff interviews the facility failed to accurately code tobacco use and type of urinary catheter utilized in admission Minimum Data Set (MDS) assessments for 2 of 20 residents (Residents #57 and #12). The findings included: 1. Resident #57 was admitted to the facility 05/25/17 with [DIAGNOSES REDACTED]. A review of Resident #57's medical record revealed a facility smoking assessment form. The form was dated 05/25/17 and signed by the admitting nurse. The form contained documentation which specified Resident #57 was deemed a safe smoker. A review of an admission MDS dated [DATE] revealed in section J1300 Current Tobacco Use, no was checked. An interview with the MDS Coordinator on 01/10/18 at 4:20 PM revealed she knew Resident #57 smoked when admitted to the facility. The MDS Coordinator confirmed the admission MDS specified the resident did not use tobacco. She explained she made an error when she checked no in section J1300. During an interview on 01/10/18 at 4:27 PM, the Director of Nursing stated she expected MDS assessments to be coded correctly. 2. Resident #12 was admitted to the facility 11/03/16 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] in section H0100 indicated Resident #12 had an external catheter. A review of the care plan revised on 10/05/17 identified the problem of intermittent self-catheterization with the goal not to develop a urinary tract infection by the next review date. The interventions included keep self-catheter supplies at the bedside. During an interview on 01/11/18 at 1:49 PM, the MDS Coordinator revealed Resident #12 used self-catheter supplies kept at the bedside to perform intermittent self-catheterization. The MDS Coordinator confirmed section H0100 of the quarterly MDS was incorrect and indicated the resident had an external catheter. She explained an error was made and she would modify the MDS to reflect the resident performed intermittent self-catheterization and did not have an external catheter. During an interview on 01/11/18 at 5:08 PM, the Director of Nursing revealed it was her expectation for the MDS to be coded correctly and reflect resident care needs. The DON also revealed it was her expectation for the MDS to be coded and reflect Resident #12 performed intermittent self-catheterization.

Based on observations, record reviews, and staff interviews, the facility failed to identify and address unintended significant weight loss for 2 of 5 sampled residents. The facility did not implement care planned interventions to address significant weight loss and have timely implementation of recommended supplements for Resident #100 and did not identify significant weight loss and follow up on dietary recommendations for Resident #53. The findings included: 1. Resident #100 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The initial Nutritional Evaluation dated 04/21/14 completed by the Dietary Manger (DM) noted her usual meal intake was 50% to 75% and she received a regular diet. This note stated her food preferences were obtained and review of this list revealed dislikes included eggs and she liked cold cereals. The admission Minimum Data Set ((MDS) dated [DATE] coded her with usually being understood and usually understands, having some inattention and disorganized thinking, having moderately impaired cognition (scoring a 10 out of 15 on the brief interview for mental status), requiring supervision and set up for eating, having a poor appetite or overeating nearly every day, having no behaviors, and weighing 210 pounds at 5 feet 6 inches tall. The Registered Dietician's (RD) nutritional evaluation dated 04/27/14 noted Resident #100 was on a regular diet and her current intake ranged from 50% to 75%. The note included the recommendation to maintain her intake at greater than 50% for all meals. The note also included the need to monitor nutrition parameters and follow up as needed. A care plan was developed on 04/30/14 for the problem of potential for weight loss related to varied intake and [DIAGNOSES REDACTED].#100 to maintain current nutritional status as evidenced by no more than a 7.4% weight loss through the next review. Interventions included to provide diet as ordered, assess meal intake and document, resident eats in her room, provide supplements as ordered, encourage good nutrition and hydration, dietician to eval as needed, monitor weights as ordered and monitor labs as ordered. Per Resident #100's weight record, on 05/06/14 she weighed 211.4 pounds and on 06/05/14 she weighed 190.6 pounds ( a one month 9.84% significant weight loss). Review of the documented intakes for Resident #100 from 05/01/14 through 06/06/14 revealed there was no documentation related to how the resident's intake was for 13 breakfasts, 13 lunches and 10 dinners. In addition the intake reports noted Resident #100 ate less than 50% of the meal for those days which were documented for 11 breakfasts, 7 lunches, and 9 dinners. Review of the physician's notes revealed he saw Resident #100 on 05/15/14 for anorexia and ordered lab work. On 05/19/14 the physician saw her again for anorexia and noted in his notes adjusted medications for potassium and [MEDICAL CONDITION]. On 05/22/14 nothing was noted about weight on this physician's visit. A nutritional evaluation dated 06/08/14 by the Dietary Manager (DM) noted that she needed tray set up assistance and her usual intake varied. The DM noted she was on a regular diet and food preferences were reviewed. Review of the food preference form dated 06/08/14 noted she still disliked eggs and now disliked cold cereal. The RD noted on 06/23/14 that she had a 9.8% wt loss in one month. The notation stated that weight loss would be beneficial to the resident at a slower rate and at adequate intake. The RD noted recommendations for a fortified meal plan and to monitor weight and intake and follow up as needed. No changes were made to the nutritional care plan. Interview with the RD at 10/14/14 at 4:20 PM revealed she never placed someone in a nursing facility on a weight loss program unless it was essential. She stated that weight loss could be beneficial for this resident and that she wanted Resident #100 to at least eat 50% of her meals. Interview with the District Dietary Manger on 10/14/14 at 4:20 PM revealed that there were recipes for fortifying foods and typically the hot cereal was fortified with more butter and sugar, mashed potatoes were fortified with whole milk and butter and extra gravy would be considered fortifying. She further stated that in this facility, all fortified foods were added to the tray on top of the planned menus. For example if oatmeal was on the planned menu, then a resident on a fortified meal plan would get a bowl of regular oatmeal and a bowl of fortified oatmeal. She confirmed with the DM who joined this interview there was no way to discern the serving of fortified foods from the nonfortified foods served, ensuring the resident would eat a fortified serving before a nonfortified serving. Per Resident #100's weight record, her weight continued to drop as documented on 07/07/14 when she weighed 185.8 pounds. Resident #100 was seen for Speech Therapy (ST) from 06/03/14 through 07/13/14. Review of the ST discharge summary revealed the resident met the goals of consuming at least 50% for at least 2 meals for 5 consecutive days to prevent malnutrition and weight loss and to improve task recognition to 90% during therapeutic opportunities to prevent malnutrition and weight loss on 07/13/14. Discharge recommendations included for caregivers to set up resident at meals and the resident was to dine in the main dining room at meals. Interview with the ST on 10/16/14 at 1:25 PM revealed that she worked with Resident #100 in order to increase the resident's intake. ST stated the breakfast meal was her worst meal for consumption and at times, she needed to sit with her, feed her and give her lots and lots of encouragement to eat. She stated Resident #100 consumed the best when she ate in the dining room which was why she recommended her to eat in the dining room as often as she would agree to go. Per Resident #100's weight record, her weights continued to drop as documented on 08/12/14 when she weighed 177.4 pounds (weight loss of 4.5 % in one month and 16.08% in 3 months). The DM's nutritional review dated 08/13/14 noted this weight loss and noted she was on a regular diet, no supplements, and her intake varied. The note stated that sometimes Resident #100 ate 50% - 75% then at times would not eat more than a bite or two. This note indicated her [MEDICATION NAME] level was low and that the plan was to continue to monitor intake. No changes were made to the care plan. The Director of Nursing provided weight committee notes dated 08/13/14 which indicated that she received a regular diet with fortified foods and was within her ideal body weight range. The corresponding interdisciplinary note dated 08/13/14 included plans to add ice cream and/or pudding to lunch and dinner trays. In addition the plan was to educate the resident about maintaining her current weight. No changes were made to the care plan. The care planned intervention to monitor her intake was inconsistently documented as the meal intake records revealed multiple meals where her intake was not documented and/or she ate less than 50% as follows from 06/07/14 through 09/07/14: *In June, breakfasts were not documented 7 times; lunch intakes were not documented 6 times; dinner intakes were not documented 7 times; *In July breakfasts were not documented 17 times; lunches were not documented 20 times; dinner was not documented 11 times; *In August breakfasts were not documented 14 times; lunches were not documented 15 times; dinner was not documented 4 times; and *In September breakfasts were not documented 4 times; lunches were not documented 25 times; dinner was not documented 1 time. Of those meals that were documented, Resident #100 was noted to eat 50% or less in 55 meals. Resident #100's weight record noted her weight on 09/04/14 as 173.4 pounds (a loss of 9% in 3 months - since 06/05/14). Review of the physician notes dated 09/04/14 revealed she was complaining of abdominal pain. He noted more laboratory testing was ordered. This note specified under the issue of weight loss that the resident "demonstrates acute changes that require increased support and frequent monitoring." Weight loss was noted as ongoing the plan was to continue to monitor and assess. Laboratory testing dated 09/08/14 showed Resident #100's [MEDICATION NAME] level was low at 2.7 g/dl (normal range starting at 3.5 g/dl) and the total protein was low at 5.0 g/dl (normal range starting at 6.0 g/dl) On 09/08/14 the RD noted a 9% weight loss in 3 months. He noted Resident #100 was on a fortified meal plan and ate approximately 50%. The RD recommended a house supplement 60 milliliters 4 times per day and follow up as needed. This was written on a recommendation form which was dated 09/08/14. The physician's orders [REDACTED]. Interview with the RD #1 on 10/14/14 at 4:20 PM revealed there were 2 dieticians who worked together and came to the facility. RD #1 stated that fortified meals were not physician ordered but just were communicated with the kitchen and placed on the tray card. Supplements were physician ordered and for Resident #100's physician's request, a supplement order would be written by the RD. RD #1 stated that although she had informed the other dietician of the need to write the supplement order, the order was not written and/or responded to until 09/21/14. Upon follow up interview on 10/14/14 at 5:51 PM, RD #1 stated that all dietician's recommendations were written on a form and provided to the dietary manager and the DON for follow up as a double check system to ensure interventions were in place. Interview with DON on 10/17/14 at 2:45 PM, revealed the facility had weekly weight committee meetings to discuss residents. He stated the RD left him and the dietary manager recommendations of those residents reviewed. He stated that at the weight committee meetings, the team had the RD's recommendations and the chart to ensure all recommendations were acted upon. He then provided the weight committee meeting notes dated 09/09/14 which showed the supplement recommendation for Resident #100. The DON could not explain how the supplement recommendation was not ordered from the physician until 9/21/14 as the team was aware of this recommendation. Review of Resident #100's meal intake records continued to reflect incomplete intake documentation as follows from 09/08/14 through 10/11/14:*23 breakfast intakes were not documented and 7 documented times she ate less than 50%; *23 lunch intakes were not documented and 7 documented times she ate less than 50%; and *7 dinner intakes were not documented with 8 documented times she ate less than 50%. Interview with Nurse Aide (NA) #4 on 10/15/14 at 2:07 PM revealed the computer on the hall where care provided by nurse aides was documented, had been broken for at least 6 months and in order to document staff had to go to another hall. She further explained that staff were not allowed to leave the hall without another staff member being present on the hall. Resident #100's latest laboratory test dated 10/08/14 revealed her [MEDICATION NAME] continued to drop and now was 2.1 g/dl. Per Resident #100's weight record, her weight continued to drop as documented on 10/12/14 at 167.8 pounds (20% significant weight loss in 6 months). Observations on 10/14/14 at 7:59 AM revealed NA #3 attempted to feed the resident breakfast while she was in bed. She would not eat but a couple of bites stating she felt nauseated. She did not touch the eggs on her tray which were listed as a dislike on her tray card. Per the intake records, she ate between 25 and 50% of this meal. On 10/15/14 at 5:36 PM, Resident #100 had a dinner tray in her room and the tray was untouched. She did have a serving of mashed potatoes. She stated she could not eat a bite and wanted something for acid reflux. She further stated the doctor needed to see her because she could not eat. Per the intake records, she ate between 50 and 75% of the meal. On 10/16/14 at 8:20 AM, Resident #100 was observed eating breakfast while in bed which consisted of sausage, cold cereal, pancakes. The tray card indicated she should have fortified foods. At 8:39 AM she had chewed and spit out a bite of sausage and stated she could not eat any more. She ate less than 25% and did not receive fortified food. On 10/17/14 at 8:30 AM, Resident #100's eaten tray was observed with NA #1 who served her food. On the tray were eggs (a dislike), english muffin, cold cereal and bacon. NA #1 confirmed there was no oatmeal on the tray. The DM stated on 10/17/14 at 11:47 AM that staff had requested eggs for Resident #100 this morning and she did not get the fortified oatmeal because the resident preferred cold cereal. DM continued that if a resident did not like hot cereal which was the fortified food for the breakfast trays, then the DM stated she had no other fortified items to send on breakfast trays. On 10/17/14 at 12:24 PM, NA #1 who served the resident breakfast this am stated the eggs were on the tray at time of service and she did not request eggs. On 10/17/14 at 12:00 PM Resident #100 was observed in the dining room. She was served the regular meal of fish and tater tots. She did not have the fortified food of mashed potatoes on her plate. When asked, the DM could not explain why the resident did not receive the fortified food item at this meal. 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #53 had severely impaired cognition, was totally dependent on staff for eating, and noted a weight of 121 pounds. Review of a quarterly MDS dated [DATE] revealed Resident #53 had severely impaired cognition, was totally dependent on staff for eating, and noted a weight of 119 pounds. Review of a care plan dated 04/26/13, and last reviewed on 07/31/14, stated Resident #53 was at risk for weight loss related to dementia and varied intake. The goal was for the resident to maintain her current nutritional status as evidenced by no more than a 7.5% (percent) weight loss through the next review on 10/31/14. Interventions included: assess meal intake and assist as needed, provide supplements as ordered, monitor weights as ordered, and Registered Dietitian (RD) to evaluate as needed. The care plan was updated on 04/27/14 to include increasing the house supplement to three times a day. Review of the medical record revealed the following recorded weights: 03/07/14- 127.4 pounds 04/02/14- 121.6 pounds 05/06/14- 121.2 pounds 06/05/14- 122.8 pounds 07/07/14- 119.2 pounds 08/06/14- 114.8 pounds 09/04/14- 111.2 pounds 10/14/14- 109.8 pounds Review of a nutrition progress note completed by the RD on 04/07/14 revealed Resident #53's current weight was 121.6 pounds which reflected a 4.55% weight loss in 30 days. The RD noted Resident #53's weight was 127.4 pounds in March 2014 with a 5.8 pound weight loss in 30 days. The RD recommended to increase the resident's house supplement to 60 cc (cubic centimeters) three times a day. Review of a nutritional review completed by the Dietary Manager (DM) on 07/14/14 stated Resident #53 consumed 75% to 100% of her meals and 100% of her supplement. The DM noted a current weight of 119.2 pounds with no significant weight loss at that time. Further review of nutritional reviews and nutritional progress notes revealed no further documentation by the DM regarding weight loss or dietary supplements. Review of a nutrition progress note completed by the RD on 09/21/14 revealed Resident #53's current weight was 111.2 pounds which reflected a 3.6 pound weight loss in 30 days. The RD further noted Resident #53 had lost 9.45 % in 90 days (3 months) and 12.72 % in 180 days (6 months). The RD indicated Resident #53's diet order was regular puree with honey thick liquids and house supplement 60 cc three time a day. The RD recommended Prostat (high calorie/complete liquid protein supplement) daily due to recent skin concerns, [MEDICATION NAME] meal plan, and to increase the house supplement to 90 cc three times a day. Observations of Resident #53 during meals revealed the following: - On 10/14/14 at 8:02 AM Resident #53 was observed in the dining room with her eyes closed. Staff attempted to wake her up to eat for 20 minutes but were not successful. - On 10/14/14 at 12:25 PM Resident #53 was alert and seated at a dining room table with a nurse aide sitting next to her. Resident #53 was totally dependent on staff with eating. Resident #53 accepted 50 % of her lunch. - On 10/17/14 at 8:50 AM Resident #53 was alert and seated at a dining room table with a nurse aide sitting next to her. Resident #53 was totally dependent on staff with eating. Resident #53 accepted 75 % of her breakfast. An interview was conducted with the Director of Nursing (DON) on 10/15/14 at 3:30 PM. The DON stated weight meetings were held every Tuesday and the Assistant Director of Nursing (ADON), MDS Coordinator, and DM attended. The DON indicated monthly weights and percentages were reviewed during the meeting to identify residents with 5% weight loss in one month, 7.5% weight loss in 3 months, and 10% weight loss in 6 months. The DON confirmed Resident #53 was discussed during the weight meeting on 09/23/14 and the RD recommendations from 09/21/14 were noted. The DON further stated Resident #53 had not triggered for significant weight loss at the 09/23/14 weight meeting but he would review his information. The DON reviewed Resident #53's medical record at the time of the interview and confirmed no order had been written for the RD recommendations noted in the nutrition progress note on 09/21/14. A telephone interview with the RD on 10/16/14 at 10:55 AM revealed she would have faxed her recommendations for Resident #53's significant weight loss to the Physician for his approval before she left the faciity on [DATE]. The RD stated she also leaves a copy of the recommendations with the Administrator, DON, and the DM. During a follow up interview on 10/16/14 at 3:00 PM the DON stated Resident #53's significant weight loss was not addressed during the 09/21/14 weight meeting. The DON further stated he was not certain they had a copy of the monthly weights and percentages for the weight meeting on 09/23/14, which would have reflected Resident #53's significant weight loss, because the DM did not attend the meeting. The interview further revealed the RD's nutrition progress note dated 09/21/14, which noted significant weight loss, was not reviewed during the weight meeting on 09/23/14. The DON indicated there were currently no parameters for follow up of dietary recommendations faxed to physicians. Resident #53's monthly weights from March 2014 through October 2014 were reviewed during the interview and the DON confirmed Resident #53 experienced continued weight loss since the 09/23/14 weight meeting. An interview with Resident #53's Physician on 10/16/14 at 4:53 PM revealed he received a large volume of faxes to his office daily and could not specifically recall the fax from the RD with dietary recommendations on 09/21/14 or when he replied to the fax. The Physician stated when he came to the facility on [DATE] the nurse did not mention weight loss being an issue when they discussed Resident #53. An interview was conducted with the DM with the DON present on 10/17/14 at 10:20 AM. During the interview Resident #53's monthly weights and percentages which calculated percentage of weight loss for March 2014 through September 2014 were reviewed. The DM and the DON both confirmed Resident #53 should have triggered for a significant weight loss of 12.72% in 6 months in September 2014. The DM stated she did not attend the weight meeting on 09/23/14 but typically printed a copy of the monthly weights and percentages for the past 6 months for all residents and gave copies to the DON and ADON for the weekly weight meeting. The interview further revealed the DM did not need a physician's orders [REDACTED].#53's diet because she did not document regarding this in the medical record.

Based on facility policy, record review, and staff interviews the facility failed to prevent a resident from an injury, which required amputation, while being pushed in her wheelchair with no footrests and wearing cloth slippers for 1 of 3 residents reviewed for supervision to prevent accidents. (Resident #55) Immediate Jeopardy began on 09/11/13 when Resident #55 was pushed in her wheelchair in the parking lot of the facility with no footrests and wearing cloth slippers resulting in severe in injuries to her feet which required amputation. Immediate Jeopardy was removed on 09/20/13 when the facility provided and implemented a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity of a level D (No actual harm but a potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: The facility's policy entitled "General Guidelines for Wheelchair Seating" dated 09/01/2011 read in part: "12. Use of leg rest panels assist in the prevention of knee flexion contractures and the legs and feet falling off of the leg rests, dangling and getting injured." Resident #55's most recent admission to the facility was 07/24/13 with [DIAGNOSES REDACTED]. Resident #55's most recent 5 Day Minimum Data Set ((MDS) dated [DATE] revealed she had moderate cognitive impairment. The MDS further assessed Resident #55 as needing the extensive assistance of two people with locomotion on unit and limited assistance of one person off unit. Resident #55 was further coded on the MDS as having a trunk restraint which was used daily. Resident #55's care plan, updated 07/31/13, for potential for adverse side effects related to the use of psychotropic medications had an intervention included which read, "with increased behaviors may take resident outside for fresh air." The care plan did not address the protection of Resident #55 feet. A Situation, Background, Assessment, and Recommendation (SBAR) form dated 09/11/13 located in Resident #55's medical record revealed a functional status change of "abrasion/wounds to toes". Assessment on this form read as follows: "Resident was being wheeled in parking lot by SW (Social Worker), feet were dragging under wheelchair." Nursing note section of this form timed 7:10 PM read, " This nurse called to shower room by DCS (Director of Clinical Services) and another nurse. Resident in shower room in wheelchair upon assessment, resident house shoes torn and covered in blood at the toes of the shoes. Further assessment of resident's foot reveal abrasions on great toe and 2nd and 3rd toe on right foot. Deep abrasions on all 4 toes on left foot and abrasion on great toe on left foot. Resident wounds cleaned and treatment orders received." Also indicated on this form was family notified 09/12/13 at 10:10 AM and physician notified 09/12/13 at 10:15 AM. This form was signed by the Unit Manager. On 09/12/13 Resident #55 was taken to the wound clinic. Notes from this encounter indicated due to the severity of the injury and potential for complications Resident #55 would have to be transferred to the local hospital. Physical exam results indicated "deep tissue abrasions over joints of several toes of both feet. The abrasions go down to the joint." On 09/12/13 Resident #55 was seen at the local hospital. Notes from this encounter indicated Resident #55 had suffered toe injuries with deep abrasions with visible muscles and tendons. Orders were written for the resident to be transferred to the trauma center hospital as the level of care/service was not available due to Resident #55's need for nephrology and orthopedic care. Hospital records from the trauma center dated 09/16/13 read in part, "...due to peripheral vascular disease and foot wounds, the resident underwent [REDACTED]." During an interview on 09/17/13 at 12:34 PM with the Unit Manager she stated the Director of Clinical Services (DCS) and the Administrator asked her to help assess the resident. She stated they took the resident to the shower room. The DCS was also in the shower room. The Unit Manager stated she noted the resident's cloth slippers were torn in the toe area. She stated she could see the resident's toes through the end of the slipper and there was obvious blood around the toe area of the slippers. She asked what happened and the DCS told her the resident's feet got caught under her while she was in the wheelchair. They removed her shoes and assessed her toes. On the right foot, the great toe and the second and third toe all had abrasions. The second toe on the right foot had the deepest abrasion. On the left foot all toes had deep abrasions on the knuckle area. The toes were curled under on the left foot but not the right foot. She cleaned the foot and did a wet to dry dressing on both feet and wrapped them in gauze. The resident yelled out while she (the Unit Manager) was cleaning her feet but when asked if she was in pain she said no. The Unit Manager stated she called the on call physician to get the order for the wound care and he told her to notify the primary physician in the morning. She told the on call doctor what had happened to the resident. She stated the resident did not normally drag her feet. The resident would self propel and was usually very good about lifting her feet. It was common for the resident to be taken outside by the staff when she was yelling. She stated the next day she received an order to send the resident to the wound clinic. The Unit Manager explained when the resident was seen at the wound clinic the person who transported her from the facility called to inform them Resident #55 was being sent to the hospital. An interview was conducted on 09/17/13 at 1:14 PM with the Administrator. He stated Resident #55 had come back from dialysis and she was calling out consistently. The resident was yelling and he could hear her from his office. The Social Worker (SW) was the liaison that night. He explained the liaison was an administrative person who took turns staying until 8 PM to "help out". The Administrator asked the SW to take Resident #55 for a walk outside. Sometimes it would calm her. The SW was walking around the building on the sidewalk. The Administrator stated he went outside and met the SW and resident #55 on the sidewalk, The Administrator stated he happened to look down and saw blood and then he saw the resident's feet. He told the SW to get a nurse and he stayed with the resident to calm her. She was still yelling out and he asked her if she was hurt and she did not respond to his question. They took her in and DCS was asked to assist in taking care of her wounds. He stated he saw blood on the sidewalk. He did not know how long they walked. He stated he had taken the resident for a walk before and she would hold her feet up or pedal along. He stated she would propel herself around the facility so that was why she did not have foot rests on the wheelchair. He stated he would have expected the SW to have noticed that the resident was dragging her feet and assessed to make sure the resident was not dragging her feet. After she was brought in the Unit Manager assessed the resident and dressed the wounds. During an interview on 09/17/13 at 1:59 PM with the Administrator he stated he had not thought of the need for the resident to have foot rests while staff was walking her outside. He stated Resident #55 had continued to intermittently scream while she was outside and when he went out to speak to the SW she was screaming. He stated now after the incident occurred with the resident's injuries he did see the need for her to have had footrests on her wheelchair. An interview was conducted 09/17/13 at 2:05 PM with the Physical Therapist (PT) who stated she was familiar with Resident #55. The PT stated the resident did not need the foot rests while she was propelling herself in the facility but she was weak so she should have had them if she was going to be pushed in her wheelchair for a long walk. During an interview on 09/17/13 at 3:55 PM the Director of Clinical Services (DCS) stated she was in the conference room when the Administrator came in and stated, "I need you". She stated she told staff to get towels to wrap the resident's feet as the slippers where bloody and there was a trail of blood. The slippers were fleece and came half way up her calf and soles had non skid treads. The toes were opened at the toe seam and were bloody. She stated Resident #55 was taken to the shower room and she told the nurses to bring the treatment cart to the shower room. She stated she took the towels and slippers off and sprayed her feet with the shower spray nozzle. The toes on her left foot were contracted around and the nails were under foot and the toes were abraded to the second knuckle. The wounds were beefy red. She stated the wounds on the right foot were on the tips of her toes and the nails. From what she could tell the nails were intact on the left foot. The Unit Manager dressed the wounds and called the on call doctor. She stated he told the Unit Manager to call Resident #55's regular physician in the morning. She explained after the first walk the SW brought Resident #55 back in and took her to her room. A few minutes later the Administrator asked the SW to take the resident outside for another walk. She stated when they brought the resident back into the building there was a streak of blood noted near the front door and a streak closer to the nursing office which she noticed as they were bringing the resident into the shower room. She pointed the bloody streak out to the Administrator and the SW. The regular physician did not see Resident #55 but gave the order to send her to the wound clinic. The wound clinic called and stated they wanted to send her to the hospital. She stated in hind sight, yes, the resident should have had footrests on her wheelchair. An interview was conducted on 09/18/13 at 9:07 AM with Nursing Assistant (NA) #1 who had worked first shift with Resident #55 the day of her accident. NA #1 stated she worked with her the next day as well. She stated she was given report on the morning of 09/12/13 from 3rd shift. They reported to her that the SW took Resident #55 into the parking lot to push her to see if it would calm her down. She explained the SW failed to notice that the resident's foot pedals were not on. Her feet were dragging under the wheelchair on the pavement. She wore knit boots that came up her calves that the NA had put on her in the morning. NA #1 stated the resident usually had the foot pedals on her wheelchair and she thought the resident left to go to dialysis with the foot pedals on her wheelchair the day of her accident. NA #1 stated when Resident #55 would propel herself in her wheelchair her feet touched the ground. Resident #55 did not wear shoes. She always wore something soft because of her contractures. She had been working with Resident #55 for a couple of months. She stated "you would have to really watch because her feet were contracted and they had dropsy". She stated if she had the foot pedals on her feet would sit on them flat but if she did not use foot pedals her feet would drop down. The resident did not pedal around the facility much. She was very sick and she would get tired and then say "push me". She stated you had to be very careful when pushing her because of the way her feet dropped. NA #1 explained when she did propel, which was very little, she would use her toes or the tips of her feet. The only time she ever saw her feet flat was when they were on the foot pedals. She asked the resident the morning of the 09/12/13 if she was hurting and she said "yes". NA #1 was helping the nurse dress the wounds and she asked the resident if she was in pain and she said "yes" and Nurse #1 went to get her something for pain. NA #1 reported the wounds on the left foot were deep holes/craters. She stated it was bad. She could not believe how bad it was. An interview was conducted on 09/18/13 at 9:50 AM with Nurse #1. She revealed the resident could self propel a very short distance out of her room or a short distance in the hall. She could not propel herself to meals. The resident did have foot rests but not always. The nurse stated she had held up her feet while the nurse was taking her to activities and to restorative dining. The cloth slippers she usually wore were made of thick fleece fabric. Nurse #1 stated she was not here on the 09/11/13 when the injury occurred. She received report that Resident #55 had some abrasions on her toes and she saw the dressing needed to be changed as it had blood on it and it was due to be changed anyway. The wounds were wrapped in gauze and taped and she saw blood coming through the bandages. When she took the dressing off the gauze was stuck and she had to get wound cleanser to spray on the wounds to loosen the gauze. The resident did have pain before she did the dressing change as the resident would pull her foot away. The knuckles were scrapped and the 2nd and 3rd toes had big red craters filled with thick blood. As she got to the forth toe it had a deep crater but was not filled with blood. The toes were raw and either the third or the forth toe appeared to be deep and down to the bone. She could tell it was hurting the resident as she did the dressing change. She then dressed the foot and sent her to the wound clinic. Using the foot rests for this resident was a usual because she would sleep a lot. On 09/18/13 at 10:20 AM an interview was conducted with the Physical Therapy Assistant (PTA) who had been working with Resident #55. The PTA stated he had been working with her to try to increase her strength. He stated the resident was weak and she would only be able to hold her feet up for short distances. A telephone interview was conducted on 09/18/13 at 4:44 PM with the Social Worker (SW). He stated it was about supper time when he went down to the dining room and Resident #55 was screaming. She had eaten a little of her supper and she said she did not want anymore. He stated he did not notice anything wrong with her feet before taking her outside for a walk. The SW stated they were outside for 15-20 minutes. He stated he did not notice any problem. When walking her around he did not look down at her feet. Resident #55 was wearing her lap buddy. He explained her position in wheelchair was sitting straight up but that she did lean forward a time or two. The SW stated she would sit back then lean forward 30 seconds to one minute then lean back. He stated as far as he knew she was still holding her feet up. He stated he did see her holding them up but did not check to see how far off the ground they were. He stated he did not notice anything wrong with her feet. He went on to explain he let her rest, put her feet on the ground and then started pushing her around again. He stated he did not look at her feet very often. The SW indicated the resident was wearing cloth slippers that came up her calf like a boot. He stated he rolled Resident #55 in parking lot and down sidewalk. He went on to say he took her back into the facility and she started to scream. He stated when he brought her back in. He did not notice any blood. He stated the Administrator asked him to take her back outside. The SW verified she screamed intermittently during the first walk and progressively more during the second walk. He stated he took Resident #55 outside for another 15 minutes at which time he was near the front porch. He stated the Administrator came to tell him he was going too fast while walking with her. He stated he walked at his usual pace but he would consider himself to be a fast walker. He was talking with the Administrator for a few minutes when the Administrator noticed the blood. He stated he did not see blood until then. He stated her toes appeared to be rubbed off. He stated he did not know where they got rubbed off. The fabric on her slippers was torn where toes were. There was a lot of blood that was soaked through the material. He stated the Administrator pointed it out. The SW stated they immediately took her back in the facility and got the DCS. The SW explained he wrote a statement about what happened and left facility the about 8:20 PM. The SW stated he couldn't tell a difference with her screaming whether it was her normal state or if she was in pain. He stated he should have immediately put on the leg rests so she would not have to hold up her legs. He does not know if she had footrests for her wheelchair. He stated he should have stopped and asked her to pick up her feet. An interview was conducted on 09/19/13 at 8:37 AM with NA #1 who had worked with Resident #55 the morning of 09/11/13. She stated when she came in that morning Resident #55 was up, dressed, and wearing her cloth slippers. She stated her slippers were clean and with out holes. During an interview on 09/19/13 at 4:05 PM the DCS she stated the resident did not have any other shoes that would have been more protective. She stated she never saw her with anything other than the cloth booties. The DCS stated she thought the cloth slippers she was wearing were purchased by the family. To her knowledge the resident did not have any footrests for her wheelchair nor did she ever see her with footrests on her wheelchair. A telephone interview was conducted 09/19/13 at 4:52 PM with the County Transport Person who transported Resident #55 to and from dialysis. He stated Resident #55 had her foot rest on her wheelchair all of the time before the last state survey (08/16/13). He stated they were taped in place on her wheelchair with electrical tape. He stated she also had anti-tippers on her wheelchair. He stated after the last state survey he never saw the foot rests on her wheelchair again. During an interview on 09/19/13 at 5:08 PM the Unit Manager stated the resident had footrests that would be used for the resident when she was being transported to dialysis but when she was in the facility she did not use them as she self propelled. An interview was conducted 09/19/13 at 5:19 PM with Nursing Assistant #2 who worked with Resident #55 on the second shift. He stated he thought the resident had footrests on her wheelchair and he had noticed there was tape around the foam padding on the legs of the wheelchair. An interview was conducted on 09/20/13 at 10:03 AM with Nursing Assistant #3. She stated she worked with Resident #55 in the past and would transfer her to the restorative dining room and to the bathroom. She reported the resident always had footrests and she made sure her feet were on the footrest. She stated she could not remember if there was any tape on the footrests. An interview was conducted 09/20/13 at 10:11 AM with Nursing Assistant #4 who stated he remembered Resident #55 had footrests for a while. He stated he thought they might have broken. He stated he accompanied Resident #55 to dialysis and he would have to help her pick up her feet because she could not pick them up. Much of the time she was asleep because they would have to give her the medicine when she would scream. He stated Resident #55 would get medicine before she went to dialysis. He stated when he would come in at 7 AM she would be screaming and by the time we took her to dialysis she would be asleep. The facility's Administrator was notified of the Immediate Jeopardy for Resident #55 on 09/18/13 at 4:30 PM. The facility provided a credible allegation of compliance on 09/20/13 at 3:30 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance (AOC) IJ SUPERVISION TO PREVENT ACCIDENTS Resident #55's most recent admission was on July 24, 2013. Admitting [DIAGNOSES REDACTED]. On 09/11/13 Resident #55 was exhibiting her chronic habitual disruptive behavior of yelling out. She was rolled outside per care plan intervention in her wheelchair without foot rests attached by Social Services Director for a walk for approximately 10 minutes and then returned to the nursing unit. After returning to the nursing unit, she continued to exhibit repetitive noises and Resident #55 was asked if she would like to go outside again at which time she stated she did and was again transported in her wheelchair without foot rests attached for a walk by the Social Services Director. The Social Services Director did not supervise the placement of the resident's feet during the walk. While outside, blood was visualized on the resident's feet by the Executive Director. Resident #55 was then escorted to the shower room by the Director of Clinical Services, Executive Director and Social services. The resident's slippers were removed and her injuries were assessed. There was evidence of trauma to the right and left distal toes, left greater than right. The injuries were beefy red with no overt evidence of bone or tendon visible. The resident's status was reported to the on call physician on September 11, 2013 at approximately 8pm. Orders were received for the dressing treatment and the resident was transported to the wound clinic on 09/12/13 for evaluation. The resident was transported from the wound clinic to the local hospital for further evaluation and treatment of [REDACTED]. All residents who use a wheelchair have the potential to be affected by this practice. Current facility residents were reviewed by the Director of Clinical Services/Nurse Manager on September 18, 2013 for possible injury potential. No other residents were noted to have any injuries related to this practice. Residents with diabetes and vascular issues that utilize wheelchairs as primary mode of mobilization will be assessed daily for open areas, discoloration and blisters by the Director of Clinical Services/Nurse Manager/Charge Nurse. On September 11 & September 12, 2013, the Director of Clinical Services and Nurse Manager assessed all residents who utilize wheelchairs. Residents that require assistance propelling themselves in their wheelchair had leg rests/foot pedals applied to their chairs or readily available. Residents self propelling their wheel chairs will remain without leg rests on their chairs, unless being propelled by a staff member. Residents who self-propel were assessed for safety and proper positioning of feet. On admission, at risk residents will be assessed for proper footwear, wheelchair locomotion and any medical conditions that would affect mobility. Proper footwear will be furnished by the facility within 24 hours, as needed. On September 18, 2013, Licensed Nurses and Certified Nursing Assistants and Administrative staff were in-serviced by the Director of Clinical services and/or Nurse Manager regarding the facility policy and procedure for maintaining residents' safety during wheelchair transport including: proper supervision of foot placement; positioning of feet in wheelchair footrests and proper footwear that covers the foot; location of wheelchair foot rests for ready application; and location and availability of wheelchairs with foot rests/leg extenders near the main entrance to the facility. Staff will not be permitted to work until they are in-serviced. Future staff will be educated during orientation. Staff will be trained to position the residents' feet in the middle of the footrests during transport. Staff will maintain visual observation of residents during transport to maintain proper positioning of feet. Staff will be educated on ensuring Residents have protective footwear when out of bed. All licensed staff will be in-serviced on diabetes and its disease processes and complications related to vascular issues. Immediate Jeopardy was removed on 09/20/13 at 2:10 PM. Observation revealed all residents, who were identified as wheelchair dependent and at risk for injury when being pushed in their wheelchair had footrests in place. Interviews conducted with staff in all departments and who worked on all shifts confirmed that they had received in-service training on the facility's policy and procedure regarding wheelchair transfers.

Based on observations, interviews, and record review, the facility failed to provide treatment for [REDACTED].# 115). The findings included: Resident # 115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent assessment was an admission Minimum Data Set ((MDS) dated [DATE] which indicated resident had impaired short term and long term memory and severely impaired cognitive skills for daily decision making. The MDS also indicated she had fluctuating inattention and daily wandering. She was assessed as needing limited assistance of staff with locomotion on and off the unit. Section M1040.G of the MDS did not indicate Resident #115 had any skin tears. Review of the Care Plan dated 06/07/13 revealed it did not address Resident #115's skin tears that were present on admission or the potential for sustaining additional skin tears due to wandering behavior and bumping into walls and furniture. Further review of Resident #115's medical record revealed an admission nursing assessment dated [DATE] which indicated the resident was admitted with a skin tear to the right upper posterior arm that measured 2.5 X 2.0 centimeters (cm), multiple small skin tears to right lower arm and left upper arm. Review of the nurse's notes revealed an entry dated 06/10/13 at 3:15 AM which indicated Resident #115 was found in the floor of her room beside her roommate's bed. She sustained 2 skin tears on her left elbow which measured 2 cm linear and 3.5 X 0.2 cm linear. Another nurse's noted dated 06/13/13 at 9:30 PM indicated Resident #115 was in dining room and became combative hitting her right elbow on the wall. resident sustained [REDACTED]. A nurse's note dated 06/14/13 at 2:00 AM indicated a skin tear was discovered on resident's right elbow. A nurse's note dated 07/29/13 indicated the physician was called about reddened areas on skin on resident's left arm and physician gave orders for Keflex (an antibiotic) 500 milligrams four times a day for 10 days. Review of the Treatment Administration Records (TARs) for Resident #115 revealed there was not a TAR for May 2013. The June, July and August 2013 TARs indicated resident had dressings applied to skin tears beginning June 14, 2013 through July 10, 2013 and from August 1 - 4, 2013. The TARs did not indicate any preventive measures were implemented to protect residents' arms from getting skin tears. Resident #115 was observed on 08/12/13 at 3:28 PM sitting in the hall near the nurse's station. She had multiple bruises on both lower arms. Resident #115 was observed on 08/14/13 at 1:30 PM, on 08/15/13 at 11:24 AM and on 08/16/13 at 10:13 AM self-propelling herself in a wheelchair in the hall. She did not appear to comprehend the need to avoid bumping into other residents in wheelchairs or to avoid hitting the walls. An interview with Nurse #2 on 08/14/13 at 9:54 AM about resident's bruises revealed resident frequently bumped into door frames, hand rail, and other items as she self-propelled in her wheelchair. Nurse #2 stated the resident talked all the time and did not pay attention to where she was going. Nurse #2 stated: "She (the resident) has zero safety awareness." When asked if there was anything that could be done to protect the resident's arms, Nurse #2 said "geri sleeves but I don't think she would keep them on. She takes her socks off all the time." When asked if staff had tried putting geri sleeves on Resident #115, Nurse #2 said "I haven't but it would be a good idea." A second interview with Nurse #2 on 08/16/13 at 10:58 AM about the cellulitis in resident's left arm that required initiation of antibiotic treatment on 07/29/13 revealed Resident #115 kept bumping the skin tear that she had when she was admitted and it would re-open. Nurse #2 described the area around the skin tear as "really hot and red" and stated that was the reason she notified the physician and he ordered antibiotic treatment. Nurse #2 was asked if any treatment was started to the skin tear when the resident was admitted and she stated there was not. An interview on 08/16/13 at 12:19 PM with the Medical Records coordinator confirmed there was not a TAR for May 2013 so there was no record of any treatment being started for the skin tears that were present on Resident #115's arms on admission. The first treatment for [REDACTED]. In an interview on 08/16/13 at 9:32 AM with the MDS Assessment Nurse about the bruises and skin tears on Resident #115's arms, the MDS nurse stated she depended on the nurses to tell her about that type of concern so she could address it. When asked if she was aware of the resident's skin problems, she stated she was not aware of them. An interview on 08/16/13 at 12:40 PM with the Director of Nursing about her expectation for treatment of [REDACTED]. When asked about her expectation for interventions for residents who have decreased safety awareness and are at risk for self-injury, the DON stated she would expect it to be reported and interventions implemented. She stated she would expect the need to be addressed on the care plan. The DON stated the facility had systems in place to address skin tears and bruises but those systems failed because the concerns were never reported.

Based on facility policy, record review, and staff interviews the facility failed to prevent a resident from an injury, which required amputation, while being pushed in her wheelchair with no footrests and wearing cloth slippers for 1 of 3 residents reviewed for supervision to prevent accidents. (Resident #55) Immediate Jeopardy began on 09/11/13 when Resident #55 was pushed in her wheelchair in the parking lot of the facility with no footrests and wearing cloth slippers resulting in severe in injuries to her feet which required amputation. Immediate Jeopardy was removed on 09/20/13 when the facility provided and implemented a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity of a level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: The facility's policy entitled "General Guidelines for Wheelchair Seating" dated 09/01/2011 read in part: "12. Use of leg rest panels assist in the prevention of knee flexion contractures and the legs and feet falling off of the leg rests, dangling and getting injured." Resident #55's most recent admission to the facility was 07/24/13 with [DIAGNOSES REDACTED]. Resident #55's most recent 5 Day Minimum Data Set ((MDS) dated [DATE] revealed she had moderate cognitive impairment. The MDS further assessed Resident #55 as needing the extensive assistance of two people with locomotion on unit and limited assistance of one person off unit. Resident #55 was further coded on the MDS as having a trunk restraint which was used daily. Resident #55's care plan, updated 07/31/13, for potential for adverse side effects related to the use of psychotropic medications had an intervention included which read, "with increased behaviors may take resident outside for fresh air." The care plan did not address the protection of Resident #55 feet. A Situation, Background, Assessment, and Recommendation (SBAR) form dated 09/11/13 located in Resident #55's medical record revealed a functional status change of "abrasion/wounds to toes". Assessment on this form read as follows: " Resident was being wheeled in parking lot by SW (Social Worker), feet were dragging under wheelchair." Nursing note section of this form timed 7:10 PM read, " This nurse called to shower room by DCS (Director of Clinical Services) and another nurse. Resident in shower room in wheelchair upon assessment, resident house shoes torn and covered in blood at the toes of the shoes. Further assessment of resident ' s foot reveal abrasions on great toe and 2nd and 3rd toe on right foot. Deep abrasions on all 4 toes on left foot and abrasion on great toe on left foot. Resident wounds cleaned and treatment orders received." Also indicated on this form was family notified 09/12/13 at 10:10 AM and physician notified 09/12/13 at 10:15 AM. This form was signed by the Unit Manager. On 09/12/13 Resident #55 was taken to the wound clinic. Notes from this encounter indicated due to the severity of the injury and potential for complications Resident #55 would have to be transferred to the local hospital. Physical exam results indicated "deep tissue abrasions over joints of several toes of both feet. The abrasions go down to the joint." On 09/12/13 Resident #55 was seen at the local hospital. Notes from this encounter indicated Resident #55 had suffered toe injuries with deep abrasions with visible muscles and tendons. Orders were written for the resident to be transferred to the trauma center hospital as the level of care/service was not available due to Resident #55's need for nephrology and orthopedic care. Hospital records from the trauma center dated 09/16/13 read in part, "...due to peripheral vascular disease and foot wounds, the resident underwent [REDACTED]." During an interview on 09/17/13 at 12:34 PM with the Unit Manager she stated the Director of Clinical Services (DCS) and the Administrator asked her to help assess the resident. She stated they took the resident to the shower room. The DCS was also in the shower room. The Unit Manager stated she noted the resident's cloth slippers were torn in the toe area. She stated she could see the resident's toes through the end of the slipper and there was obvious blood around the toe area of the slippers. She asked what happened and the DCS told her the resident's feet got caught under her while she was in the wheelchair. They removed her shoes and assessed her toes. On the right foot, the great toe and the second and third toe all had abrasions. The second toe on the right foot had the deepest abrasion. On the left foot all toes had deep abrasions on the knuckle area. The toes were curled under on the left foot but not the right foot. She cleaned the foot and did a wet to dry dressing on both feet and wrapped them in gauze. The resident yelled out while she (the Unit Manager) was cleaning her feet but when asked if she was in pain she said no. The Unit Manager stated she called the on call physician to get the order for the wound care and he told her to notify the primary physician in the morning. She told the on call doctor what had happened to the resident. She stated the resident did not normally drag her feet. The resident would self propel and was usually very good about lifting her feet. It was common for the resident to be taken outside by the staff when she was yelling. She stated the next day she received an order to send the resident to the wound clinic. The Unit Manager explained when the resident was seen at the wound clinic the person who transported her from the facility called to inform them Resident #55 was being sent to the hospital. An interview was conducted on 09/17/13 at 1:14 PM with the Administrator. He stated Resident #55 had come back from dialysis and she was calling out consistently. The resident was yelling and he could hear her from his office. The Social Worker (SW) was the liaison that night. He explained the liaison was an administrative person who took turns staying until 8 PM to "help out". The Administrator asked the SW to take Resident #55 for a walk outside. Sometimes it would calm her. The SW was walking around the building on the sidewalk. The Administrator stated he went outside and met the SW and resident #55 on the sidewalk, The Administrator stated he happened to look down and saw blood and then he saw the resident ' s feet. He told the SW to get a nurse and he stayed with the resident to calm her. She was still yelling out and he asked her if she was hurt and she did not respond to his question. They took her in and DCS was asked to assist in taking care of her wounds. He stated he saw blood on the sidewalk. He did not know how long they walked. He stated he had taken the resident for a walk before and she would hold her feet up or pedal along. He stated she would propel herself around the facility so that was why she did not have foot rests on the wheelchair. He stated he would have expected the SW to have noticed that the resident was dragging her feet and assessed to make sure the resident was not dragging her feet. After she was brought in the Unit Manager assessed the resident and dressed the wounds. During an interview on 09/17/13 at 1:59 PM with the Administrator he stated he had not thought of the need for the resident to have foot rests while staff was walking her outside. He stated Resident #55 had continued to intermittently scream while she was outside and when he went out to speak to the SW she was screaming. He stated now after the incident occurred with the resident's injuries he did see the need for her to have had footrests on her wheelchair. An interview was conducted 09/17/13 at 2:05 PM with the Physical Therapist (PT) who stated she was familiar with Resident #55. The PT stated the resident did not need the foot rests while she was propelling herself in the facility but she was weak so she should have had them if she was going to be pushed in her wheelchair for a long walk. During an interview on 09/17/13 at 3:55 PM the Director of Clinical Services (DCM) stated she was in the conference room when the Administrator came in and stated, "I need you". She stated she told staff to get towels to wrap the resident's feet as the slippers where bloody and there was a trail of blood. The slippers were fleece and came half way up her calf and soles had non skid treads. The toes were opened at the toe seam and were bloody. She stated Resident #55 was taken to the shower room and she told the nurses to bring the treatment cart to the shower room. She stated she took the towels and slippers off and sprayed her feet with the shower spray nozzle. The toes on her left foot were contracted around and the nails were under foot and the toes were abraded to the second knuckle. The wounds were beefy red. She stated the wounds on the right foot were on the tips of her toes and the nails. From what she could tell the nails were intact on the left foot. The Unit Manager dressed the wounds and called the on call doctor. She stated he told the Unit Manager to call Resident #55's regular physician in the morning. She explained after the first walk the SW brought Resident #55 back in and took her to her room. A few minutes later the Administrator asked the SW to take the resident outside for another walk. She stated when they brought the resident back into the building there was a streak of blood noted near the front door and a streak closer to the nursing office which she noticed as they were bringing the resident into the shower room. She pointed the bloody streak out to the Administrator and the SW. The regular physician did not see Resident #55 but gave the order to send her to the wound clinic. The wound clinic called and stated they wanted to send her to the hospital. She stated in hind sight, yes, the resident should have had footrests on her wheelchair. An interview was conducted on 09/18/13 at 9:07 AM with Nursing Assistant (NA) #1 who had worked first shift with Resident #55 the day of her accident. NA #1 stated she worked with her the next day as well. She stated she was given report on the morning of 09/12/13 from 3rd shift. They reported to her that the SW took Resident #55 into the parking lot to push her to see if it would calm her down. She explained the SW failed to notice that the resident ' s foot pedals were not on. Her feet were dragging under the wheelchair on the pavement. She wore knit boots that came up her calves that the NA had put on her in the morning. NA #1 stated the resident usually had the foot pedals on her wheelchair and she thought the resident left to go to dialysis with the foot pedals on her wheelchair the day of her accident. NA #1 stated when Resident #55 would propel herself in her wheelchair her feet touched the ground. Resident #55 did not wear shoes. She always wore something soft because of her contractures. She had been working with Resident #55 for a couple of months. She stated "you would have to really watch because her feet were contracted and they had dropsy". She stated if she had the foot pedals on her feet would sit on them flat but if she did not use foot pedals her feet would drop down. The resident did not pedal around the facility much. She was very sick and she would get tired and then say "push me". She stated you had to be very careful when pushing her because of the way her feet dropped. NA #1 explained when she did propel, which was very little, she would use her toes or the tips of her feet. The only time she ever saw her feet flat was when they were on the foot pedals. She asked the resident the morning of the 09/12/13 if she was hurting and she said "yes". NA #1 was helping the nurse dress the wounds and she asked the resident if she was in pain and she said "yes" and Nurse #1 went to get her something for pain. NA #1 reported the wounds on the left foot were deep holes/craters. She stated it was bad. She could not believe how bad it was. An interview was conducted on 09/18/13 at 9:50 AM with Nurse #1. She revealed the resident could self propel a very short distance out5 of her room or a short distance in the hall. She could not propel herself to meals. The resident did have foot rests but not always. The nurse stated she had held up her feet while the nurse was taking her to activities and to restorative dining. The cloth booties she usually wore were made of thick fleece fabric. Nurse #1 stated she was not here on the 09/11/13 when the injury occurred. She received report that Resident #55 had some abrasions on her toes and she saw the dressing needed to be changed as it had blood on it and it was due to be changed anyway. The wounds were wrapped in gauze and taped and she saw blood coming through the bandages. When she took the dressing off the gauze was stuck and she had to get wound cleanser to spray on the wounds to loosen the gauze. The resident did have pain before she did the dressing change as the resident would pull her foot away. The knuckles were scrapped and the 2nd and 3rd toes had big red craters filled with thick blood. As she got to the forth toe it had a deep crater but was not filled with blood. The toes were raw and either the third or the forth toe appeared to be deep and down to the bone. She could tell it was hurting the resident as she did the dressing change. She then dressed the foot and sent her to the wound clinic. Using the foot rests for this resident was a usual because she would sleep a lot. On 09/18/13 at 10:20 AM an interview was conducted with the Physical Therapy Assistant (PTA) who had been working with Resident #55. The PTA stated he had been working with her to try to increase her strength. He stated the resident was weak and she would only be able to hold her feet up for short distances. A telephone interview was conducted on 09/18/13 at 4:44 PM with the Social Worker (SW). He stated it was about supper time when he went down to the dining room and Resident #55 was screaming. She had eaten a little of her supper and she said she did not want anymore. He stated he did not notice anything wrong with her feet before taking her outside for a walk. The SW stated they were outside for 15-20 minutes. He stated he did not notice any problem. When walking her around he did not look down at her feet. Resident #55 was wearing her lap buddy. He explained her position in wheelchair was sitting straight up but that she did lean forward a time or two. The SW stated she would sit back then lean forward 30 seconds to one minute then lean back. He stated as far as he knew she was still holding her feet up. He stated he did see her holding them up but did not check to see how far off the ground they were. He stated he did not notice anything wrong with her feet. He went on to explain he let her rest, put her feet on the ground and then started pushing her around again. He stated he did not look at her feet very often. The SW indicated the resident was wearing cloth slippers that came up her calf like a boot. He stated he rolled Resident #55 in parking lot and down sidewalk. He went on to say he took her back into the facility and she started to scream. He stated when he brought her back in. He did not notice any blood. He stated the Administrator asked him to take her back outside. The SW verified she screamed intermittently during the first walk and progressively more during the second walk. He stated he took Resident #55 outside for another 15 minutes at which time he was near the front porch. He stated the Administrator came to tell him he was going too fast while walking with her. He stated he walked at his usual pace but he would consider himself to be a fast walker. He was talking with the Administrator for a few minutes when the Administrator noticed the blood. He stated he did not see blood until then. He stated her toes appeared to be rubbed off. He stated he did not know where they got rubbed off. The fabric on her slippers was torn where toes were. There was a lot of blood that was soaked through the material. He stated the Administrator pointed it out. The SW stated they immediately took her back in the facility and got the DCS. The SW explained he wrote a statement about what happened and left facility the about 8:20 PM. The SW stated he couldn't tell a difference with her screaming whether it was her normal state or if she was in pain. He stated he should have immediately put on the leg rests so she would not have to hold up her legs. He does not know if she had footrests for her wheelchair. He stated he should have stopped and asked her to pick up her feet. An interview was conducted on 09/19/13 at 8:37 AM with NA #1 who had worked with Resident #55 the morning of 09/11/13. She stated when she came in that morning Resident #55 was up, dressed, and wearing her cloth slippers. She stated her booties were clean and with out holes. During an interview on 09/19/13 at 4:05 PM the DCS she stated the resident did not have any other shoes that would have been more protective. She stated she never saw her with anything other than the cloth slippers. The DCS stated she thought the booties she was wearing were purchased by the family. To her knowledge the resident did not have any footrests for her wheelchair nor did she ever see her with footrests on her wheelchair. A telephone interview was conducted 09/19/13 at 4:52 PM with the County Transport Person who transported Resident #55 to and from dialysis. He stated Resident #55 had her foot rest on her wheelchair all of the time before the last state survey (08/16/13). He stated they were taped in place on her wheelchair with electrical tape. He stated she also had anti-tippers on her wheelchair. He stated after the last state survey he never saw the foot rests on her wheelchair again. During an interview on 09/19/13 at 5:08 PM the Unit Manager stated the resident had footrests that would be used for the resident when she was being transported to dialysis but when she was in the facility she did not use them as she self propelled. An interview was conducted 09/19/13 at 5:19 PM with Nursing Assistant #2 who worked with Resident #55 on the second shift. He stated he thought the resident had footrests on her wheelchair and he had noticed there was tape around the foam padding on the legs of the wheelchair. An interview was conducted on 09/20/13 at 10:03 AM with Nursing Assistant #3. She stated she worked with Resident #55 in the past and would transfer her to the restorative dining room and to the bathroom. She reported the resident always had footrests and she made sure her feet were on the footrest. She stated she could not remember if there was any tape on the footrests. An interview was conducted 09/20/13 at 10:11 AM with Nursing Assistant #4 who stated he remembered Resident #55 had footrests for a while. He stated he thought they might have broken. He stated he accompanied Resident #55 to dialysis and he would have to help her pick up her feet because she could not pick them up. Much of the time she was asleep because they would have to give her the medicine when she would scream. He stated Resident #55 would get medicine before she went to dialysis. He stated when he would come in at 7 AM she would be screaming and by the time we took her to dialysis she would be asleep. The facility's Administrator was notified of the Immediate Jeopardy for Resident #55 on 09/18/13 at 4:30 PM. The facility provided a credible allegation of compliance on 09/20/13 at 3:30 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance (AOC) IJ SUPERVISION TO PREVENT ACCIDENTS Resident #55's most recent admission was on July 24, 2013. Admitting [DIAGNOSES REDACTED]. On 09/11/13 Resident #55 was exhibiting her chronic habitual disruptive behavior of yelling out. She was rolled outside per care plan intervention in her wheelchair without foot rests attached by Social Services Director for a walk for approximately 10 minutes and then returned to the nursing unit. After returning to the nursing unit, she continued to exhibit repetitive noises and Resident #55 was asked if she would like to go outside again at which time she stated she did and was again transported in her wheelchair without foot rests attached for a walk by the Social Services Director. The Social Services Director did not supervise the placement of the resident's feet during the walk. While outside, blood was visualized on the resident's feet by the Executive Director. Resident #55 was then escorted to the shower room by the Director of Clinical Services, Executive Director and Social services. The resident's slippers were removed and her injuries were assessed. There was evidence of trauma to the right and left distal toes, left greater than right. The injuries were beefy red with no overt evidence of bone or tendon visible. The resident's status was reported to the on call physician on September 11, 2013 at approximately 8pm. Orders were received for the dressing treatment and the resident was transported to the wound clinic on 09/12/13 for evaluation. The resident was transported from the wound clinic to the local hospital for further evaluation and treatment of [REDACTED]. All residents who use a wheelchair have the potential to be affected by this practice. Current facility residents were reviewed by the Director of Clinical Services/Nurse Manager on September 18, 2013 for possible injury potential. No other residents were noted to have any injuries related to this practice. Residents with diabetes and vascular issues that utilize wheelchairs as primary mode of mobilization will be assessed daily for open areas, discoloration and blisters by the Director of Clinical Services/Nurse Manager/Charge Nurse. On September 11 & September 12, 2013, the Director of Clinical Services and Nurse Manager assessed all residents who utilize wheelchairs. Residents that require assistance propelling themselves in their wheelchair had leg rests/foot pedals applied to their chairs or readily available. Residents self propelling their wheel chairs will remain without leg rests on their chairs, unless being propelled by a staff member. Residents who self-propel were assessed for safety and proper positioning of feet. On admission, at risk residents will be assessed for proper footwear, wheelchair locomotion and any medical conditions that would affect mobility. Proper footwear will be furnished by the facility within 24 hours, as needed. On September 18, 2013, Licensed Nurses and Certified Nursing Assistants and Administrative staff were in-serviced by the Director of Clinical services and/or Nurse Manager regarding the facility policy and procedure for maintaining residents' safety during wheelchair transport including: proper supervision of foot placement; positioning of feet in wheelchair footrests and proper footwear that covers the foot; location of wheelchair foot rests for ready application; and location and availability of wheelchairs with foot rests/leg extenders near the main entrance to the facility. Staff will not be permitted to work until they are in-serviced. Future staff will be educated during orientation. Staff will be trained to position the residents' feet in the middle of the footrests during transport. Staff will maintain visual observation of residents during transport to maintain proper positioning of feet. Staff will be educated on ensuring Residents have protective footwear when out of bed. All licensed staff will be in-serviced on diabetes and its disease processes and complications related to vascular issues. Immediate Jeopardy was removed on 09/20/13 at 2:10 PM. Observation revealed all residents, who were identified as wheelchair dependent and at risk for injury when being pushed in their wheelchair had footrests in place. Interviews conducted with staff in all departments and who worked on all shifts confirmed that they had received in-service training on the facility's policy and procedure regarding wheelchair transfers.