Every finding on record at Corning Specialty Care

Based on direct observation, record review, staff interview, facility policy review, and Iowa Food Safety guidelines, the facility failed to serve food to residents in a safe and hygienic manner by making bare skin contact with residents food during the serving process and while assisting residents to eat for 2 of 3 meals observed. The facility reported a census of 25. Findings include: 1. A direct continuous observation of meal preparation and service on 02/17/2026 starting at 11:00 AM and ending at 12:36 PM revealed the following: At 11:28 AM Staff D, Cook, made direct bare skin contact with ready-to-eat foods when she used her fingers to push a slice of cake off of a spatula onto a plate for resident consumption. At 11:29 AM Staff D again made direct bare skin contact with cake, using her fingers to lift and place a slice of cake from the spatula onto a plate. At 11:39 AM Staff D made bare skin contact with a grilled cheese sandwich, holding it down with her hands and cutting it in half. This was then served to a resident. At 11:43 AM Staff D used her hand to take out a hamburger bun, separate the two halves, and then prepared a cheeseburger for service to a resident. At 11:44 AM Staff D used her hands to place premade bread and butter on a plate for resident consumption. At 11:46 AM Staff D began using her bare hands to prepare a peanut butter and jelly sandwich for resident consumption. While hands were washed at the start of the observation, they were not sanitized again until after the 11:46 AM observation, where the Dietary Manager intervened and requested she remake the peanut butter and jelly sandwich. During the continuous observation, Staff D touched numerous contaminated surfaces, door knobs, and picked and item up off of the floor. At not time until the 11:46 AM observation was hand washing or hand sanitizer used. In an interview on 02/17/2026 at 12:17 PM, Staff D stated she knew better than to touch food with bare skin, and acknowledged she should perform hand hygiene more frequently. In an interview on 02/17/2026 at 12:34 PM with the Dietary Manager, she confirmed the observations the surveyor had of the preparation and serving process. She stated it was not an acceptable standard of practice to touch ready-to-eat foods with bare skin and acknowledged that it was why she intervened at 11:46 AM. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of cerebrovascular accident (stroke), non-Alzheimer's dementia, and malnutrition. The MDS revealed the resident had a Brief Interview for Mental Status score of 5 out of 15, indicating severely impaired cognition. The MDS indicated the resident required partial to moderate assistance for eating. The Care Plan revised 1/21/26 revealed the resident had a nutrition risk related to a CVA with left sided weakness. The Care Plan interventions included for the resident to sit at an assist table in the dining room to ensure staff assisted her as needed, provide a regular diet, monitor for tolerance of her diet and cut meats into bite sizes. The Clinical Physician Orders revealed Resident #1 on a Level 7 regular diet (everyday foods that are easy to chew and cut easily, including sandwiches). During observation on 2/15/26 at 11:46 AM, Staff B, Certified Nursing Assistant (CNA) sat next to Resident #1 in the dining room. Staff B picked up the bun on top of a sandwich with her bare hand, placed the bun back on the sandwich, then took a knife and cut the sandwich in half while she held her bare hand over the bun. Staff B then picked up the sandwich and placed the sandwich in Resident #1's hand for the resident to eat. The resident then started to feed herself the sandwich. In an interview on 2/17/26 at 2:46 PM, the Director of Nursing (DON) reported she expected staff wore gloves if handling or touching food for the residents. A Preventing Foodborne Illness -Food Handling policy revised 7/2014 revealed food handled and served so that the risk of foodborne illness is minimized. A Food Preparation and Service policy revised 4/2019 revealed bare hand contact with food is prohibited. Gloves are worn when food is handled directly and changed between tasks.

Based on clinical record review, observation, staff interviews, policy review and manufacturer's instructions the facility failed to properly prime an insulin pen and administer insulin per the manufacturer guidelines for 1 or 3 residents observed for insulin administration to ensure the proper amount of insulin administered (Resident #4). The facility reported a census of 25 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had diagnoses of diabetes. The MDS documented the resident took insulin. The Care Plan revised 10/31/25 revealed the resident had diabetes and took insulin medication.The Medication Administration Record for Resident # 4 listed Lantus insulin 14 units subcutaneously (SQ) once a day for hyperglycemia (high blood sugar) was administered on 2/16/26 during the scheduled AM medication pass by Staff A, Licensed Practical Nurse (LPN). During observation on 2/16/26 at 10:35 AM, Staff A, LPN, attached a needle on the end of a Lantus insulin autoinjector pen. Staff A held the pen horizontally, turned the dial on the end of the pen to 2, then pushed the button on the end of the pen. Staff A then dialed the pen to 14. Staff A removed the cap on the pen, placed the pen by the resident's left abdomen, pushed the button on the end of the pen and held the pen in place for under 3 second. Staff A then removed the pen from the insertion site. At the time, Staff A reported he had recently hired to work at the facility but he had been a nurse for over 10 years. In an interview 2/17/26 at 2:40 PM, Staff C reported the process for administering insulin with a pen. Staff C reported after she checked the order, she wiped the end of the pen with alcohol, attached the needle, and then dialed the pen to 2. She held the pen straight up, pushed the end of the pen and watched for a bubble in order to prime the pen. Staff A reported she then dialed the pen to the amount of insulin that she needed to give to the resident. When she gave insulin with a pen, she held the pen in place for 10 seconds before she pulled the pen away from the insertion site. Staff C reported Staff A came to her on 2/16/26 and she went over what Staff A needed to do when he used an insulin pen. Staff A had only been at the facility under 2 weeks. In an interview on 2/17/26 at 2:46 PM, the Director of Nursing (DON) reported they did not have a policy for insulin pens. She expected the nursing staff to follow the manufacturer instructions. The DON walked through the process for using an insulin pen: Remove the cap on the pen, cleanse the end of the pen with an alcohol swab, attach the needle, dial the pen to 2, waste or prime by pushing the button and holding the pen upright, then dial to the amount of insulin needed. She would then wipe off the area she planned to inject the insulin, insert the needle, hold the pen at a 90 degree angle, and push the end of the pen to administer the insulin. The pen should be held in place for at least 5 seconds before she pulled the needle out.An Insulin Administration policy revealed the nurse will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use.The Lantus manufacturer instructions dated 8/2022 revealed the following procedural steps when gave an insulin injection: Remove the pen cap.Wipe the pen tip (rubber seal) with an alcohol swab.Screw the needle on.Remove the outer cap of the needle.Dial the pen to 2 units.Hold the pen with the needle pointed up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help get the most accurate dose.Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero. If no insulin comes out, repeat the test two more times. Use a new needle and repeat the test again if no insulin came out. Turn the dose selector to the number of units needed.Cleanse the site with alcohol.Hold the pen straight and insert the needle into the skin.Press the injection button all the way down until the dose counter shows O. Slowly count to 10 before removing the needle from the skin to ensure the full insulin dose got administered. Release the button and remove the needle from the skin.

Based on documents reviewed, staff interviews and policy review, the facility failed to report an alleged violation of verbal abuse in a timely manner. The facility failed to report observed verbal interactions between a staff member and Resident #1 within the required timeframe. The facility reported a census of 25. Findings include: The Intake Information to the State Agency for the Facility Reported Incident (FRI) revealed a submission date and time of 2/19/25 at 7:45 PM. The document revealed the date of the alleged abuse occurred on 2/19/25. On 5/27/25 at 12:42 PM Staff B, Certified Nurse Assistant (CNA), stated she heard Staff G, CNA, tell Resident #1 you did this to yourself, so you can get yourself up and clean yourself up. Staff G initially stated she notified the Director of Nursing (DON) within 24 hours of the incident, then stated she notified the DON immediately as the primary nurse was on a break. On 5/27/25 at 12:55 PM Staff A, Licensed Practical Nurse (LPN), stated she heard the comment made by Staff G to Resident #1, and separated the staff from the resident. Staff A stated she told Staff G she could not make those statements to a resident, and Staff G was not happy with Staff A. The staff stated the resident was crying. On 5/27/25 at 1:07 PM Staff C, CNA, stated she was working on the date of the verbal statement by Staff G, CNA, to Resident #1. The staff stated she provided care to Resident #1 following the statement by Staff G as the resident was crying and requested Staff G not help him anymore. The facility's self report document revealed the Director of Nursing was notified on 2/19/25 by Staff B of a comment made to Resident #1 by Staff G that he soiled himself and needed to clean himself up. The facility's document, Staff Statements, provided a written statement by Staff C stating Resident #1 requested the staff to assist him following Staff G's statement to him on the date of the reported incident and not wanting Staff G to work with him anymore. Staff C's statement further included witnessing on many occasions Staff G tell Resident #1 he was a grown ass man and needs to wipe his own ass. A written statement by Staff B revealed the staff witnessed Staff G make a comment to Resident #1 regarding soiling himself and needing to clean himself up on 2/18/25. Staff B's written statement further revealed witnessing Staff G making these types of statements prior to 2/18/25 and had assumed it had been reported by other staff. A statement written by Staff A revealed on 2/19/25 Staff G told her she (Staff G) told Resident #1 she was not going to clean his ass, if he was going home he needed to do it himself. The facility's Nursing Schedule 2/6/25-2/19/25 confirmed Staff G worked on 2/18/25 and not on 2/19/25. The document revealed Staff A, Staff B, and Staff G worked on 2/18/25 and 2/19/25. In an interview with Staff E and Staff F, Administrator, on 5/28/25 at 10:17 AM the DON stated she was notified of Staff G's statement to Resident #1 on 2/19/25. Staff F acknowledged at the time of the notification she had left the building for the day. Staff E stated she was getting ready to leave when Staff B returned to the facility and provided the statement regarding the interaction between Staff G and Resident #1. Staff E confirmed Staff B had completed her shift for the day when she returned to the facility and reported the interaction. When questioned whether the verbal statement by Staff G to Resident #1 occurred on 2/18/25 or 2/19/25 as it was reported on the FRI to the State Agency, Staff E and Staff F acknowledged the interaction had occurred on 2/18/25 not 2/19/25. Staff E and Staff F admitted as staff had not reported the verbal incident from Staff G to Resident #1, Staff G continued to work with the resident until 2/19/25 when the administration was notified after Staff G's shift. Staff E and Staff F expected staff to report alleged violations of abuse within the required time frame. The facility's Abuse Policy and Procedures, Dependent Adult Abuse 11/19 Edition, revealed mental abuse is the use of verbal conduct which causes or has the potential to cause resident humiliation, shame or degradation. The document revealed verbal abuse included mocking or ridiculing the resident and could be construed as a type of mental abuse. The document disclosed neglect included failure by the facility or employees to provide services to residents that was necessary to avoid mental anguish. The document revealed all allegations of resident abuse, neglect, or mistreatment must be reported immediately to the Charge Nurse, who is responsible for immediately reporting the allegation(s) to the Administrator or designated representative. The document further provided that all allegations of abuse shall be reported to the SA no later than 2 hours after the allegation was made.

Based on clinical record review, facility document review, staff interviews, and facility policy review the facility failed to provide dignity to 1 of 4 residents (Resident #1). The facility failed to provide dignity to the residents as demonstrated by a staff telling the resident to complete their own peri care when assistance was requested by the resident. The facility reported a census of 25 residents. Findings Include: The Minimum Data Set (MDS) for Resident #1, dated 1/15/25 in progress, identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognitive functioning. The resident had diagnoses of other fractures, seizure disorder or epilepsy, and Schizophrenia. The document identified the dependence for toileting hygiene and lower body dressing, and significant/maximal assistance for transfers and bed mobility. The document revealed frequent incontinence of bladder or always incontinent of bowel. Resident #1's Care Plan dated 3/24/25 revealed a focus area of Activities of Daily Living (ADL's) initiated on 1/10/25 with interventions including healing fractures of low back and pelvis with pain and needing time to adjust and instruct in safe manners to move when completing ADL's, partial assistance of 1 staff with gait belt and walker for toilet transfers, and dependence for toileting hygiene with date of 1/10/25. Resident #1's Electronic Medical Record (EMR) identified diagnoses of fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing. The EMR toileting hygiene document identified 39 entries of Resident #1 requiring dependent assistance from staff 10 entries for substantial/maximal assistance from staff, 2 entries for partial/moderate assistance, 2 entries for supervision, and 2 entries for independence. On 5/27/25 at 12:42 PM Staff B, Certified Nurse Assistant (CNA), stated she heard Staff G, CNA, walk into Resident #1's room and state you did this to yourself, so you can get yourself up and clean yourself up. Staff B stated Resident #1 told her Staff G had previously refused to provide care to him. On 5/27/25 at 12:55 PM Staff A, Licensed Practical Nurse (LPN), stated she heard Staff G make the comment to Resident #1 to clean himself up after an incontinence episode. Staff A stated she separated Staff G from Resident #1, and Resident #1 was crying after the statement by Staff G. Staff A stated Staff G had used inappropriate language in front of residents prior to the reported incident. On 5/27/25 at 1:07 PM Staff C, Certified Medication Aide (CMA), stated when working on 2/18/25 that Resident #1 requested she help him get up after Staff G made the statement, as he didn't want her (Staff G) helping any more. Staff C stated the resident was crying, and indicated he couldn't complete his own peri care all the time and sometimes had accidents. The facility provided document, interview with the identified resident, dated 2/19/25, revealed an interview with Resident #1 and Staff E, Director of Nursing (DON), and Staff F, Administrator. The document revealed Resident #1 identified Staff G told him you can clean your butt, you did it yourself. The resident stated Staff G makes him do it like every day. The facility provided document, Staff Statements, revealed Staff C's written statement that she had witnessed Staff G on many occasions tell Resident #1 that he is a grown ass man and needs to wipe his own ass. The statement also revealed Resident #1 requested Staff G no longer work with him due to the way she spoke to him. A written statement by Staff B revealed on 2/18/25 she heard Staff G tell Resident #1 to clean himself up after soiling himself. The statement further revealed Resident #1 acted upset and held his head down when Staff G made this comment to the resident. A statement written by Staff A revealed on 2/19/25 Staff G told her she (Staff G) told Resident #1 she was not going to clean his ass, if he was going home he needed to do it himself. On 5/28/25 at 10:17 AM Staff E and Staff F stated they expected facility staff to follow the residents' Care Plans, treat residents with respect, and follow the facility's Abuse Policy. The facility's document, Resident Rights, revised 12/16, revealed residents have the right to a dignified existence, and be treated with respect, kindness and dignity. The facility's document, Resident's [NAME] of Rights, revised 1/17, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of the resident's quality of life, recognizing each resident's individuality. The document further revealed the facility must protect and promote the rights of the resident. The document disclosed each resident has the right to be treated with dignity and respect.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not dating open food items or dispose of expired food items and not appropriately wearing hair restraints (hair nets). The facility reported a census of 26 residents. Findings include: 1. On [DATE] at 8:24 AM an observation revealed a single door freezer had a bag of open undated sausage patties. The double door refrigerator had a container of strawberries that were expired on [DATE], a pitcher of tomato juice that expired on [DATE], a 46 oz box of prune juice that was open and undated and a 46 oz box of cranberry juice cocktail that was open and undated. The dry storage had a 16 oz bag of potato chips that were open and undated and 8 bottles of Worcestershire sauce that was best if used by [DATE]. On [DATE] at 8:51 AM Staff A, Dietary Services Manger stated all drinks in pitchers were good for 3 days. Staff A acknowledged the pitcher of tomato juice and the container of strawberries were expired. Staff stated all food should be dated when the item was opened. Staff A acknowledged the sausage patties, box of prune juice, box of cranberry juice cocktail and the bag of potato chips were undated and all should have been dated. Staff A acknowledged the date of the Worcestershire sauce. Staff A removed all the bottles and stated she would be dumping them. Staff A stated the Worcestershire sauce was not ordered by her but the previous kitchen manager. Staff A stated she worked every Sunday and checked for expired items then and must have missed the Worcestershire sauce. On [DATE] at 1:59 PM Staff A stated there had been people who had walked through the kitchen not wearing a hair net. Staff A stated a hair net was required at all times when in the kitchen where food could be prepared. Staff A stated 2 weeks ago there was a verbal conversation with Staff C about the need for her to wear a hair net in the kitchen. Staff A stated staff had reported Staff C was not wearing a hair net at night while in the kitchen. On [DATE] at 3:12 PM Staff C, Cook, Dietary Aide, House Keeping Aide, and Laundry Aide stated she had worked at the facility since [DATE]st 2024. Staff C stated there had been times when she observed staff in the kitchen without hair nets. Staff C stated Staff A had discussed with her the need for her to wear hair nets while in the kitchen. Staff C stated somebody had reported to Staff A that she was not wearing a hairnet while in the kitchen. Staff C acknowledged she had not been wearing a hair net appropriately while in the kitchen. Staff C stated she did not have any formal disciplinary actions about not wearing a hair net, just a conversation. Review of policy revised ,d+[DATE] titled, Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of policy revised ,d+[DATE] titled, Preventing Foodborne Illness - Employee Hygiene And Sanitary Practices documented Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. On [DATE] at 3:09 PM the Administrator stated the facility's expectation was that all items of food opened should have an open date on them and expiration dates would be followed and food would be disposed of. The Administrator stated the facility's expectation was that hair nets would be worn by all staff at all times in the kitchen. 47079 2. On [DATE] at 1:48 pm, Staff A, DM and Staff C, [NAME] were observed in the kitchen area walking toward the exit door without hair nets. At 2:08 pm, Staff A, DM stated staff are to don a hairnet upon entry through the door and remove it at the door upon exit. She stated there was no reason for she or her staff to have not had their hairnets on at that point in the kitchen. She also stated all food was stored and the kitchen was clean but admitted she was not aware of that being an exception to the policy. On [DATE] at 7:55 PM, Staff D, DA was observed in the kitchen without a hair net. She stated she wasn't serving food but was rolling silverware. She stated she thought the facility's policy required hair nets in the kitchen.

Based on observation, resident and staff interviews, clinical record review, and policy review, the facility failed to develop and implement a Comprehensive Care Plan for 7 of 12 residents (Resident #10, #11, #13, #17, #22, #76, and #176) reviewed for care plans. The facility reported a census of 26 residents. Findings include: 1. On [DATE] at 9:49 AM, Resident #76 was observed lying in bed watching television. He stated he had been on oxygen (O2) for about 3 years. The oxygen delivery setting on his concentrator was observed at 4 liters per minute (LPM) or (L) via nasal cannula (NC). The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Atrial Fibrillation (abnormal heart beat), Coronary Artery Disease (narrow or hardened heart arteries), and Chronic Obstructive Pulmonary Disease (COPD). It did not include the resident's use of oxygen but was still being completed at the time of the survey. The Electronic Health Record (EHR) Physician Orders dated [DATE] included an order for Oxygen continuously at (3 L), maintain O2 Sat. of 88% and above. The Admission Orders dated [DATE] included oxygen inhale 3 L/min into the lungs continuous. Titrate to O2 saturation of 88%. Do not exceed 4 L/min. On [DATE] at 10:02 AM, the Director of Nursing (DON) stated the Admission Orders were accurate. The Oxygen (O2) saturation summary indicated the resident's blood oxygen level on [DATE] at 9:27 AM was 94%. It did not specify whether the resident was receiving supplemental oxygen at the time. The Care Plan dated [DATE] included OXYGEN SETTINGS: O2 via nasal cannula @ 3 L at rest and 4 L with exertion. The Care Plan failed to match admission orders. 49628 2. The MDS for Resident #10 dated [DATE] identified a BIMS score of 10 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of Anxiety Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). It did not identify any lack of pleasure, interest or feeling down/depressed, or potential indicators of psychosis. It also revealed the resident exhibited behavioral symptoms not directed toward others, but indicated the identified symptoms put the resident at significant risk for physical illness or injury, significantly interfered with resident's care, and with the resident's participation in activities or social interactions. It further indicated the resident rejected care and exhibited worsening in behavior, and care rejection compared to prior assessments. The MDS identified Resident #10 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #10's Physician Orders dated [DATE] identified the resident was prescribed a.) Fluoxetine HCI Capsule 40 mg 1 capsule and 10 mg 1 capsule by mouth for a total of 50 mg daily for depression b.) Olanzapine 5 mg 1 tablet daily for psychotic disorder related to Major Depressive Disorder, Recurrent, Moderate, and Generalized Anxiety Disorder. An Electronic Medical Record (EMR) Progress Note dated [DATE] identified occasional behavioral disturbances as mild. Behavior Symptoms documentation did not identify any behaviors in the past 30 days. Resident #10's Care Plan revised [DATE] included an antidepressant medication focus area related to major depressive disorder. A goal identified decreased symptoms of depression throughout the review period. However, the interventions/tasks did not include the resident s target behaviors of depression. It also included an antipsychotic medication focus area related to anxiety and cognitive function decline with behaviors. A goal of decreased behavioral episodes throughout the review period was noted. However, the interventions/tasks did not identify the resident's target behaviors. 3. The MDS for Resident #11 dated [DATE] identified a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of Anxiety Disorder, and Depression. It neither identified any symptoms of lack of please/interest or feeling down/depressed nor potential indicators of psychosis. It revealed the resident exhibited behavioral symptoms not directed toward others, and the identified symptoms did not significantly impact the resident or others in the environment. The document revealed no change in behavior or other symptoms. The MDS identified the resident took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #11's Physician Orders dated [DATE] identified the resident was prescribed a.) Risperdal (Risperidone) Oral Tablet 2 mg 1 tablet twice daily for Major Depression, b.) Sertraline HCI 150 mg once daily for Major Depression, and Clonazepam Tablet .5 mg 1 tablet twice daily for Generalized Anxiety. The EMR Progress Notes identified on [DATE] the resident isolated to his room most times with refusals to get up. An entry on [DATE] indicated the resident was pushing against staff during personal care but was redirectable without further behaviors, and refused to get out of bed. The Behavior Symptoms documentation revealed the resident had behaviors of rejection of care on [DATE] and kicking/hitting on [DATE]. Resident #11's Care Plan revised on [DATE] did not identify focus areas, goals, or interventions related to the antipsychotic and antidepressant medications and their respective target behaviors. 4. The MDS for Resident #13 dated [DATE] identified a BIMS score of 3 out of 15 which indicated severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia, and Alzheimer's Disease. It neither identified any symptoms of lack of please/interest or feeling down/depressed nor potential indicators of psychosis. It revealed the resident exhibited behavioral symptoms directed toward others. The MDS identified the resident took antipsychotic medication during the last 7 days of the assessment period. Review of Resident #13's Physician Orders dated [DATE] identified the resident was prescribed a.) Seroquel Oral Tablet 25 mg (Quetiapine Fumarate) give 1 tablet daily for behavioral disturbances b.) Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) give 1 tablet in the evening for Vascular Dementia. The EMR Progress Notes from [DATE] to [DATE] revealed numerous entries with behaviors of yelling at staff and other residents, attempts of hitting staff and residents and delusions regarding deceased family members. The Behavior Symptoms documentation revealed rejection of care on [DATE]. Resident #13's Care Plan revised on [DATE] revealed a psychotropic medication focus area related to vascular dementia for behavioral management. A goal identified decreased symptoms of depression throughout the review period. However, the interventions/tasks did not include the resident's target behaviors of depression. It also included an antipsychotic medication focus area related to anxiety and cognitive function decline with behaviors. A goal of decreased behavioral episodes throughout the review period was noted. However, the interventions/tasks did not identify the resident's target behaviors. 5. The MDS for Resident #17 dated [DATE] identified a BIMS score of 15 out of 15 which indicated normal cognitive impairment. The MDS included diagnoses of Anxiety Disorder and depression. It did not identify any symptoms of lack of please/interest or feeling down/depressed, but did indicate rare instances of social isolation. It neither identified potential indicators of psychosis nor behavioral symptoms towards others, herself or rejection of care. The MDS identified the resident took an antidepressant medication during the last 7 days of the assessment period. Review of Resident #17's Physician Orders dated [DATE] identified the resident was prescribed Fluoxetine HCI Oral Tablet 10 mg 3 tablets for a total of 30 mg daily for depression. The EMR Progress Notes from [DATE] to [DATE] revealed entries with anxiety behaviors related to ailments, attention, medications, and weight. The Behavior Symptoms documentation revealed no behaviors. Resident #17's Care Plan revised on [DATE] revealed an antidepressant medication focus area related to bipolar. A goal identified freedom from discomfort or adverse reactions related to antidepressant therapy. However, the interventions/tasks did not include the resident's target behaviors of depression. 6. The MDS for Resident #22 dated [DATE] identified a BIMS score of 15 out of 15 which indicated normal cognitive impairment. The MDS included diagnoses of Anxiety Disorder and depression. It identified symptoms of feeling down/depressed for ,d+[DATE] days and sometimes socially isolated. It identified hallucinations, rejection of care for 1 to 3 days, and worsened behaviors and rejection of care. The MDS identified the resident took antipsychotics and antidepressant medications during the last 7 days of the assessment period. Review of Resident #22 Physician Orders dated [DATE] identified the resident was prescribed a.) Seroquel 12.5 mg at bedtime for Hallucinations b.) Namenda (Memantine HCI) 10 mg 1 tablet daily for Major Depressive Disorder c.) Zoloft (Sertraline HCI) Oral Tablet 100 mg 2 tablets for 200 mg daily for depression d.) Wellbutrin XL Oral Tablet Extended Release 24 hour 150 mg (Bupropion HCI) 1 tablet daily for depression. The EMR Progress Notes from [DATE] to [DATE] revealed entries with hallucinations (verbal and audible), isolation, refusal of getting up, and medication refusals. The Behavior Symptoms documentation revealed no behaviors. Resident #22's Care Plan revised on [DATE] revealed a risk for side effects from antipsychotic drug use. A goal identified no injury related to medications and maintenance of normal/therapeutic blood drug range. The Care Plan did not identify target behaviors related to the use of an antipsychotic medication. 7. The MDS for Resident #176 dated [DATE] was an Admission Medicare - 5 day document and did not contain a BIMS, diagnoses, medications, or treatments. The EMR included diagnoses of depression, hypertension, and pain. Review of Resident #22 Physician Orders dated [DATE] identified the resident was ordered to have oxygen continuously at 3 Liters (L) every night shift. The hospital discharge document dated [DATE] revealed oxygen administration 3 L at night. The Order Summary Report dated [DATE] indicated oxygen continuously at 3 L every night shift. Resident #176's Care Plan initiated on [DATE] revealed altered respiratory status/difficulty breathing related to COPD and needing oxygen focus area. A goal identified no signs and symptoms of poor oxygen absorption through the review date. The interventions/task revealed oxygen setting of oxygen via nasal cannula with prongs using 3 L/minute continuously and may use 4 liters with exertion. The intervention did not match with physician orders. The facility policy, Goals and Objectives, Care Plans, revised [DATE], revealed objectives should be resident oriented, behaviorally stated and are derived from the information contained in the comprehensive assessment. It indicated goals and objectives were written for all disciplines to have access to information and report whether the desired outcomes are being achieved. On [DATE] at 8:03 AM the Administrator, Director of Nursing (DON), and MDS Coordinator stated the interventions/tasks of a Care Plan should reflect the focus area. The DON stated it should be specific to the focus area. The staff stated the Certified Nursing Aides (CNAs) utilize a Kardex system for reference on a residents needs and abilities which is condensed from the interventions of the Care Plan. The DON acknowledged that if target behaviors for a particular medication were not identified on the interventions/tasks the staff would not be able to report them.

Based on clinical record review, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic medication use for 5 of 12 residents reviewed (Resident #10, #11, #13, #17, and #22). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #10 dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of Anxiety Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). It did not identify any lack of pleasure, interest or feeling down/depressed, or potential indicators of psychosis. It also revealed the resident exhibited behavioral symptoms not directed toward others, but indicated the identified symptoms put the resident at significant risk for physical illness or injury, significantly interfered with resident's care, and with the resident's participation in activities or social interactions. It further indicated the resident rejected care and exhibited worsening in behavior, and care rejection compared to prior assessments. The MDS identified Resident #10 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #10's Physician Orders dated [DATE] identified the resident was prescribed a.) Fluoxetine HCI Capsule 40 mg 1 capsule and 10 mg 1 capsule by mouth for a total of 50 mg daily for depression b.) Olanzapine 5 mg 1 tablet daily for psychotic disorder related to Major Depressive Disorder, Recurrent, Moderate, and Generalized Anxiety Disorder. The Physician Orders failed to include target behaviors for each psychotropic medication order. An Electronic Medical Record (EMR) Progress Note dated [DATE] identified occasional behavioral disturbances as mild, but did not identify specific target behaviors. Behavior Symptoms documentation did not identify any behaviors in the past 30 days. Resident #10's Care Plan revised [DATE] included an antidepressant medication focus area related to major depressive disorder, and an antipsychotic medication focus area related to anxiety and cognitive function decline with behaviors. However target behaviors were not identified in the document. 2. The MDS for Resident #11 dated [DATE] identified a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of Anxiety Disorder, and Depression. It neither identified any symptoms of lack of please/interest or feeling down/depressed nor potential indicators of psychosis. It revealed the resident exhibited behavioral symptoms not directed toward others, and the identified symptoms did not significantly impact the resident or others in the environment. The document revealed no change in behavior or other symptoms. The MDS identified the resident took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #11's Physician Orders dated [DATE] identified the resident was prescribed a.) Risperdal (Risperidone) Oral Tablet 2 mg 1 tablet twice daily for Major Depression b.) Sertraline HCI 150 mg once daily for Major Depression c.) Clonazepam Tablet .5 mg 1 tablet twice daily for Generalized Anxiety. The Physician Orders failed to include target behaviors for each psychotropic medication order. The EMR Progress Notes identified on [DATE] the resident isolated to his room most times with refusals to get up. An entry on [DATE] indicated the resident was pushing against staff during personal care but was redirectable without further behaviors, and refused to get out of bed. The Behavior Symptoms documentation revealed the resident had behaviors of rejection of care on [DATE] and kicking/hitting on [DATE]. Resident #11's Care Plan revised on [DATE] did not identify focus areas, goals, or interventions related to the antipsychotic and antidepressant medications and their respective target behaviors. 3. The MDS for Resident #13 dated [DATE] identified a BIMS score of 3 out of 15 which indicated severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia, and Alzheimer's Disease. It neither identified any symptoms of lack of please/interest or feeling down/depressed nor potential indicators of psychosis. It revealed the resident exhibited behavioral symptoms directed toward others. The MDS identified the resident took antipsychotic medication during the last 7 days of the assessment period. Review of Resident #13's Physician Orders dated [DATE] identified the resident was prescribed a.) Seroquel Oral Tablet 25 mg (Quetiapine Fumarate) 1 tablet daily for behavioral disturbances b.) Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) 1 tablet in the evening for Vascular Dementia. The Physician Orders failed to include target behaviors for each psychotropic medication order. The EMR Progress Notes from [DATE] to [DATE] revealed numerous entries with behaviors of yelling at staff and other residents, attempts of hitting staff and residents and delusions regarding deceased family members. The Behavior Symptoms documentation revealed rejection of care on [DATE]. Resident #13's Care Plan revised on [DATE] revealed a psychotropic medication focus area related to vascular dementia for behavioral management, and an antipsychotic medication focus area related to anxiety and cognitive function decline with behaviors. However it did not identify the resident's target behaviors. 4. The MDS for Resident #17 dated [DATE] identified a BIMS score of 15 out of 15 which indicated normal cognitive impairment. The MDS included diagnoses of Anxiety Disorder and depression. It did not identify any symptoms of lack of please/interest or feeling down/depressed, but did indicate rare instances of social isolation. It neither identified potential indicators of psychosis nor behavioral symptoms towards others, herself or rejection of care. The MDS identified the resident took an antidepressant medication during the last 7 days of the assessment period. Review of Resident #17's Physician Orders dated [DATE] identified the resident was prescribed a.) Fluoxetine HCI Oral Tablet 10 mg 3 tablets for a total of 30 mg daily for depression. The Physician Orders failed to include target behaviors for each psychotropic medication order. The EMR Progress Notes from [DATE] to [DATE] revealed entries with anxiety behaviors related to ailments, attention, medications, and weight, but not target behaviors. Resident #17's Care Plan revised on [DATE] revealed antidepressant medication use, but did not include target behaviors for staff to monitor. 5. The MDS for Resident #22 dated [DATE] identified a BIMS score of 15 out of 15 which indicated normal cognitive impairment. The MDS included diagnoses of Anxiety Disorder and depression. It identified symptoms of feeling down/depressed for ,d+[DATE] days and sometimes socially isolated. It identified hallucinations, rejection of care for 1 to 3 days, and worsened behaviors and rejection of care. The MDS identified the resident took antipsychotics and antidepressant medications during the last 7 days of the assessment period. Review of Resident #22's Physician Orders dated [DATE] identified the resident was prescribed a.) Seroquel 12.5 mg at bedtime for Hallucinations, Namenda (Memantine HCI) 10 mg 1 tablet daily for Major Depressive Disorder b.) Zoloft (Sertraline HCI) Oral Tablet 100 mg 2 tablets for 200 mg daily for depression c.) Wellbutrin XL Oral Tablet Extended Release 24 hour 150 mg (Bupropion HCI) 1 tablet daily for depression. The Physician Orders failed to include target behaviors for each psychotropic medication order. The EMR Progress Notes from [DATE] to [DATE] revealed entries with hallucinations (verbal and audible), isolation, refusal of getting up, and medication refusals. The Behavior Symptoms documentation revealed no behaviors. Resident #22's Care Plan revised on [DATE] revealed a risk for side effects from antipsychotic drug use, but did not identify target behaviors. On [DATE] at 8:03 AM the Administrator, Director of Nursing (DON), and MDS Coordinator acknowledged target behaviors should be identified for each psychotropic medication. The facility did not provide a policy related to medications and target behavior identification.

Based on observation, resident and staff interviews, clinical record review, and policy review, the facility failed to revise a resident's Care Plan to include a newly inserted indwelling catheter. The facility reported a census of 26 residents. Findings include: On 1/21/25 at 10:32 AM, Resident #16 stated he had an indwelling catheter (urinary catheter) for about 6 months per his request. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated a completely intact cognition. It included diagnoses of hypertension, Diabetes Mellitus (DM), pneumonia, Chronic Kidney Disease (CKD), hemiplegia (one-sided weakness), and difficulty walking. It indicated the resident was independent with eating, required set-up assistance with oral and personal hygiene, required maximum assistance with toilet transfers, and was dependent with lower body dressing and toileting hygiene. It also revealed the resident was frequently incontinent. The Electronic Health Record (EHR) included a physician order for an indwelling catheter dated 12/03/24. The last Care Plan revision was dated 11/19/24 and did not include an indwelling catheter. On 1/23/25 at 10:02 AM, the Director of Nursing (DON) stated staff should have revised the Care Plan after inserting the resident's indwelling catheter. A policy titled Goals and Objectives, Care Plans revised April 2009 indicated goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved; c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and d. At least quarterly.

Based on observation, clinical record review, staff interviews, and facility procedure review the facility failed to protect a resident from a possible accident and injury by pushing the resident in a wheelchair without foot rests for 1 of 12 residents (Resident #11) reviewed. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) for Resident #11 dated 10/30/24 identified a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of Anxiety Disorder, and Depression. It revealed the resident required substantial or maximum assistance for sit to/from stand positions, and transfers to/from bed, wheelchair and toilet. It further indicated the resident utilized a manual wheelchair and could wheel at least 150 feet with setup assistance. Resident #11's Care Plan revealed he required substantial to dependent assistance for transfers to/from the wheelchair. Observation on 1/21/25 at 12:26 PM revealed Staff E, Certified Nursing Assistant (CNA) pushed Resident #11 from the dining room to his bedroom with both of the resident's feet touching the floor with no footrests present. The distance was approximately 50 feet. Observation on 1/22/25 at 11:47 AM revealed Staff F, CNA, use a handheld grasp with Resident #11 while walking to the side and slightly ahead of the resident while in the wheelchair. The resident appeared to be pulling on the staff's hand to move forward. The resident's feet were on the floor and were attempting to move the wheelchair. The resident stopped every 4-5 feet. The last 10 feet the staff pulled the resident to his dining table with no movement of the resident's feet. Observation on 1/22/25 at 12:16 PM revealed Resident #11 self propelled from the dining room to his bedroom independently. On 1/22/25 at 12:45 PM Staff G, CNA, stated residents must have footrests on to be pushed in their wheelchairs. The staff stated they are trained upon hire to use footrests. Staff G stated if a resident does not have footrests they cannot be pushed, and footrests should be kept on the back of the wheelchair. On 1/22/25 at 2:28 PM Staff B, Licensed Practical Nurse (LPN), stated residents must have footrests on their wheelchairs to be pushed. The staff stated training has been provided on the use of footrests on wheelchairs in the past several months. The staff stated she has observed other staff push residents without footrests. On 1/23/25 at 8:40 AM the Administrator, MDS Coordinator, and Director of Nursing (DON) concurred that the facility had the requirement for residents to be pushed in their wheelchairs and footrests must be in place. The Administrator stated residents should not be pushed without footrests. The DON stated it was part of basic training to be a CNA that footrests were to be in place on wheelchairs to prevent injuries. The facility document, Wheelchair (use of) from Nursing Guidelines and Procedure Manual, dated January 2015 edition, revealed footrests were to be out of the resident ' s way for safety prior to transfer, but not removed from the wheelchair. It further indicated footrests were to be lowered, and the resident's feet placed on the footrests once the resident was seated in the wheelchair.

Based on observation, staff interviews, clinical record review and policy review the facility failed to ensure the residents were free of significant medication errors to 1 of 6 residents reviewed (Resident #16). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #16 entered the facility on 3/23/22. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented Resident #16 had a diagnosis of type 2 diabetes mellitus with hyperglycemia. Review of Resident #16's Medication Administration Record (MAR) documented an order for insulin glargine solution (Lantus)100 UNIT/ML inject 50 unit subcutaneously one time a day in the morning. On 1/22/25 at 7:18 AM an observation of Staff B Licensed Practical Nurse (LPN) drawing insulin to administer to Resident #16 revealed Staff B removed Lantus insulin from the medication cart, cleansed the insulin bottle septum with an alcohol wipe, and drew out 46 units from the insulin bottle. Staff B stated her intent was to give Resident #16 Lantus insulin prepared in the syringe. The surveyor then requested Staff B to verify the amount of insulin ordered with the amount of insulin in the syringe. Staff B acknowledged 46 units in the syringe and Resident #16 had an order for 50 units of Lantus insulin. Staff B then drew up 50 units and administered the insulin. On 1/22/25 at 7:42 AM the DON stated the nurse should have followed policy. Stated she should have followed the rights of medication administration and the physicians order. Review of policy revised 4/19 titled, Administering Medications documented The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observations, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 26 residents reviewed. The facility reported a census of 26 residents. Findings include: On 1/21/25 at 11:45 AM an observation of lunch service revealed Staff A completed hand hygiene and started lunch service. Two mechanical soft roast beef in portions on a plate and a single puree portion of roast beef in a bowl placed on the steam table after being prepared in the food processor. Staff A acknowledged intent to serve mechanical and puree plates. Temperature check requested by surveyor of puree and mechanical soft roast beef. The temperature of the mechanical soft roast beef on the plates were 99 degrees and 97 degrees. The temperature of the puree roast beef was 92 degrees. Staff A heated all 3 dishes in the microwave. Pureed roast beef heated to 152.6 and mechanical soft roast beef heated to 152.7 and 158.2. On 1/22/25 at 8:29 AM Staff A stated a temperature of 155 - 165 would be an acceptable temperature to serve the mechanically altered food. Staff A acknowledged the food was not at an acceptable temperature to serve to the residents. Review of policy revised 4/19 titled, Food Preparation and Service documented Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds. On 1/22/25 at 4:15 PM the Administrator stated the facility's expectation was the cook would have followed the facility's policy. The Administrator stated her expectation was the mechanically altered hot food would remain above 135 degrees or reheated to 165 for at least 15 seconds.

Based on resident and staff interview, clinical record review, and policy review, the facility failed to ensure accurate and complete resident records for 1 of 12 residents reviewed. Resident #22 did not have an inventory sheet in her record, and the resident stated she had lost a phone. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) for Resident #22 dated 12/4/24 identified a BIMS score of 15 out of 15 which indicated normal cognitive impairment. The MDS included diagnoses of Anxiety Disorder and depression. The Electronic Medical Record (EHR) Progress Notes reviewed from 3/1/24 to 1/23/25 revealed the resident had made a report of a missing jacket on 8/16/24, which was found. Other Progress Note entries revealed the resident had a vehicle that was full of belongings, and lived in multiple locations prior to admission to the facility. The notes reflected the resident having stacks of items in her room and does not like assistance with these items or for people to touch her items. The Care Plan dated 12/6/24 did not reveal Resident #22 to have behaviors of making false reports of missing items. The Care Plan lacked behaviors regarding the keeping of excessive items in her room or car, or refusing of assistance for organization of her items. On 1/21/25 at 11:02 AM and on 1/22/25 at 12:10 PM Resident #22 stated she had lost a cell phone towards the end of June 2024 after returning from the hospital. The resident stated she notified the Business Office Manager (BOM). On 1/22/25 at 2:47 PM the BOM stated the resident did not inform her of a missing cell phone in June of 2024. The staff stated the resident had a phone in her room that she knew of. The BOM looked through the resident's room with the resident present and with permission and found a blue phone. The BOM stated the resident told her the blue phone was an old phone and the missing phone was blue. The BOM stated the itemized inventory list was managed by the Social Services Coordinator who also had the same first name and the resident may have told her about the missing phone. On 1/22/25 at 3:26 PM and 3:39 PM the Social Services Coordinator (SSC) stated there may or may not be an itemized inventory list for the resident. The staff stated she was aware of the resident's blue phone, but did not know anything about a missing pink phone. The SSC stated she was unable to locate an inventory sheet for the resident. The staff stated the resident had bags of items located in her closet, as well as her personal vehicle which was parked in a neighboring parking lot. The staff stated the resident had a history of making false claims regarding missing items. The staff stated the inventory list for the resident would likely be inaccurate due to the number of items the resident accumulated. The staff stated the resident was provided with donated items upon admission as she did not have appropriate clothing and personal items due to prior living arrangements of living in hotels. The SSC stated the resident would report if a cell phone was missing. On 1/22/25 at 3:45 PM the Regional Consultant confirmed there was not an itemized inventory sheet for the resident. The facility policy, Personal Property, revised March 2021, revealed a resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. On 1/22/25 at 4:00 PM the Administrator acknowledged that without an itemized inventory sheet the facility could not verify a resident's belongings and would not be able to know whether a resident was making a false claim. The Administrator expected there to be itemized inventory sheets for all residents.

Based on observations, clinical record review, resident and staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not following physician orders for 1 of 12 residents (Resident #176) reviewed. The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) for Resident #176 dated 1/18/24 was an Admission Medicare - 5 day document and did not contain a Brief Interview of Mental Status score, diagnoses, medications, or treatments. The Electronic Medical Record (EMR) included diagnoses of depression, hypertension, and pain. Review of Resident #22 Physician Orders dated 1/20/25 identified the resident was ordered to have oxygen (O2) continuously at 3 Liters (L) every night shift. The Hospital Discharge document dated 1/18/25 revealed O2 administration 3 L at night (HS). The Order Summary Report dated 1/20/25 indicated O2 continuously at 3 L every night shift. Resident #176's Care Plan initiated on 1/19/25 revealed altered respiratory status/difficulty breathing related to COPD and needing oxygen focus area. A goal identified no signs and symptoms of poor oxygen absorption through the review date. The interventions/task revealed oxygen via nasal cannula with prongs using 3 L/minute continuously and may use 4 liters with exertion. The intervention did not match with physician orders. On 1/21/25 at 9:25 AM observed Resident #176 seated in her recliner awake with oxygen via nasal cannula with the concentrator set at 3 L. The oxygen tubing did not have a date of placement or initials of staff who placed the tubing. On 1/21/25 at 3:46 PM observed the resident to be lying in bed with oxygen via nasal cannula with the concentrator set at 3 L. On 1/22/25 at 11:09 AM observed the resident lying in bed sleeping with oxygen via nasal cannula with the concentrator set at 3 L. On 1/22/25 at 1:06 PM observed the resident lying down with O2 via nasal cannula at 3 L. On 1/22/25 at 2:22 PM Staff B, Licensed Practical Nurse (LPN), stated tubing for oxygen is changed every Sunday night and should be documented in the Treatment Administration Record (TAR). The staff stated if an order indicated 3 L at HS, it would be expected the oxygen would be used at bedtime. On 1/23/25 at 8:35 AM the Director of Nursing (DON) and MDS Coordinator stated that if an order for a resident indicated HS they would expect oxygen would be used when the resident was sleeping at night. On 1/23/25 at 8:40 AM the DON and the Administrator stated they expected care to be provided to the residents per physician orders. The facility policy, Administering Medications, revised April 2019, revealed medications are administered in accordance with prescriber orders, including any required time frame.

Based on record view, family, staff, clinic staff and physician interview, the facility failed to ensure 1 of 3 residents went to their follow up appointments post hospitalization (Resident #1). The facility reported a census of 26 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 5/23/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented the resident was admitted to the facility on [DATE]. The following diagnoses were listed for Resident #1: sepsis, anemia, atrial fibrillation, heart failure, septicemia, stroke, malnutrition, anxiety, and depression. The Care Plan focus area with an initiation date of 5/31/24 documented Resident #1 had a biliary drain. The After-Visit Summary dated 5/4/24 through 5/17/24 was faxed to the facility on [DATE], to the previous Director of Nursing (DON). The summary included the following scheduled appointment: a. May 24, 2024 at 10:20 AM video tele-medicine with a Physician's Assistant (PA) at a Nephrology Clinic. Review of Resident #1's Progress Notes revealed no documentation about her 5/24/24 appointment with the nephrologist. Clinical record review revealed Resident's record lacked documentation from her 5/24/24 appointment with the nephrologist. Review of the facility's appointment book for May 2024 revealed no appointments for Resident #1 had been documented for 5/24/24. On 7/2/24 at 2:07 PM the MDS Coordinator/Interim Director of Nursing (DON) stated the family had requested some labs to be completed on Resident #1 and discussed the missed appointment. This prompted the MDS Coordinator/Interim DON to go through Resident #1's After-Visit Summary. As she reviewed that summary, found the appointment with her nephrologist was missed. She called them to get that rescheduled. On 7/3/24 at 2:54 PM a call was placed to the nephrologist clinic where Resident #1's 5/24/24 appointment was scheduled at. The clinic staff indicated they had documented on 5/24/24 the resident was a no show with no follow-up communication to indicate why it was missed. She indicated a month ago today, it looked like they wanted to know if another tele-health appointment was ok. The clinic indicated the resident would need to be seen in person and rescheduled the appointment for 7/11/24. When asked to speak with the PA that the resident was scheduled to see, she indicated she was out of the office. She added this would have been the first time the PA would have seen Resident #1 and was unsure how much information she could provide. On 7/5/24 at 11:27 AM the Regional Nurse Consultant acknowledged she was unable to find any documentation on the missed 5/24/24 appointment. She added she was not able to find the appointment in their schedule book either. On 7/5/24 at 1:17 PM the previous Director of Nursing (DON) stated Resident #1's first tele-health appointment was missed. She had the MDS Coordinator/Interim DON rescheduled that appointment for the resident. When asked what appointment was missed, she thought it may have been with the Nephrologist. When asked who had set up the initial appointment, the previous DON indicated she wanted to say it was on her discharge instructions but was not 100% on that. When asked why the appointment was missed she stated it may have been an IT type of issue. On 7/5/24 at 2:35 PM the Administrator spoke with the MDS Coordinator/Interim DON about the 5/24/24 appointment for Resident #1. They have a Registered Nurse (RN) that does all the scanning of documents for the facility. Believed at that time, the RN was on vacation. When the Administrator was asked if the nurse admitting the resident to the facility is responsible for review hospital documentation to reconcile medications, note any appointments, or anything pertinent to the hospitalization , he acknowledged they should be reviewing the discharge paperwork. The facility provided a document titled Admission Orders. The documented indicated the purpose was to provide essential care according to physician directives. Staff are to obtain information for orders from transfer forms received from resident and/or family, or any other accompanying information. Orders must be obtained at a minimum for food service, medical administration, routine care, additional specific needs, and rehabilitation directives.

Based on clinical record review, guidance from the Resident Assessment Instrument (RAI), and staff interview, the facility failed to document the Minimum Data Set (MDS) assessment to accurately reflect the resident status for 4 of 4 residents reviewed (Resident #5, #16, #19 and #21). The facility reported a census of 24 residents. Findings include: 1. The MDS of Resident #5 dated 11/18/23 documented the resident was currently taking an anticoagulant medication. The Care Plan of Resident #5, revision date 2/5/24 documented the resident to be on antiplatelet therapy related to atrial fibrillation. The Medication Administration Report (MAR) for Resident #5 for the month of November, 2023 failed to reveal documentation of the resident receiving any anticoagulant medication. The MAR reflected the resident received 81 mg of aspirin, delayed release, daily in the month of November. 2. The MDS of Resident #16 dated 11/4/23 failed to document the use of anti-anxiety medication. The Care Plan of Resident #16, revised 2/5/24 documented Resident #16 to be taking two separate anxiety medications, Ativan and Buspirone. The MAR of Resident #16 for the months of October and November, 2023 revealed the resident received Buspirone daily for both months captured in the 7 day look back period of the MDS. 3. The MDS of Resident #19 dated 11/11/23 failed to document the use of anti-anxiety medication. The Care Plan of Resident #19 reflected a focus area of use of anti-anxiety medications initiated on 10/24/22 and revised on 2/1/24. The MAR of Resident #19 for November of 2023 revealed the resident received clonazepam, an anti-anxiety medication, three times daily during the month. 4. The MDS of Resident #21, dated 11/18/23 identified Resident #21 to be currently considered by the state level II PASRR (Preadmission Screening and Resident Review ) process to have a serious mental illness and/or intellectual disability or a related condition. Additionally, the MDS failed to document the use of anti-anxiety medication. The Care Plan of Resident #21 revealed a focus area dated 2/15/22 noting the use of anti-anxiety medication by the resident. The Maximus Notice of PASRR Level 1 Screen Outcome, dated 2/15/22 of Resident #21 revealed the resident did not require a PASRR Level II. The MAR of Resident #21 for the month of November 2023 documented the resident took Xanax, an anti-anxiety medication daily during the month. On 2/6/24 at 3:37 pm, via email, the Administrator verified the 2/15/22 PASRR is the most current PASRR for Resident #21. On 2/8/24 at 10:01 am, the Director of Nursing stated the facility currently does not have an MDS Coordinator in the building but has a remote person who is currently completing the MDS. She stated she will be notifying them of these errors to have them modified for accuracy and her expectation of the the MDS to be completed accurately. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, October 2023, directed for PASRR to code 0, no, if a PASRR Level I screening did not result in a referral for a Level II screening. Additionally the RAI manual directed to check for anti-anxiety drug use if an anxiolytic (anti anxiety) medication was taken by the resident at any time during the 7-day look back period, with the same instruction for anticoagulant medication.

Based on observation, staff interview, facility policy review, and the 2022 Food and Drug Administration (FDA) Food Code, the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 24 residents. Findings include: During a continuous observation on 02/05/24 at 11:45 AM Staff C, Dietary Services Manager, completed pureeing the main entree. The staff then took the entree's temperature and found it to not be at the required degree. Staff C used a new alcohol pad and wiped the thermometer, and placed the thermometer uncovered on the serving counter with the dirty wipe. The staff placed the pureed entree in the microwave to bring it up to the correct temperature. Staff C took the thermometer from the serving counter and used it to check the regular roast beef on the warmer. The staff utilized the same alcohol wipe from the pureed entree to wipe off the thermometer after the regular roast beef. Staff C placed the used wipe on the serving counter again, and used it following temperature checks for the chicken patty, and mechanical soft roast beef on the warmer. The staff obtained a single new wipe for use following the temperature checks of mashed potatoes, corn, and cake. Following the completion of all temperature checks the staff discarded the 2 dirty wipes. Observed the cook obtain a new thermometer to check the milk temperature prior to serving. She utilized a new alcohol wipe for cleaning the thermometer, threw it away, and then replaced the thermometer. Staff recorded all temperatures on the temperature log. Staff C completed the meal service and then applied hand sanitizer prior to donning a single glove on the left hand. Using the gloved hand, the staff obtained a slice of bread from its package on the serving counter, placed it on the plate, and used the other hand (right) to hold the plate. Staff C then moved the plate to the left hand, glove still in place, and used the right hand for managing utensils to obtain items from the warmer. After placing the plates in the window for non-identified staff to pick up and serve to residents, Staff C then utilized the gloved hand to hold the plates while using the non-gloved hand (right) she picked up pieces of bread or buns for placement on the plates for serving. The staff completed 6 servings with the non-gloved hand touching the bread, while the gloved hand held the plate. Staff C self recognized the error and stopped serving. She put down the current piece of bread on the far side of the packaged bread, removed the glove, and placed it on the serving counter by the contaminated slice of bread. Following application of hand sanitizer, Staff C donned a new glove, placed it on the left hand, and obtained a new slice of bread while the right hand held the plate. Staff C continued to use the gloved hand to touch the bread packaging and plates between obtaining slices of bread. Staff C left the serving area to obtain frozen items for residents. The staff removed the glove and threw it into the receptacle as she left the serving area. Staff C washed her hands and donned gloves on both hands prior to returning to the serving area. The staff changed the gloved hand 3 times with 2 of the 3 dirty gloves placed on the serving counter beside the bread. At the end of the meal service, Staff C threw all the dirty gloves and bread into the trash receptacle. On 02/06/24 at 01:04 PM The Administrator stated he has been a proctor and instructor for Certification for Dietary Manager (CDM). He expected that gloves in the kitchen would be changed after touching hair, face, smoking, raw foods or other things. The Administrator stated staff are to wash their hands or use hand sanitizer before donning gloves and after gloves are removed. If staff utilized any utensils or grabbed other items while using gloves, it would be expected that gloves would be removed, and hand washing/sanitizer utilized before re-donning of gloves. The Administrator stated the technique for removal of gloves would be peeling away from the wrist, folding the glove into itself and discarding. The Administrator stated dirty gloves should be thrown away in the trash receptacle. The Administrator stated that to serve bread staff could use serving tongs or deli sheets. If staff are using gloves they would be required to remove and sanitize their hands if they touch other items. The facility policy titled Handwashing/Hand Hygiene, revision date August 2019, documented the facility considers hand hygiene the primary means to prevent the spread of infection. The document further stated the use of gloves does not replace hand washing/hand hygiene. Management of the gloves is completed by performing hand hygiene before applying non-sterile gloves, removing one glove from the dispensing box at a time touching only the top of the cuff. To remove the glove it is pinched at the wrist and peeled away from the hand, turning the glove inside out, rolling the second glove down and folding it inside the first glove. Hand hygiene is then completed. The facility does not have a hygiene specific policy for the kitchen. The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3, Section 3-301.11 documented: Employees may not contact exposed, read-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment.

Based on clinical record review, observation, staff interview, and facility policy review, the facility staff failed to change gloves and sanitize hands during cares, failing to maintain infection control practices during incontinence care for 1 of 1 residents reviewed (Resident #11). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) of Resident #11 dated 12/30/23 reflected the resident frequently incontinent of bladder and always incontinent of bowel. The MDS reflected the resident to be dependent on staff for toileting hygiene. The Care Plan, revised 8/9/20, documented Resident #11 needed help with her activities of daily living due to a diagnosis of multiple sclerosis. It directed staff to provide incontinency cares as needed. On 2/7/24 at 12:49 observed Staff A, Certified Medication Aide (CMA) and Staff G, Certified Nurse aide provide cares to Resident #11 with a transfer from her wheelchair to her bed and incontinence cares. Hand hygiene was performed by both staff members prior to transferring the resident via Hoyer mechanical lift to her bed. Once the resident was in bed, both staff members placed gloves on their hands. Staff A reached for a clean trash liner and placed it in the trash bag and assisted the resident to lower her pants. She opened the incontinence brief of the resident and verified her brief was wet. Staff G held a package of cleansing wipes and handed them to Staff A to use to perform peri care (cleansing of the groin area of the resident). After cleansing the groin area of the resident, Staff A tucked the soiled brief underneath the resident and assisted the resident to turn onto her right side. She removed her gloves and placed new gloves on her hands with no hand cleansing or sanitizing. Staff A cleansed the resident's buttocks, removed the soiled brief and threw it in the trash can. Remaining in the same gloves, Staff A placed a clean brief under the resident. She assisted the resident to turn to her other direction to complete placing a new brief under her. Staff A removed her gloves and performed hand hygiene. Staff G lifted the new brief into place and fastened the security tabs to keep the brief in place. Staff G removed her gloves and removed the residents pants from the bed and placed them on the resident's wheelchair. Both staff members then placed protective pressure relieving footwear on the resident and placed a blanket over her and verified her comfort. Staff G then washed her hands prior to leaving the room. On 2/8/24 at 8:11 am, the Director of Nursing (DON) stated her expectation is staff should perform hand hygiene and use clean gloves anytime a task is changing from dirty to clean. The facility policy Perineal Care, revision date February 2018 directed to raise resident's gown or lower pajamas, then put on gloves. After cleaning and drying the perineum area of a female resident, remove gloves and sanitize or wash hands, don new gloves prior to washing the rectal area.

Based on clinical record review, resident interview, family interview, staff interviews, and the facilities Admission Agreement, the facility failed to exercise reasonable care for the protection of the personal property for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) of Resident #5, dated 11/18/23, identified a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. On 2/5/24 at 1:00 pm, Resident #5 stated she had a Smart Phone when she admitted to the facility which was lost shortly after she admitted . She stated she reported this loss to the facility and several staff members looked for it but it was never found. She said the staff told her she must have knocked it off her table and into the trash and it probably went out with the trash. Resident #5 stated her trash can was across the room from where her chair was and this could not have happened. The facility did not assist with the replacement of the lost phone and her family ended up replacing it but with a different model which was not as nice as the lost phone. On 2/6/24 at 4:13 pm, a family member of Resident #5 stated the lost phone was a Samsung Smart Phone. She stated the facility was notified of the missing item. She further stated several staff members came in and helped look for it. It was never found and the facility did nothing to offer to replace it. On 2/7/24 at 7:21 am the Administrator stated the facility will try to replace an item one time if it's clothing or other lower dollar items. He stated for higher value items, the facility replacing items are looked at on a case by case basis. He stated he would check with other staff to see if they were aware of the missing phone. On 2/7/24 at 7:32 am the Administrator stated he spoke with the Social Services Director (SSD) and the Business Office Manger (BOM) and neither of them recalled knowing about the missing cell phone. The Administrator also stated he reviewed the Grievance Log and saw no record of the missing phone. He stated the BOM did report remembering a conversation that the family of Resident #5 mentioned they would be providing a new phone to Resident #5 but was not aware it was a replacement for a missing phone. He stated the procedure for handling missing items is the staff member who gets the report of the missing item is to fill out a grievance log and forward that to the department manager. The morning of the next business day, it would be discussed in the morning meeting. He stated all staff receive education regarding this and it was most recently discussed in the January 2024 in-service. On 2/7/24 at 8:22 am the Director of Nursing (DON) stated that the SSD called the daughter of Resident #5. The family member was able to name one of the staff members who had assisted in looking for the phone. The DON called that staff member (Staff F, Certified Medication Aide [CMA]) stated she did remember this episode. The DON stated the Staff F also recalled that Resident #5 did tell her that she had brought the phone to the dining room at least once. Staff F received education to make sure and forward any concerns of any missing items to management. On 2/7/24 at 8:24 am the Administrator stated the facility was unable to locate an inventory sheet for Resident #5. On 2/7/24 at 9:17 am, Staff F, CMA stated she had been off work for a couple of days at the time the phone went missing. She recalled when she returned to work, Resident #5 reported the missing phone to her. She stated she helped look for the phone including tipping the resident's recliner upside down, looking under the bed, through dresser drawers and anywhere else they could think of. She stated other nursing staff, and housekeeping were aware of the missing phone and helped look for it. She stated Resident #5 stated she might have left it at the dining table so the kitchen staff was also notified of it. She believed Resident #5 told her daughter it may have fallen in the trash. She stated she also reported this to the charge nurse but she did not recall which staff member this was. Review of the Progress Notes for Resident #5 revealed no documentation of the resident missing her phone. The Admission Agreement for residents of the facility stated: Facility reserves the right to limit personal belongings of Resident as allowed by law. Resident acknowledges that Facility is unable to exercise complete control over Resident's personal items. The Admission Agreement additionally stated: Resident is permitted to keep reasonable amounts of personal clothing and possessions for Resident's use while at the Facility. The Facility shall inventory Resident's personal items upon admission. Resident and Resident Representative shall take preventative measures to prevent theft or loss of valuable possessions, including, but not limited to marking all personal items with Resident's first and last name and professionally marking items such as glasses, dentures and hearing aides prior to admission.

Based on clinical record review, staff interview, and policy review the facility failed to revise and implement care plans for 1 of 3 residents (Resident #12) reviewed. The facility reported a census of 24 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #12 dated 1/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further revealed diagnosis of cancer, coronary artery disease, diabetes mellitus, intervertebral disc degeneration in the lumbar region, spinal stenosis, and wedge compression fracture of the fourth lumbar vertebrae. Review of Resident #12's Care Plan dated 1/5/24 revealed Resident #12 ambulates with assistance of 1 staff using a four wheeled walker. Further review of the care plan revealed Resident #12 requires assistance of 1 staff when transferring, or toileting. Review of a facility provided document dated 1/24/24 from a book title, Staff Communication Book, revealed a note from physical therapy stating Resident #12 may be independent in her room using a 2 wheeled walker. During an interview 2/6/24 at 11:33 AM with Staff A Certified Medication Aide/Certified Nurse Aide (CMA/CNA) and Staff B CNA revealed that Resident #12 was independent in her room with a 2 wheeled walker. During a follow up interview 2/6/24 at 12:15 PM with Staff A revealed that information about residents being independent in her room would be in the Care Plan. During an interview 2/6/24 at 12:20 PM with Staff D Licensed Practical Nurse (LPN) revealed she could not locate in the Care Plan where resident #12 was independent in her room. During an interview 2/6/24 at 12:30 PM with the Director of Nursing (DON) revealed her expectations were for care plans to be updated and implemented in a more timely manner. Review of a facility provided policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed: a. Care plans are revised as information about the residents and the residents' conditions change.

Based on interviews with staff and residents and record review the facility failed to implement interventions to prevent potential abuse for 1 of 16 residents reviewed for resident rights. Certified Nursing Assistant (CNA) Staff A made threats to Resident #24, used curse words, and was alledged to treat the resident rough in the whirlpool bathtub. The facility reported a census of 24 residents. Findings Include: According to the Minimum Data Set (MDS) dated [DATE], Resident #24 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). The resident was totally dependent on 2 staff for bed mobility, transfers, dressing and bathing. The resident had diagnosis including cerebral infarction, vascular dementia, dysphagia, anxiety disorder, dysphonia and muscle wasting. The care plan dated 3/6/22 showed that Resident #24 require staff assistance for all Activities of Daily Living (ADL). The resident required one person assistance in the bath after transfer and required a mechanical lift for transfers with 2 person assist. The resident was said to be verbally aggressive at times, related to dementia and mental/emotional illness. Staff were directed to not argue with the resident, and to talk in a calm voice when the behavior was disruptive. When the resident became agitated, staff were to intervene before the agitation escalated or to walk away and approach later. A nursing note dated 9/15/2022 at 5:03 PM showed that Resident #24 had alleged that he had been abused by CNA Staff A while she was assisting him with a bath on that date. According to a facility incident investigation report created by the Director of Nursing (DON) and dated 9/15/22, Resident #24 reported to Licensed Practicing Nurse (LPN) Staff C that CNA Staff A did not give him a bath that morning as she stated. The DON addressed it with Staff A and noted that Staff A had documented that she had given the resident a bath so she was expected to complete that task before the end of her shift. Staff A responded that she thought one of the afternoon aides could complete the bath. CNA Staff B reported to the DON that she heard Staff A say, I'm going to drown that [curse word]. Resident #23 signed a statement saying that she also heard Staff A make this threat; (according to Resident #23's MDS dated [DATE] she had a BIMS score of 15). In an interview on 11/08/22 at 9:33 AM, Resident #24 said that there was a CNA at the facility that had been very rude to him. He said that she would swear at him and she bumped his leg in the tub and she was very rough with him. On 11/8/22 at 9:53 AM, Staff B said that Staff A was very angry that she had to complete a bath for Resident #23 on 9/15/22. Staff B said that she assisted Staff A to transfer the resident into the whirlpool tub and Staff A angrily said to the resident, Oh, you want a bath? Well, you're going to get one now. As they transferred the resident from the wheel chair to the whirlpool chair with the Hoyer mechanical lift, Staff A forcefully pulled back on the sling which caused the resident's back to hit hard on the seat and he responded ouch and cursed. Staff B said that once the resident was in the whirlpool chair she left the room. After talking to Staff C they decided that the resident should not be left alone in the shower room with Staff A given her state of mind so Staff B went back in to complete the bath. When Staff B went back into the shower room, she saw Staff A spraying water at the resident's forehead and the water was shooting over the resident's face and head. The resident was yelling at her to stop. On 11/8/22 at 2:42 PM, Staff C said that Staff A didn't like Resident #24 and she often heard her yell at him to shut the [curse word] up. Staff C stated that she did report the other incidences to the previous DON in the summer of 2022. Staff C said that Resident #24 usually liked to get a bath and rarely refused. Staff C said that on the morning of 9/15/22, Staff A wheeled the resident into the dining room and Staff C asked him how his bath was. The resident responded that she didn't give him a bath and only gave him a shave. Staff C reported this to the DON and the DON told Staff A that she could not leave for the day until she gave him a bath. Once the resident had been taken back into the shower room, Staff C heard Staff A say, I'm going to drown his [curse word]. Staff B then went into the shower room to help transfer the resident then came out and said that Staff A was spraying water in the resident's face. Staff C decided to send Staff B back in to complete that task. Staff A then came out of the shower room, got her coat and walked out of the facility. Staff C assessed the resident after his bath and he told her that he didn't want Staff A to touch him as she hurt his legs and that she had shoved him around in the tub. Staff C said that she did not see any bruises or scrapes on the resident. On 11/9/22 at 8:14 AM, Staff A denied having any disciplinary actions against her during her 6 years at the facility. She said that Resident #24 was mean and would call the staff derogatory names. She denied getting upset with him when he would call her names and said that she would just redirect him. She said that on the morning of 9/15/22, Resident #24 didn't want a bath that day, he just wanted to lay down and she convinced him to at least let her shave him. He then went and told the administrator that he didn't get a shower. She said that when she was told to give him in the shower she went ahead and did it and that he was mean to her. She said that Staff B said that she would finish the bath so she could leave for the day. She said that the resident called her a [curse word], but she denied ever swearing at him or calling him names. She said that he didn't like water and she only sprayed water over his head when she was washing his hair. She said that she wasn't sure if the resident had bumped his legs or feet on the tub when she transferred him, but it could have happened. On 11/9/22 at 8:55 AM, CNA Staff D had worked with Staff A many times and had heard her raise her voice to resident more than once. Staff D said that more than once she would tell Staff A to take a break and step away from Resident #24 when she was angry with him. Staff D said that Staff A had been rough with other residents especially when she was frustrated. She said that Staff A had a poor attitude. On 11/10/22 at 7:29 AM, Resident #10 said that he shared a bathroom with Resident #24 and conversations in the next room were easily overheard. He said that Staff A had a foul mouth and would especially verbally attack Resident #24. He said that she was very moody, loud, disrespectful. On 11/10/22 at 8:13 AM, Registered Nurse (RN) Staff E said that she had become concerned about Staff A's mood and inappropriate language because of some things that she would hear on the Walkie Talkies and toward other staff. She was concerned that she may have been talking to residents that way but did not know of any specific examples. A review of the employee files revealed an annual evaluation dated 7/15/22 for Staff A that included concerns of a negative attitude, reports of disrespect toward supervisor and coworkers. The staff member was in need of improvement in knowledge of resident rights and use of tactfulness and professionalism during times of frustration. The evaluation stated that the staff member needed to improve upon her ability to turn a negative situation around before she would become so upset that she allowed her emotions to get out of control. She could become easily frustrated and then projected that attitude at the residents. The evaluation was signed by Staff A on 7/19/22. On 11/9/22 at 8:44 AM, the Administrator and the DON said that Staff A had just one employee evaluation in her file and that was completed by the current DON. She did not have any disciplinary actions or reports in her file.

Based on observations, clinical record review, and staff interviews the facility failed to prevent a pressure ulcer for 1 of 1 residents reviewed (Resident #27). The facility assessed the resident at risk for pressure sore development per the Braden scale assessment tool. The resident required extensive assist of 2 for bed mobility, transfers, and toileting; and the resident was incontinent of urine. The care plan failed to identify the resident was at risk for pressure ulcers with interventions in place to prevent pressure ulcers prior to the development of the pressure ulcer, even though the resident required 2 staff to reposition, transfer, and cares. A Stage 3 pressure sore developed on the resident's coccyx. The facility reported a census of 28 residents. Findings include: A Minimum Data Set (MDS) for Resident #27, with a completion date of 12/21/20, listed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS), documented a 9 out of 15 indicating moderately impaired cognition. The MDS documented the resident required extensive assist of 2 staff for bed mobility, transfers, and toileting; and extensive assist of 1 staff for personal hygiene. The resident was coded as frequently incontinent of urine and occasionally incontinent of bowels. During initial tour on 4/26/21 at 3:15 PM, the resident stated she had area that staff had to complete dressing changes on, however, treatment already been completed for the day. The resident could not state how she got the area. According to the Matrix, Resident #27 had a facility acquired stage 3 pressure ulcer. The MDS identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Care plan with date initiated 12/2/19, revealed a focus area the resident required assist with mobility related to balance. Interventions included: not using bed and choose to sleep in recliner, bed removed from my room (5/29/20), due to refusing to get out of recliner, it was soiled and needed cleaning, bed placed in room and resident comfortable (12/30/20). Care plan with date initiated 1/14/21, revealed a focus area the resident had excoriation to buttocks. Interventions included: adjust treatment if no healing within 2-4 weeks (1/14/21), alternating low air loss mattress on bed (1/14/21), and keep skin folds clean and dry (1/14/21). Care plan with date initiated 1/21/21, revealed a focus area the resident had a pressure ulcer to coccyx and potential for pressure ulcer development related to immobility, incontinence, and declining health. Interventions included: hospice contacted regarding alternating air mattress (1/21/21), follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the wound on 4/28/21 at 10:12 AM, revealed scattered open areas with red bases, various sizes, to the resident's bilateral buttocks. Multiple observations during the survey period, found the resident to have cushion in place in wheelchair and air mattress overlay on the bed and functioning. Progress notes revealed: 12/30/20 at 4:56 PM, nurses note - [MEDICATION(S)] ointment (moisture barrier used to protect and help heal skin irritations) applied to buttocks to prevent further skin breakdown. The resident resting in bed quietly at this time. No complaints of pain or discomfort this shift. 1/7/21 at 1:15 PM, care plan conference summary - care plan conference date/time: 1/7/21 at 1:15 PM; attended by the Resident, Social Services, and the Director of Nursing. Risks/Consequences: the resident at risk for impaired skin integrity due to impaired immobility and incontinence. 1/13/21 at 2:32 PM, focused evaluation - incontinent of urine, checked and changed before and after meals. Lower buttocks show irritation from incontinence. Repositioned with pillows to keep off buttocks. 1/14/21 at 2:55 PM, focused evaluation - incontinent of urine, checked and changed before and after meals. Lower buttocks show irritation from incontinence. Air mattress overlay applied to bed. Repositioned with pillows to keep off buttocks. 1/21/21 at 4:20 PM, pressure - pressure injury located coccyx, 3 centimeters (cm) length x 1.8 cm width x 0.2 cm depth. Stage 3, onset 1/21/21. Appearance of the pressure injury bed, loose yellow/tan slough. Odor present after irrigation. Physician and family notified. 1/21/21 at 4:30 PM, incident, accident, unusual occurrence note - open area left inner buttock 3 cm x 1.8 cm, cleansed and [MEDICATION(S)] sacral foam dressing applied. Braden Scale for predicting pressure sore risk dated 12/16/20, indicated the resident at risk for developing a pressure ulcer with a score of 15. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Policy titled Prevention Of Pressure Ulcers dated January 2015: to promote good skin integrity and to relieve pressure, restore circulation and promote skin protection in the affected area. Equipment: a. Skin lotion b. Elbow protector c. Heel protector d. Pressure reduction mattress e. Pressure reduction wheelchair cushion f. Foot or bed cradle g. Positioning pillows/wedges Guidelines: a. Report all areas of concern to Charge Nurse for evaluation and follow-up b. Provide skin care after each episode of incontinence. Check and change incontinent residents frequently. c. Keep skin clean and dry. d. Change bed linen whenever wet or soiled. e. Keep foundation sheet dry and free of wrinkles and debris. f. Utilize pressure-reduction devices on bed and chair as necessary. g. Reposition resident routinely and position with pads and pillows to protect bony prominences and maintain proper alignment. h. Active and passive range of motion exercises will promote better circulation. i. Whenever possible, teach the resident to change position at regular intervals and shift weight when in the wheelchair j. Use elbow &/or heel protectors if needed k. Use bed cradle to prevent pressure from bedding as needed l. Assist the resident at mealtime to assure adequate nutrition m. Encourage extra fluids for adequate hydration Note: Any reddened area that remains red longer than thirty minutes after pressure is relieved is at high risk for a pressure sore to develop. Documentation: a. Preventative measure used b. Any change noted in skin integrity c. Resident/family education and notification d. Physician involvement Resident Care plan: a. Identify problem b. Establish goals with resident input c. Develop approaches with responsible disciplines identified. On 4/28/21 at 10:24 AM, the Administrator and Director of Nursing (DON) stated when the resident admitted to the facility she slept in a recliner. The Administrator and DON stated facility staff placed cushions in the resident's wheelchair. The Administrator and DON stated the resident accepted a bed in September 2020, however, within a few days, requested the bed be removed. The Administrator and DON stated in December 2020, the resident accepted the bed, and the bed remained in the room. The Administrator stated the facility staff attempted to utilize cushions in the recliner and offer more assist with toileting due to increased difficulty while the resident was in the recliner. On 4/28/21 at 11:00 AM, the Administrator stated the nurse's charted by exception for skin weekly assessments prior to 1/21/21, and only documented when the resident had a specific area that needed to be assessed. The Administrator stated the facility staff attempted, on different occasions, different mattresses, air overlays, wheelchairs cushions. On 4/28/21 at 11:01 AM, Staff B Registered Nurse (RN) confirmed she documented the irritated area in the resident's progress notes on 1/13/21. The RN identified the area as blanchable and not open, so she did not complete a skin assessment. The RN stated she applied barrier ointment and planned to follow up. The RN stated on 1/14/21, she followed up and added the skin irritation to the resident's care plan, and added an air mattress to the resident's bed. The RN confirmed she did not complete a formal assessment of the area, to include a description &/or measurements of the area. The RN stated prior to January 2021, no weekly skin assessments completed for residents that did not have skin issues, however, currently one bath day per week all residents have a skin assessment. On 4/28/21 at 11:02 AM, the DON confirmed the care plan failed to identify the resident at risk for pressure ulcers with interventions in place to prevent pressure ulcers. On 4/28/21 at 9:38 PM, Staff C Licensed Practical Nurse (LPN) identified the resident with a history of skin breakdown to coccyx. The LPN stated the facility utilized dressings, ointments, and creams at various times related to open areas to coccyx. On 4/29/21 at 12:25 PM, the DON stated she expected information that the resident at risk for pressure ulcers to be on the resident's care plan with interventions in place. The DON stated she did not know how it got missed on Resident #27. The DON stated with Resident #27, was trial and error with interventions On 4/29/21 at 12:37 PM, Staff B RN stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated once the resident was in bed, facility staff would reposition and apply barrier cream to keep skin intact.

Based on observation, clinical record review, and staff interview the facility failed to adequately supervise residents for 1 of 4 residents with falls reviewed (Resident #8). Staff did not provide adequate supervision to a resident who staff assisted to the bathroom, left unattended and fell resulting in a [CONDITION(S)]. Staff failed to maintain supervision of the resident as the care plan directed. The facility reported a census of 28 residents. Findings include: A Minimum Data Set (MDS) for Resident #8, with a completion date of 5/29/20, listed diagnosis of [CONDITION(S)] and hypertension. The Brief Interview for Mental Status (BIMS), documented a 1 out of 15 indicating severely impaired cognition. The resident required extensive assist of 1-2 staff for bed mobility, transfer, toilet use and personal hygiene. The MDS coded the resident not steady and only able to stabilize with staff assistance when moving from seated to standing position and moving on and off the toilet. The MDS coded the resident as occasionally incontinent of urine and always continent of bowel. Care Plan: Care Plan focus with date initiated of 7/11/19, revealed Resident #8 at risk for falls due to balance. Interventions included: do not leave unattended while on the toilet (7/21/20), encourage to use call light for assistance as needed (7/11/19 and resolved 9/9/20), toilet me after supper (9/14/19), safe environment without clutter (9/6/19 and resolved 9/9/20), and frequent well checks (12/7/19). Care plan focus with date initiated of 10/1/19, revealed the resident required assist with activities of daily living. Interventions included: like to go to bed prior to 7:00 PM at night (10/1/19), recently broke my right hip and require hoyer lift for transfer, remove sling lift once transferred (8/13/20), assist with ambulation as needed, use a walker (10/1/19 and resolved 8/13/20). Care plan focus with date initiated 7/11/19 and resolved 8/11/20, revealed the resident unable to transfer independently. Intervention included: assist of 2 needed with transfers using sit to stand lift (7/11/19 and resolved 8/11/20). Care plan focus with date initiated 7/11/19 and resolved 8/11/20, revealed the resident required assistance with ambulation. Interventions included: weight bearing as tolerated (7/11/19 and resolved 10/1/19), assist of 1 with ambulation (10/16/19 and resolved 6/2/20), ambulate with walker and assist of 1 (6/2/20 and resolved 8/11/20), and require assist with finding where needs to be, assist as needed (7/12/19 and resolved 8/11/20). Care plan focus with date initiated 7/22/19 and resolved 8/11/20, revealed the resident was forgetful at times. Intervention included: provide cues, re-orientation, and supervise as needed (7/22/19 and resolved 8/11/20). Observations: a. 4/27/21 at 8:55 AM, the resident up in wheelchair, with platform at feet. Well groomed. Compression stockings on. Call light in reach. b. 4/27/21 at 1:02 PM, the resident sitting in wheelchair in room with call light in reach. Staff H CNA and Staff I CNA assisted resident to the toilet and then to bed with the use of the full body lift, Hoyer. Call light placed within reach. c. 4/28/21 at 2:17 PM, the resident sitting up in bed with call light on. The bed in the lowest position, down to the floor. d. 4/28/21 at 2:20 PM call light off, the resident laying in bed with wash cloth on her forehead and sheet covering her. Fall Risk assessment dated [DATE], identified the resident with a score of 13. Total score of 10 or greater represented high risk for falls. The resident at high risk for falls due to intermittent confusion, ambulatory and incontinent, unable to evaluate gait and balance, takes 3-4 medications (anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemic, narcotics, [CONDITION(S)], sedatives/hypnotics) currently or in past 7 days, and 1-2 predisposing diseases. Progress notes revealed: a. 8/2/20 at 8:00 PM, incident, accident, unusual occurrence note - resident forgetful, wanting to maintain independence. Resident continues to ambulate independently, not using call light for assistance and asked to. Poor balance, arthritic. No signs or symptoms of injury at this time. Passive range of motion (PROM) done, slight discomfort noted when asked to bend her knees. Resident able to pull knees up a little stating right knee felt sore. No signs or symptoms of trauma to right knee. b. 8/3/20 at 9:55 AM, order note - physician notified of the resident's complaints of pain in right hip, groin, and knee. Order received to transfer to the local emergency room (ER) for evaluation. Daughter notified and to meet at the ER. c. 8/3/20 at 1:23 PM, nurses note - call to the local ER, small fracture right greater trochanter and awaiting approval for transfer to another hospital for further treatment. d. 8/11/20 at 4:55 PM, admit/re-admit - included vital signs, orientation to bathroom call light meal time. Orientated to person, place, and time; forgetful. e. 8/12/21 at 1:41 AM, daily skilled short - residents diagnosis: fracture of unspecified part of neck of right femur. Skin warm dry and intact. Dressing to incision site right hip remains clean, dry, and intact. Denies pain or discomfort as of this assessment. Incident report, un-witnessed fall, dated 8/2/20, revealed per nursing description: the resident found on the floor outside door of the bathroom, back up against the wall. The resident had to go to the bathroom. The Certified Nurse's Aide (CNA) assisted the resident and asked the resident to use the call light when finished, and the CNA would assist the resident back to her recliner. The call light was within reach. Resident description: the resident stated it was her fault, she was finished going. The resident's walker was near the recliner. Immediate action: assist to standing with 2 staff, transferred to wheelchair and then to bed. PROM done to extremities. Legs of equal length, no hip rotation. PROM to right knee, some discomfort when asked to pull knees up. No sign of abrasion or trauma to knee. Staff may need to stay with her until she is finished in the bathroom and make sure her walker is within reach if she attempts to ambulate independently. Injuries observed at time of incident: No injuries observed at time of incident. Level of consciousness: alert. Mobility: wheelchair bound. Mental status: orientated to person, place, time and situation. Injuries report post incident: no injuries observed post incident. Predisposing environmental factors: none. Predisposing Physiological factors: gait imbalance and impaired memory. Predisposing situation factors: ambulating without assist. Notes: 8/3/20, intervention: keep forward wheeled walker within reach at all times; and sent to the ER for x-ray. emergency room Provider notes dated 8/3/21 identified: a. Resident #8 fell previous evening while attempting to get off the toilet. This morning unable to bear weight and required assistance of 2. The resident complained of right hip pain. b. Right hip: decreased range of motion, decreased strength, and tenderness, and bony tenderness c. Right knee: decreased range of motion and deformity. Right lower extremity slightly shortened. Tenderness in the right groin. d. X-ray of right hip revealed new acute proximal femoral periprosthetic fracture. The resident transferred to another hospital for surgical repair of the fracture. Document dated 7/20/20, Clarification: Staff need to remain in the room with the resident during toileting to ensure that she does not get up and transfer on her own with assistance, especially after recent fall in her room. This is to ensure her safety. Document titled Statement Regarding: Resident #8 fall 8/2/20. Per phone interview on 8/6/20, with Staff E CNA conducted by the Administrator. Staff E CNA informed the Administrator that she took Resident #8 from the dining room to her room around 6:30 PM, toileted the resident and transferred the resident to the recliner. Staff E informed the Administrator, awhile later Resident #8 pulled call light to go to the bathroom, the resident informed Staff E she needed to have a bowel movement. Staff E informed the Administrator after she took the resident to the bathroom, Staff E CNA moved the resident's walker out of the bathroom so she would not be tempted to get up by herself. Staff E informed the Administrator she showed the resident the call light and told the resident she would return to check on her and encouraged the resident to use her call light when done. Staff E informed the Administrator that within 10-15 minutes the nurse on duty asked for assistance because Resident #8 was on the floor. Document titled Statement Regarding: Resident #8 fall 8/2/20. Per phone interview on 8/6/20 with Staff F CNA conducted by the Administrator. Staff F CNA informed the Administrator that he and Staff G CNA assisted residents that required assist of 2 staff when the nurse on duty called on the radio that Resident #8 was on the floor. Staff F informed the Administrator that he & Staff G went to Resident #8's room and observed the resident on the floor beside the recliner. Staff F informed the Administrator that Resident #8 informed the staff to get her up when they entered the room, however, Staff F told the resident they had to wait for the nurse on duty. Staff F informed the Administrator that the nurse on duty asked the resident if she was hurt and the resident stated her knee. Staff F informed the Administrator that the nurse on duty did an assessment and there was no rotation of the resident's legs, however, the resident stated her knee hurt. Staff F informed the Administrator that he left the room and during checks throughout the night, the resident had no complaints of pain and went to sleep. Document titled Regarding: Resident #8 fall, dated 8/6/20. Staff G CNA wrote the nurse on duty requested assist on the radio in room 304 (Resident #8). Staff G wrote that Staff F and she assisted residents to bed that required assistance of 2, and both went to Resident #8's room. Staff G wrote upon entering the room, Resident #8 was sitting on the floor between the recliner and the bathroom with her head against the wall. Staff G wrote after the nurse on duty completed an assessment, Staff F and herself assisted the resident into her wheelchair and then into bed. Staff G wrote the resident complained of knee pain, no hip pain, and was not crying or tearful. Staff G wrote Staff E came into the resident's room and stated he put Resident #8 on the toilet and gave her the call light before leaving. Document signed by Staff G CNA. Document titled Statement Regarding: Resident #8 fall 8/2/20. Per phone interview on 8/6/20 with the nurse on duty conducted by the Administrator. The nurse on duty informed the Administrator that she heard another resident yelling for assistance due to someone on the floor. The nurse on duty informed the Administrator she found Resident #8, out of the bathroom on the floor with her back against the wall, like she slid down the wall. The nurse on duty informed the Administrator that she did an assessment and requested assistance on the radio. Staff G & Staff F CNA's assisted the resident to the wheelchair and then into bed. Document titled Regarding: Resident #8 fall 8/2/20, dated 8/6/20 by the Administrator stated during conversation with Staff E CNA, Staff E stated she didn't know she should stay with Resident #8 in the bathroom. The Administrator asked Staff E about communication on 7/2/20 that stated Resident #8 was not to be left alone in the bathroom. Staff E informed the Administrator that she just had looked at the communication, however, did not realize what it said. On 4/27/20 at 11:53 AM, the resident's responsible party stated the resident had a fall last August that resulted in hip fracture. The resident's responsible party stated at the time of the fall, the resident required assist and walker for ambulation. The resident's responsible party stated fall interventions prior to the fall was call light in reach. The resident's representative stated the resident would try and get up independently and take self to the bathroom that the resident did not like to wait for assistance. Staff Working when the fall Occurred: On 4/28/21 at 2:58 PM, Staff E CNA confirmed she worked on 8/2/20, and left Resident #8 alone on the toilet and the resident fell . The CNA stated she was aware of the communication book that the resident was not to be left unattended in the bathroom. The CNA stated Staff F CNA requested assistance over the radio and she told him she was with Resident #8 and it would be a few minutes. The CNA stated the nurse on duty came on the radio and told her to assist Staff F with a transfer to prevent a fall for another resident. The CNA stated she then left Resident #8 unattended in the bathroom and then heard on the radio that Resident #8 was on the floor. The CNA stated she could have prevented the fall of Resident #8. The CNA stated the Resident #8 was not good about using her call light to ask for assistance prior to the fall on 8/2/20. The CNA stated she knew Resident #8 would get up without waiting for staff assistance. On 4/28/21 at 3:10 PM, Staff F CNA confirmed he worked on 8/2//20, when Resident #8 fell . The CNA stated he had been in another resident room and requested assistance with a transfer over the radio. Staff E CNA responded that she was with Resident #8, and it would be a bit before she could assist him. Staff F CNA stated the nurse on duty informed Staff E CNA that she could leave Resident #8 unattended in the bathroom and assist Staff F. Staff F CNA stated Resident #8 would attempt to self-transfer and did not use call light properly. Staff F CNA stated there were only 2 CNA's on the floor at the time of Resident #8's fall. Staff F stated Staff G CNA left at 8:00 PM, and that it was normal to have 2 CNA's on duty after 8:00 PM. On 4/28/21 at 3:13 PM Staff G CNA confirmed she worked on 8/2/20, when Resident #8 fell . Staff G CNA stated she worked with Staff F CNA, assisting with transferring residents to bed that required assist of 2. Staff G CNA stated Staff E CNA, assisted Resident #8 to the bathroom and left her unattended without her walker or call light. Staff G CNA stated Resident #8 was not to be left alone in the bathroom. Staff G CNA stated she found Resident #8 on the floor, just outside of the bathroom door with her head against the wall. Staff G CNA stated she called for assistance and Staff F CNA came and then the nurse on duty arrived. Staff G stated Resident #8 complained of right hip pain, and staff waited for the nurse on duty to assess prior to transferring. Staff G CNA stated after the nurse on duty assessed the resident, they transferred the resident with the assistance of 3 and gait belt. Staff G CNA stated Resident #8 informed the nurse she had hip pain. Other staff: On 4/28/21 at 2:21 PM, Staff A Licensed Practical Nurse (LPN) stated Resident #8 did not use the call light to use the bathroom prior to the fall 8/2/20. The LPN stated even now the resident will propel self to the bathroom, thinking she is able to take herself. The LPN stated there were days the resident would understand to use to the call light if she needed to use the bathroom, however, would not wait for assist. The LPN stated if there were changes related to resident's care or to the care plan, there would be notes left in the staff communication book at the nurse's station. The LPN stated are to sign or initial after reading the communication noted. On 4/28/21 at 2:26 PM, Staff D CNA stated Resident #8 did not consistently use her call light prior to her fall on 8/2/20, however, she was encouraged to use it. The CNA stated there were days the resident would get up without assistance and other days she would use the call light. The CNA stated Resident #8 was not allowed to be left unattended in the bathroom prior to her fall on 8/2/20. The CNA stated the resident would use her call light now due to requiring use of hoyer left for transfers and inability to get up. The CNA stated if there were changes that facility staff needed to be aware of, they would be in the communication book at the nurse's station. The CNA stated facility staff are to read prior to their shift and initial or sign acknowledgement. On 4/28/21 at 2:30 PM, the Administrator stated staff could not leave Resident #8 unattended in the bathroom prior to the fall on 8/2/20. The Administrator confirmed the intervention on the care plan dated 7/21/20 that directed staff not to leave the resident unattended while on the toilet. The Administrator stated Staff E CNA, left the resident alone, and initialed the communication book dated 7/20/20, not to leave Resident #8 alone in the bathroom. The Administrator stated staff left the resident alone and the resident fell sustaining the fracture. The Administrator stated Staff E received a written verbal warning for leaving the resident. The Administrator revealed Staff E stated she did not realize what she signed off on in the communication book. On 4/29/21 at 12:25 PM the Director of Nursing (DON) stated at the time of the fall, Resident #8 was not to be left unattended in the bathroom. The DON stated she expected staff to stay with the resident while in the bathroom. The DON confirmed the care plan intervention do not leave unattended on the toilet was put into place on 7/21/20 (prior to the 8/3/20 fall with fracture).

Based on clinical record review, staff, resident, family interviews and facility policy review, the facility failed to assess an injury of unknown origin for 1 resident and failed to complete a thorough assessment on 1 resident after two separate falls, one with a head injury (Resident #3 & #10). The facility reported a census of 22 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documented Resident #3 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The MDS documented Resident #3 required extensive assistance of 1 staff member for bed mobility, dressing, personal hygiene, bathing and walking. Resident #3 required extensive assistance of 2 staff members for transfers and toileting. The MDS identified Resident #3 used a walker for ambulation. The MDS listed [DIAGNOSES REDACTED]. The care plan dated [DATE] listed Resident #3 at risk for falls and instructed staff to walk Resident #3 with the walker and assist of 1 staff member. The Incident/Accident/Unusual Occurrence Form dated [DATE] at 8:40 a.m. documented Resident #3 complained of pain in the right ankle when standing. Resident #3 ' s right ankle noted with swelling, redness, and warm to the touch. The Director of Nursing (DON) called the physician. The physician ordered blood tests and scheduled Resident #3 to be seen by the physician on [DATE]. an order for [REDACTED]. A Consultation/Clinic Referral form dated [DATE] revealed the physician examined Resident #3 and documented a right fibula fracture and to not to bear weight on the right leg. An x-ray report dated [DATE] at 9:59 a.m. indicated Resident #3 had a mildly displaced distal fibular diaphysis fracture. Review of the restorative program dated [DATE] revealed Resident #3 used the Omni-cycle or Nu Step machine for the lower body exercises 6 times a week. According to the Restorative Record for February 2015, Resident #3 participated in lower body exercises on [DATE], [DATE], and [DATE]. Resident #3 did not participate in the restorative program after [DATE]. Interview on [DATE] at 10:00 a.m. Resident #3 stated hurt her/his ankle during exercise on the bike in therapy. During an interview on [DATE] at 9:45 a.m. Resident #3's spouse stated the resident hurt his/her leg on the exercise bike in the therapy room. Resident #3 ' s spouse stated the resident complained a couple of days before the fracture was identified. Review of the nurse's notes dated [DATE] documented a change in Resident #3's medication. Staff made no further assessments until [DATE] when Resident #3 complained of right ankle pain and staff called the physician. Nursing Progress notes dated [DATE] at 11:00 a.m. documented Resident #3 returned from the physician ' s office with a [DIAGNOSES REDACTED]. The record lacked documentation of interventions implemented for the fractured right fibula. The Nursing Progress notes dated [DATE] at 9:00 p.m. documented Resident #3 complained the boot cast on the right leg felt heavy. The clinical record failed to contain any further indication or orders for the use of a boot cast for Resident #3. The Medication Administration Record [REDACTED]. During an interview on [DATE] at 10:44 a.m. Staff G, certified medication aide (CMA), stated on [DATE] and [DATE] Resident #3 used the Nu Step exercise machine. Staff G stated Resident #3 usually turns feet outward and thought he/she may have twisted the ankle trying to get the legs straight on the exercise machine. Staff G stated at that time Resident #3 did not complain of pain. During an interview on [DATE] at 11:37 a.m. Staff P certified nursing assistant (CNA), stated she worked the evening shift on [DATE]. Staff P stated the day shift reported Resident #3's leg hurt and to use two staff to transfer Resident #3. Staff P stated Resident #3 usually walked to the dining room and that night needed a wheelchair. Staff P stated she told Staff A, licensed practical nurse (LPN), that Resident #3 had ankle pain. Staff P stated she thought Staff A gave Resident #3 some Tylenol. After supper, Resident #3 wanted to walk to the bathroom but had too much pain and had to use the wheelchair to get into bed. Staff P stated Staff A commented that Resident #3 ' sright ankle was swollen and bigger than the left ankle. During an interview on [DATE] at 1:50 p.m. Staff K CNA, stated she worked the evening shift on [DATE] and received report from day shift Resident #3 needed 2 staff to transfer. Staff K stated Resident #3 used a wheelchair to go to the dining room. Staff K reported Resident #3 had pain but Staff A stated she already knew. Staff K stated she and Staff P assisted Resident #3 to the toilet between 2:00 p.m. and 4:00 p.m. When Resident #3 stood, he/she stated ouch. Resident #3 stated he/she hurt his/her leg on the exercise bike. During an interview on [DATE] at 2:05 p.m. Staff N CNA, stated she worked the over-night shift on [DATE]. Staff N stated Resident #3 did not want to get out of bed so she checked Resident #3 for incontinence every two hours. Staff N stated Resident #3 did not complain of any pain. During an interview on [DATE] at 2:40 p.m. Staff F CNA, stated she worked the day shift on [DATE] and Resident #3 complained of right ankle pain for a couple days prior. Staff F thought the nurse contacted the physician and gave Resident #3 Tylenol for pain. Resident #3 stated to Staff F that he/she bumped his/her leg on the dining room table or foot pedal. During an interview on [DATE] at 2:43 p.m. Staff A LPN stated in report the CNA ' s and the nurse from day shift told Staff A that Resident #3 complained of leg pain and required assist of 2 staff instead of 1 staff as previously needed. Staff C LPN reported to Staff A that Resident #3 turned his/her foot funny in therapy. Staff A stated she gave Tylenol for leg pain per Resident #3's request at breakfast. At bedtime Resident #3 requested something for pain in the leg. Staff A LPN asked Resident #3 to move his/her foot and Resident #3 able to move the foot with some discomfort. Staff A assumed Staff C reported Resident #3's pain and an increase in assistance. Staff A LPN assumed Resident #3 had generalized pain and had discomfort from sitting up in the wheelchair. During an interview on [DATE] at 3:28 p.m. Staff O CNA, stated she worked the evening shift on [DATE]. Staff O stated she assisted Staff P with Resident #3's transfer and Resident #3 complained of right leg pain in the calf area. Staff O told Staff A and thought Staff A LPN assessed Resident #3. Staff O stated was a busy night and Resident #3 made no further complaints of pain. During an interview on [DATE] at 10:45 a.m. Staff C LPN, stated she worked the day shift on [DATE]. In report she learned Resident #3 required more assistance with transfers and walking. Staff C stated Resident #3 complained of right leg pain and she administered Tylenol. The day before she asked Staff Q LPN, to examine Resident #3 ' s right foot. Staff Q stated the right ankle had swelling but not abnormal for Resident #3. Staff C stated she did not notify the physician of Resident #3's pain and increased need for activities of daily living. During an interview on [DATE] at 1:03 p.m. Resident #3's physician stated he first heard about Resident #3 complaining of right ankle pain on [DATE] when he ordered some blood tests. The physician though Resident #3 may have had gout. Once the blood test can back normal, he set up an appointment for the next day where the x-ray showed the fibula fracture. 2. The face sheet for Resident #10 documented the resident was admitted to the facility on [DATE]. The face sheet listed the following [DIAGNOSES REDACTED]. The fall risk evaluation for Resident #10 dated [DATE] identified a high risk for falls. The Death Record dated [DATE] identified Resident #10 died of a Massive [MEDICAL CONDITION] according to the physician. Review of admission documentation for Resident #10 revealed previous Hospice certification dated [DATE] for the [DIAGNOSES REDACTED]. The nurse ' s notes dated [DATE] at 3:00 p.m. revealed Resident #10 was admitted to the facility. The nurse ' s notes dated [DATE] at 5:00 p.m. revealed documentation of Resident #10 ' s admission assessment with temperature of 98.6, pulse of 88, respirations of 20 and blood pressure ,[DATE] while seated and ,[DATE] standing. The hospice nurse commented to staff Resident #10 ' s blood pressure runs high due to the aneurysm. Family members informed the facility Resident #10 has trouble more at night regarding cognition and attempts to ambulate independently. The facility applied an alarm to Resident #10 ' s bed. The nurse's notes dated [DATE] at 7:50 a.m. documented Resident #10 observed sitting on the floor next to the bed. According to notes Resident #10 denied hitting his/her head during the fall. The documentation failed to identify alarm sounding related to the fall. The nurse's notes staff sent a facsimile to the physician and notified the family. According to the nursing dated [DATE] at 4:30 a.m. Resident #10 complained of pain in the right thigh and right foot. Staff noted the right foot as swollen and Resident #10 unable to ambulate and required assistance of two staff members for mobility. Staff member only documented a lack of pain noted with range of motion. According to the nursing note Resident #10 was very restless and wanted family. The facility documentation for [DATE] at 4:30 a.m. failed to contain any assessment beyond the range of motion check for Resident #10 ' s right leg pain and the swollen right foot. The nurse's notes dated [DATE] at 2:35 p.m. documented a fall in the common area of Resident #10. According to the nurse ' s notes Resident #10 hit his/her head on the coffee table sustaining a bump behind the left ear. The nurse's notes documented staff would notify the family in the morning and staff sent a facsimile to the physician. The nurse's notes failed to include a head to toe assessment including neurological assessments since Resident #10 hit his/her head. Review of the physician notification facsimile dated [DATE] at 4:27 p.m. noted Resident #10 as not responding to verbal stimuli from the morning. Blood pressure ,[DATE], respirations 24 and shallow, pulse oximetry (machine that measures blood oxygen level) of 78, staff started oxygen by nasal cannula for Resident #10. The facility documented Resident #10 ' s speech as garbled. The facsimile failed to contain any further neurological assessments. The nurse's notes dated [DATE] at 9:15 p.m. documented Resident #10 fell in his/her bedroom. Resident #10 complained of bilateral wrist pain and had a bump on the right wrist. The nurse's notes failed to include a head to toe assessment. Review of the physician notification facsimile dated [DATE] noted both falls one at 2:30 p.m. and 9:15 p.m. Staff did not send the facsimile until 11:49 p.m. The notification failed to contain any documentation of neurological assessment or a head to toe assessment for Resident #10 following identification of the two falls. Review of the Incident/Accident/Unusual Occurrence form dated [DATE] at 2:35 p.m. and 9:15 p.m. lacked documentation of a complete head to toe assessment and any neurological assessment. The nurse's notes dated [DATE] at 9:45 p.m. documented staff contacted the Hospice nurse. The nurse's notes dated [DATE] at 3:00 a.m. documented Resident #10 died at 12:15 a.m. During an interview on [DATE] at 9:05 p.m. Staff A stated she could not recall performing a physical and neurological assessment related to Resident #10 ' s falls. Staff A stated she sent the physician a facsimile around midnight knowing the physician would not receive the document until morning. Staff A called the Hospice nurse and attempted to call the family. Staff A stated she sat Resident #10 in the common area to supervise the resident. Staff A stated Resident #10 died shortly after Hospice arrived. During an interview on [DATE] at 9:27 a.m. Staff R, Hospice nurse, stated she received a call from the facility and arrived about 11:50 p.m. on [DATE] When she arrived, she assessed Resident #10 in the common area and felt a faint pulse. Staff R stated she went to obtain her stethoscope and when she returned, Resident #10 had died . Staff R stated she had difficulty notifying the family. During an interview on [DATE] with the DON at 11:00 a.m. revealed an expectation by staff after a fall occurs with a head injury staff are directed to complete a full set of vital signs, perform a head to toe assessment including neurological checks every 15 minutes x four, every 30 minutes x four, every 4 hours x four then every 8 hours. The DON stated during a follow up interview at 1:20 p.m. on [DATE] the expectation was for staff to notify the physician of incidents. The Falls Protocol Quick Reference dated [DATE] instructs staff to complete a head to toe assessment of the resident after a fall, complete an investigation form to assess the resident's environment at the time of the fall, interview residents and staff that witnessed the fall, notify the resident's family and physician, continue assessment/observation of the resident for 24 hours or until stable.

Based on clinical record review, facility record review, staff interviews, resident interview, observation, and equipment instruction manual review, the facility failed to ensure an adequate system was in place to monitor the hoyer slings (slings used for a mechanical lift) for wear and tear to prevent a resident from falling during a Hoyer transfer for 1 resident out of 4 total residents transferred with a Hoyer (Resident #5). The facility reported a census of 22. Findings include: The MDS assessment dated [DATE] identified Resident #5 as cognitively intact with a BIMS score of 15 out of 15. According to the MDS Resident #5, required extensive assistance of two staff members for bed mobility and transfers. The balance during transfer section of the MDS listed Resident #5 as not steady and only able to stabilize with staff assistance and walking listed as an activity that failed to occur. The MDS listed a wheelchair for mobility. Resident #5 ' s [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the same cognition, [DIAGNOSES REDACTED].#5 continued to require extensive assistance of 2 staff member for bed mobility, transfers and a wheelchair for a mobility device. The care plan with a date of 8/1/14 and revised on12/11/14 identified a problem area of need for help with activities of daily living related to MS, CVA, and right above knee amputation with prosthesis. The care plan directed staff to transfer with a mechanical lift (Hoyer) and the assistance of 2 (persons). The care plan intervention dated 8/24/14 directed staff to check the (Hoyer) sling for being frayed prior to using. The fall risk evaluation form dated 7/18/14 documented a score of 10; a score of 10 or above represented a high risk for falls. The fall risk evaluation dated 8/29/14 documented a score of 12. An incident/accident/unusual occurrence form completed on 8/25/14 at 1:00 a.m. by Staff A LPN, documented Resident #5 lifted by the Hoyer lift and the assistance of 2 staff members at 9:30 p.m. on 8/24/14. The form reported the sling strap broke allowing Resident #5 to fall to the floor hitting his/her head and left shoulder on the floor. The report documented Resident #5 complained of pain to the left shoulder and back of head as well as obtained a swollen upper lip. The injury investigation form completed by Staff A LPN, on 8/24/14 documented a fall from the Hoyer with swelling, strap on sling broke, and the staff intervention put in place to prevent injury as staff educated to check each sling each time before use. A new fall interventions form dated 8/24/14 documented instructions of when using a Hoyer lift, check each sling with each use to ensure safety of resident and staff. The form contained 14 staff initials to indicate staff read and understood the new intervention. The physician notification fax form completed by Staff A, LPN dated 8/24/14 documented Resident #5 lifted in a Hoyer with 2 assist, sling strap broke allowing Resident #5 to fall to the floor, hit head and left shoulder on floor, Resident #5 complained of pain to left shoulder and back of head, swollen upper lip noted, and Resident #5 transported to the hospital via ambulance for evaluation. The fall investigation for nurses form completed on 8/24/14 by Staff A LPN, documented the strap on the sling broke during the use of the Hoyer lift and contributed to the fall. The section of the form that asked staff to describe the immediate action taken to prevent another event failed to contain any documentation. The fall investigation for CNAs form completed on 8/24/14 by Staff I Certified Medication Aide (CMA), documented Resident #5 lifted in the Hoyer lift, the strap broke, and Resident #5 fell hitting the left shoulder and head. Under the section of the form where staff record new interventions suggested preventing falls from happening, Staff I CMA, documented check all lift slings for fraying, wear, and tear. The fall investigation for CNAs form completed on 8/25/14 by Staff H CNA, documented Resident #5 positioned in the Hoyer lift and being moved to the bed when the Hoyer lift tab broke. Under the section of suggestions to prevent the fall from happening, Staff H documented checking straps before lifting. The five minute meeting for employees form dated 8/25/14 written by the DON documented a summary of the meeting as follows: a. When using Hoyer slings, make sure to hook more than just the loop you are using on the machine. This will provide backup, should a loop fail. Please be aware of your loops as you are hooking them up. Is there any fraying? If so, do not use, remove from service immediately. There are 3 loops on each corner, the one on the end being the safety loop. b. There is to be a charge nurse present during Resident #5's transfers for the next few days as she/he is scared and this will give him/her peace of mind. c. Addendum dated 8/27/14 - facility home office stated the facility does not double loop slings and to make sure loops are inspected prior to use. d. The form contained 17 staff signatures that included Staff A LPN, Staff I CMA, and Staff H CNA. The major injury determination form completed on 8/25/14 at 9:45 a.m. by the DON documented date and time of injury of 8/24/14. Under circumstances causing the injury documented the strap broke on the Hoyer sling. Under description of injury the form documented no acute injury upon exam at the ER (emergency room ) and the resident complained of shoulder pain. The physician notification fax form completed by the DON dated 8/25/14 documented Resident #5 complained of stiffness and soreness in the left shoulder and back from a fall incident and a new order received for Voltaren gel (a topical pain medication) to be applied twice a day. The H&P (history and physical) notes form the local hospital dated 8/26/14 at 7:40 a.m. documented Resident #5 had fallen the day before and sustained a shoulder contusion and head concussion. An undated pain evaluation form documented an assessment of occasional acute pain in the left shoulder with an onset date of 8/24/15 and the origin of pain from a recent fall. The nurses notes dated 8/24/14 at 9:40 p.m. for Resident #5 documented a fall from the Hoyer lift after straps broke allowing the resident to fall to the ground hitting his/her head and left shoulder on the floor. The documentation listed Resident #5 sustained a swollen upper lip during the fall. The nurse ' s notes documented Resident #5 was transported to the local hospital for evaluation and treatment. The nurse ' s notes entry dated 8/25/14 at 2:00 a.m. documented Resident #5 returned from the hospital where she/he was treated for [REDACTED].#5 ' s head and left should for pain. The ice was documented as placed on for 30 minutes and off for 30 minutes. The entry dated 8/25/14 at 10:45 a.m. reported Resident #5 stated his/her head and shoulder hurt. At 6:10 p.m. the notes documented a new physician's orders [REDACTED]. The resident assessment data collection form/initial care plan dated 8/29/14 documented a bruise on the back of the head that measured 7.5 x 6.5 centimeters (cm) and left cheekbone that measured 2.6 x 1.0 cm. The nurse ' s notes entry dated 8/30/14 at 10:00 a.m. documented Resident #5 stated his/her left shoulder hurt and rated a 3 on the pain scale. The entry reported Resident #5 remained nervous with the use of the Hoyer with the nurse standing by during transfers. Nurse ' s notes dated 8/31/14 at 8:45 a.m., 8/31/14 at 5:50 p.m., 9/1/14 at 8:45 a.m., 9/2/14 at 9:45 a.m., 9/3/14 at 2:30 a.m., and 9/4/14 at 8:40 a.m. all documented Resident #5 complained of left shoulder pain. The nurse ' s notes dated 9/8/14 at 2:45 p.m. reported the nurse supervises all Hoyer lift transfers per Resident #5's request. The clinic note dated 9/9/14 by Resident #5's physician documented Resident #5 ' s still sore from the fall over the right shoulder. The comments/interventions form documented the following by the DON: a. 8/28/14 - on 8/24/14 at 9:30 p.m. Resident #5 transferred to bed with a Hoyer lift and assist of 2 staff members when the Hoyer sling strap broke and Resident #5 fell to the floor. Resident #5 was transferred to the ER per ambulance for evaluation. Resident #5 returned, no injury, and complained of shoulder pain. Staff educated to inspect all sling straps prior to use; all slings inspected on 8/25/14, no other slings had signs of wear. b. 9/4/14 - all slings inspected prior to use, staff educated. c. 9/10/14 - audited staff during transfers with Hoyer lift, slings being inspected by staff. The five minute meeting for employees form dated 10/9/14 written by the DON documented a summary of the meeting as proper use of Hoyer slings with EZ Way. The form contained 11 staff signatures. The operator's Instructions manual for the Hoyer lift (EZ Way Smart Lift) with a revised date of 8/28/09 included the following information: a. All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. b. All EZ Way slings are capable of bearing a 1,000 lb. weight load. c. Sling laundering instructions - the user must examine the product to ensure its integrity before each use. d. EZ Way recommends replacement after 1 year or if the sling shows any sign of damage or wear. e. Users must accept full responsibility for checking the condition of all slings before each and every use on a patient. f. Tumble dry, temperature 100 degrees F (Fahrenheit) maximum. High heat will weaken the fabric. The form titled orientation checklist: nursing assistant documented Staff I CMA, was reviewed on 3/10/10 for mechanical lift assistance by Staff G CMA. The form titled competency check off for Staff I CMA, documented competency checked on 3/25/14 for Hoyer transfers by Staff B Registered Nurse (RN).. The form titled orientation checklist: nursing assistant for Staff H CNA, documented a review on 7/15/14 of mechanical lift assistance (Hoyer). Interview on 2/24/15 at 10:20 a.m. revealed Resident #5 recalled the incident regarding the broken Hoyer sling and his/her fall. According to Resident #5 during the fall hit his/her head and shoulders. The fall caused Resident #5 to feel sick to his/her stomach related to the incident. During an interview on 2/24/15 at 2:15 p.m., Staff J, CNA, stated there is a supply stock of Hoyer slings in the clean linen closet and staff go by the sizes marked on the totes. Staff J reported size of sling used is guesstimate. Staff J verbalized awareness of 1 fall from a Hoyer transfer last fall with Resident #5. She stated there had been in-service training and she tries to watch the loops for fray but thinks laundry does also. During an interview on 2/24/15 at 2:22 p.m., Staff G, CMA, stated size of Hoyer sling used determined by the color of the rim. Staff G reported size of new people determined just by sizing up the people then check. Staff G verbalized everybody is responsible to look for wear and tear. Staff G stated she received training from a guy from the (Hoyer) manufacturer before and after the incident with Resident #5, twice a year from the restorative therapist, as well as audited by a RN (registered nurse) every month. Staff G unaware of any other incident involving falls from Hoyer transfers. During an interview on 2/24/15 at 2:28 p.m., Staff K CNA stated all staff keep an eye on the slings for wear and tear. Staff K reported slings taken to the DON if damaged. During an interview on 2/24/15 at 2:30 p.m., Staff A, LPN, stated aware of 1 fall with a Hoyer transfer, that involved Resident #5. Staff A confirmed being the charge nurse that inspected the broken left shoulder strap of the sling used during the incident on 8/24/14. Staff A reported the strap appeared frayed after the incident and had broken in half. Staff A stated she did not ask the CNA's if they had checked the straps prior to the transfer and they did not say at the time of the investigation. Staff A informed the size of a sling used is determined by weight. Staff A LPN verbalized staff are directed to check a sling for fraying before each use. Staff A stated no formal process conducted prior to the incident to check the slings, only informal. Observation on 2/24/15 at 2:45 p.m. in the clean linen supply closet revealed 6 totes of Hoyer slings on a wire rack. A total of 18 Hoyer slings inspected by the surveyor with 1 small sling found to have fraying with signs of wear and tear; the label not legible. During an interview on 2/24/15 at 3:05 p.m., the DON stated the small sling found by the surveyor would need to be thrown away. The DON reported the process for checking slings for wear and tears is by the CNAs before each use; no other system in place. The DON informed the audit tool used for transfers remained the same as the one used before the incident that included a step where the CNAs are to check the slings for wear and tear before use. During an interview on 2/24/15 at 3:55 p.m. Staff I CMA, stated she had been audited with transfers on a random basis. Staff I reported she did not know who was responsible for checking the slings. Staff I did not recall checking the straps but reported nothing caught her attention prior to the transfer with Resident #5. Staff I stated the left strap by the shoulder broke and Resident #5 fell to the left and landed on his/her shoulder and head. During an interview on 2/24/15 at 6:55 p.m., Staff H CNA stated she did not check the straps before putting on the Hoyer lift prior to the transfer with Resident #5. Staff H reported the left shoulder strap broke and she was under the assumption the sling is thoroughly checked before put into use. Staff H verbalized she had been audited before the incident on Hoyer transfers. Staff H stated the DON educated her the next day that she needed to check slings for fraying before hooking up the sling. During an interview on 2/25/15 at 9:00 a.m., the DON stated 4 residents in the facility care planned for Hoyer transfers. During an interview on 2/25/15 at 9:37 a.m., Staff L, laundry aide, stated laundry responsible to wash Hoyer slings with no bleach, hang slings to dry, then fold and put away in the supply room. During an interview on 2/25/15 at 10:05 a.m. with the DON, Administrator, and Staff M, corporate nurse consultant, present, the DON stated she taught staff to look for fraying on edges and in the lining of the loop itself. The DON reported she did not have a system to have anyone check the loops where they attach or the reinforced edging that secured the loop to the main strap. The DON verbalized there to be no system of dating the Hoyer slings when they are put into use; only monitor for fraying for taking slings in and out of service. The surveyor then demonstrated the ability with a light pull of the hand to pull a loop off of the small frayed Hoyer sling that had been in circulation for use in the supply closet. The DON stated obviously they needed a system to check the slings where the loops attach and the facility may need to initiate dating the slings when they put them into service. The DON acknowledged the label not legible. The DON confirmed the facility currently did not date the slings and aware of the manufacturers guidelines/recommendations to replace after a year of service. During an interview on 2/25/15 at 11:12 a.m., the DON reported she scheduled an all CNAs staff in-service for 2:00 p.m. to educate the staff on checking the Hoyer slings for safety of use. The five minute meeting for employees form dated 2/25/15 written by the DON documented a summary of the meeting as follows: a. Hoyer slings - must be inspected prior to each use. To inspect - look at all loops and binding for fraying, then look at how securely the loop is attached to the sling, pull on the loop to make sure stitching remains strong. Check handles for loose stitching or tears. Also check body fabrics for tears, holes or weak spots. b. If you pass slings out at beginning of shift, please inspect them at that time also. If any weaknesses noted with a sling, do not use it, bring it directly to the DON or place in DON office. c. Each sling will be numbered, and laundry will be checking them each time washed. d. The form contained 14 staff signatures.

Based on record review and physician office staff, resident and staff interviews, the facility failed to implement the physician's order [REDACTED].#1). The facility failed to follow the physician's order [REDACTED].(Resident #3). The sample consisted of 4 residents. The facility reported a census of 34 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 1/11/13, which identified [DIAGNOSES REDACTED]. The MDS revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 of 15. A score of 15 indicated the resident had no short or long term memory problems and no problems with cognitive skills for daily decision making skills. The MDS identified the resident as independent with ADLs (Activities of Daily Living). The Care Plan identified a problem with a blood clot in the resident ' s leg and required [MEDICATION NAME] medication (anticoagulant-slows clotting time). The goal date of 1/26/2013 indicated the resident would show no signs of excessive bleeding. The Care Plan directed staff to elevate leg to help with the swelling, monitor for signs and symptoms of bleeding of gums, urine, stools, excessive bruising, weak, pale and clammy skin. The resident would have frequent laboratory draws (for testing of clotting time). The physician's order [REDACTED]. The Nurse ' s Notes dated 2/27/2013 at 8:40 a.m. indicated the resident left for an appointment. At 12:15 p.m. the resident returned to the facility. The resident had a bladder stone which is causing pain. The physician would have surgery scheduled in Omaha (Nebraska). The Nurse's Notes dated 3/6/13 at 3:00 p.m. revealed staff had talked with the resident's personal physician's office regarding clarification orders for [MEDICATION NAME] and [MEDICATION NAME]. The orders are as follows: - 3/16 & 3/17 [MEDICATION NAME] 30 mg (milligrams) to be given in the morning - 3/18 day of surgery/procedure no [MEDICATION NAME] that evening and to give [MEDICATION NAME] 5 mg. - 3/19/13 Resume [MEDICATION NAME] 30 mg in the morning and [MEDICATION NAME] 5 mg that evening. The record lacked indications that the above order had been written out on the Physician's Telephone Order's for the physician verification of order and signature nor had the order been transcribed on the facility's [MEDICATION NAME] Administration and Laboratory Data sheet. The order had not been transcribe completely on the MAR (medication administration record). Review of facsimiles to the resident's personal physician on 3/6/13 and 3/17/13 revealed the resident as having surgery on 3/18/13. The resident's surgeon wants the resident to be off [MEDICATION NAME] for one week prior starting on 3/11/13. The physician wrote orders for the [MEDICATION NAME] to be discontinued and [MEDICATION NAME] 30 mg daily 2 days before surgery and 2 days after procedure and [MEDICATION NAME] 5 mg to be given on 3/18 and 3/19/13 with a recheck of lab levels to be done on 3/20/13. Review of laboratory results of INR/PT dated 3/7/13 identified high levels and the physician gave orders to hold the [MEDICATION NAME], with no set date or amount of [MEDICATION NAME] to resume. Staff failed to contact the physician for clarification of this order. The Nurse's Notes dated 3/11/13 at 1:50 p.m. indicated the resident's procedure rescheduled to remove the bladder stones on 3/14/13. (Physician) orders to give [MEDICATION NAME] (blood thinner) two days prior to procedure and 2 days after, give [MEDICATION NAME] 5 mg day after procedure and have lab draw for a check of PT/INR (blood test for level of blood thinning medication) on 3/16/13. The record lacked indications that this physician's orders [REDACTED].[REDACTED]. Review of the MARs dated 3/11 & 3/12/13 revealed [MEDICATION NAME] 2.5 mg had been administered to the resident on both those dates. The Nurse's Notes dated 3/13/13 at 3:30 p.m. revealed staff had been informed that [MEDICATION NAME] had been given and the resident's procedure had been rescheduled. Staff notified the family of the medication error and rescheduling procedure. Family said they had just talked with the hospital. The Nurse's Notes dated 3/20/13 3:00 p.m. indicated the resident's surgeon ' s nurse telephoned (the facility) with orders as to what medications the resident can take in the morning prior to the procedure being performed. The Nurse's Notes dated 3/21/13 at 7:10 a.m. Indicated the resident left the facility with family to have the procedure performed. On 3/29/13 at 9:50 a.m. the resident's surgeon ' s office person was interviewed and stated the surgeon had been notified by the pre-op Nurse at the hospital on [DATE] that the resident had received [MEDICATION NAME] on 3/11 & 3/12/13. The office person reported the surgeon gave orders to have the surgery rescheduled for 3/21/13. The surgeon ' s office personnel contacted and notified the family. The office person stated after contacting the resident's family, the family stated they would notify the facility. On 3/28/13 at 11:45 a.m. and on 3/29/13 at 10:40 a.m., and 4:00 p.m., the DON (Director of Nursing) was interviewed and stated the staff failed to follow the physician's orders [REDACTED]. The DON further stated the facility had no system/policy in place for administration of [MEDICATION NAME] or receiving physician orders [REDACTED]. The DON further stated she is now monitoring all [MEDICATION NAME] and other new orders on a daily basis and that she has educated staff about [MEDICATION NAME] orders and holding orders on resident's medication. The DON indicated that when orders are received via fax from the physician then staffs are expected to stamp the back of it and ensure all the check boxes are completed and signed off by two nurses, which staff failed to do. The DON stated she expected staff to write up (document) any physician orders [REDACTED]. On 3/28/2013 at 8:00 a.m. the resident was interviewed and stated she/he had surgery last week. The resident stated it had been delayed due to the [MEDICATION NAME] was given when it was to be held and not given. The resident voiced she/he had already been in pain and the delay increased the (my) pain. The resident stated she/he needed to take more pain medication due to the pain and delay in the surgery. The resident stated it could have been fatal if the physician's (Hospital pre-op) nurse had not informed her/his daughter of her/him taking the [MEDICATION NAME] prior to surgery. Although the March 2013 MAR indicated [REDACTED]? tab four times a day, on a routine basis, the resident still expressed she/he had increased pain after the surgery was cancelled and rescheduled. 2. Resident #3 had an MDS assessment with a reference date 1/04/13 which identified the resident with [DIAGNOSES REDACTED]. The MDS revealed the resident had a BIMS score of 15 of 15, indicating the resident had no short or long term memory problems and no problems with cognitive skills for daily decision making skills. The MDS identified the resident requiring assist of staff for supervision for bed mobility, transfers, ambulation in room, and toilet use. Review of the Care Plan dated 1/10/13 listed a problem with a blood clot from groin to knee and in the other leg, one in calf. The goal for the resident is to have no complications from medications. The approaches directed staff that the resident receives medication for blood clots. The Nurse's notes dated 1/14/13 at 10:40 a.m. revealed the resident's blood draw completed and taken to the lab for PT/INR anticoagulation levels. At 12:30 p.m. the facility received the lab results and the staff faxed the results to the resident's physician. At 6:00 p.m. staff documented the resident is to continue on [MEDICATION NAME] 5 mg and to recheck PT/INR on 1/16/13. The records lacked indication how the order to continue the [MEDICATION NAME] 5 mg and recheck PT/INR on 1/16/13 had been received or had been transcribed to a Physician's Telephone Order for the physician's verification and signature of order. The resident's coagulation laboratory results dated [DATE] revealed a PT of 54.1 and INR of 5.6, each represented high levels of anticoagulant of [MEDICATION NAME]. The Record of [MEDICATION NAME] Administration and Laboratory Data dated 1/14/13/& 1/15/13 revealed [MEDICATION NAME] 5 mg given on both dates. An interview with the DON indicated this had been the order from the physician after review of the laboratory results of 1/14/13, and the physician had wrote the order on the [MEDICATION NAME] Data sheet and faxed it to the facility. Review of the MARs indicated [MEDICATION NAME] 5 mg was administered to the resident on 1/14 & 1/15/13. The Coagulation Tests with a collected Date 1/16/13 revealed PT of 67.7 and INR 7.1, each represents high levels of anticoagulation [MEDICATION NAME] levels. The Physician's Telephone Orders dated 1/16/13 directed to hold the resident's [MEDICATION NAME] for today. The Physician's Telephone Orders dated 1/17/13 indicated to hold the resident's [MEDICATION NAME] today and tomorrow and recheck PT/INR on 1/19/13. Review of the Clinic Note of the resident's physician, with a dictation date of 1/18/13 indicated the resident is on anticoagulation, [MEDICATION NAME], because of [MEDICAL CONDITION]. For some reason, there was a mix up in the order, and the facility had continued to give [MEDICATION NAME] 5 mg daily when the resident had an INR of 5.6. The intention was that the resident should not be receiving the [MEDICATION NAME] at that point, and to recheck an INR on 1/16/13. Of course, this INR was even higher at 7.1. Last night we told the facility not to give the resident any [MEDICATION NAME] today or tomorrow and to recheck INR on 1/19/13 and will likely resume [MEDICATION NAME] at a lower dose once the resident is no longer over-coagulated. Will continue to monitor closely and orders were clarified with staff at the facility.