Every finding on record at Country Lane Manor

Based on clinical record review, facility policy review, staff and resident interviews, the facility failed to ensure resident free from financial exploitation when a staff member didn't return change from a purchase made on behalf of a resident for 1 of 10 (Resident #3) reviewed. The facility reported a census of 46 residents.Findings include:The Minimum Data Set (MDS) assessment for Resident #3, dated 1/20/26 included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS identified the resident as always able to make herself understood and always able to understand others. A list of diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure and muscle weakness. A review of the electronic health record (EHR) revealed Resident #3 diagnosed with COVID on 3/19/26.Review of the facility's self-reported incident submitted 3/26/26 described Resident #3 reported she gave a Housekeeper (Staff A) $20 on 3/23/26 to purchase bottled water and chips for her, and Staff A returned with 3 bottles of water, 2 bags of chips, and used $3 for a drink for herself. The resident reported she gave Staff A an additional $10 for bottled water, she had not received the water and Staff A owed her $17. The document detailed Staff A was suspended pending investigation results, law enforcement notified, staff educated and they reimbursed the resident $17.Review of Resident #3 Care Plan, dated 3/26/26 revealed a Focus area to address [Name redacted, Resident #3] was involved in an allegation of misappropriation of funds by a staff member. Interventions included the following, in part:a. Administrative staff will assist [Name redacted, Resident #3] in using her personal funds for personal items. Date Initiated: 3/27/26.b. [Name redacted, Resident #3] will not give staff members money to purchase items for her. Date Initiated: 3/27/26.c. Document all actions taken, including dates, times, and persons involved. Date Initiated: 4/2/26.d. Psychosocial well-being check in 2x per week for 2 weeks. Date Initiated: 3/27/26.During an interview on 4/14/26 at 10:32 a.m., Resident #3 stated she gave Staff A, Housekeeper, money in the past to buy things for her and it was never a problem, she always bought them and provided the receipt with the items. When she was in isolation for COVID on a Monday (March 23, 2026) she gave Staff A a $20 bill and asked her to get her bottled water and 2 bags of chips. Staff A brought her 3 bottles of water and said that was all they had (normally $1 apiece) and 2 bags of chips, there was no receipt and the resident estimated the purchases would have totaled $14. The resident stated she gave Staff A a $10 bill at that time and asked her to get her more water, and asked for a hand-held pencil sharpener, like what kids used in elementary school. Staff A came back with an electric pencil sharpener, said it cost $7 and the store didn't have her bottled water, did not provide a receipt, said she used $3 to buy herself an energy drink and she would pay her back the next time she worked. She had not seen Staff A since that time and reported the information to facility staff on 3/26/26. The resident stated the facility reimbursed her $17 for her loss.During an interview on 4/15/26 at 10:13 a.m., the Administrator stated the facility had designated staff for personal shopping for the residents, either the Activity Director or the Social Service Director, and not aware that residents asked other staff to shop for them until 3/26/26, when reported by Resident #3. The Administrator stated she initiated an investigation immediately, reimbursed the resident $17 from facility funds, the amount estimated by the resident's report, suspended Staff A pending investigation, reported the incident to the Sheriff and the Iowa Department of Inspections, Appeals & Licensing (DIAL) as required, and educated staff and residents that designated staff were available to shop for residents. The Administrator stated it was not acceptable for staff, other than the designated staff, to handle resident's money or finances, there was a process for the designated staff at the facility to handle and document resident finances and expenses.During an interview on 4/15/26 at 9:45 a.m., Staff A, Housekeeper, stated the resident had asked her to get flavored bottled water for her 3 times that she purchased at a local store. The resident was in isolation and asked her to shop for her when she cleaned her room. Most recently the resident gave her $20, requested flavored bottled water and a bag of chips, she purchased 8 bottles of water because that's all they had and a bag of chips, brought them to the resident with the receipt and her change of $6. The resident gave her $10 to get a pencil sharpener and more bottled water, she bought the pencil sharpener for $7, the store was out of the water she liked, she bought herself an energy drink from a vending machine at the facility for $3 and told the resident she would get her change to her when she came back to work. She hadn't returned to work when she received a phone call from the Administrator and asked about shopping for the resident. She would have returned the resident's change but was suspended over that and directed she could not be at the facility.During an interview on 4/15/26 at 8:14 a.m., Staff B, registered nurse (RN) stated Resident #3 was very alert and oriented, able to communicate her needs, and had not known her to exaggerate things or make false statements.During an interview on 4/15/26 at 10:22 a.m., Staff C, Maintenance Supervisor stated he was Staff A's supervisor, she did her job duties, she was not insubordinate and was not aware of any complaints about her work performance. Resident #3 was a family member of his and he often shopped for her when she requested, and was surprised to hear that she asked Staff A to shop for her. He had never known his family member or Staff A to be dishonest, and did not know what to make of the allegation.During an interview on 4/16/26 at 7:41 a.m. Staff D, Activity Director, stated she shopped for residents when requested, Resident #3 had asked her 5 or 6 times to shop, she always wanted her favorite flavored bottled water that they could get at a local store. The last time she requested her to shop was on 4/10/25, prior to that it was on 3/31/26, and some time in mid-March prior to that. The resident usually gave her cash, when she returned with the requested items she counted the change back to the resident and had the resident sign the receipt. Staff D was not aware the resident asked other staff to shop for her, she was off work due to a Covid infection during the time the allegation occurred and at that time 21 of the residents including Resident #3 were in isolation for Covid infections.During an interview on 4/16/26 at 8:06 a.m. Staff E, Business Office Manager (BOM) stated Resident #3 has a Resident Trust Account and asked to withdraw money 2 times since she [the BOM] worked at the facility. The resident was accurate and knew her balance in the account, she had not returned or deposited funds into the account and she believed the resident also had funds from another source that was not part of the Resident Trust Account.Review of the facility undated policy titled, Abuse Policy directed staff, in part:a. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.b. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.c. Exploitation is defined as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion.d. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) or a reasonable suspicion of a crime shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and or designee. Those who report allegations of potential or actual abuse and neglect shall be free from retaliation or reprisal.e. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source, misappropriation of resident property) and reasonable suspicion of a crime resulting in bodily injury will be reported immediately, but not later than:1. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. f. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) may have disciplinary action up to and including termination taken.

Based on observation and staff interview, the facility failed to follows safe sanitation and food handling practices to prevent cross contamination and foodborne illness. The facility reported a census of 51 residents.Findings include:1. During the initial tour of the kitchen on 8/4/25 at 10:49 AM with the Dietary Manager (DM) included:a. Partially uncovered leftover chocolate cake on a cookie tray set in the dry goods storage areab. A gallon of 2% white milk with a date of 8/2/25 in the walk-in refrigerator. The Dietary Manager stated she thought the milk good for 3 days past the expiration date.c. An 18-quart container with shredded yellow cheese in the walk-in refrigerator. The container had a date of 7/6/25 written on a label. The Dietary Manager disposed of the container.d. The inside of a [brand name redacted] microwave had dried tan residue on the inside of the device. 2. During the observation of the noon meal process on 8/6/25 started at 11:00 AM, the following noted:a. The inside of the [brand name redacted] microwave continued to have dried tan residue on the inside of the device. b. During the puree and mechanical soft diet food preparation process, Staff J, Dietary [NAME] used different spatulas for each food item blended. After checking for the desired consistency, Staff J placed the spatula on the counter top, without a barrier. During an interview on 8/6/25 at 11:13 AM, Staff A, Dietary Cook, reported he is responsible for checking food in refrigerator for outdates. He stated he does not use milk after the expiration date. He also stated the [NAME] working is responsible for cleaning the inside of the microwave. During an interview on 8/7/25 at 9:13 AM, the DM stated milk should be discarded by the expiration date. She stated on 8/6/25 she threw away 10 gallons of milk because the staff did not rotate them properly. The DM stated the night [NAME] is responsible for checking item in the refrigerator for outdated food times nightly.

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to prevent three deficiencies identified in the 2024 recertification from being cited again during the current recertification survey. The facility reported a census of 51 residents.Findings include: Review of the facility's CMS-2567 form the Recertification survey conducted from 9/09/24 to 9/16/24 revealed the following 3 (three) deficiencies cited:a. F690 (Bowel/Bladder, Incontinence, Catheter, UTI);b. F812 (Food Procurement, Store/Prepare/Serve-Sanitary);c. F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt). During the most recert Recertification survey conducted 8/4/25 to 8/12/25 a total of 10 (ten) deficiencies cited, which included:a. F690 (Bowel/Bladder, Incontinence, Catheter, UTI);b. F812 (Food Procurement, Store/Prepare/Serve-Sanitary);c. F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt). During an interview on 8/12/25 at 9:45 AM, the Administrator stated Quality Assurance Committee meets monthly and decides what to work on based on any grievances, information from resident council meetings, and from 5-star nursing home report data. When queried about repeat deficiencies noted from previous recertification survey to present, the Administrator agreed that facility continued to have repeat deficiency areas and planned to implement a focus on kitchen processes until audits show sustained improvements and continue to work on an established QAPI plan to reduce incidents related to bowel/bladder complications which included follow up on physician notifications and initiating interventions. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), revised 9/2022, revealed a Policy statement, which declared Our facility is committed to developing, implementing, and maintaining an effective, comprehensive, data-driven QAPI program that focuses on indicators on of outcomes of care and quality of life. The policy listed the organization's governing body and the facility administrator to have accountability for the QAPI program. The QAPI Feedback, Data Systems, and Monitoring section directed: A. Performance indicators will be developed for each aspect of care and services being monitored.B. A data collection and monitoring plan will be developed by following the CMS guide Measure/Indicator Collection and Monitoring Plan. C. Goals will be established by using the CMS Goal Setting Worksheet. D. Feedback will include communication of the information to those who need to know.E. The assigned QAPI team will identify gaps and opportunities for improvement and communicate them to the QAA Committee and the leadership team. F. Improvement activities will be assigned and high-risk, high frequency, and problem prone issues will be assigned to a Performance Improvement Project (PIP). G. The QAA Committee will work with the QAPI team to establish a frequency for monitoring the area of concern.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to notify the physician of low blood pressure results, and of persistent coughing despite a change in diet order and the administration of an as needed cough syrup for 2 of 2 residents (Resident #17 and #46) reviewed for physician notification. The facility reported a census of 51 residents.Findings include: 1.Review of the Minimum Data Set (MDS) assessment, dated 7/29/25, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The list of diagnoses included orthostatic hypotension, quadriplegia (limited ability with movement or sensation of upper and lower extremities, and benign paroxysmal vertigo of unspecified ear (dizziness caused by an inner ear condition). Review of the Care Plan, date initiated 1/06/2022, revealed Resident #17 had a self-care deficit and was at risk for falls due, in part, to hypotension (low blood pressure). The Care Plan lacked identification of signs or symptoms of hypotension to monitor for or interventions related to diagnosis of orthostatic hypotension.Review of Resident #17's electronic health records (EHR) recorded the following blood pressure readings:a. 69/41 recorded on 1/10/25 at 9:22 AMb. 73/52 recorded on 2/08/25 at 3:50 PMc. 70/54 recorded on 2/24/25 at 9:18 AMd. 70/53 recorded on 3/19/25 at 9:17 AMe. 62/60 recorded on 4/14/25 at 8:42 AMf. 66/52 recorded on 5/13/25 at 9:23 AMg. 70/49 recorded on 6/07/25 at 3:30 PMh. 72/48 recorded on 6/22/25 at 3:46 PMi. 65/45 recorded on 6/27/25 at 9:03 AMj. 72/60 recorded on 7/09/25 at 3:33 PMk. 70/68 recorded on 7/29/25 at 9:01 AMl. 78/50 recorded on 8/03/25 at 3:03 PMReview of the Medication Administration Record (MAR), revealed an order for Midodrine 10 milligrams (mg), with instructions to give one tablet by mouth twice a day related to hypotension and instructed not to give this medication at bedtime. The MAR recorded Resident #17's blood pressure twice per day with administration of Midodrine and lacked parameters on when to notify physician of blood pressure results. Review of the EHR lacked documentation of physician notification related to blood pressure outside of normal limits. Normal limits may depend on the individual or physician orders, top number or systolic blood pressures normally read between 90 millimeters of mercury (mmHg) and 120mmHg and the bottom number or diastolic blood pressure normally read between 60-80 mmHg. During an interview on 8/07/25 at 1:45 PM, Staff B, Registered Nurse (RN) stated blood pressures with top number below 90, should typically be reported to the physician. Staff B explained that Certified Medication Assistants (CMA) staff would check resident blood pressure during medication administration and report abnormal results to the nurse. Staff B stated Resident #17 had low blood pressure a couple of times and stated if Resident #17 had systolic blood pressure less than 90mmHg, the medication should be held and provider notified. Staff B denied knowledge of Resident #17 having blood pressure results requiring physician notification and stated documentation of provider notification would be found in EHR Nursing (general) Notes. During an interview, on 8/11/25 at 12:55 PM, Staff G, CMA, revealed that Resident #17 required blood pressure check before giving morning medications and denied having parameters in which to report blood pressure readings. Staff G stated she would report to nurse if Resident #17's blood pressure results had a top number below 90mmHg and/or bottom number below 60mmHg. Staff G denied having to report any low blood pressure readings on Resident #17 to the nurse. During an interview on 8/11/25 at 2:16 PM, Director of Nursing (DON), stated she would expect that nursing staff report low blood pressure results to physician, even for residents with chronic low blood pressure. The DON explained that a request for blood pressure parameters had been sent to physician and would be implemented when facility received orders.2. The MDS assessment, dated 7/29/25, revealed Resident #46 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included cerebrovascular accident (CVA, also known as stroke) and aphasia (difficulty speaking). The MDS indicated Resident #46 had no difficulty swallowing, had no oral or dental concerns and required a mechanically altered diet. Review of the Care Plan, date revised 7/30/25, lacked identification of chronic cough, symptoms of a respiratory condition, or interventions related to Resident #46 cough. Review of the clinical record revealed a General Note, entered on 1/23/25 at 3:14 PM, which documented that Resident #46 had admitted to the facility on [DATE] with rehabilitation orders, plan to receive Physical Therapy, Occupational Therapy, and an evaluation with Speech Therapy. Review of a Speech Therapy (ST) Evaluation, dated on 1/23/25, revealed Resident #46 had referral for ST due to decline in overall functional abilities following hospitalization with diagnosis of influenza A, was referred for evaluation of swallowing function and cognitive communication abilities. The ST Evaluation summarized that Resident #46's abilities were consistent with prior level of function and determined ability to safely consume general consistency foods and liquids with no further ST intervention indicated.Review of a General Note, entered on 3/19/25 at 7:39 AM, revealed that Resident #46 was up to wheelchair for breakfast and had usual morning coughing episode. Note documented that Resident #46 had a history of persistent cough. Review of a General Note, entered on 3/24/25 at 3:07 PM, revealed that Resident #46 presented with a cough for the past few days when drinking liquids and documented that a 3 day trial of nectar thickened liquids would be completed. Review of a facsimile (fax) communication with provider, dated 5/07/25, revealed notification that Resident #46 had a hacking, persistent cough since admission to facility. The fax documented a nursing request for something for Resident #46's cough. The provider acknowledged fax, dated 5/16/25, and ordered Geri-tussin (cough syrup) 5 milliliters (mL) every 4 hours to be given as needed for cough. Review of MAR for the months of June, July, and August 2025, revealed an order for Geri-Tussin Liquid 100 milligrams (mg) per 5 milliliters (mL) with instructions to give by mouth every 4 hours as needed for cough. Order started on 5/15/25. The MAR recorded the following Geri-Tussin administrations: a. On 6/09/25 at 6:40 AM, provided effective relief. b. On 6/21/25 at 5:12 AM, provided effective relief. c. On 7/20/25 at 5:05 AM, unknown effectiveness. d. On 8/01/25 at 7:00 PM, unknown effectiveness. Review of Resident #46 EHR lacked documentation of physician notification related to continued cough following the change to nectar thickened liquids and the implementation of an as needed cough syrup order. The EHR lacked record or documentation of request for follow up ST evaluation when Resident #46 required change to nectar thickened liquids (3/24/25) or when Resident #46 was noted to have persistent, hacking cough since admission [DATE]). During an observation on 8/05/25 between 8:26 AM and 8:30 AM, Resident #46 sat in her wheelchair in the common area and had a frequent hacking type cough without staff acknowledgement or intervention. During in observation on 8/05/25 at 11:28 AM, Resident #46 had a hacking cough, that was heard as she sat in her wheelchair in the therapy room. During an interview, on 8/07/25 at 1:45 PM, Staff B, RN, stated Resident #46 coughs really hard and just can't be comfortable. Staff B reported that she had tried to get Resident #46's cough addressed a couple of times and informed that the cough syrup sometimes helps. Staff B explained that she believed Resident #46's cough was related to drinking thin liquids due to some improvement noted with change to thickened liquids.During an interview, on 8/11/25 at 2:16 PM, the DON stated Resident #46 would cough at times and that a ST evaluation had been completed when resident was admitted to the facility (1/23/25). During an interview, on 8/12/25 at 9:30 AM, the Administrator stated it is the expectation of nursing staff to report to the physician any changes in a resident's baseline health condition or functional status. Review of the facility policy titled, Notification of Changes, dated 12/2023, revealed a purpose statement to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Section A. Compliance Guidelines directed, in part, circumstances requiring notification to include: 3. Circumstances that require a need to alter treatment. This may include: a. New treatment.b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition.iii. Exacerbation of a chronic condition.

Based on staff interview, clinical record review, and facility policy review, the facility failed to attempt to designate resident representation for 1 of 1 residents (Resident #23) with a moderate cognitive impairment and intellectual disability, to ensure medical and financial decisions were made with informed consent. The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 6/24/25, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included mild intellectual disabilities, mood disorder, psychotic disorder, anxiety disorder, and depression. The MDS indicated Resident #23 had limited ability in making concrete requests and responded adequately only to simple, direct communication. Review of Resident #23's admission Record (also referred to as a Resident Face Sheet), revealed an admission date of 9/26/24 to the facility, and listed Resident #23 (self) as the only contact. Review of the Care Plan, revealed a Focus area, dated 4/09/25, to address Resident #23 impaired cognitive function or impaired thought processes related to mild intellectual disabilities with interventions to administer medications as ordered and to engage resident in simple, structured activities that avoid overly demanding tasks.The Care Plan also included a Focus area, dated 2/19/25, related to the Pre-admission Screening and Resident Review (PASRR) identification of rehabilitation services that must be implemented to address resident rehabilitation with an intervention listed, in part:a. Nursing Facility to assist in determining if there is an appropriate family member, friend, or support person who is well qualified to serve as Power of Attorney (POA), conservator, or guardian. If none available, a referral may be made to the Office of Substitute Decision Maker, Iowa Department on Aging.b. Nursing Facility staff will facilitate the identification and designation of a power of attorney for healthcare and/or finances.Review of a Provider Visit note, dated 3/01/25, revealed Advanced Care Planning (ACP) was attempted with Resident #23, but patient's cognitive status prohibited and/or Medical Power of Attorney (MPOA) could not be named. On 8/07/25 at 1:45 PM, Staff B, Registered Nurse (RN), reported that Resident #23 will call out or shut eyes when she hurts or doesn't feel good and stated that Resident #23 often is, in her own world. On 8/11/25 at 9:17 AM, Director of Social Services, denied having made attempts for designation of conservator, guardian, or POA for Resident #23.On 8/11/25 at 11:15 AM, Staff C, Certified Nursing Assistant (CNA), reported that Resident #23 was often disoriented to time of day. On 8/11/25 at 11:26 AM, Staff D, CNA, reported that Resident #23 was often disoriented to location and would think she's somewhere else. On 8/11/25 at 1:07 PM, Staff E, RN, stated that Resident #23 was pleasantly confused and unable at times to engage in conversation. Staff E explained that Resident #23 would be able to make decisions about what to drink, eat, or wear, but was unable to make medical or financial decisions related to health care. On 8/11/25 at 2:16 PM, Director of Nursing (DON), stated that Resident #23 was pleasantly confused and explained that resident was able to make simple decisions but would be best if she had someone to assist in medical or financial decision making. On 8/12/25 at 9:30 AM Facility Administrator denied having record of additional information related to facility attempts for resident representation. The facility policy, titled Advanced Directives, dated 9/2022, defined health care decision-making capacity as referring to possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice. The Section C, Decision-Making Capacity directed, in part:Upon admission, the interdisciplinary team assesses the residents decision-making capacity and identify the primary decision-maker if the resident is determined not to have decision-making capacity.The interdisciplinary team conducts ongoing review of the residents decision-making capacity and invokes the resident representative, or health care agent, if the resident is determined not to have decision-making capacity. Changes are documented in the Care Plan and Medical Record.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to complete a self-medication assessment for 1 of 1 residents (Resident #9) who self-administered insulin. The facility reported a census of 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 7/31/25, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included type 2 diabetes mellitus, paraplegia, and spina bifida. The MDS indicated Resident #9 received insulin injections on a daily basis. During an observation on 8/06/25 at 11:40 AM, Staff B, Registered Nurse (RN), prepared Resident #9's Novolog Flexpen by attaching needle and dialing pen to 30 units of insulin, as ordered. Resident #9 cleaned own right lower abdominal area with an alcohol wipe, Staff B handed the the prepared insulin pen to Resident #9, and Resident #9 injected self in right lower abdomen with insulin, then held pen in place as she counted to 10, as Staff B watched. Following Resident #9 self administration of insulin, Staff B removed and discarded the needle into a sharps container. Review of the Care Plan, date initiated 4/17/25, revealed a Focus area to address diagnosis of type 2 diabetes mellitus. Interventions included, in part: a. Administer diabetes medications as ordered and observe, document for side effects and effectiveness. b. Resident #9 utilizes insulin. c. Observe, document, and report signs or symptoms of low blood sugar or high blood sugar.The Care Plan lacked identification of Resident #9 request to self administer medication (insulin). Review of Resident #9's Order Summary, dated 8/06/25, revealed an active order for Novolog Injection Flexpen, with instructions to inject 30 units subcutaneously three times daily before meals. Review of Resident #9's electronic health records revealed a lack of a self medication assessment for safety and competency to determine if resident able to self administer any medications. During an interview on 8/07/25 at 1:45 PM, Staff B, RN reported being unable to locate any completed assessments on Resident #9 prior to observation of insulin self administered on 8/06/25.During an interview on 8/11/25 at 2:16 PM, the Director of Nursing (DON), stated she would expect a resident assessment to be completed prior to self administration of any medications to ensure safety. The DON reported that an assessment had not been completed on Resident #9 to self-administer medication prior to 8/06/25.On 8/12/25 at 9:30 AM, the Administrator, reported that an assessment of self-administration competency had been missed on Resident #9 and explained that the typical process is to complete an assessment prior to a resident self-administering any medication, to ensure resident safety with administration. Review of the facility policy, titled Self-Administration of Medications, dated 2/2021, revealed that Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. The Section A. Policy Interpretation and Implementation directed, in part:3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status.

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to allow 1 of 1 residents (Resident #28) reviewed for smoking, to choose to continue smoking after the facility changed their smoking policy to be a smoke free campus. The facility reported 51 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 5/27/25, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The list of diagnoses included anxiety disorder and depression. The MDS indicated Resident #28 independent for all transfers and activities of daily living. The MDS identified an admission date of 11/25/2024. Review of the Care Plan, date initiated 1/09/25, revealed a Focus area to address Resident #28 liked to smoke related to a history of smoking. Interventions included, in part:a. Ensure Resident #28 is aware of facility smoking policy. b. Show Resident #28 where smoking is allowed and how to access. Review of a facility provided document titled, Memo to Resident Representative, dated 5/19/25, Subject: 30 Day Notice of a Change to Residents Smoking Policy revealed in part: We are writing to inform you of an important upcoming change to our facilities smoking policy. Effective June 23, 2025 Country Lane Manor will become a smoke-free campus for all residents. This means that smoking will no longer be permitted anywhere on the premises, indoors, or outdoors by resident of the facility.Review of the clinical record revealed an Interdisciplinary Note, entered on 5/29/25 at 11:22 AM, which documented Resident #28 had history of depression and anxiety and noted that behaviors increase with inability to smoke tobacco. During an interview on 8/05/25 at 12:39 PM, Resident #28 stated she used to be able to go outside and smoke at the facility, but is now using nicotine patches, which she said helped with smoking cravings. Resident #28 reported that she planned to continue smoking when she was able to return home.Review of Resident #28's electronic health records (EHR) revealed the lack of a completed smoking assessment to determine the residents safety and compliance with the facilities smoking policy upon admission. The EHR also lacked the resident and/or resident representative written or verbal understanding and agreement to the 6/23/25 change in the facility Resident Smoking Policy. Review of the EHR revealed a Behavior Note, entered on 6/25/25 at 8:30 AM, Resident has been in her room and not come out since the facility went to no smoking on 6/23/25. Resident has been compliant to wearing her nicotine patch daily. CNA (Certified Nursing Assistant) reported this morning to Nurse resident was asking what the temperature was outside today. Review of a Nursing Note, entered on 6/25/25 at 10:40 AM, revealed Resident attempted to go outside to smoke. Nurse attempted to redirect resident. Resident became combative and placed both of her hands with long fingernails on each side of nurses face and scratched down the sides of the nurses face and attempted place her hands around nurses neck. Nurse removed residents hands, resident went to the back door to try to get out. Door code had been changed. Resident unable to get out. Nurse went and got Administrator. Administrator was able to talk to resident and ger to go back to her room. Review of a Nursing Note, entered on 6/26/25 at 4:22 PM, revealed Resident told staff she will be going outside to smoke this evening. ADON (Assistant Director of Nursing) and BOM (Business Office Manager) were notified, they spoke with resident. Resident became highly agitated and angry at ADON. ADON and BOM left the room. Resident was reminded of the no smoking policy. During an interview on 8/07/25 at 1:45 PM, Staff B, Registered Nurse (RN), reported that Resident #28 had been very upset about the facility smoking policy change and became very self-isolating, refusing to leave her room. Staff B stated that Resident #28 would love to continue smoking. During an interview, on 8/11/25 at 1:07 PM, Staff E, RN, reported that Resident #28 used to go outside and smoke but had isolated self in room since policy change.During an interview on 8/12/25 at 9:30 AM, the Administrator identified Resident #28 as the only current resident who resided and was able to smoke on facility premises before policy change on 6/23/25. The Administrator revealed that the smoking policy change included a Memo sent to residents and resident representative issuing a 30-day notice of non-smoking. Administrator stated that she spoke directly with Resident #28 who initially had been upset, believed she was being punished. When asked if Resident #28 was able to be grandfathered in to the new non-smoking policy, the Administrator denied allowing any residents to continue smoking on facility premises when new policy went in to affect. Review if the facility provided policy titled, Smoking Policy and Procedure, dated effective 1/31/24, revealed the purpose of the policy to establish and clarify the policy and process for residents who desire to smoke. The Section A, Policy and Procedure directed, in part: Bullet Point #8. An assessment will be completed to determine which residents are safe and unsafe smokers and what restrictions, if any. These will be placed on the resident's smoking privileges. Bullet Point #9. Any smoking-related privileges, restrictions, and concerns shall be noted in the Care Plan. All personnel caring for the resident shall be alert to these. Residents shall also be alerted to these items. Bullet Point #10. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Bullet Point #12. The staff will review the status of residents smoking privileges quarterly and as needed with significant changes. Bullet Point #16. Any resident who has been determined to have the capacity to smoke independently by the Interdisciplinary Team and has a physician's order allowing independent smoking, may access his or her cigarettes and other smoking items and sign him or herself out on leave of absence in accordance with facility leave of absence policies and procedures, and during the hours established for such purpose by the facility Administrator.

Based on observation, clinical record review and staff interviews the facility failed to include the use of an indwelling catheter prior to admission on the care plan for 1 of 1 residents (Resident #49) reviewed for care plans. The facility reported a census of 51 residents.Findings include: Review of the admission Minimum Data Set (MDS) assessment, dated 7/01/25, revealed the list of diagnoses for Resident #49 included benign prostatic hyperplasia (BPH or enlarged prostate), urinary tract infection (UTI) within the last 30 days, and overflow incontinence. The MDS indicated Resident #49 required an indwelling urinary catheter and was always incontinent of bowel. The MDS indicated an admission date of 6/26/25. Review of an admission Order Sheet, signed by physician on 6/27/25, revealed that Resident #49 had an indwelling catheter which was to be changed every 30 days for diagnoses of BPH and overflow incontinence. During an observation, on 8/04/25 at 12:44 PM, Resident #49 sat in wheelchair, with an urinary catheter tubing and drainage bag stored underneath wheelchair, urine visible within the tubing appeared light yellow and cloudy.Review of the Care Plan, date initiated: 6/26/25, revised 7/16/25 revealed a Focus area to address [name redacted] incontinent of bowel and bladder. The Interventions did not include the use of a indwelling urinary catheter or directions for care of the device. During an interview, on 8/07/25 at 1:45 PM, Staff B, Registered Nurse (RN), reported that Resident #49 had indwelling urinary catheter since admission to facility and indications for catheter included diagnosis of BPH.Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, revealed a Policy Statement which declared A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation section directed, in part: 7. The comprehensive, person-centered Care Plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to clarify orders for indwelling catheter care and follow up on an order for a urinalysis in a timely manner for 1 of 2 residents (Resident #49) reviewed for urinary catheters. The facility reported a census of 51 residents.Findings include:Review of the Minimum Data Set (MDS) assessment, dated 7/01/25, revealed Resident #49 had a Brief Interview for Mental Status score of 12 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included benign prostatic hyperplasia (BPH or enlarged prostate), urinary tract infection (UTI) within the last 30 days, and overflow incontinence. The MDS indicated Resident #49 required an indwelling urinary catheter and was always incontinent of bowel. Review of the Baseline Care Plan, dated for admission on [DATE], revealed Resident #49 required indwelling urinary catheter. Review of the Care Plan, date initiated 6/26/25, revised 7/15/25 lacked identification of Resident #49 required use of an indwelling urinary catheter or interventions to instruct care of the urinary catheter. Review of an admission Order Sheet, signed by physician on 6/27/25, revealed orders for an indwelling catheter to be changed every 30 days for a diagnosis of BPH. The order did not specify the size or type of indwelling catheter for Resident #49. Review of the Treatment Administration Records (TAR) for the months of June 2025 and July 2025 revealed a lack of an order to specify the size, type, or frequency to change Resident #49's indwelling urinary catheter. The August 2025 TAR included an order, started on 8/08/25 at 10:00 AM for 16 French foley catheter with 10cc balloon and drainage bag to gravity, and instructions to change catheter as needed for leakage, dislodgement or occlusion, one time a day every 30 days, and instructions to check for catheter placement and patency. An additional order, started on 8/06/25 at 6:15 PM, directed for catheter cares to be completed every shift. During an observation, on 8/04/25 at 12:44 PM, Resident #49 sat in wheelchair, urinary catheter tubing and drainage bag stored underneath wheelchair, urine visible within the tubing appeared light yellow and cloudy. Review of Resident #49s EHR revealed the following Nursing Notes: a. On 8/06/25 entered at 5:13 AM, Resident’s urine is cloudy and foul smelling. Fax sent to [provider name redacted] for an order to obtain UA (sample of urine for a urinalysis – a lab test to determine if someone has a urinary tract infection). b. On 8/7/25 entered at 3:19 PM, Nurse contacted [provider name redacted] to report resident c/o (complained of) discomfort in lower abdomen, his tiredness, and cloudy urine. Order obtained for Urine C&S (culture and sensitivity – and order to test for specific antibiotic effectiveness if a infection is present) x1. Nurse contacted resident’s wife and notified her of UA and that his cath will be changed on 8/8/25. c. On 8/8/25 entered at 1:42 PM, Rc’d (received) call per [name of nurse and physician from provider office redacted] new order for change monthly et recheck UA after new foley catheter placement, rec’d call from res spouse as res c/o via text to her of side discomfort. [Wife name redacted] update do new order rec’d via [physician name redacted]. d. On 8/8/25 entered at 2:17 PM, removed prev cath et (and) 10 cc fluid from balloon (a [NAME] of saline used to maintain the indwelling catheter placement) et res c/o discomfort et mucousy discharge et foul odorous drainage noted form penis upon d/c foley with balloon deflated but intact, reinserted 16 fr (catheter size) per sterile technique, with dark scant amt of urine with copious amounts of sediment noted, foley drainage et straw colored urine noted with scant amount sediment noted, et clean catch UA obtained presently et will send to lab. e. On 8/08/25 entered at 2:52 PM, res UA obtained et reports discomfort in right flank is relieved et no further c/o voiced, lab sheet et results pending post-delivery to Lab. f. On 8/11/25 entered at 12:58 PM, received verbal order from [physician name redacted] resident will begin Levaquin (antibiotic) 750 milligrams (mg) QD (daily) x 7 days. During an interview, on 8/07/25 at 1:45 PM, Staff B, Registered Nurse (RN) stated a urinary catheter would typically be changed every 30 days and as needed, unless a resident's Urologist had ordered a different change frequency. Staff B reported that Resident #49 should have orders for urinary catheter and orders would be found on the TAR. Staff B stated urinary catheter orders should include size of catheter, indication for use, and frequency of change. On 8/07/25 at 2:34 PM, when queried about collection of a urinalysis on Resident #49, Staff B stated that the fax request for urinalysis related to cloudy urine, noted by a previous nurse, had been sent to the wrong provider, and a urinalysis had not yet been collected. Staff B reported that Resident #49's last documented indwelling urinary catheter change, had been at the hospital on 6/25/25, prior to his admission [DATE]). During an interview, on 8/07/25 at 3:04 PM, the Director of Nursing (DON) stated Resident #49 last documented catheter change had been on 6/25/25, prior to admission and was unsure if Resident #49 had any follow up appointments scheduled with Urology. The DON stated that the facility's policy was to change indwelling urinary catheters every 90 days and as needed. When queried if a written or verbal order had been obtained from the physician on size of catheter or change frequency every 90 days, the DON stated a physician order had not yet been obtained. During an interview, on 8/11/25 at 1:07 PM, Staff E, RN, confirmed performing change of Resident #49's catheter on 8/08/25 and stated the urine appeared very cloudy with chunks of sediment that resembled snot noted in his urine. Staff E reported that Resident #49 had complained of flank (lower back/side) pain which improved following catheter change and claimed to have received a call from physician instructing nurse to change his catheter and collect a urinalysis. Staff E explained that indwelling urinary catheters typically should be changed monthly unless otherwise ordered. During an interview on 8/12/25 at 9:30 AM, the Administrator, revealed expectation of orders for the size, frequency of change, and indication of use to be in place for a resident who admits to facility with an indwelling urinary catheter, as well as documentation by Certified Nursing Assistant (CNA) staff of urinary output. Facility Administrator stated resident's Care Plan should also reflect use of urinary catheter to direct care and how to manage catheter. Review of the facility policy, titled Catheter Care, Urinary, dated 8/2022, revealed a Purpose Statement which declared the purpose of the procedure is to prevent urinary catheter -associated complications, including urinary tract infections. The Complications section directed, in part: 1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately: a. if the resident indicates that his or her bladder is full or that he or she needs to void (urinate); b. if urine has an unusual appearance (i.e., color, blood, etc.); c. in the event of bleeding, or if the catheter is accidently removed; d. if the resident complains of burning, tenderness, or pain in the urethral area; or e. if signs and symptoms of urinary tract infection or urinary retention occur.

Based on attendance record review and interview, the facility failed to have the minimum required members in attendance at their Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 51 residents. Findings include:Review of the facility's QAPI attendance sheets since the last recertification survey on 9/16/24, revealed that QAPI meetings were held on 10/18/24, 11/13/24, 1/15/25, 4/9/25, and 7/16/25. The attendance records revealed that the Medical Director was present only at the meeting on 4/9/25. On 8/12/25 at 8:50 a.m., the Administrator stated that the QAPI Policy does not address the members who need to be present quarterly. The Administrator added that she felt the Medical Director was at more than one meeting in the past year but cannot find anything to prove it.

Based on observation, record review and staff interview, the facility failed to follow infection prevention protocols for 2 of 3 residents (Resident #9 and Resident #14) reviewed with indwelling urinary devices. The facility reported a census of 51 residents.Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #9 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The list of diagnoses included diabetes mellitus, spina bifida and necrotizing fasciitis. The MDS identified Resident #9 dependent on staff assistance for toileting, showers, lower body dressing, putting on a taking off footwear. It also identified Resident #9 required partial/moderate staff assistance with upper body dressing, personal hygiene and transfers and had an ostomy (had both colostomy and urostomy). The MDS indicated Resident #9 admitted to the facility with a urostomy. Review of the Care Plan, dated 7/22/25, revealed a Focus area to address [name redacted] utilizes a urostomy and a colostomy. Review of the interventions revealed a lack of direction regarding the use of Enhanced Barrier Precautions during device care. During an observation on 8/5/25 at 1:23 PM, Staff F (Certified Nursing Assistant) donned an isolation gown, a face shield and gloves. She then emptied Resident #9's colostomy bag. Staff F removed the face shield and gown and disposed of the bag with the waste from the colostomy into the soiled utility room. Upon returning to the room, Staff F, donned gloves and without putting on an isolation gown, placed a barrier underneath a graduated cylinder and proceeded to empty the urostomy bag. During an interview on 8/11/25 at 10:44 AM, Staff C, CNA reported when emptying out a urinary drainage bag, she would need to don an isolation gown, gloves and face shield as the resident should be in Enhanced Barrier Precautions and place a barrier underneath the graduate when emptying the bag.During an interview on 8/11/25 at 2:16 PM, the Director of Nursing (DON) stated when emptying out a urinary drainage bag, she would expect to wear a gown, gloves, goggles or face shield and place a barrier underneath the graduate before emptying the bag.Review of the facility policy titled, Catheter Care, Urinary, revised August 2022, did not address the need to place residents with an indwelling urinary device in Enhanced Barrier Precautions2. Review of the MDS dated [DATE] identified Resident #14 as cognitively intact with a BIMS of 15. The list of diagnoses included diabetes mellitus, cerebrovascular accident (stroke) and hemiplegia (paralysis of one half of the body). The MDS also identified Resident #14 dependent on staff for toileting, showers, lower body dressing, putting on and taking off footwear and personal hygiene. The MDS indicated Resident #14 utilized an indwelling device Review of the Care Plan, dated 7/16/25, revealed a Focus area to address [name redacted] utilizes a nephrostomy tube. 7/16/25 suprapubic cath placed. Review of Physician Orders revealed an order, dated 7/27/25 to Cleanse Suprapubic catheter site with NSS (normal saline solution) and apply dry dressing, every day shift. During an observation on 8/5/25 at 2:05 PM, Staff B, Registered Nurse (RN) donned gloves and cleansed the suprapubic catheter insertion site. Without a change of gloves, Staff B proceeded to apply a new dry dressing on the site. During an interview on 8/11/25 at 1:07 PM, Staff E, RN reported when she cleanses the suprapubic catheter insertion site, she would need to change her gloves afterward and before she applies the new dressing.During an interview on 8/11/25 at 1:56 PM, Staff B, RN reported when she cleanses the suprapubic catheter insertion site, she would need to change her gloves afterward and before she applies the new dressing. She stated she may have forgotten to change her gloves when observed during site care on 8/5/25. During an interview on 8/11/25 at 2:16 PM, the DON stated after providing suprapubic catheter insertion site care, she would expect the nurse to remove her gloves, perform hand hygiene and put on new gloves before she applies the dressing.Review of the facility policy titled, Suprapubic Catheter Care, dated 2001 revealed a Purpose statement which declared The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the residents urinary tract. The policy did not address the steps to apply a clean dry dressing.

Based on clinical record review and staff interview, the facility failed to initiate treatment for an eye infection timely and in accordance with professional standards of practice for 1 of 5 residents reviewed. (Resident #3) The facility reported census was 53. Findings include: According to a Minimum Data Set (MDS) with a reference date of 4/29/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, indicating a severely impaired cognitive status. Resident #3's diagnosis included non-Alzheimer ' s dementia. According to a Progress Note dated 4/20/25 at 6:09 p.m. and written by Staff B, Licensed Practical Nurse (LPN), Resident #3's family summoned the nurse to assess Resident #3's right eye. The right eye was swollen, reddened and draining. Resident #3 indicated it was itchy and hurt a bit. Staff B indicated a communication note was left for the provider (nurse practitioner or physician). A Communication with Provider form was filled out by Staff B, dated 4/20/25 indicating Resident #3's right eye was swollen, reddened , with some drainage and Resident #3 was complaining of her eye itching and hurting a bit. There was no response from the nurse practitioner or physician on the form. According to a Progress Note dated 4/28/25 at 10:34 a.m. written by Staff A, Registered Nurse (RN), a call was placed to Resident #3's Nurse Practitioner noting right eye red with slight drainage on the outer canthus of eye. Received a new order for an antibiotic eye drops to be given twice a day for two days and the daily for five days. Review of the April 2025 Medication Administration Record revealed the following orders: a. AZASITE sol 1% INSTILL ONE DROP IN RIGHT EYE TWICE DAILY FOR 2 DAY (indications for use: Eye infection). Start Date: 4/9/25. b. Ciprofloxacn Sol 0.3% OP (eye) Instill 1 drop in affected eye(s) every 2 hours while awake for 2 days *wait 5 min (minutes) between administering different drops. Start Date: 4/30/25. During an interview on 5/8/25 at 1:45 p.m. Staff A, RN queried regarding Resident #3 ' s right eye infection. Staff A stated on 4/28/25 a family member approached her, concerned about Resident #3 ' s right eye swelling and discomfort. The family member stated she had told another nurse earlier. Staff A stated she assessed the right eye and contacted her physician to get antibiotic eye drops started. Staff A stated normally when there are concerns, the nurse will fill out a physician notification form and place it in a box for the nurse practitioner or physician to review. If the concern warrants treatments, she fills out the notification form and contacts a physician immediately for treatment orders. Staff A stated the nurse practitioner visits weekly and primary care physician every two weeks.

Based on observations, food temperatures during food services, and resident interview, the facility failed to serve food in an attractive and palatable manner for 1 of 2 meals. The facility reported census was 59. Findings include: On 2/12/25 at 12:15 p.m., a sample lunch tray provided to the State Agency. The meal consisted of a chicken patty and green beans. The chicken patty edges were hard, tough and chewy. No concerns with the green beans noted. An observation in the dining room revealed the puree green beans served to a resident appeared to be of a soup consistency. According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognitive status. Resident #7 was independent with transfers, mobility, dressing, toilet use and personal hygiene needs and was occasionally incontinent of bladder. Resident #7's diagnosis included congestive heart failure, diabetes mellitus and chronic obstructive pulmonary disease. During an interview on 2/12/25 at 12:50 p.m. Resident #7 stated he ate lunch in his room. He stated his lunch consisted of a chicken patty and green beans and a pudding cup. Resident #7 stated the green beans were ok, but the chicken patty was hard and difficult to cut. Resident #7 stated meats served are often hard. On 2/17/25 at 12:00 p.m. a sample lunch tray provided to State Agency. The meal consisted of spaghetti and mixed vegetables with a seasoned bread stick. Food was an served at a palatable temperature. The mixed vegetables were bland. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognitive status. Resident #1 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was frequently incontinent of bladder and occasionally incontinent of bowel. Resident #1's diagnosis included congestive heart failure, coronary artery disease, diabetes mellitus and hip fracture. During an interview on 2/17/25 at 12:45 p.m. Resident #1 complained of her meal, noting the mixed vegetables were bland and the spaghetti and breadstick was just carbohydrates.

Based on clinical record review, policy review, provider and staff interviews the facility failed to implement a physician order to change a type of wound dressing for 1 of 3 residents (Resident #6) with a wounds. The facility reported a census of 57 residents. Finding include: The Minimum Data Set (MDS) assessment, dated 9/12/24, revealed Resident #6 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating intact cognition. The MDS revealed the resident required partial/moderate assistance with rolling from left to right; sit to standing; and upper body dressing. The MDS identified the resident dependent for chair/bed to chair transfers. The MDS list of diagnoses included necrotizing fasciitis (bacterial infection that destroys tissue under the skin), diabetes mellitus, and wound infection. The MDS documented the resident had two Stage III pressure ulcers present on admission, along with surgical wounds. The Nursing Note dated 9/6/24 at 2:52 PM revealed resident arrived at facility via hospital transport accompanied by transport driver. Resident is a spina bifida (malformation of spinal cord) and has been whole life. Resident lives alone and cares for self, resident has 2 grown children, and a 14 lb (pound) cat. Resident has an ileostomy (opening in abdominal wall to allow collection of waste outside of the body) on her right abdomen and a colostomy (another name for opening in abdominal wall) on her right abdomen. Resident is independent with providing her own ostomy (opening in abdominal wall) cares and prefers to provide her own ostomy cares. Resident recently had necrotizing fasciitis and has a right buttock wound up through her right vaginal area. Resident states she doesn't get dressing change until after she receives a pain pill because the dressing is so painful. Resident states she has a motorized wheelchair at home and that is her mobility. Resident has mepilexes (a type of absorbent foam dressings) on each heel the right is for prevention and the left is for a wound. Resident oriented to her room and routine. The Care Plan, Date Initiated: 9/11/24, Revision on: 9/20/24 included a Focus area to address [Name redacted] has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) necrotizing fascilitis. Interventions included, in part; [Name redacted] is a one assist with repositioning in bed. Resident able to help with repositioning, [name redacted] utilizes an AIR mattress d/t (do to) wounds on a bariatric (heavy duty bed) bed. Interventions Date Initiated: 9/20/24. The Care Plan, Date Initiated: 9/20/24, included a Focus area to address [Name redacted] has 2 pressure ulcers r/t immobility. Dx (diagnosis) of necrotizing fasciitis. Interventions included, in part; Assess/record/observe wound healing (FREQ) (frequently). Measure length, width, and depth where possible. Assess and document state of wound perimeter, wound bed healing progress. Report improvements and declines to the MD (medical doctor). Intervention Date Initiated: 9/20/24. A review of Physician Orders revealed: a. Ordered on 10/6/24- Vashe wound sol therapy Left heel stage 3 ulcer. Cleanse with vashe and pat dry. Apply prisma or equivalent to wound bed only and cover with bordered foam silicone dressing daily. Encourage side to side positioning and heal suspension. b. Cleanse buttock open area with Vasche daily. Apply Puracol or equivalent directly onto wound bed, cover with foam adhesive bandages. One time a day for wound care. Encourage side to side positioning and heel suspension. Ordered 10/10/24. c. Hydrocodone/acetaminophen 7.5/325 mg (milligrams)- 1 tab every 4 hours as needed for moderate pain. Ordered 9/14/2024. The provider Clinic Note, dated 11/1/24, for a Nursing Home Visit revealed: a. Primary diagnosis: Pressure ulcer of right buttock, stage 3 b. Chief complaint: follow-up c. History of Present Illness: Resident #6 is being seen at [facility name redacted] for follow up on her wounds: left heel pressure ulcer, vulva and buttocks from previous surgical debridement due to necrotizing fasciitis. She previously had pressure areas to sacrum and buttocks as she is wheelchair bound due to spina bifida. Had extensive debridement at [hospital name redacted] in [city and state redacted]. Since being admitted to [facility redacted] to [facility name redacted] she has had been receiving daily dressing changes. Had previously discussed having wound consult and treatment with wound clinic at [hospital name redacted] and she declined. Today she denies any new pain. States that the left heel rarely has pain given her spina bifida. Reports that perineum and buttocks are only painful with dressing changes and that levels vary depending. Nurse states that Resident #6 continues to be resistant to lying side to side and does not get out of bed. States that she has not had any follow up with surgeon since admission in August. Nurse feels as thought the heel is stable, but buttocks wounds are worsening. d. Assessment and Plan 1. Current medications and orders reviewed-advised of orders that were duplicated, completed or no longer applicable 2. [Facility name redacted] chart reviewed including notes and assessments. 3. Epic records since previous visit reviewed including consultations, labs and imaging if applicable . 4. New orders given today: wound consult at [hospital name redacted] (was told after visit that she would like to be seen), wound culture and will start Doxycycline while waiting for results. 5. Follow up per nursing home guidelines and as needed. The untitled facility form, with facility name, address and phone number, dated 11/1/24, revealed, in part; a. Wound location: buttocks 1. Etiology: Pressure Stage III 2. Cleanser: Vashe 3. Primary Dressing: Calcium Alginate AG- cut to size of wound 4. Secondary dressing: non-adherent then ABDs 5. Secure with: Paper and silicone tape 6. Frequency: daily and PRN (as needed) b. Wound location: right heel prevention 1. Primary dressing: hydrocolloid 2. Frequency: change Q (every) 3 d (days) and PRN Provider Signature and Date: [Name redacted], 11/1/24. The second page of the untitled form, labeled Provider Order Form, dated 11/1/24, revealed; Orders: 1. Culture of wound. Take to [hospital name redacted]. Completed during visit. 2. Start doxycycline 100 mg PO BID (twice daily) x 10 days. DX (diagnosis): wound infection. Provider Order Form signed on 11/1/24 by provider [name redacted]. The Provider Order form did not have documentation of facility review. A review of the clinical record did not reveal documentation of the 11/1/24 wound dressing orders for the heel and buttocks orders or implementation of the orders. A Nursing Note, dated 11/2/24 at 7:27 PM, revealed resident was initiated on ATB (antibiotic) [doxycycline] 100 mg i po (oral) bid x 10 days for dx of wound infection. first dose was pulled from cubex (brand name of medication storage/dispensing equipment). temp 97.2 tymp. (tympanic - temperature taken via ear canal) notice was received from pharmacy statingATTN: nursing staff. [name redacted] Pharmacy staff is clarifying (doxycycline) med not covered by insurance. will await a response. A Nursing Note, dated 11/6/24 at 3:10 PM, revealed Call received from [name redacted for local hospital] regarding resident's return from wound clinic appointment. [Provider's name redacted] has ordered an IV (intravenous) antibiotic for resident to be treated with every 12 hours. Informed [local hospital name redacted] team that [facility name redacted] can not accommodate every 12 hour IV antibiotics and that we do not feel comfortable accepting her back with that order. [local hospital name redacted] asked if resident would be accepted back following completion of IV antibiotic therapy, and they were informed that we will accept resident back at that time. [name redacted] stated she would call back when she had more information. During an interview on 11/12/24 at 4:00 PM, Staff B (Registered Nurse) after queried on Resident #6 orders stated she reviewed the orders under the documents tab in the EMR (electronic medical record) and then reviewed the resident's chart. Staff B stated she didn't see the new dressing orders. Staff B asked when wound dressing orders get processed and she stated usually right away, they sent it to pharmacy and they put them in and discontinued the old order. Staff B stated she was not sure what happened and she couldn't find anything for the dressing change order on 11/1. Staff B stated she didn't see a progress note for the wound dressing orders. During an interview on 11/13/24 at 9:12 AM, Staff A, Advanced Registered Nurse Practitioner (ARNP) after queried on the resident's new orders for dressing changes on 11/1/24 stated she would of liked to been notified if the supplies not available to change the dressing and she didn't see where anyone notified her. Staff A stated she expected new orders for dressing changes to be implemented at the next scheduled dressing change. Staff A stated she was not aware the new dressing changes didn't get started. During an interview on 11/13/24 at 11:19 AM, Staff C, RN after queried about Resident #6 wounds stated she saw Resident #6 with Staff A, ARNP on rounds on 11/1/24 and said Staff A went through everything with her and Staff C told Staff A she was unclear on the wound dressing orders. Staff C stated Staff A stated she would write down the orders and Staff C shift was over before the orders received. Staff C stated the night or weekend nurse would of taken care of it. During an interview on 11/13/24 at 1:47 PM, the Administrator after queried about how orders being processed worked explained they received the orders from the providers when the residents seen and they gave the orders directly to the nurse and if the resident seen at the clinic, they came back with orders and the orders given to the nurse. The Administrator stated the nurse manually put the orders into the computer. The Administrator informed of the new dressing change orders for Resident #6 and she stated she expected the orders go in when they are received and she would do re-education on the processing of orders. During an interview on 11/13/24 at 3:52 PM, the DON (Director of Nursing) after queried on Resident #6 new wound dressing change orders stated she expected the staff to be doing the new dressing changes as ordered and they needed to make sure the orders placed in the computer when they received it. A facility policy, dated November 2014, titled Medication Orders, Purpose statement declared The purpose of this procedure is to establish uniform guildelines in the receiving and recording of medication orders. The Recording Orders section #6. Treatment Orders - When recording treatment orders, specify the treatment, frequency, and duration of the treatment.

Based on record review, facility provided documents, and interviews the facility failed to provide sufficient qualified nursing staff to provide nursing services that meet the residents' needs safely and in a timely manner and promotes each resident's rights, physical, mental, and psychosocial well-being The facility reported a census of 56 residents. Findings include: In an interview on 9/12/24 at 1:30 PM, Staff C, RN, indicated that during the process of admissions, when the resident comes to the facility from the hospital a packet will be sent with them. This packet includes the resident's health history, medication orders, lab orders, and any treatment or therapy orders. There have been times this packet was not available, the nurse would need to find who has it (at times has been the DON or administrative staff), if the nurse is not able to locate the packet they are to contact the hospital and get it faxed to them. Once the packet is reviewed orders are faxed to the pharmacy. The MDS nurse does the batch orders (standing orders including the resident's level of care and general admission orders) and sometimes when the nurses are busy on the floor, during meal time and/or end of shift administration will fax the orders to the pharmacy for nurses. The charge nurses do not contact the provider to notify the resident is admitted to the facility, the provider is made aware of resident admissions through our management team, after they come into the building. This was previously done by the ADON (Assistant Director of Nursing), but the facility no longer has an ADON. If the nurses have questions about medications or treatments, we contact the provider and get clarification. Staff C stated the admission process is broken and a fragmented process, due to only having one nurse working on the floor each shift and not having time to complete admissions especially at shift change the oncoming nurse often does not have time to review the admission or complete it. In an interview on 9/12/24 at 1:52 PM, Staff I, Admissions Coordinator, stated she usually lets the provider know. The nurse also sends a face sheet to notify providers. In an interview on 9/11/24 at 3:17 PM, DON stated concerns about having enough staffing to be able to fully review admissions, received orders, and process any communication. On 9/6/24 three new residents were admitted to the facility. The admission orders for these residents had not been reviewed or confirmed as they should be due to staffing. The DON had been worked overnights, and the Administrator had come in at 2:00 AM to work as an LPN on the floor due to the scheduled overnight nurse calling in. DON continued to verbalize the staffing concerns, stating the facility is working with bare minimum for all shifts, she often has worked the floor and had many hours of overtime. There have been times after 6:00 PM there is only one CNA for the 100 & 200 hall (approximately 30 residents) and one nurse. She has concerns of staff burnout and the safety of the residents and staff. In an interview on 09/11/24 at 10:19 AM, the Administrator provided daily staffing sheets for the days of 9/9/24-9/12/24 and indicated the areas that do not have a staff member assigned will be filled with administrative staff. Having to fill these open positions happens daily for the administrative staff resulting in the administrative staff not able to complete their assigned responsibilities. Review of daily nursing schedules dated 8/8/24-9/8/24 revealed average staffing during day shift included one nurse, one med aid (to pass medications), one CNA for each hall (100, 200, 300, 400) and one CNA for showers. On weekends shower CNA is not scheduled. Night shift indicated one nurse and two to three CNAs when the facility had a census of 56 residents. Review of the facility's Center For Medicare and Medicaid Services PBJ (Payroll Based Journal) Staffing Data Report for Quarter 3 2024 (April 1- June 30) indicated One Star Staffing Rating (facility's staffing quality is considered to be much below average) was triggered. Excessively Low Weekend Staffing was triggered. (The Staffing Date Report identifies areas of concern that will be triggered) Review of staffing policy, revised October 2017 revealed the following: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met. 4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. 5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

Based on observations, clinical record review, and staff interviews the facility failed to have a consistent plan and procedure for advance directives for 6 of 25 residents reviewed. (Resident #9, #17, #19, #34, #42, and #60). The facility reported a census of 56 residents. Findings include: 1. Review of facility document, Policy For Resuscitative Services/Cardiopulmonary Resuscitation (CPR), indicated on [DATE] Resident #9 signed she would like to have CPR performed in the event that her respirations or pulse would cease. Review of Resident #9's EHR (Electronic Health Record) on [DATE], failed to indicate a code status on the header of Resident #9's file. Observations on [DATE] revealed a Full Code magnet outside of Resident #9's door was placed on the right side of the door. Magnets on the right side indicated the Resident in bed B, Left side indicated bed A. Resident #9 was in bed A. Revealing the magnet was on the wrong side of the door. 2. Review of Resident #17's EHR header indicated Full Code status and Policy For Resuscitative Services/Cardiopulmonary, indicated on [DATE] Resident's Power of Attorney signed Resident #17 would like to have CPR performed in the event that her respiration or pulse would cease. Observation on [DATE] 11:02 AM revealed a FULL CODE magnet on the outside Resident #17's door was placed on the left side of the door. (Indicated resident in bed A) Resident #17 was in bed B. 3. Review of Resident #19's Policy For Resuscitative Services/Cardiopulmonary Resuscitation (CPR) signed by Resident #19 and dated [DATE], indicated Resident #19 did not want CPR. On [DATE] at 11:03 AM, Resident #19 had a magnet on the outside of her door on the left side of the door when looking into the room, which indicated Resident #19 (bed A) had Full Code status. Staff A, Certified Nurse Aide (CNA), stated she did not know what the meaning of a magnet on a doorframe was. The Administrator then went to look at the magnet for Resident #19's room. She stated the magnet should be on the other side of the door as it is Resident #17 who is a full code not Resident #19. This Administrator stated that the CNA told her she did not know about the magnet as well. The Administrator acknowledged that Staff A should have known this. 4. Review of Resident #34's Policy For Resuscitative Services/Cardiopulmonary Resuscitation (CPR) was signed by Resident #34's Durable Power of Attorney (DPOA) and dated [DATE], indicated Resident #34 was a Full Code-wanted CPR performed. On [DATE] at 9:38 AM, it was noted that Resident #34 did not have a magnet on the door. On [DATE] at 9:48 AM, Staff D, CNA stated that she didn't think Resident #34 was a full code. She said there is a magnet on the door if a resident is a full code. Staff D stated the magnet would be located on the right side of the door if the resident was in the first bed (Bed A) and on the left side of the door if the resident was in the second bed (Bed B). She checked a list in the nurses station and said oh I guess he is a full code. When asked if there was a magnet on this resident's door, Staff D walked down to his room and she acknowledged there was not a magnet there. Staff D stated she would get a magnet and put it up on the door. Staff D said there had been recent room changes so that's probably why the magnet wasn't on the doorframe. When asked if Resident #34 had a recent room change, this CNA stated she wasn't sure as she had just returned to work from a 10 day quarantine. 5. Review of Resident #42's Policy For Resuscitative Services/Cardiopulmonary Resuscitation (CPR) was signed by Resident #42 and dated [DATE], indicated Resident #42 was a Full Code-wanted CPR performed. On [DATE] at 10:08 AM, it was noted that Resident #42 did not have a magnet on her door frame. Following this observation, Staff C, Registered Nurse (RN), checked code status for both Resident #34 and Resident #42. Staff C verified that both Resident #34 and Resident #42 were to be full codes. Staff C verified they both should have magnets on their doors and verified that Resident #42 did not have a magnet on her door. 6. Review of Resident #60's EHR on [DATE] failed to indicate a code status on the EHR header and failed to provide a signed Policy For Resuscitative Services/Cardiopulmonary document. Observation on [DATE] revealed Resident #60 did not have a Full Code indicator magnet outside of his room door. In an interview on [DATE] at 02:16 PM, Staff C revealed she would find a resident's code status by checking the magnet outside of the resident's door, if the magnet is on the left side it indicated resident in bed A and if on the right side it indicated resident in bed B. If Staff C was not in or near the resident's room she would verify status by checking the resident's EHR header. On [DATE] at 4:30 PM, the Administrator acknowledged the concerns with advanced directives. She stated when her Director of Nursing (DON) returns she plans to have a discussion regarding getting rid of the magnets altogether. She stated it's too difficult to keep them accurate and they have residents who wander the hallways who could remove/move the magnets. An Emergency Procedure-Cardiopulmonary Resuscitation policy revised [DATE], directed: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines Sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms (arrhythmia). Cardiac arrest occurs soon after symptoms appear. It is a leading cause of death among adults. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden cardiac arrest. Typically heart attacks are less sudden than SCA. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis), with MD order. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives.

Based on observation, interview, and facility policy review, the facility failed to prevent potential for contamination when gloves were not changed at appropriate times during meal service for 1 of 1 meal services observed. The facility failed to ensure resident food had been stored at appropriate temperatures and expired food had been removed when 1 of 1 resident food refrigerators lacked a thermometer, temperature log, labels, and opened dates of food or drinks. The facility further failed to ensure dish sanitation when the dishwasher log lacked entries for safe wash and rinse temperatures and the cups used for service appeared to have a coating of white film for 1 of 1 facility dishwashers. The facility reported a census of 56 residents. Findings include: On [DATE] at 10:46 AM, during initial tour of the kitchen, a refrigerator/freezer kept in the dining room, contained many undated and unlabeled food and drinks. The Dietary Manager revealed this refrigerator contained resident food and drinks brought in for resident use. The Dietary Manager confirmed the resident food refrigerator lacked a thermometer or temperature log to ensure safe food temperatures and stated they would provide one. The resident food refrigerator stored an undated/unlabeled plastic storage container that contained shredded lettuce with brown liquid pooled at the bottom of container. Additionally, observed a can of whipped cream with an expiration date of ,d+[DATE], a bag of shredded mozzarella cheese that expired [DATE], a carton of eggs dated [DATE], and a blueberry yogurt cup that expired [DATE]. The facility had one dishwasher kept in the kitchen, Dietary Manger revealed dishwasher required high temperature wash and rinse. Dishwasher temperature log kept on wall near dishwasher, revealed checks to be completed three times a day, had lacked many evening entries throughout the month of September, 2024. Log also instructed staff to report any wash temperatures less than 155 degrees Fahrenheit (F) and any rinse temperatures less than 180 degrees F. On [DATE] at 11:50 AM, a resident personal food refrigerator, kept in dining room, had a thermometer in place and kept at appropriate cooling temperature. Refrigerator continued to store container of spoiled shredded lettuce, expired cheese, eggs, whipped cream, and yogurt. On [DATE] at 12:15 PM, during mid-day meal service, Staff B, Cook, wore the same pair of gloves to touch scoops, tongs, various surfaces, pen and paper, without glove change before grabbing and opening hamburger buns served to the residents. On [DATE] at 1:15 PM, Staff B, Cook, revealed that all resident food required a label and an opened date, then thrown away 2 to 3 days after opened or made. Staff B, unsure of process for dishwasher temperature log and stated responsibility belonged to Dietary Aides to complete log. On [DATE] at 10:30 AM, Dietary Manager, revealed that resident food should not be directly handled by staff. Dietary Manager informed that kitchen staff would take over responsibility of resident food refrigerator in dining room and planned to clean out the fridge of expired and undated food. Dietary Manager revealed dishwasher temperatures are to be recorded three times a day on the log and informed education would be provided to staff on temperature check frequency and reporting any low temperatures to the Dietary Manager. The facility policy titled, Food Storage, dated [DATE] revealed that a thermometer is to be available in all refrigeration units and informed that Dietary Manager, Cook, or designee to maintain record of temperature checks twice daily. Policy instructed that any left-over food be labeled, dated, and stored for a period not to exceed 3 days. The facility policy titled, Use of Dish Machine, dated ,d+[DATE], revealed expectation of dish machines to be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. Guidelines included completing a test run before putting dishes in machine and instructed when minimal temperatures are not achieved, staff to notify Dietary Manager and/or Administrator. Policy revealed dish machine temperatures to be retained for 12 months.

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last six months. The facility reported a census of 56 residents. Findings include: Review of the facility's CMS-2567 form from a recertification survey which occurred 4/29/24 to 5/02/24 revealed the facility received non-harm level citations for the following areas: resident rights/dignity, reasonable accommodation of needs, services provided meet professional standards, bowel/bladder incontinence, or catheter, sufficient nursing staff, psychotropic drug use, food procurement/storage/service/sanitation, and QAPI program/plan. The facility's current recertification survey, entrance date 9/09/24, resulted in multiple repeated non-harm level deficient practices for the following areas: resident rights/dignity, reasonable accommodation of needs, services provided meet professional standards, bowel/bladder incontinence, or catheter, sufficient nursing staff, psychotropic drug use, food procurement/storage/service/sanitation, and QAPI program/plan. On 9/16/24 at 11:40 AM, facility Administrator revealed Quality Assurance Committee meets monthly and continues to review concerns for at least 3 months after improvement to ensure resolution. When queried about repeat deficiencies noted from previous recertification survey to present, Administrator agreed that facility continued to have repeat deficiency areas and stated they would be adding staffing, catheters, medication administration/reconciliation, dignity, and accommodation of needs to current month's QA/QAPI, which would be kept in place until audits show sustained improvement. The facility policy, titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, listed the Administrator as responsible for assuring that the facility's QAPI program complies with federal, state, and local regulatory agency requirements and revealed objectives for the QAPI program are to: A. Provide a means to measure current and potential indicators for outcomes of care and quality of life. B. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. C. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. D. Establish systems through which to monitor and evaluate corrective actions. The QAPI Program revealed an expectation of the QAPI committee to oversee implementation of QAPI plan with key component of the process to include the monitoring or evaluating for effectiveness of corrective action/performance improvement activities, and revisiting as needed.

Based on interviews, record review, and policy review, the facility failed to provide Monthly Drug Regimen Reviews for the month of July. The facility reported a census of 56 residents. Findings include: During a review of the monthly pharmacy reviews, it was revealed there were no reviews done for any residents residing in the facility for the month of July. On 9/10/24 at 4:02 p.m., the Administrator stated that there was no pharmacy review done in July. The Administrator handed an email from a Consultant Pharmacist. The Administrator stated that the pharmacist that wrote the email was not the facility's normal consultant pharmacist. An email dated 8/8/24 at 8:13 a.m., from a Consultant Pharmacist, documented that the consultant pharmacist noted that recommendations from July were not completed. The Consultant Pharmacist documented that she had re-issued any recommendations that were still relevant. This pharmacist requested that the facility let her know if there was anything she could do to assist with getting these taken care of. A Consultant Pharmacist Reports - Medication Regimen Review (Monthly Report) policy dated 2006, directed the following: The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing, the attending physician, the medical director and if appropriate the administrator. -the consultant pharmacist reviews the medication regimen of each resident at least monthly.

Based on observation, resident and staff interview, and clinical record review, the facility failed to ensure resident choice of caregivers had been respected for 1 of 3 residents (Resident #18) reviewed for dignity, when a caregiver continued to assist with cares following resident request otherwise. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition and intermittent behavior that included rejection of care. Diagnoses included anxiety disorder, depression, and neuropathy. The Care Plan, revised 7/25/24, revealed Resident #18 had a self-care deficit and required one person staff assistance for bed mobility, dressing, transfers, and toileting. The Care Plan informed that Resident #18 would refuse a gait belt at times but lacked indication for refusal of cares or preferences with caregivers. Review of Nursing Progress Notes, revealed the following entries: 1. On 7/13/24 at 6:54 PM, staff reported Resident #18 made accusations that staff were killing her and breaking her body. 2. On 7/23/24 at 2:48 AM, Nurse and Staff F, Certified Nursing Assistant (CNA), entered Resident #18's room for over night cares. Resident #18 responded to questions, I'm not dumb, accused Staff F of walking away from her roommate, and told Staff F, You don't have to be that way. 3. On 8/22/24 at 2:29 AM, Resident #18 refused incontinence cares, stated she knows her rights, and that the CNA staff come in right after she falls asleep to wake her up, says she would not allow it anymore. Review of a behavior log for the last 30 days, dated 8/14/24 through 9/08/24, revealed Resident #18 had refused cares on 6 different occasions. On 9/09/24 at 1:30 PM, Resident #18 reported feeling that a CNA who worked overnights had been mean and rude to her, Resident #18 informed that she reported this information and had been told the CNA would not be back in her room. Resident #18 stated approximately 5 days after being told the CNA would not be back, the same CNA was in her room to assist with cares. On 9/09/24 at 4:00 PM, the Facility Administrator stated she had not been aware of Resident #18 report of a night shift CNA being mean or rude and informed that she would speak with Resident #18 for a statement on this allegation. On 9/10/24 at 10:22 AM, the Facility Administrator notified that Resident #18 stated she did not like the CNA and made a statement that the aide was ignorant, Resident #18 denied feeling afraid of the CNA. Administrator determined through staff interview that Resident #18 had referred to Staff F, CNA. Administrator stated that Staff F would no longer go in to help Resident #18 and that the resident was made aware of this. On 9/11/24 at 8:54 AM, Resident #18 stated Staff F, CNA, came in at 3:00 AM and woke her up to see if resident needed changed. Resident #18 revealed that one of the main ladies had been in the day before and promised Staff F would not be back in her room. On 9/11/24 at 12:05 PM, Staff C, Registered Nurse (RN), reported being notified 9/11/24 in morning report that something happened overnight where Staff F went in Resident #18's room to answer a call light and got Resident #18 upset. On 9/11/24 at 2:29 PM, the Director of Nursing (DON) revealed that Resident #18 can be particular with cares on a day to day basis, but informed that Staff F, is currently not to go in Resident #18's room as it causes the resident to be upset. The facility policy, titled Resident Rights, reviewed 8/2016, revealed that the facility will protect the rights of each resident, including the right to chose Provider and treatment, and participate in decisions and care planning and the right to voice grievances and have facility respond to those grievances.

Based on clinical record review, policy review, resident interview and staff interviews, the facility failed to carry out assessments and interventions for 2 of 5 residents reviewed for a change in condition (Resident #10, and #209). The facility failed to carry out assessments/interventions for a resident with a low blood sugar (#10), and failed to carry out interventions after a resident did not have a bowel movement for multiple days (#209). The facility reported a census of 58 residents. Findings include: 1. The MDS assessment dated [DATE] revealed Resident #10 scored a 14 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed diagnoses for acute and chronic respiratory failure with hypoxia, heart failure, renal insufficiency, neurogenic bladder, and diabetes mellitus. The Care Plan revealed a focus area revised on 4/23/24 for risk for alterations in blood glucose levels related to diabetes diagnosis. The interventions dated 4/19/24 revealed glucagon kit as ordered; observation for signs/symptoms of hypoglycemia and report to nurse/provider as needed such as shakiness, sweating, headache, nausea, fatigue, irritability, dizziness, tingling/numbness of lips, tongue, and cheeks. The Progress Note dated 10/24/23 at 4:40 PM, revealed the nurse called into the resident's room due to Certified Nurse Aide (CNA) stated that he acted funny. When the nurse arrived in the room the resident found lethargic and barely kept his eyes open. Blood glucose checked and read 60 mg/dl (milligrams per deciliter). Two glucagon packets and 3 cups of orange juice with sugar administered due to resident still able to swallow and continued to check blood glucose and only able to get resident up to 75 mg/dl. The provider notified and ordered glucagon 1 mg intramuscular injection. The nurse administered glucagon and continued to monitor the resident. Twenty minutes later residents blood glucose was in the 200s. The provider called and ordered for continued monitoring the resident though out the night. The e-Interact Transfer Form V5 dated 10/25/23 at 3:48 PM revealed resident sent to the local hospital on 10/25/23 at 3:55 PM for hypoglycemia. The blood glucose registered 62 on 10/25/23 at 3:19 PM. The vitals signs revealed 130/60 blood pressure; 70 heart rate per minute; 14 breaths per minute; temperature 96.9 F; and pulse oximetry 90% on oxygen via nasal at 3.5 liters. The resident started antibiotics on 10/20/23 for cellulitis. The Progress Note dated 10/25/23 at 3:45 PM, notified of POA (Power of Attorney) on the condition of resident and notified her of order to transfer resident to local hospital for evaluation and treatment. The Progress Notes lacked documentation of assessments between 10/24/23 at 4:40 PM and 10/25/23 at 3:48 PM. The Transfer to Hospital Summary dated 10/25/23 at 3:55 PM revealed provider notified of resident's condition and received verbal order to transfer to local hospital for evaluation and treatment. At 5:43 PM, 911 notified; at 3:45 PM the POA notified of resident's condition and transferred to local hospital; and EMS (Emergency Medical Services) arrived at the facility and got the resident stable. At 3:55 PM, EMS transported resident to local hospital ER (emergency room ) for evaluation and treatment. This form revealed incorrect documentation and struck out on 2/7/24 at 8:03 PM. The Blood Sugar Summary revealed the following blood glucose readings: a. 10/25/23 at 12:32 PM 110.0 mg/dL b. 10/25/23 at 3:19 PM 62.0 mg/dL During an interview on 5/2/24 at 10:54 AM, Staff G, LPN (Licensed Practical Nurse) queried about the incident on 10/25/23 and she stated they fill out a transfer form and document in nursing notes. She stated he had a low blood glucose and they got it back up and then ended up shipping him out to the hospital for awhile. During an interview on 5/2/24 at 3:07 PM, the ADON (Assistant Director of Nursing) queried on the incident with Resident #10 on 10/25/24 and the documentation and she stated she expected a lot more documentation such as what happened, if he was hypoglycemic from the night before. She stated the assessment needed documented. 2. Due to Resident #209 recent admission to the facility, completed MDS assessment not available for review. The Care Plan dated 4/15/24 revealed a focus area for self-care deficit as evidenced by requiring assistance with ADLs, impaired balance during transitions required assistance and/or walking, and incontinence. The interventions revised on 4/23/24 revealed resident needed a person assist with toileting. The EMR revealed the following Medical Diagnoses: a. slow transit constipation b. fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing. On 4/29/24 at 11:48 AM the resident stated he hadn't pooped in 5 days. they gave him MOM and that didn't help. He stated if they give him a can of rotel tomatoes, that would open him up. The Physician Orders revealed the following medications: a. ordered 4/30/24- Milk of Magnesia Suspension (MOM) 7.75 %- give 30 ml (milliliter) by mouth every 24 hours as needed for constipation b. ordered 4/30/24- Enema Disposable Rectal Enema- insert 1 application rectally every 24 hours as needed for constipation c. ordered 4/30/24- Bisacodyl Suppository 10 mg (milligrams)- insert 1 suppository rectally every 24 hours as needed for constipation Give 10 mg suppository per rectum daily PRN constipation d. ordered 4/14/24- Oxycodone/acetaminophen 5/325 mg- give 1 tablet orally every 6 hours as needed for pain e. ordered 4/14/24- Senna-time tablet 8.6 mg- give 1 tablet orally every 12 hours as needed for slow constipation The April MAR (Medication Administration Record) revealed the resident received MOM on 4/27/24 at 9:21 AM. The April MAR revealed the resident didn't receive Senna-time tab one time during the month. The May MAR revealed the resident received enema disposable rectal enema on 5/1/24 at 7:17 AM The POC Response History for Bowel Elimination revealed Resident #209 did not have a bowel movement from 4/25/24 at 1:59 AM through 5/2/24 at 2:42 AM. During an interview on 5/2/24 at 1:32 PM, Staff C, RN (Registered Nurse) stated the facility had a bowel list and the night shift nurse left a bowel list for the nurses every morning. Staff C stated no one said anything to her about the resident's constipation. She stated the resident had this issue before and his home caregiver came in and brought things that worked for him and they received good results. During an interview on 5/2/24 at 3:25 PM, the ADON queried on Resident #209 constipation and she stated they gave him an enema the day before and MOM the day before that. She stated they used a 3-day bowel protocol and if in 3 days no bowel movement, the resident received MOM and if no results, they received a suppository, and then after that an enema. She stated everyone usually gets an order set when admitted and Resident #209 didn't and they came to her about his constipation and they got the order set ordered. She stated they should have noticed on Day 3 and the staff needed to look at the bowel list every day. The facility policy Conducting an Accurate Resident Assessment, implemented 12/1/23, stated residents would receive accurate assessments, reflective of the resident's status at the time of the assessment. The policy directed staff to document resident medical, functional, and psychosocial problems and address areas of decline.

Based on observations, staff interviews, resident interview, provider interview and clinical record review, the facility failed to implement timely interventions for residents identified at high risk for pressure ulcer development and to prevent worsening of wounds, perform thorough and consistent assessment which included wound measurements and wound description, and coordinate which staff from the clinical team staged and measured wounds for two of three residents reviewed for pressure ulcers (Resident #20, Resident #208). Resident #20 developed a deep tissue injury to the right heel and stage two pressure ulcer to the coccyx, and Resident #208 admitted with wounds not thoroughly assessed by the facility on admission, nor consistently monitored, staged, or measured following the resident's admission. The facility reported a census of 58 residents. Findings include: 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. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 revealed the resident was rarely to never understood. Per this assessment, Resident #20 was at risk for pressure ulcers/injuries, and did not have unhealed pressure ulcers. The assessment revealed Resident #20 had a pressure reducing device for chair and bed, and was not on a turning/repositioning program. The Care Plan initiated on 3/20/23, resolved on 4/30/24, documented, Resident #20 has impaired skin integrity. R (right) heel, unstageable (obscured full-thickness skin and tissue loss) wound. The current Care Plan for Resident #20 dated 4/2/24, revised 4/30/24, documented, Resident #20 has issues with skin integrity. Resident #20 has a deep tissue wound to her R (right) heel. Daily treatments are being applied at this time and Q 3 D (every three days). The Intervention dated 4/2/24 revealed, Monitor and document changes in wound. Measure wound weekly and PRN (as needed). Review of the resident's Braden assessment dated [DATE] identified Resident #20 at high risk for pressure ulcers. The Skin assessment dated [DATE] revealed the resident did not have any alterations in skin integrity. The Late Entry Skin/Wound Note dated 3/11/24 at 10:44 AM documented, family notified of suspected DTI (deep tissue injury-persistent, non-blanchable deep red, maroon or purple discoloration) to right heel as well as Nurse Practitioner. The Weekly Nursing Skin assessment dated [DATE] revealed the resident had an area to the right heel, and documented, duoderm in place, heel protectors on and float heels on blue pillow. This assessment documented the wound as not new. The Weekly Pressure Wound assessment dated [DATE], locked 3/15/24, revealed the resident had a deep tissue injury (DTI) to the right heel, which measured 3 cm (centimeters) length (L) by 3 cm width (W) by 0.0 cm depth (D). The stage documented, suspected deep tissue injury. The assessment documented date of onset as 3/11/24. The Physician Order, start date 3/11/24, revealed, heel booties on at all times every shift for skin. Review of the resident's Treatment Administration Record (TAR) dated March 2024 revealed documentation of floating heels/heel booties began 3/11/24. The Progress Note dated 3/12/24 at 3:10 AM revealed, resident received N.O. (new order) to wear heel protectors at all times and float heels while lying in bed. Resident complied with booties all this shift. The Progress Note dated 3/15/24 at 7:20 AM revealed, Daily dressing change done on coccyx area. Review of the resident's Medication Administration Record (MAR) and TAR dated March 2024 lacked documentation of a treatment to the resident's coccyx. The Weekly Nursing Skin assessment dated [DATE] revealed the resident had an area to the right heel. The assessment lacked description of the wound, and lacked measurements of the wound. The skin assessment did not address a wound present to the resident's coccyx. The Provider Progress Note for Resident #20 dated 3/27/24 authored by the facility's Nurse Practitioner (NP) revealed the following Chief Complaint/Nature of Presenting Problem: Wound. Per the Progress Note, Resident #20 had a stage two pressure ulcer to the coccyx which measured 3 cm x 3 cm x 0.25 cm, had mild serous drainage, and a fragile periwound. The resident also had a deep tissue injury to the right heel which measured 3 x 2 cm. The Plan section documented, in part, the following: a. Pressure injury of sacral region, stage 2: Medihoney, and Mepilex to be changed daily and PRN (as needed). b. Pressure-induced deep tissue damage of right heel: Now open, Change to Medihoney and Mepilex to be changed daily. Review of a Physician Order Form for Resident #20 dated in March (date and year unable to be read) revealed, change wound care to R (right) foot (and sign) bottom to Medihoney (and sign) cover with Mepilex to be changed daily (and sign) PRN (as needed). This Physician Order not signed on the nurse signature line and no date present next to nurse signature line. Although date and year unable to be read, it was noted per the resident's MDS assessment the resident admitted to the facility in November 2023. The Physician Order dated 3/27/24 at 7:00 AM started on the resident's MAR on 3/27/24: MEDIHONEY GEL WOUND Apply to right heel topically in the morning for wound healing. A prior treatment order to the right heel which started 3/14/24 remained active as well as the more current treatment order for the resident's heel dated 3/27/24. Both orders remained active on the resident's April 2024 TAR as well. Review of Resident #20's MAR and TAR for the month of March 2024 lacked a Physician Order to address the resident's pressure injury of the sacral region, or charting to indicate completion of treatment. The Nurses Note dated 3/29/24 at 1:25 PM revealed, prostat 30 ml (milliliter) TID (three times per day) and stress tab ordered for wound healing per Nurse Practitioner. The Weekly Nursing Skin assessment dated [DATE] and 4/6/24 revealed the resident had an area to the right heel, and duoderm in place. heel protectors on at all times along with floating heels on pillow. The assessment also revealed, open area to coccyx. Mepilex in place. The assessment lacked wound measurements or additional descriptions of the wounds. Per this assessment, the areas were not new for the resident. The assessment dated [DATE] revealed, treatments done daily. Review of the resident's TAR dated April 2024 revealed treatment to the coccyx began to be documented 4/5/24, although first noted in Progress Notes on 3/15/24. The Orders-Administration Note dated 4/8/24 at 1:09 PM revealed, ACETAMINOPHEN 650MG (milligram) TAB Give 650 mg orally every 8 hours as needed for Pain residents complaining of pain on her coccyx. The Weekly Nursing Skin assessment dated [DATE], locked on 4/30/24, and the assessments done 4/20/24 and 4/27/24 revealed the resident had an area to the right heel, and duoderm in place. heel protectors on at all times along with floating heels on pillow. The Weekly Nursing Skin assessment dated [DATE] also revealed, open area to coccyx. treatment in place. The assessment dated [DATE] and 4/27/24 provided the same description, although the word treatment had been changed to Mepilex on these assessments. The Assessments 4/13/24 4/20/24, and 4/27/24 lacked wound measurements or additional descriptions of the wounds. The Weekly Wound Log dated 4/27/24 provided by the Assistant Director of Nursing (ADON) revealed the resident had a deep tissue injury to the right heel. Per the log, the wound measured 3 by 2 by 0.1 (no unit of measure documented). Per the log, the resident had a moisture associated wound to the buttock which measured 3 x 2 x 0.2 (no unit of measure documented). Observation on 5/1/24 at 1:19 PM revealed Resident #20 present in the common area between the 300/400 unit. The resident had blue soft boots to their lower legs/feet. Observation conducted 5/2/24 at 10:04 AM revealed Staff C, Registered Nurse (RN) performed wound care to the resident's right heel wound. Resident #20 observed in bed with a cushion under the lower legs to elevate the resident's lower legs from the bed. Per Staff C, the wound was facility acquired. Staff C further explained the wound had necrotic eschar (dead or devitalized tissue), and the Medihoney got it off of there. The resident observed to have the wound to the inner right heel, and Staff C explained the wound looked so much better. Per Staff C the area did not have redness present, was not boggy, and dried. On 5/02/24 at 10:12 AM, Staff C explained the resident had an open area near the right inner cheek which was facility acquired. The resident assisted to turn in the bed, and the old dressing removed. The sticky surrounding edges of the dressing pulled when the dressing was removed from the resident's backside, and some bloody drainage present with the old dressing removal. A wound observed to the top of the resident's gluteal cleft. During the observation the resident noted to have yellow substance which appeared to be urine in their brief when the resident's brief was partially removed in order to access the area of the resident's wound. Staff C described the wound bed as white fibrous tissue, maceration, and healing wound bed with red beefy granulation. Per Staff C, the wound had slight clear serosanguineous drainage, and the area surrounding the wound was a little red. Staff C explained it was better than a week ago. Staff C completed the dressing change, and per observation the same brief as previously described was reapplied for Resident #20. On 5/2/24 at 11:10 AM Staff G, Licensed Practical Nurse (LPN) queried about assessment of skin. Staff G explained if she saw anything it would be reported to the ADON (Assistant Director of Nursing) to let them know if there is a pressure sore, or even thought a pressure sore, anything like that. Per Staff G, they would open up a skin sheet so could continue to monitor it at least on a weekly basis. Staff G acknowledged this would occur in the assessment tab. When queried who measured the wounds, Staff G responded she did not as she worked nights (night shift), and responded she was not sure. Staff G further explained she knew the NP was measuring them when she came in, but did not know if she did so any more. On 5/2/24 at 1:09 PM the ADON explained there was a time where the Nurse Practitioner (NP) monitored wounds every week, the facility did not have an actual full-time person to do the wounds, and the nurses were asked to help keep the measurements up. When queried what nurses were to do weekly, the ADON responded weekly pressure and weekly non-pressure assessments should be opened with all skin issues/skin wounds, and after opened populate weekly unless healed. The ADON explained they needed to be opened first. The ADON explained there was a time she measured weekly, however could not always keep up with it when the facility didn't have a Director of Nursing (DON). Per the ADON, she charted in weekly pressure and non-pressure. When queried about staging of wounds, the ADON responded the NP staged, said we don't stage at all, and further explained the facility did not call a pressure until they said so. The ADON explained the DON (Director of Nursing) was going to take over wounds for the facility. It was noted the facility had a new DON starting during the week of the survey. On 5/2/24 at 1:40 PM during an interview with the NP, the NP explained she was doing measurements, and it then went back to the facility. When queried about the facility measuring wounds, the NP responded she thought it was being done. Per the NP, the facility would stage wounds. The NP explained she measured Resident #20's wound on 3/27/24, and this was the last time took care of wound. The Facility Policy titled Skin and Wound Management System dated 4/17, revised 9/22 revealed, it is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. 47336 2. The MDS assessment dated [DATE] revealed Resident #208 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed impairment on both sides in the upper and lower extremities. The MDS revealed resident needed substantial/maximal assistance with toileting hygiene; shower or bathing self; upper and lower body dressing; rolled from left to right. The MDS revealed resident dependent with toilet transfer and chair/bed to chair transfer. The MDS revealed medical diagnoses of multiple sclerosis and risk for malnutrition. The MDS revealed risk for developing pressure ulcers/injuries. The MDS revealed one Stage 2 pressure ulcer; one Stage 3 pressure ulcer; and one Stage 4 pressure ulcer present on admission. The Care Plan revealed a focus area dated 4/23/24 for Stage 4 pressure ulcer on right hip; Stage 3 pressure ulcer on left heel; and Stage 2 pressure ulcer on the right ankle. The interventions dated 4/23/24 revealed treatments as ordered. The Wound Care Routine dated 3/7/24 at 11:32 AM from a hospital clinic revealed the following special instructions: a. Apply betadine to left heel daily cover with foam border b. Apply a thin layer of Mupirocin along to buttock wounds and red areas daily c. Apply a thin layer of mometasone with Mupirocin to red area along left hip and groin daily The Admission/Readmission Narrative dated 4/12/24 on 1:33 PM revealed the following for the skin: a. alterations in skin integrity: multiple b. site 1. right iliac crest- no measurement documented 2. coccyx- no measurement documented 3. right knee- no measurement documented 4. left heel- no measurement documented 5. right buttock- no measurement documented 6. left buttock- no measurement documented 7. left ankle- no measurement documented 8. groin- no measurement documented The Progress Note dated 4/12/24 at 2:00 PM, revealed resident arrived by ambulance and ambulance crew. The resident transferred to bed with max assist of 5 people. Resident fully oriented and alert, unable to walk, stand, had multiple skin integrity issues which have been identified on admission skin assessment. Resident incontinent. The Physician Orders revealed the following medications: a. start date of 4/13/24- Mepilex border- apply to sacrum topically in the morning b. start date of 4/13/24- Mepilex border- apply to left ankle topically in the morning for wound c. start date 4/15/24- Weekly skin assessment (Day of Week)- one time a day every Monday d. start date of 4/16/24- clean wound to right hip with normal saline apply maxorb to wound bed cover with foam dressing daily one time a day for wound healing e. start date of 4/16/24- apply betadine to left heel and ankle apply Mupirocin ointment 2% to ankle then cover ankle and heel with foam dressing in the morning for wound healing f. start date of 4/17/24- liquacel liquid orange- give 30 ml orally two times a day for wound healing g. start date of 4/18/24- apply border gauze to bony prominence on bilateral feet for prevention. change every 3 days in the morning every 3 day(s) for wound healing h. start date of 4/28/24- Mupirocin ointment 2% to wound on left ankle The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 3:59 PM revealed the following: a. Does this resident have any alterations in skin integrity?- yes b. Are any of the above areas new for this resident- yes The Progress Note from the Provider on 4/15/24 revealed the resident had multiple pressure wounds, patient referred to wound care. Patient had wounds to left ankle, sacrum covered with Mepilex, patient had a wound to right hip covered with Maxorb and foam dressing. Wound to left heel covered with foam dressing with Mupirocin being applied daily. The Physical Exam revealed the Integumentary: Dry, warm, normal color multiple pressure wound and wounds covered at this time, and unable to visualize. The Progress Note dated 4/17/24 at 1:49 PM, revealed the nurse received a phone call from [name redacted] infectious disease physician office located in another city and inquired about resident and how his wounds were progressing. An update given as doing treatments as ordered. phone number if questions arose or resident needed to have a follow-up appointment given. They felt the resident did not need to come back to their office if he under our care, but if needed to call them. The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 4:12 PM revealed the following: a. this resident have any alterations in skin integrity?- no b. Are any of the above areas new for this resident- no The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 7:48 AM revealed the following: a. Does this resident have any alterations in skin integrity?- no b. Are any of the above areas new for this resident- no The Progress Note from the Provider on 4/24/24 revealed the resident reported that on Thursday he was lifted by a Hoyer and hit his left ankle on the Hoyer, he reported his wound came back open. I assessed left ankle, bruising around wound. Resident reported severe pain to left ankle. discussed ordering an x-ray, resident agreeable. reported to ADON. No other new issues reported. Medications reviewed. Wound #1 on the left ankle was a pressure, with no odor; red wound bed, and periwound- bruising. The Weekly Wound Log dated 4/27/24 for Resident #208 revealed the following: a. right hip - date acquired on admit and measured 2 x 2.3 x 0.5 cm b. left foot - date acquired on admit and measured 4.3 x 1.3 x 0 cm c. heel - date acquired on admit and measured on 1.3 x 1.6 cm The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 4:12 PM revealed the following: a. Does this resident have any alterations in skin integrity? no b. Are any of the above areas new for this resident- no The Weekly Nursing Skin Assessment/Shower Skin assessment dated [DATE] at 11:27 AM revealed the following: a. Does this resident have any alterations in skin integrity?- no b. Are any of the above areas new for this resident- no During an interview on 4/29/24 at 11:04 AM, Resident #208 stated he had a pressure ulcer on one of his ankles and one on his hip. He stated the pressure ulcers present prior to admission. He stated the facility did daily dressing changes. During an interview on 5/1/24 at 1:40 PM, Resident #208 stated he thought they only measured his wounds twice and he thought his insurance wanted them measured every week, but he didn't know if they did that here. During an interview on 5/1/24 at 8:18 AM, the ADON queried on where the skin assessment documented and she stated she just audited them this week and they were not completed correctly. The ADON asked if they documented on paper and she stated no. The ADON asked if she documented any skin measurements and she stated she documented one measurement on Resident #208. During an interview on 5/2/24 at 1:25 PM, Staff C, RN (Registered Nurse) queried on where the skin assessments documented and she stated her and the ADON spoke about it this morning and she was doing it wrong. She stated when she clicked off the dressing change, it should go over to the progress note to document. Staff C stated she misinterpreted because the last place she was at, they hired a skin nurse and she thought the skin nurse measured and the floor staff didn't so the measurements were not off. Staff C stated she knew now she needed to measure and document the measurements weekly. During an interview on 5/2/24 at 1:42 PM, the ARNP (Advanced Registered Nurse Practitioner) stated she expected the facility to do measurements on the wounds and she thought they did the measurements. She stated the facility staged the wounds. The ARNP stated she didn't measure the resident's wounds but she looked at them. During an interview on 5/2/24 at 3:14 PM, the ADON queried on Resident #208 pressure wounds and she stated she knew they needed better measurements for sure and wanted the stages of healing with them. She stated measurements needed done weekly.

Based on observations, clinical record review, policy review, and staff interviews, the facility failed to ensure an environment free of accidents and hazards for 4 of 6 residents reviewed for supervision. The facility failed to provide adequate supervision to prevent falls for Residents #42 and #18, and #19, and failed to utilize both foot pedals during wheelchair locomotion for Resident #211. The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 10/27/23, listed diagnoses for Resident #42 which included fracture of the right femur (leg bone), non-Alzheimer's dementia, and heart failure. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating impaired cognition. The MDS stated the resident required partial/moderate assistance for transfers and walking. The MDS stated during the review period, the resident had 1 fall with injury and 2 falls with a non-major injury. The MDS listed the Brief Interview for Mental Status (BIMS) score as 6 out of 15, indicating severely impaired cognition. The Care Plan initiated 7/3/23 documented the resident at risk for falls related to impaired balance and impaired safety awareness. The Care Plan lacked any interventions dated prior to 8/3/23. The Fall Report dated 7/21/23 at 9:00 p.m. stated the resident laid on the floor of his room on the right side. Staff toileted the resident at 8:30 p.m. The resident sustained an abrasion to the right side of his nose and had pain in his right thigh. The Nurse Notes documented the following: On 7/22/23 the resident had an acute fracture of the right hip. On 8/2/23 the resident returned from the hospital with a diagnosis of right hip fracture and had a surgical incision. On 8/4/23 the resident had a surgical repair of the right hip. The Medicare Part B Note dated 8/9/23 stated therapy would work with the resident on strengthening. The Fall Report dated 8/30/23 stated the resident was on the floor lying on his right side. He sustained a skin tear to the right wrist and an abrasion to the right knee. The facility educated the Certified Nursing Assistants (CNA's) to place the bed in a low position. The Fall report dated 9/10/23 stated staff found the resident between the bed and the bathroom door on the floor. The facility carried out additional education to CNA's regarding frequent toileting and toileting immediately following meals. The Nurse Notes documented the following: On 9/10/23 the resident was educated on the use of the call light. On 9/14/23 the family requested to have the resident's diuretic (a medication used to rid the body of fluid) reduced in an effort to reduce his falls due to self-transferring. On 10/12/23 the facility would begin 1-hour checks at bedtime due to the resident's falls. The Fall Report dated 10/12/23 stated staff found the resident sitting on the floor with his legs stretched out in front of him and the resident stated he had to urinate. The resident sustained a skin tear to the right elbow. A 10/12/23 Care Plan entry stated the family was aware that he fell due to him falling at home. The entry stated there were no new intervention ideas from the family. A 10/26/23 Therapy to Facility Communication form stated the resident required the assistance of 1 staff and a 4 wheeled walker for walking and transfers. The Fall report dated 10/27/23 stated the resident laid on his floor in the bathroom on his left side. A 10/27/23 Fall-Initial note stated staff would take him to the bathroom every 2 hours and encourage him to sit for at least 10 minutes. A 10/27/23 Care Plan entry directed staff to utilize a pressure activated call light to the exiting side of the bed. A 10/30/23 Interdisciplinary Team (IDT) Note stated the resident was placed on a fluid restriction as an intervention to the 10/27/23 fall. A 10/30/23 Care Plan entry stated the resident had an evaluation with urology (a medical specialty focused on the urinary tract) on 10/24/23. The Fall Report dated 11/1/23 stated the nurse was called into the front offices where the resident laid on his right side. The resident complained of left hip pain. Staff took the resident into a common area for increased supervision and the resident started yelling that his hip hurt. The facility obtained an order to send the resident to the ER for evaluation. The Fall-Initial note dated 11/1/23 at 7:00 p.m. stated the resident fell in the office of the Business Office Manager and the Activity Supervisor and when found the resident stated he wanted to see what was going on in there. The note stated staff last toileted the resident at 5:30 p.m. The Nurse Notes documented the following: On 11/1/23 at 9:32 p.m. the resident transferred to the hospital. On 11/1/23 at 11:15 p.m. the resident had a left hip fracture. An 11/9/23 hospital History and Physical stated the resident had a fall on 11/1/23 and sustained a fracture of the left hip. The resident underwent a left hip hemiarthroplasty (surgical repair of the hip). An 11/10/23 Admission Assessment stated the resident returned to the facility. On 5/2/24 at 11:31 a.m., the Activity Supervisor stated the resident fell in her office when it was after office hours and the door was not locked. She stated he got into the room sometime around supper and no staff were in the office at the time. On 5/2/24 at 11:36 a.m., the Business Office Manager stated normally the last person to leave the office would lock the door. On 5/2/24 at 2:08 p.m., the Administrator stated the door to the office the resident fell in was usually kept locked. He stated there were documents and items in the room and the room needed to be locked. The facility policy Falls Management System, revised 2016, stated the facility would provide an environment that remained as free of accident hazards as possible. The policy stated the facility would provide each resident with adequate supervision to prevent accidents and would provide appropriate evaluations and interventions to prevent falls. Resident Care Plans would include interventions which addressed elements determined as probable causal factors which contributed to the fall. 47336 2. The MDS assessment dated [DATE] revealed Resident #19 scored a 11 out of 15 on the BIMS exam, which indicated moderately impaired cognition. The MDS revealed impairment on one side of the upper extremity. The MDS revealed resident needed partial/moderate assistance with toileting hygiene; chair/bed to chair transfer; and toilet transfer. The Care Plan revealed a focus area revised on 1/10/24 for risk for fall due to heart failure, cervicobrachial syndrome, and history of fall with fracture prior to admission with a fall on 1/8/24 with a right hip fracture. The resolved intervention dated 1/8/24 revealed floor alarm in room, and floor alarm removed on 1/18/24 and pull away alarm placed on resident. The EMR (Electronic Medical Record) revealed the following Medical Diagnosis: a. Fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing. The Fall-Initial Note dated 1/8/24 at 8:10 AM, revealed the following: a. Type of Incident: unwitnessed fall b. Date and Time: 1/08/24 at 8:10 AM c. Location of fall: in resident's room d. Description & Potential Root Cause: non-compliant self-transferred e. Injuries: complaining of inner et outer right hip pain f. Pain: 5/10 on pain scale g. Vitals (include ortho's if able to stand): h. Footwear at time of fall: yes, his regular shoes i. Assistive devices and their location at time of fall: he has 4 wheeled walker that was by his bed at the time of fall j. If resident wore glasses, were they on? no k. Was the call light on at time of fall? yes l. Last time toileted: right before fall m. Any Incontinence: no n. ROM (Range of Motion) Impairments: able to move bilateral lower extremities, but is complained of right leg pain o. Care Provided (how assisted up, first aid): assisted to standing position with assist x 2; neuros initiated p. Intervention/prevention to prevent recurrence (Must complete): floor mat put in room q. received order for resident to be taken to local hospital emergency room for x-rays. r. Provider/ Family notifications: provider and POA (Power of Attorney) The Progress Notes for the resident documented the following: On 1/8/24 at 8:28 AM, Resident #19 fell in his room self-transferring to the bathroom. He stated that he was able to transfer himself. The resident unable to use his right hip at this time order obtained from the provider to transfer resident to local hospital emergency room for evaluation. POA notified verbalized understanding. On 1/8/24 at 10:26 AM, resident noted to be laying on back with legs out in front of him in front of his window. Resident noted to have his regular shoes on, walker over by his bed. Call light on for assistance. Resident started complaining of right outer and inner hip pain. Received order per provider to transfer to local hospital emergency room to be evaluated and treated. POA notified. Neuros initiated. On 1/8/24 at 10:33 AM, CNA responded to call light and asked resident to give her a second so she could gown up, at that time another CNA called and stated that other resident climbing out of her wheelchair. They repositioned that resident and the CNA then finished gowning up and then at that point she heard a crash and heard Resident #19 say ouch. She then opened the door and saw resident laying on the floor and called for the nurse. On 1/8/24 at 11:22 AM, Fall Committee Meeting: Resident fell on [DATE] at 8:10 AM. Resident found on the floor. Resident stated that he was getting a pair of socks out of his dresser. Root cause analysis performed showed that resident attempted to self transfer, lost balance/got weak and fell . Based on the root cause analysis the intervention will be to place a floor alarm in residents room and place it in front of him while he is in his room. Care Plan updated with changes. On 1/8/24 at 1:30 PM, the resident returned per facility vehicle with facility staff. Resident weight bearing as tolerated with walker, continue with NSAIDS (non-steroidal anti-inflammatory drugs) for pain, follow-up with hospital. Resident noted to have multiple fractures to right hip. Resident assisted to his room to his recliner, call light within reach. On 1/13/24 at 3:32 PM, resident alert resting in bed at this time with call light within reach continue to encourage to use call light for all assist verbalized a good understanding. Denies any pain at this time, still verbalized pain when he moved, encouraged to let the nurse know if he needed anything for pain. He verbalized an understanding. Stand aid with assist x 2 utilized today for all transfers. The Provider Progress Note dated 1/8/24 revealed resident seen in ER (emergency room ) after fall that resulted in fracture to right pelvis and hip. Resident to be referred to Ortho. Patient reports pain about a 5 out of 10. Tramadol 50 mg every 6 hours PRN (as needed) ordered. The Plan indicated closed fracture of right pubis, unspecified portion of pubis, sequela. Repeated falls: Encouraged use of assistive device. Change positions slowly to avoid dizziness that could result in fall. Ask for assistance from staff when ambulating/transferring. The IDT Resident Care Conference dated 1/17/24 at 12:21 PM, documented looked into more local hospitals for an appointment to see if Resident #19 needed to have surgery on his hip. Coming out of isolation on 1/17/24 at midnight due to diagnosis of COVID. The Progress Note dated 1/19/24 by provider revealed the following information: a. [AGE] year-old male resident seen today for follow-up visit related to recent fractures and COVID. b. Resident appeared to be feeling better. Resident's lungs clear throughout. Patient continues to have 2 liters of oxygen nasal cannula as needed. c. Resident waiting on Ortho referral. d. Resident reported continued constant pain to the hip. Patient currently prescribed tramadol 50 mg every 6 hours as needed, will increase to every 4 hours as needed. e. Plan: Right hip pain: Waiting on ortho referral tramadol for pain, increased to every 4 hours PRN During an observation on 4/30/24 at 12:57 PM, the resident sat in his wheelchair and self-propelled down the hallway. The chair alarm hooked to his shirt and attached to the wheelchair. During an interview on 5/2/24 at 10:45 AM, Staff G, LPN (Licensed Practical Nurse), stated she believed she worked the day Resident #19 fell and fractured his hip. She stated he needed assistance with walking because he wasn't steady on his feet. She stated he self-transferred when he broke his hip, and we always wanted him to ask for assistance. During an interview on 5/2/24 at 1:57 PM, Staff I, CNA stated Resident #19 supposed to be a one assist but not always compliant. During an interview on 5/2/24 at 2:05 PM, Staff J, CNA stated Resident #19 a one assist and he would try to self-transfer and we tried to get him, but hard for him to understand to not transfer. During an interview on 5/2/24 at 3:27 PM, the ADON queried on Resident #19 fall on 1/8/24 and she stated the resident not compliant, and you couldn't convince him to wait and use the call light and he self transferred and fell . He was not compliant, you could not convince him to wait and use his call light, he self transferred and he fell . She stated the situation tricky, you can try and prevent one fall and another one happened. Since the CNA didn't go into the room yet, she went and helped someone else. The ADON stated the situation depended on the other person, if it was Resident #19 neighbor who had dementia, he would need assistance. You weigh your options. Resident #19 oriented. If someone else falling, easier to catch the person who wasn't safe. 3. The MDS assessment dated [DATE] revealed Resident #211 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed resident impaired on side of upper and lower extremity and used a wheelchair. The MDS revealed resident dependent to wheel 50 feet with two turns once seated in wheelchair. The MDS revealed diagnoses of stroke, CVA (cerebral vascular accident), or TIA (transient ischemic attack); hemiplegia or hemiparesis; and seizure disorder. The Care Plan revealed a focus area dated 5/1/24 for a self-care deficit due to diagnosis of chronic kidney disease, hypotension, gatroesophageal reflux disease, Type II diabetes mellitus, depression. The interventions dated 5/1/24 revealed resident utilized her left foot pedal and didn't use the right foot pedal, if she self-propelled. During an observation on 4/30/24 at 12:00 PM, the resident pushed in the wheelchair by Staff O, CNA with left foot on the foot pedal and the right foot barely lifted off the floor (no foot pedal on the right side of wheelchair). During an observation on 4/30/24 at 12:03 PM, the resident pushed by Staff O, CNA out of the shower room with the right foot lifted off the floor (no foot pedal on the right side) and the left foot on a foot pedal. During an interview on 5/2/24 at 9:18 AM, Staff N, CNA queried where a resident's feet needed located when transferred in a wheelchair and she stated on the foot pedals and or if able then could raise their feet. She stated she had the resident raise their feet and she would push slowly and watch them to make sure their feet stayed off the ground. She stated if the resident self-propelled and they had a bag on the back of their wheelchair with foot pedals in them, she would take them out of the bag and put the foot pedals on the wheelchair. During an interview on 5/2/24 at 1:16 PM, Staff C, RN stated if a resident is being pushed, they needed foot pedals. During an interview on 5/2/24 at 2:00 PM, Staff I, CNA stated they shouldn't move the resident in a wheelchair unless their feet are placed on foot pedals. She stated the facility used a policy called no pedal, no push. During an interview on 5/2/24 at 2:15 PM, Staff O, CNA queried where the foot should be when pushing a resident in a wheelchair and she stated on foot pedals, unless they can propel themselves. Staff O asked about Resident #211 and she stated no, you can't push her without foot pedals, she messed up on that. During an interview on 5/2/24 at 2:49 PM, the ADON queried where a resident's feet needed located when pushed in a wheelchair and she stated on the pedals. She stated if a resident didn't use foot pedals, they shouldn't be pushed, they are supposed to be mobile. 45338 4. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed the resident was rarely to never understood. Per this assessment, Resident #18 had fallen since admit, entry, reentry, or prior assessment, and had two or more falls since admit or prior assessment with no injury. The Care Plan dated 9/27/23, revision date 4/26/24, documented the following: Resident #18 has had an actual fall without injury from a rolling chair in the dining room. She didn't realize this type chair would roll out from underneath her due to her poor communication/comprehension. Falls documented on: 8/30/2023 9/26/2023 12/24/2023-No Injury 12/29/2023- No Injury 2/16/2024-No Injury 2/19/2024-No Injury 2/23/2024-No Injury 3/04/2024-No Injury 3/29/2024- No Injury 3/31/2024- No injury 4/15/2024-No Injury 4/18/2024-No Injury 4/23/2024-No Injury Care Plan interventions in 2024 included the following: a. Date initiated 3/31/24: 3/31/2024 Ensure proper footwear while ambulating. b. Date initiated 4/26/24: 4/18/2024 Broda chair was given to resident d/t (due to) weakness at times of walking. c. Date initiated 9/27/24: Be sure the rolling chairs in the dining room are kept out of residents reach. d. Date initiated 2/16/24: 2/16/24 Offer fresh water multiple times a day. (resident is sick at this time) e. Date Initiated 12/26/23, revised 2/19/24: 2/19/24 PCP (Primary Care Physician) review medication. f. Date Initiated 2/26/24, revised 3/4/24: 2/23/24 Funding verification paper work is being filed to see if resident can get PT/OT (physical therapy/occupational therapy) UPDATE: Funding form approved g. Date Initiated 3/4/24, revised 3/6/24: 3/4/24 Request an eye appointment. (Son stated that resident would not wear glasses even if she had them). h. Date Initiated 12/29/23: 12/29/23 give resident a snack when she is agitated. i. Date Initiated 4/1/24: 3/29/24 PCP (Primary Care Provider) see resident on rounds. j. Date Initiated 4/26/24: 4/23/24 Recliners in 300 alcove replaced with a couch for a large circumference to sit on. Review of Resident #18's clinical record revealed the resident had fallen eleven times between 12/24/23 and 4/23/23. The Fall-Initial Note dated 12/24/23 at 9:00 PM revealed the resident fell in the 300 common area. The Description and Potential Root Cause section revealed, resident in the 300 common area and was trying to sit in a chair but missed it landing on her buttocks. The Fall Initial Note dated 12/29/23 at 1:57 PM revealed the resident fell in another resident's room. The Description and Potential Root Cause section revealed, resident was seen sitting on the floor in [room number redacted], feet out in front of her facing the hallway. The Incident Report revealed there were no witnesses to the event. The Progress Notes for the resident documented the following: On 1/9/24 at 10:18 AM assessed left knee noted blue hematoma from fall earlier this week no s/s (signs/symptoms) of pain noted no moaning yelling or facial grimacing noted will continue to monitor. On 2/16/24 at 6:01 PM called to 300 hall per CMA (Certified Medication Aide) [Name Redacted] noted res sitting in high back chair per staff noted res attempt to sit in chair missed hit posterior head on arm of the chair fell on floor neuro's stated and vitals obtained no injury noted. The Fall Initial Note dated 2/19/24 at 8:43 AM documented: the resident had an unwitnessed fall in their room. The Description & Potential Root Cause documented, resident found lying between wall and bed. resident has recently been ill with flu. Due to cognition resident is unaware of safety issues, is unable to communicate verbally and wanders throughout building 24/7. resident does become restless and agitated at times. Resident can be redirected at times. The Incident Report revealed there were no witnesses to the event. The Fall-Initial Note dated 2/23/24 at 10:10 AM revealed the resident had an unwitnessed fall with no injury noted. The Description & Potential Root Cause documented, weakness after having influenza last week. The Progress Notes for the resident documented the following: On 2/26/24 at 2:32 PM Fall committee meeting: Resident had a fall on 2/23/2024 at 1010. Resident was found sitting on the floor between 2 recliners and had bedside table behind her. Resident appears to have been attempting to sit in a chair but missed with and fell to floor. Root cause analysis was performed and showed that resident thought she was in front of chair, but obviously was not. Based on the root cause analysis the intervention will be to have a funding verification paper filed to see if resident would be able to work with PT/OT (physical therapy/occupational therapy). On 3/4/24 at 8:38 AM resident had an un witnessed fall this morning attempting to sit in recliner missed chair sat herself on the floor. Neuros started vitals obtained no injury noted with assessment .Going to move recliners to see if that helps with the falls. The Incident Report revealed there were no witnesses to the event. The Fall-Initial Note dated 3/29/24 at 2:47 PM documented the resident fell in the 300 hallway, with location of fall documented as 300 alcove. The Description & Potential Root Cause: section documented, resident missed the recliner when she went to sit down. The Fall-Initial Note dated 3/31/24 at 1:45 PM documented the resident had a fall with no injury, and fell at the 200 alcove in front of beauty shop. The Description & Potential Root Cause documented, this nurse was called over walkie to the 200 alcove where resident was sitting on the floor next to the recliner in front of the beauty shop with feet out in front of her wearing gripper socks and no shoes. Cna (Certified Nursing Assistant) witnessed fall. Cna stated that resident was attempting to sit in the recliner and slipped. Review of the Incident Report revealed staff was summoned by a family member. The Fall-Initial Note dated 4/15/24 at 11:44 AM documented the resident slid off of recliner and onto floor. Location of fall documented the 3/400 common area, and documented per the Description & Potential Root Cause section, resident has UTI (urinary tract infection) and is on an antibiotic. The Fall-Initial Note dated 4/18/24 at 7:16 AM for a witnessed fall revealed the resident fell in the 300 common area. The Description & Potential Root Cause revealed, went to sit to soon in the chair. The IDT Note dated 4/20/24 at 9:46 AM documented, Fall Committee Meeting: Resident had a fall on 4/18/2024 at 0550. Resident was found sitting on the floor by recliner. Resident appears to have gotten weak and sat before making it to the recliner. Root cause analysis was performed and showed that resident may have gotten weak while walking and wanted to sit down in recliner. Based on the root cause analysis the intervention will be to assist resident to broda chair when resident appears to be getting weak. Care Plan updated with changes. The Fall-Initial Note dated 4/23/24 at 11:15 AM documented the resident had a witnessed fall in the 300/400 alcove sitting common area. The Description & Potential Root Cause section revealed, resident was witnessed sitting self down on floor between two chairs. On 4/30/24 at 12:18 PM observed Resident #18 stand up from a recliner chair in the 300/400 common area, then sit back down. The resident had yellow grip socks to her feet. Observation on 5/1/24 at 9:56 AM revealed Resident #18 in the common area/tv area between the 300 and 400 hallways. Resident #18 had yellow socks to their feet, and staff not observed in the common area or the medication cart area. At 9:57 AM, a staff member walked past the common area, another staff walked near the common area, and one staff went towards 300 hall while the other staff went towards 400 hall (away from the common area). Staff members walked past the common area and went in different directions away from the common area. At 10:04 AM, the resident observed in a recliner chair with yellow grip socks to her feet. Observation on 5/1/24 at 1:28 PM revealed Resident #18 on a couch in the common area. The resident had yellow socks to their feet. On 5/2/24 at 11:03 AM, Staff G, Licensed Practical Nurse (LPN) explained sometimes Resident #19 would sit too soon and would miss the chair. Staff G explained the resident mainly stayed in the 300/400 area. On 5/2/24 at 1:12 PM when queried about Resident #18's falls, the Assistant Director of Nursing (ADON) explained for almost every one of the falls the resident tried to sit in a chair and did not make it to the chair. The ADON acknowledged this occurred in the 300 alcove for the most part, where the resident spent a lot of time. Per the ADON the resident did wander, and stop signs were present as the resident liked to go into other people's room.

Based on observations, clinical record review, policy review, staff interviews, family interview and resident interviews, the facility failed to develop and implement interventions to prevent/treat weight loss for 2 of 5 residents reviewed for nutrition (Residents #13 and #52) and failed to provide ordered supplements for 2 of 5 residents reviewed for nutrition (Residents #18 and #34). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 3/27/24, listed diagnoses for Resident #52 which included dementia, adult failure to thrive, and muscle weakness. The MDS stated the resident required partial/moderate assistance with eating and listed her Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. A Dietary Assessment, dated 3/26/24 listed the resident's weight as 97.8 lbs. The residents Weight Summary report documented the resident weighed 99.8 lbs on 3/22/24 and 93.0 lbs on 4/16/24, which calculated as a 6.81% loss. Care Plan entries, dated 3/26/24, stated the resident had the potential for altered nutritional status and directed staff to: a. provide alternate meals if she did not like the meal served; b. offer milkshakes with meals; c. provide supervision and assistance at meals as needed; d. notify the physician of significant weight changes. The Care Plan did not address the resident's weight loss and did not include additional interventions to assist the resident in gaining weight. A 4/24/24 Clinic Note did not address the resident's weight loss and stated nursing reported no concerns. The facility lacked documentation of provider notification of the resident's weight loss and lacked documentation of further interventions attempted from 4/16/24 until the start of the survey week on 4/29/24. On 4/29/24 at 4:00 p.m., observed the resident sitting in her room and a plate of food untouched in front of her. The utensils clean and had not been used. On 5/1/24 at 3:30 p.m., the Assistant Direct of Nursing (ADON) stated if a resident had a weight loss, they would start supplements and consult with the dietician and the provider. She stated she would look to see if there was any physician communication to the provider. On 5/2/24 at 10:04 a.m., the ADON stated the facility obtained an order for supplements and they implemented that nurses would document the weights. She stated she spoke with staff about providing feeding assistance to the resident. The facility policy Nutrition and Hydration to Maintain Skin Integrity, revised October 2010, stated the procedure would provide guidelines for the assessment of resident nutritional needs to aide in the development of an individualized care plan. The policy directed staff to conduct nutritional assessments for each resident as indicated by a change in condition and to define meaningful interventions for the resident at risk for or with impaired nutrition. 47336 2. The MDS assessment dated [DATE] revealed Resident #13 scored a 6 out of 15 on the BIMS exam, which indicated moderately impaired cognition. The MDS revealed the resident required set up or clean up assistance with eating. The MDS revealed diagnoses of depression, schizophrenia, and non-Alzheimer's dementia. The MDS revealed a loss of 5% in one month or 10% in 6 months without a prescribed weight-loss regimen. The MDS revealed the resident took an antidepressant. The Care Plan revealed a focus area revised on 3/18/24 for dysphagia and a risk for aspiration pneumonia, excessive salivation, airway obstruction and dehydration. The interventions dated 10/19/23 revealed encourage resident to eat slowly and take small bites and small single sips and provide appropriate diet consistency as ordered. The Care Plan revealed a focus area revised on 4/25/24 for a nutritional problem related to her history of dementia, diabetes mellitus hyperlipidemia, GERD (gastroesophageal reflux disease), depressive episodes, constipation and the need for a mechanically altered diet texture. Resident at risk for weight loss related to her history of decreased appetite (significant losses noted March and April 2024). The interventions dated 3/10/24 revealed to honor food preferences and special requests as able. The resident enjoyed drinking chocolate milk, hot chocolate, orange juice, or water, which needed thickened to nectar consistency. The interventions revised on 3/10/24 revealed general/pureed, nectar thick liquid diet with provided assistance as needed. The Weight Summary revealed the following weights: a. 10/2/23 12:26 AM 131.8 Lbs b. 11/25/23 11:07 AM 129.4 Lbs c. 12/5/23 11:16 AM 128.0 Lbs d. 1/1/24 1:02 PM 124.6 Lbs e. 2/2/24 10:42 AM 121.4 Lbs f. 2/22/24 12:06 PM 121.0 Lbs g. 3/11/24 10:01 AM 117.4 Lbs h. 4/4/24 1:59 PM 113.0 Lbs On 10/02/2023, the resident weighed 131.8 lbs. On 02/23/2024, the resident weighed 117.4 pounds which is a -10.93 % Loss. On 10/02/2023, the resident weighed 131.8 lbs. On 04/04/2024, the resident weighed 113 pounds which is a -14.26 % Loss. The Physician Orders revealed the following orders: a. ordered on 3/7/24- regular diet, pureed texture, nectar consistency with small bites and sips liquid to assist for dysphagia b. start date of 3/12/24- House Supplement 60 ml - two times a day The Progress Note dated 3/12/24 at 1:34 PM, revealed the Dietician recommends adding House Supplement 60 ml (milliliter) BID (twice a day) due to weight loss. The resident representative called and notified of new order, and the doctor faxed. The Dietary Note dated 4/25/24 at 8:15 PM, revealed based on April monthly weight of 113 pounds (4/4), Resident #13 experienced significant weight losses of 9.3% x 3 mo. and 14.3% x 6 mo. She triggered for loss last month as well. The diet texture downgraded on 3/7/24. House supplement 60 ml BID between meals ordered on 3/18, and will continue this intervention. Meal intakes averaging 50-60% at meals. Noted GDR for Duloxetine ordered 4/11, which had the potential to impact appetite/intake. Care plan updated. Requested nursing notify provider of weight status. The Provider Note dated 4/11/24 lacked documentation of the resident's significant weight loss. The April MAR revealed the following dates the resident did not received the house supplement due to medication not available: a. 4/13/24 at 10:00 AM b. 4/13/24 at 2:00 PM c. 4/14/24 at 10:00 AM d. 4/14/24 at 2:00 PM e. 4/15/24 at 10:00 AM f. 4/15/24 at 2:00 PM g. 4/16/24 at 10:00 AM h. 4/16/24 at 2:00 PM i. 4/17/24 at 10:00 AM j. 4/17/24 at 2:00 PM k. 4/18/24 at 10:00 AM l. 4/18/24 at 2:00 PM m. 4/19/24 at 10:00 AM n. 4/19/24 at 2:00 PM o. 4/28/24 at 2:00 PM p. 4/29/24 at 10:00 AM q. 4/29/24 at 2:00 PM r. 4/30/24 at 10:00 AM s. 4/30/24 at 2:00 PM During an interview on 4/30/24 at 9:17 AM, the resident representative stated Resident #13 had weight loss and she had a hard time swallowing. She stated the resident didn't like the soft food and it being all mixed up, but the resident representative thought her mom was getting to used to it. During an observation on 4/30/24 at 12:24 PM, the resident served lunch of glass of water and a glass of milk. The meal served in a divided plate with pureed beans and [NAME] in one section, and pureed Italian blend vegetables in another section. During an observation on 4/30/24 at 12:36 PM, staff came over to the resident and pushed her plate gently in front of her, and the resident shook her head sideways. The staff member left and the resident continued to drink her milk. During an observation on 4/30/24 at 12:53 PM, Resident #13 ate less than 25% of her meal, and drank her 8 ounces of milk. She didn't get served her pureed bread. During an interview on 5/1/24 at 1:43 PM, the Dietary Manager queried if the resident received any options at meals and she stated puree diets don't get options. She stated they get whatever is on the menu. The Dietary Manager asked if the resident given choices if she didn't eat what she was served and she stated she never really thought about it. The Dietary Manager asked if anyone prompted Resident #13 to eat and she stated she prompted her once or twice but she didn't think the CNA prompted her. During an interview on 5/2/24 at 1:18 PM, Staff C, RN (Registered Nurse) stated at times it was hard to get Resident #13 to eat. Staff C stated they gave her supplements to help build her weight back up. During an interview on 5/2/24 at 1:44 PM, the ARNP (Advanced Registered Nurse Practitioner) stated she didn't see Resident #13 for weight loss but her and the doctor alternate. During an interview on 5/2/24 at 2:03 PM, Staff J, stated Resident #13 felt like a hit and miss situation, sometimes the resident ate everything and other times wouldn't eat at all. Staff J didn't know if it was because of the texture or something else. She stated when the resident did eat, it took a lot of encouraging and she needed to approach her multiple times to eat. Staff J stated she thought the resident's drink were optional and they could give her cottage cheese or yogurt. During an interview on 5/2/24 at 2:51 PM, the ADON queried on Resident #13 weight loss and she stated she knew they had issues with her weight loss and tried to implement different things. She stated at one time they had issues getting her weights completed, but now they hired someone to do the weights. The ADON stated the nurse needed to put in the weights on the computer otherwise the weight loss wouldn't pop up. She stated she hoped with the nurse putting in the weights, the communication would improve with her and the provider. The ADON stated if the alert came up, the resident needed assessed earlier, and a fax needed sent at the very least. The ADON stated if the residents had a 3 pound weight loss, the doctor needed notified. The ADON asked if the resident received choices or prompted to eat her meals and she stated with Resident #13, it was difficult because they tried to assist her before and the resident wouldn't eat. The ADON stated they should probably give her choices, but if the resident not eating, she not going to eat. She stated the staff needed to least offer the residents options. 45338 3. Review of the MDS assessment dated [DATE] for Resident #18 revealed the resident was rarely to never understood. The Physician Order dated 9/7/23 for Resident #18 revealed, an order for House Supplement three times a day for Dietary Supplement 90 ml (milliliter). Review of the resident's Medication Administration Record (MAR) dated April 2024 revealed 21 instances in the month of April when the resident's supplement was marked with a code of 11, which indicated the medication was not available. 4. The MDS assessment for Resident #34 dated 2/1/24 revealed the resident scored 00 out of 15 on a BIMS assessment, which indicated severely impaired cognition. The Physician Order dated 10/28/22 documented, an order for House Supplement three times a day 120 ml. Review of the resident's Medication Administration Record (MAR) dated April 2024 revealed 26 instances in the month of April when the resident's supplement was marked with a code of 11. During an interview conducted on 5/2/24 at 12:56 PM, the facility's Assistant Director of Nursing (ADON) queried about trouble getting the house supplement, and responded there was a time when had issues with back ordered and not being available. Per the ADON, it did take a little while to come in, and with the change of corporations and suppliers there were a few times it took longer to come in.

Based on observation, clinical record review and staff interviews, the facility failed to safely provide cares when turning a resident in bed which led to a fall with facial fractures for 1 of 4 residents reviewed for supervision. (Resident #1) The facility reported census was 53. Findings include: According to the Quarterly Minimum Data Set (MDS) with an assessment reference date of 5/17/23, Resident #1 had long- and short-term memory deficits and a severely impaired cognitive status. Resident #1 required extensive to total dependence of two staff with mobility, transfers, dressing, toilet use and personal hygiene needs and a diagnosis, which included Non-Alzheimer's Dementia. In an interview on on 7/25/23 at 8:17 a.m. Staff J, Certified Nurse Aide (CNA), stated on 6/8/23 she was preparing to get Resident #1 ready for supper. As was a common practice, Staff J was changing and positioning a Hoyer sling beneath her. As she rolled Resident #1 by her shoulders and waist towards her, Resident #1 was stiff and pushed up against her and then without notice let go and began sliding off of her bed. Staff J stated she tried to stop her, but she fell on to the floor injuring herself. Staff J stated she had been an aide for ten years and had never known differently that one person couldn't position a sling under a resident unless specifically indicated on the care plan. Staff J stated she was instructed by the facility that what she did was an acceptable practice at the facility but was unable to identify who told her. In an interview on 7/31/23 at 10:24 a.m. Staff Q, Licensed Practical Nurse (LPN), stated on 6/8/23 at around 5:00 p.m. she was in the 300/400 hall nurse's station when Staff J, CNA approached her stating she had screwed up. Staff J stated Resident #1 had rolled out of her bed onto the floor. Staff Q immediately responded and when she entered the room saw Resident #1 on the floor and knew she would need help. Staff Q ran and got Staff P MDS Coordinator and Staff F, ADON, then called 911 before returning to Resident #1's room and assisting with care. Staff J stated she had rolled Resident #1 from her stomach to her back, before getting help and stated she was attempting to position a Hoyer sling beneath her when she rolled and fell to the floor. According to Resident #1's Plan Of Care she is unable to complete activities of daily living due to her cognitive status and weakness with interventions which include completing bed mobility, toileting hygiene, dressing and mechanical lift transfers with two person assist. According to Resident #1's Bedtime Kardex Report under resident care, Bed Mobility, Resident #1 is able to complete bed mobility with two staff assistance. In an interview on 7/25/23 at 3:32 p.m. Staff I, CNA, stated she was assigned 300 hall and Staff J was assigned 400 hall on 6/8/23 and together they would help one another with the two person residents. That evening supper had started and Staff J had not started getting her residents to supper yet. Staff I stated she had been getting residents to the dining room and stayed in the dining room to help with feeding and told Staff J to call her when she needed help. The next thing she knew an ambulance was arriving. Staff I stated it did not need to happen if Staff J had just called for help. In an interview on 7/26/23 at 10:40 a.m. Staff P, MDS coordinator, stated Resident #1 was coded as an extensive assistance of two people with mobility due to her decline and contracture status making her unsafe to move by yourself. This level of assistance needed is also reflected in the care plan. Staff P stated some residents are coded as a two person assist for mobility on the MDS, but on the care plan they may only be an assist of one noting those residents are felt to be safe to move by one person. However, regardless of their mobility status, all residents who are a two-person mechanical lift transfer requires two staff to be moved, including positioning the sling underneath the resident prior to the lift. Staff P indicated there was no facility policy clarifying the need for a second staff person when positioning the sling, but that has always been their expectation. Staff P stated in the case of Resident #1's fall on 6/8/23, she was care planned as a two person assist with mobility and the staff failed to have the second person present while positioning the sling at the time of the fall. In an interview on 7/25/23 at 3:10 p.m. Staff F, Assistant Director of Nursing, stated Resident #1 was a large-women, was stiff and sometimes resisted with cares and that is why she was determined as needing two-person assist with bed mobility. Staff F stated she would normally consider bed mobility in the context of repositioning, but admits positioning a sling beneath her, requires her being rolled. Staff F stated they train their aides to use two people when positioning a sling beneath a resident in bed, but notes there is no policy. The facilities Orientation for Agency CNAs form indicates: #2 You will partner with another aide for your two-person transfers after cares are completed. #4 Mechanical Lifts-there must be two people whenever using a mechanical lift (either a standing lift or a full body lift). No exceptions. Make sure the leg strap is secured when utilizing a standing lift. During observations on 7/26/23 at 4:46 p.m. P and Staff F accompanied surveyor to Resident #1's old room and demonstrated the height and positioning of the bed when they arrived into the room following her fall on 6/8/23. The bed was positioned with the left side against the wall and the bed height was 29 inches to the top of the mattress. Ambulance Report dated 6/8/23 with dispatch time of 5:09 p.m. indicated resident observed on floor following a fall with a large laceration/avulsion to her forehead across most of her forehead, blood and an abrasion on her left eye just below the eye on her lower eye lid and a tear on her upper lip under her nose and going up along the left side of her nose. Resident reportedly slipped off the side of bed onto her face as a staff member was attempting to position a Hoyer lift sling under her. According to the Emergency Department report, a CT scan noted nondisplaced right occipital condyle (base of the skull, above C1 vertebrae) fracture and nondisplaced angulated nasal bone fractures. According to Major Injury Determination form Resident #1 sustained a major injury, noting a fractured nasal bone and right condyle occipital fracture. According to the facilities investigative conclusion for incident that occurred on 6/8/23 at approximately 5:00 p.m., after review of the incident and review of statements of the certified nurse aides involved and other staff present, it is apparent that Staff J, who had previously worked with Resident #1 and knew that two staff were needed for bed mobility and transfers, chose not to wait for additional staff prior to doing bed mobility and care. Staff were present and available to assist. Staff J also had previous knowledge Resident #1 and how she transferred, yet chose to proceed without any assistance resulting in a fall from the bed onto the floor. Resident #1 sustained injuries related to this incident. Staff J had everything needed to perform the task safely; experience and knowledge of the resident and available staff assistance.

The following deficiency relates to complaint -I and -C : Based on record review and staff interviews, the facility failed to provide adequate supervision and assistance devices to mitigate a resident's risk for falls for 2 of 4 residents reviewed (Residents #1 and #5). The facility reported census was 38. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 exhibits impaired short and long term memory deficits and moderately impaired cognitive status. Resident #1 required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. Resident #1 required total dependence on one staff member for ambulation using a walker or wheelchair. Resident #1 was determined as frequently incontinent of bowel and bladder. Resident #1's [DIAGNOSES REDACTED]. Resident #1's plan of care indicated Resident #1 at risk for falls related to an unsteady gait/balance and lack of safety awareness. Interventions included using a pressure alarm whenever sitting or lying and check the function every shift. Hip protectors on at all times. In an interview on 12/30/15 at 2:50 p.m. Staff A CNA (certified nurse aide), stated on 12/5/15, prior to supper the nurse, Staff C RN (Registered Nurse) was ambulating Resident #1 down 200 hall and asked Staff A CNA to grab his/her wheelchair. Staff A CNA brought the wheelchair to the 200 hall TV area and left. At around 7:00 p.m. Staff A CNA went to her supper break and recalled seeing Resident #1 sitting on the love seat in the 200 hall TV area. Staff A CNA returned to the floor at 7:32 p.m. (time card) and as she was walking down the 200 hall she saw a figure fall forward from the 200 hall TV area. Staff A CNA dropped her belongings and ran towards Resident #1. Staff B CNA and Staff C RN noted standing in the 200 hall and responded to assist Resident #1 after the fall. Staff A CNA comforted Resident #1 as Staff C RN assessed him/her and eventually they got Resident #1 up and to his/her room, where Resident #1 was treated for [REDACTED].#1 was last sitting in. Staff A CNA stated she was not aware Resident #1 required a chair alarm. In an interview on 12/30/15 at 3:15 p.m. Staff B CNA, indicated on the evening of 12/5/15, she was standing outside room 202 talking with Staff C RN, when Staff A CNA alerted them that Resident #1 just fell . Staff B CNA turned and responded to the 200 hall TV area. Resident #1 found lying on the floor. Staff B CNA stated there was no alarm sounding or chair alarm present. Staff B CNA stated Resident #1 required a chair alarm as a safety intervention. Staff B CNA stated another staff member assisted Resident #1 into the love seat and therefore Staff B was unaware Resident #1 did not have a chair alarm in use. Incident/Accident Report and Investigation form dated 12/5/15 at 7:50 p.m. indicated Resident #1 got up from couch in 200 hall alcove, took a few steps and fell on to his/her right side. Upon assessment, Resident #1 was able to manipulate all extremities without complaints of pain. Resident #1 sustained 4 skin tears to his/her right upper extremity. The form indicated no safety alarm device was used at the time of the fall. Progress Notes dated 12/6/15 at 8:15 a.m. documented the Director of Nursing (DON) was called to Resident #1's room. Resident #1's right arm dressings are saturated in blood. Dressings removed and staff members cleansed 4 skin tears, edges well approximated and steri-strips applied. The DON assessed Resident #1's right hip as resident complained of hip pain with movement. Resident #1's right hip was bruising with a moderate sized hard bump noted to outer hip. The DON instructed staff to contact an ambulance for further evaluation. At 9:40 a.m. Resident #1 was transported to the hospital. Radiology report dated 12/6/15 indicated a fracture of the intertrochanteric right femur. In an interview on 12/30/15 at 4:00 p.m. the DON stated on the following morning after Resident #1's fall she was called to the room. The DON cleaned and redressed Resident #1 ' s skin tears to the right arm. Resident #1 was complaining of pain to his/her right hip. The DON had an ambulance contacted and sent Resident #1 to the hospital. Hospital x-rays confirmed a fractured right femur. Resident #1 was sent to another hospital and he/she underwent surgery to repair the right hip. Resident #1 returned to the facility on [DATE]. 2. According to the MDS assessment dated [DATE], Resident #5 ' s Brief Interview for Mental Status (BIMS) score of 11 indicated Resident #5 experienced moderately impaired cognitive issues. Resident #5 ' s delirium section revealed inattention and disorganized thinking. Resident #5 required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS identified behaviors of delusions noted. Resident #5 utilized a walker and wheelchair for mobility. The MDS noted Resident #5 as frequently incontinent of urine and always incontinent of bowels. Resident #5's [DIAGNOSES REDACTED]. Resident #5's plan of care indicated Resident #5 at high risk for falls related to an unsteady gait/balance and poor cognition. Interventions included using a pressure alarm at all times to alert staff when Resident #5 is attempting to self-transfer. Incident/Accident Report and Investigation form dated 11/13/15 at 5:00 a.m. indicated Resident #5 slid off his/her bed onto the floor. Resident #5 was found lying on his/her left side. The form indicated the bed alarm was removed by Staff C RN at the request of Resident #5 as Resident #5 stated he/she was unable to sleep with the alarm sounding. The form also noted Resident #5 was confused at times, noncompliant with calling for assistance and thinks he/she can walk independently. There was no indication in the progress notes or incident report of Staff C RN implementing any alternative interventions to address Resident #5's high risk for falls after removing Resident #5's alarm.

Based on record review, policy review, and staff and family interviews, the facility failed to provide necessary care and services for one of six residents reviewed (Resident #1). Resident #1 admitted to skilled care at the facility and current physician order to be resuscitated if his/her heart stopped. The resident was found without a heartbeat and staff failed to initiate Cardiopulmonary Resuscitation (CPR) as requested by Resident #1 and ordered by the physician. The facility reported census as 38 residents. Findings include: Resident #1 ' s five day MDS (Minimum Data Set) assessment with an entry date of [DATE] revealed short and long term memory deficits and moderate cognitive impairment. The signs and symptoms of [MEDICAL CONDITION] section identified fluctuations of inattention, disorganized thinking and altered level of consciousness. The MDS reflected Resident #1 as dependent on ,[DATE] staff for almost all activities of daily living except eating. [DIAGNOSES REDACTED]. The Goal setting section of the MDS Resident #1 expected to be discharged back to the community. Review of a Hospital Visit Summary admitted d [DATE] revealed Resident #1 was admitted to a regional hospital on [DATE] after falling at home. [DIAGNOSES REDACTED]. The report noted the resident had a short splint applied to his/her left foot, discharged to home on [DATE], and scheduled for home health care. Review of an emergency room Visit Summary dated [DATE] revealed Resident #1 was admitted to a local hospital with a principal [DIAGNOSES REDACTED]. Past medical history [DIAGNOSES REDACTED]. Review of Physician's Admit Orders dated [DATE] revealed Resident #1 was admitted to the facility for skilled care. The orders included instructions for Resident #1 ' s Code status- as requested CPR (Cardiopulmonary Resuscitation), use of AED (Automated External Defibrillator-device used to shock the heart), use of antibiotics, and hospitalization . DNR (do not resuscitate) was marked in the no column. The form was signed by Resident #1's physician. During an interview on [DATE] at 11:00 a.m. with the facility Social Worker, Staff F stated when a resident is admitted to the facility from an acute hospital stay the physician orders for code status are sent with the resident upon admission. Staff F stated she reviewed Resident #1's code status with the resident and spouse on [DATE]. She stated the orders as written by the physician were approved by Resident #1. The resident told Staff F that he/she would like to start the paperwork to identify his/her spouse as Resident #1 's POA (Power of Attorney- a written document in which one person appoints another person to act as an agent on his or her behalf) and Staff F stated she would begin the paperwork for this. Staff F stated Resident#1 was alert and oriented during the review of the code status and had no concerns regarding Resident #'1s ability to approve the code status orders. Staff F stated after she confirmed the code status orders with Resident #1 she notified the nursing department and the orders were placed in an Advance Directives binder kept in the nurse's chart room. The orders were entered into the computer with Resident #1's information and code status was reflected on Resident #1 ' s dashboard heading on every electronic page of Resident #1's chart. The initial Care Plan with an onset date of [DATE] identified Resident #1 with a problem of activities of daily living deficit and directed staff to assist the resident with cares, ambulation, and toilet use. The resident was noted to have oxygen therapy related to [MEDICAL CONDITION] and [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The care plan failed to identify Resident#1's code status. Review of Resident #1's Order Summary Report for [DATE], included the code status orders to provide CPR, to hospitalize resident as needed, and to use the AED if [MEDICAL CONDITION]. The discharge plan/potential was noted as good. Review of Resident #1 ' s skilled nursing notes dated [DATE] at 10:30 p.m. and documented by Staff B, Licensed Practical Nurse (LPN), revealed Resident #1's vital signs were recorded as apical pulse (listening to heart beat with stethoscope) 80 beats per minute, blood pressure ,[DATE], respiratory rate- 22 breaths per minute- normal breathing, clear lung sounds, oxygen saturation rate of 97%, and oxygen by nasal cannula. The assessment documented Resident #1 ' s temperature at 97.6. The narrative nursing notes stated Resident #1 was alert but confused, and required toileting by two staff during the night, oxygen on at two liters per minute. The nursing notes for Resident #1 entered at 10:30 a.m. on [DATE] by Staff A, Registered Nurse (RN) revealed the nurse was called to Resident #1's room at 6:05 a.m. Staff documented Resident #1 was cold to touch, no visible respirations, no blood pressure obtained, and spouse at bedside and stated he/she just arrived and identified Resident #1 was cold to touch. The documentation stated when the spouse was approached by Staff A about resuscitation the spouse stated Resident #1 was too far gone and he/she did not want CPR done at this time. The documentation revealed the physician, the assistant Director of Nursing (ADON), the administrator, and funeral home were contacted. Review of the Death Report dated [DATE] and signed by the physician noted Resident #1's final [DIAGNOSES REDACTED]. The cause of death was noted as [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interview on [DATE] at 9:00 a.m. with the Administrator identified concerns nursing staff failed to be aware of Resident #1 ' s code status. Another concern expressed by the Administrator involved nursing staff failed to check Resident #1 for lividity (blood pooling) according to the facility policy on Cardiopulmonary Resuscitation. During an interview on [DATE] at 9:10 a.m. with the Director of Nursing (DON) stated concerns the nurses failed to complete a head to toe assessment after the incident with Resident #1 to determine lividity and if CPR needed initiated. The DON stated code status of Resident #1 was available from the CPR binder in the nurse's chart room, any computer on the resident Kardex. DON stated the spouse was not Resident #1's POA at the time of the incident. Resident #1 requested to be resuscitated if needed. During an interview on [DATE] at 11:30 a.m. with the Assistant Director of Nurse ' s (ADON), stated she received a phone call at 6:40 a.m. on [DATE] from Staff A, RN, who stated Resident #1 had passed away. The ADON asked Staff A what Resident #1's code status was and Staff A replied she did not know. The ADON stated she heard Staff A tell Staff B how to access Resident #1's code status on the computer and then Staff A told the ADON Resident #1 was a full code. The ADON instructed Staff A to begin CPR on Resident #1. The ADON then drove to the facility. The ADON called the facility again before arriving and was told Resident #1's spouse stated he/she did not want CPR initiated. When the ADON arrived at the facility she started to investigate the incident. The ADON stated she would have expected the nurses to immediately check code status and assess the resident for signs of irreversible death (rigor mortis, lividity, or decapitation) upon finding the resident pulseless and if these signs were not present to initiate CPR. During an interview on [DATE] at 10:15 a.m. with the spouse of Resident #1, the spouse stated he/she entered the facility at 5:30 a.m. and went to Resident #1's room and thought he/she was sleeping. The spouse stated left the room, talked to the staff, and returned to the room at 5:45 a.m. and touched Resident #1's hand and the hand was ice cold. The spouse stated he/she exited the room, told a CNA Resident #1's hand was cold. The CNA entered the room and felt Resident #1's hand. The CNA stated Resident #1 had passed away. Resident #1 ' s spouse left the room to call Resident #1's daughter. He/she stated at approximately 6:10 a.m. a nurse told the spouse staff should have started CPR on Resident #1 and asked if he/she wanted CPR initiated now. The spouse stated he/she said not to start CPR because Resident #1 was ice cold and it was too late. The spouse wanted the incident to be investigated so this didn ' t occur to another resident in the future. During an interview on [DATE] at 11:35 a.m. with Staff C, CNA stated she was in shift report at approximately 6:00 a.m. on [DATE] when Resident #1's spouse came out to CNA ' s and stated Resident's skin was cold. Staff C stated Staff E went into the room. Staff C called the nurses to come to Resident #1 ' s room as soon as possible. According to Staff C the vital sign cart has a thermometer, oxygen saturation monitor and sometimes a blood pressure cuff and stethoscope. Staff C remained in the hallway with Resident #1 ' s spouse. According to Staff C the nurses exited the room and directed Staff C and Staff G to clean up Resident #1 in preparation for transfer to the funeral home. During an interview on [DATE] at 5:00 p.m. with Staff E, CNA stated she worked the night shift and was informed Resident #1 was on hourly checks during night shift and Staff B, LPN, told her not to wake Resident #1 as the spouse requested and just to peek in the room. Staff E stated twice between 11:00 p.m. and 1:10 a.m. Resident #1 removed his/her oxygen nasal cannula and the CNA went into the room to replace it. Staff E stated at 1:10 a.m. she and Staff B assisted Resident #1 onto the bedside commode. Staff E stated Resident #1appeared lethargic and completely leaned on the CNA during the transfer. Staff E stated Resident #1 asked the nurse for a pain pill and the nurse administered a pill. Staff E stated she checked on Resident #1 at 2:00 a.m., 3:00 a.m., 4:00 a.m. and 5:00 a.m. Staff E stated she observed Resident #1 from the open doorway and noted the resident was sleeping and breathing as Staff E observed chest movement during the checks. Staff E did not go into the room during the checks because the spouse requested the resident not be disturbed. Staff stated at 6:00 a.m. she was giving report to Staff C, and Staff G, both day shift CNAs, when the spouse come to them and said Resident #1's hand was cold and could they check on the resident. Staff E went into the room and stated Resident #1's skin was cold, one lower leg was mottled, and Resident #1's fingernails were blue on one hand. Staff E stated she told Staff C and Staff G to call the nurses down right away. When the nurses arrived Staff E went into the room with them and watched while the nurses checked for a pulse on Resident #1 ' s wrist. Staff E stated at approximately 6:15 a.m. Resident #1's daughter arrived and Staff E left the room. During an interview on [DATE] at 5:30 p.m. with Staff B, Licensed Practical Nurse (LPN), stated she had worked the night shift and fully assessed Resident #1 at the beginning of the shift (see nurse's notes entry above). Staff B stated around 1:00 a.m. she assisted Staff E CNA to transfer Resident #1 from the bed to the bedside commode and noted Resident #1 appeared tired at the time. Staff B stated she administered a pain pill to Resident #1 sometime between 11:30 p.m. and 1:00 a.m. per request of the resident. Staff B stated she looked in the room during the night and Resident #1 appeared to be sleeping. Staff B stated she was finishing report with the on-coming day nurse, Staff A, RN, when asked to go to room [ROOM NUMBER]. Staff B stated not informed it was a code situation so she did not take a stethoscope. Staff B stated she stayed with Resident #1's spouse to console him/her while Staff A went into the room. Staff B stated the spouse told her the night before to not disturb the resident during the night because he/she wanted Resident #1 to rest. Staff B stated about 3 minutes later she went into the room and said Resident #1 appeared to be deceased . Staff B stated Resident #1's color was poor and there was blood coming from the resident's mouth so Staff B checked Resident#1's wrist for a pulse and determined the resident was pulseless. Staff B stated she placed her cheek next to Resident #1's mouth to feel for air exchange and did not feel any air movement. Staff B and Staff A returned to the chart room to check Resident #1 ' s code status. Staff B stated Staff A called the ADON while Staff B looked up Resident #1 ' s code status. Staff B stated unaware what the ADON said to Staff A over the phone. Staff B stated Staff E, night CNA, had checked on Resident #1 every hour during the night shift. Staff B stated Staff E was a responsible and dependable CNA. During an interview on [DATE] at 12:15 p.m. with Staff G, CNA stated at approximately 6:00 a.m. she was getting shift change report from Staff E, night CNA, when Resident #1's spouse approached the CNAs and asked when the resident was last checked on. The spouse stated Resident #1 looked like he/she was barely breathing. Staff C stated Staff E said she knew that and the resident was sleeping. The spouse continued to speak with the CNAs about some concerns he/she had with Resident #1's medications and Staff G told the spouse she would pass on his/her concerns to the nurse. The spouse returned to Resident #1's room. Approximately five minutes later the spouse came out and stated Resident #1's hand was cold. According to Staff G, Staff C went to the phone and called the chart room for the nurses. Staff G stated failed to see any vital signs performed by staff on Resident #1. Staff G stated assisted with cleansing the body and noted a red splotchy oval shaped area on Resident #1 ' s right side. Staff G stated Resident #1 ' s entire body was cold except the area between the inner thighs that was touching. During an interview on [DATE] at 1:30 p.m. with Staff D, CNA/CMA (Certified Medication Aide) stated she was in the nurse's chart room when she received a phone call from Staff C requesting the nurse's come down to room [ROOM NUMBER] right now. Staff D stated she told the nurse's this two times needed in room [ROOM NUMBER] STAT (Immediate response needed) and then Staff D headed to room [ROOM NUMBER] as the nurse's followed. When Staff D arrived at the room she went into the room and Resident #1 lacked visible respirations. Staff D returned to the hallway, the nurses remained in the room. Staff D assisted Resident #1's daughter with a phone call and returned to the nurse's chart room where she observed Staff A, RN, on the phone directing Staff B, LPN, on how to look up code status on the computer at the same time. Staff D stated during her time in room [ROOM NUMBER] and in the hallway she did not see anyone take vital signs on Resident #1. During an interview on [DATE] at 5:35 p.m. with Staff A, Registered Nurse (RN), stated she punched in to work day shift on [DATE] at 5:53 a.m. Staff A stated at approximately 6:00 a.m. she received report from Staff B, night shift LPN, when they were asked to come down to room [ROOM NUMBER] (Resident #1 's room). Staff A stated she and Staff B were not told the situation was an emergency so she did not take a stethoscope or vital signs equipment to the room. Upon arrival to room [ROOM NUMBER] she stated the Certified Nurse Aides (CNA) and Resident #1's spouse were standing in the hall outside the room and the spouse told the nurses Resident #1 had passed away. Staff A stated she entered the room and observed Resident #1 in a fetal position, arms flaccid, mottling on lower extremities, skin cold, and Resident #1's head slumped to one side with a small amount of blood on the right cheek and chin. Staff A stated she checked Resident #1's radial pulse (felt at the wrist for a pulse) and did not find a pulse. Staff A stated she determined Resident #1 had passed away because of the mottling, the cold skin, and the drainage on the cheek and chin. Staff A stated she did not have a stethoscope so she did not listen for lung sounds or an apical pulse. Staff A stated she did not think to check Resident #1's code status until 6:30 a.m. when she called the ADON to report Resident #1 had passed away. Staff A stated she cannot recall what the ADON told her on the phone but she did check Resident #1's code status at that time on the computer and observed the resident was to receive CPR if in [MEDICAL CONDITION]. Staff A stated she returned to room [ROOM NUMBER] and asked the spouse if he/she wanted staff to initiate CPR and the spouse replied no. Staff A stated she should have been more prepared for the emergency situation and checked code status immediately upon finding the resident pulseless. Staff A stated she does not know why she did not think to do this at the time Resident #1 was found to be pulseless. A telephone interview on [DATE] at 11:30 a.m. with Resident #1's physician revealed she was unable to state a timeline for the development of lividity on a patient when death occurs. The physician stated she would expect nursing staff to initiate CPR if a resident's code status is to resuscitate and the resident is found pulseless unless lividity or rigor mortis has occurred. The physician stated Resident #1 had multiple comorbities (comorbidity is a disease or condition that coexists with a primary disease but also stands on its own as a specific disease). Review of the facility Policy and Procedure for Cardiopulmonary Resuscitation (CPR), revised ,[DATE], states CPR certification is mandatory for all licensed nursing staff, each shift will have a staff person scheduled who will perform CPR unless the resident has a do not resuscitate (DNR) order, the resident has obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transections, or decomposition) or the initiate of CPR could cause injury or peril to the rescuer. During an interview on [DATE] at 11:45 a.m. the facility administrator provided documentation of staff CPR certifications and identified Staff A, RN, Staff B, LPN, Staff H, LPN (first day orienting on [DATE]), Staff D, CNA, Staff G, CNA, and Staff C, CNA, were all certified in CPR at the time of the resident ' s death. She stated it was not mandatory policy for CNAs to have CPR certification however she would like to see this become a mandatory requirement for all CNAs. If a CNA thinks a resident is in [MEDICAL CONDITION] and is not certified to begin immediate CPR she/he should contact the charge nurse immediately and follow her/his lead. She stated CPR certification is available to any staff member who wants to be certified and Staff I, LPN and Certified CPR instructor provides the training on request. Note: At the time of the complaint investigation, the complaint was coded at a " J " , immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " D " level. The facility provided staff training and updates on resident code status in the facility. As of exit date [DATE] of the extended survey the facility failed to monitor nursing staff regarding code status as directed by the facility policy.

The following deficiency relates to incident -I: Based on record review and staff interviews the facility failed to provide adequate supervision to prevent accidents for two of four residents identified as at risk of falls (Residents #1 and #3). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference date of 7/22/14 indicated Resident #1 with a Brief Interview for Mental Status (BIMS) score of 14 indicating no short or long-term memory deficits and his/her cognitive skills for daily decision making intact. Resident #1 required one staff to assist with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene and bathing. The test for balance identified Resident #1 unsteady and only able to stabilize his/her balance with staff assistance when moving from a seated to standing position, when walking, when turning around, when moving on and off the toilet and during surface to surface transfers ( transfers between bed and chair or wheelchair). Resident #1's plan of care dated 6/25/14 indicated Resident #1 was at risk for falls related to right sided weakness, gait/balance problems and history of falls. Interventions included: 1) Assuring resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. (7/1/14) 2) Evaluate resident for a pressure related call light to alert staff when resident attempts to get up. (8/17/14) Facility Incident Report dated 7/20/14 at 11:31 a.m. indicated Resident #1 was found sitting on the floor in the bathroom between the wheelchair foot pedals. Resident #1 stated he/she was trying to get to the toilet and fell . Resident #1 stated he/she didn't use the call light initially because he/she needed to go to the bathroom urgently. No injury identified. Facility fall investigation form dated 7/20/14 indicated Resident #1 failed to utilize the call light system for assistance. Preventative interventions following the fall included resident education on using the call light and to use wheelchair brakes. The predisposing physiological factors listed gait imbalance. Progress Notes dated 7/25/14 at 7:21 p.m. indicated Resident #1 does not always use the call light to ask for help. Resident #1 had taken him/her (self) to the bathroom unassisted before supper. Progress Notes dated 7/26/14 at 2:30 p.m. indicated Resident #1 self-transferred from bed to the bathroom unassisted earlier in the shift. Facility Incident Report dated 7/27/14 at 12:40 a.m. indicated Resident #1 was found lying on his/her stomach outside the bathroom door. Resident #1 complaining of a headache with no observed injuries, but sent to the hospital for further evaluation. In an interview on 9/9/14 at 5:20 a.m. Staff A, certified nurse aide, indicated she was working the overnight shift on 7/26/14, when sometime after mid night she heard Resident #1 saying help. Staff A responded and found Resident #1 lying on the floor outside of the bathroom. Facility fall investigation form dated 7/27/14 indicated Resident #1 failed to utilize the call light system for assistance. Preventative interventions following the fall included resident education on using the call light and to not leave the resident unattended in the bathroom. Progress Notes dated 7/27/14 at 12:52 a.m. indicated Resident #1 was transferred by ambulance to the hospital. Resident #1 returned to the facility at 3:55 a.m. At 4:05 a.m., bruising noted to Resident #1's right thumb, wrist and forearm areas. Progress Notes dated 8/2/14 at 2:15 a.m. indicated Resident #1 self-transferred to bathroom unassisted and was found using the toilet. Resident #1 was encouraged to use the call light. Facility Incident Report dated 8/13/14 at 3:09 p.m. indicated Resident #1 was found sitting in the doorway floor of the bathroom with his/her pants pulled down around his/her knees. Towel rack in bathroom was broken where Resident #1 apparently had grabbed for support. No injury identified. In an interview on 9/8/14 at 2:32 p.m. Staff C, certified nurse aide, indicated on the afternoon of 8/13/14 she assisted Resident #1 onto the toilet and handed him/her the call light. Staff C returned in about 1 minute and found Resident #1 on the floor. Staff C indicated she was not aware that she was not to leave Resident #1 unattended in the bathroom until after the fall incident. Facility fall investigation form dated 8/13/14 indicated Resident #1 failed to utilize the call light system for assistance. Preventative interventions following the fall included employee education on not leaving resident unattended in the bathroom, placing a sign in the resident's room to use the call light and not to leave resident unattended in his/her chair. Adding an alarm was also mentioned, but not initiated. Facility Incident Report dated 8/16/14 at 4:33 p.m. indicated Resident #1 was found lying on floor in bedroom. Resident #1 indicated he/she does not know where he/she was going. Resident #1 encouraged to use the call light. No injury identified. In an interview on 9/8/14 at 2:50 p.m. Staff B, certified nurse aide, indicated she was the only aide working the evening shift on 300-400 halls on 8/16/14. Staff B had been trying to get all of the residents checked on and to the bathroom and Staff D from the 100-200 halls came back to help. Staff B indicated she had not gotten to Resident #1's room thus far into her shift and at around 4:30 p.m. Staff D discovered Resident #1 on the floor. Staff B indicated Resident #1 had fallen when he/she attempted to get out of bed unassisted. Staff B stated at the time of the fall the only safety interventions she was aware of was to not leave Resident #1 unattended in his/her chair or bathroom. Staff B noted there was no increased frequency of checks at that time. Facility fall investigation form dated 8/16/14 indicated Resident #1 failed to utilize the call light system for assistance. Preventative interventions following the fall included resident education on utilizing the call light, employee education on not leaving resident unattended in his/her chair and to bring Resident #1 into the solarium after toileting. Facility Incident Report dated 8/17/14 at 3:31 a.m. indicated Resident #1 was found sitting on the floor on the right side of his/her bed. Resident #1 reported he/she needed to go to the bathroom. Resident #1 did not use his/her call light. Resident #1 was last toileted by staff at 11:00 p.m. and asleep during previous checks. Resident #1 initially seemed alright and when assisted to the bathroom, began complaining of pain. In an interview on 9/9/14 at 5:20 a.m. Staff A, certified nurse aide, indicated she was working the overnight shift on 8/16/14. Staff A had been informed that Resident #1 had fallen earlier that day and she was checking on Resident #1 every 30-45 minutes. At around 3:30 a.m., Staff A entered Resident #1's room and discovered him/her lying on the floor. Staff A indicated she had last assisted Resident #1 to the toilet at around 11:00 p.m. and since that time Resident #1 was always in bed asleep during her checks. Staff A indicated it was common for Resident #1 to get up unassisted and the only intervention she knew of was to "watch him/her closely". Facility fall investigation form dated 8/17/14 indicated Resident #1 failed to utilize the call light system for assistance. Preventative interventions following the fall included resident education on using the call light and a bed alarm. Progress Notes dated 8/17/14 at 4:15 a.m. indicated certified nurse aide (CNA) had increased frequency of checking Resident #1 every 45-60 minutes following earlier fall on 8/16/14. CNA discovered Resident #1 on the floor at 3:30 a.m. Progress Notes dated 8/17/14 at 6:43 a.m. indicated Resident #1 started complaining of right lower extremity pain at 5:30 a.m. At 6:20 a.m. Resident #1 was sent to the hospital for further evaluation. Progress Notes dated 8/17/14 at 9:00 a.m. indicated Resident #1 returned to the facility with a [DIAGNOSES REDACTED]. Discussed putting a high low bed, squeeze type call light and signs all over the room to remind resident to use call light. Resident educated and verbalized understanding, but after breakfast attempted to get up unassisted. Radiology Result Report dated 8/18/14 for Resident #1 indicated a non displaced right pubic and ischial rami fracture at the symphysis pubis. 2). The Minimum Data Set (MDS) with an assessment reference date of 8/27/14 indicated Resident #3 with a Brief Interview for Mental Status (BIMS) score of 14 indicating no short or long-term memory deficits and his/her cognitive skills for daily decision making intact. Resident #3 required two staff assistance for transfers, toilet use, bathing and ambulation. The resident used a walker and wheelchair for mobility. Resident #3's plan of care dated 5/20/14 indicated Resident #3 had limited physical mobility related to a cerebral vascular accident with left sided weakness. Interventions included: 1) Toilet Use: Resident requires 2 staff participation to use toilet. Do not leave unattended in the bathroom. Encourage resident to use the call light to request assistance. Facility Incident Report dated 7/30/14 at 10:20 a.m. indicated Resident #3 was being assisted to ambulate to the restroom with gait belt and hemiwalker. As Resident #1 was turning around in the bathroom the hemiwalker got tangled up with the toilet seat assist bar causing Resident #3 to lose his/her balance. The aide was able to lower Resident #3 to the floor without injury. The report listed a medical condition of [DIAGNOSES REDACTED] (paralysis on one side of the body); and weakness as factors that may have contributed to the incident. In an interview on 9/9/14 at 6:30 a.m. Staff E, certified nurse aide, indicated she was assisting Resident #3 to the restroom on 7/30/14, when his/her hemiwalker got tangled on the toilet assist bar. Resident #3 lost his/her balance and Staff E lowered him/her to the floor. Staff E stated at the time of the fall Resident #3 was an assist of one staff and after the fall he/she became an assist of two staff. Facility fall investigation form dated 7/30/14 indicated Resident #3 was lowered to the floor when his/her hemiwalker got tangled with the toilet seat arm rests. Preventative interventions following the fall included removing the arm rest over the toilet seat. The facility failed to recognize that the assistance was being provided by one staff when the care plan required an assistance of two staff. Facility Incident Report dated 8/11/14 at 5:25 a.m. indicated Resident #3 was being assisted back to bed after using the toilet. Resident #3 got beside the bed and sat down onto the floor. Staff lowered the resident to the floor without injury. The report noted the resident had predisposing physiological factors such as gait imbalance and weakness; and situation factors due to his/her gait unsteady and unsteady with transfers. In an interview on 9/9/14 at 6:10 a.m. Staff F, certified nurse aide, indicated she was working the overnight shift on 8/10/14 and at around 5:30 a.m. Resident #3 requested to use the bathroom. Resident #3 was upset that he/she had been recently moved to another room. Staff F got Resident #3 up with a gait belt and into his/her wheelchair, took the resident to the bathroom and then returned to him/her to bedside. While transferring Resident #3 back into bed, Resident #3 grabbed the side rail and threw him/herself forward. Staff F lowered Resident #3 to the floor. Staff F indicated she thought at the time Resident #3 was a one person assist with transfers and only after the fall 8/11/14 he/she was changed to a two person assist. Facility fall investigation form dated 8/11/14 indicated Resident #3 is unsteady with transfers and the aide was unable to prevent the fall. Preventative interventions following the fall included using the EZ stand lift for transfers and an assist of two staff with transfers. The facility failed to recognize that the care plan already required an assistance of two staff. In an interview on 9/8/14 at 12:45 p.m. Staff H, certified nurse aide, indicated Resident #3 is a two person assist when transferred to the bedside commode. During an observation on 9/4/14 at 4:20 p.m. Resident #3 was assisted by one staff (Staff G) onto and off of a bedside commode.

The following deficiency relates to incident -I: Based on record review and staff interviews, the facility failed to ensure one (1) of four (4) residents received adequate supervision from hazards (Resident #1). Resident #1 attempted to self- transfer when he/she fell and sustained facial injuries. The facility used alarms to alert staff of resident's needs to self-transfer. At the time of Resident #1's fall, the alarm did not sound. Staff interviews revealed the resident was known to turn off his/her alarm, the resident's care plan lacked updates to address his/her safety need. The facility identified a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated of 6/25/14, Resident #1 scored 1 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive test, indicating severe cognitive impairments for daily decision making. Resident #1 required one staff to physical assistance with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene and bathing. Resident #1's plan of care dated 6/4/14 identified Resident #1 had the inability to perform ADLs (activities of daily living) independently. Resident #1 had an increased risk for falls related to his/her gait/balance and lack of safety awareness. The care plan interventions included assuring the resident had been wearing appropriate footwear with non-skid sole when ambulating or utilizing the wheelchair. The care plan called for using a cushion in chair, high rise toilet, grab bars on his/her bed to assist with positioning. The care plan directed staff to not leave the resident unattended in bathroom or bedroom when out of bed. (The care plan did not mention the use of bed alarm which according to staff interviews, had been used for several months prior to the resident's fall on 7/25/14.) According to the Incident Description dated 7/25/14 at 3:18 a.m., (with a revision date of 8/5/14), the Certified Nurse Aide (CNA) reported Resident #1 had been on the floor with visible head trauma. The resident had been lying on the right side, with his/her pants down around his/her ankle. The resident ' s right eye had a bleeding laceration with moderate amount of blood on the floor. The resident ' s right eye was black, blue/purple color and swollen shut. The report noted the alarm had not sounded, and the aide reported the resident turned off his/her alarm. The alarm had been checked and worked correctly. The resident had been transferred to the emergency room . Radiology Report dated 7/25/14 identified the facial bones CT (Computerized Tomography) scan revealed the resident had a fracture involving the right inferior orbital floor with a very mild inferior displaced of fracture fragments. There was no epidural, subdural or intracerebral hemorrhage. In an interview on 8/7/14 at 5:30 a.m. Staff A, certified nurse aide (CAN), indicated she had worked the overnight shift on 7/24/14. Staff A stated that it had been extremely hectic the night with several residents restless. Staff A had been propelling a resident in a wheelchair in 400 hall when she heard a thump (sound coming) from Resident #1's room. Staff A immediately proceeded to Resident #1's room as Staff B was exiting another resident's room. Staff A stated Resident #1 had fallen and to get Staff C. Staff A immediately noticed serious facial bleeding and got a wet cloth and placed it over Resident #1's wound. Staff B and Staff C responded within minutes. Staff A indicated Resident #1 had a bed alarm in place, but it had been turned off. Staff A stated it was very common for Resident #1 to get up unassisted at night and turn off the bed alarm despite staff's efforts to position the alarm under the bed, out of reach. Staff A indicated Resident #1 had shut off his/her alarm since his/her admission (4/9/13). Staff A noted Resident #1 will get up unassisted 3-5 times a night. Staff A indicated the facility recently moved Resident #1 at the end of the 400 hall where it is probably the most difficult area to hear the alarm and monitor the resident. Staff A indicated she had reported her concerns. In an interview on 8/7/14 at 5:00 a.m. Staff B, certified nurse aide, indicated she had worked the overnight shift on 7/24/14. Staff B indicated at around 3:00 a.m. she had been walking out of a resident's room on 400 hall, when Staff A indicated she had heard a thud (sound) in Resident #1's room and to go get Staff C. Staff B found Staff C and responded within minutes. Staff B indicated it was common knowledge that Resident #1 would shut off his/her alarms to avoid "bothering anyone". Staff B indicated Resident #1 gets up unassisted every night and always tries to shut the alarm off. Sometimes staff heard the alarm briefly before Resident #1 gets the alarm turned off. In an interview on 8/7/14 at 6:30 a.m. Staff C, Licensed Practical Nurse, indicated she was with another resident when Staff B informed her of Resident #1 falling. Staff C immediately responded and upon entering the room saw Resident #1 on the floor with Staff A holding a wet clothe over Resident #1's forehead. Staff C assessed Resident #1 and made arrangements for him/her to be sent to the hospital. Staff C stated that she was informed by staff that the alarm was not sounding and it had been shut off by Resident #1. Staff C and Staff B tested the alarm and it had functioning properly. Staff C indicated this was the first time she was informed of Resident #1 shutting off his/her alarm. In an interview on 8/7/14 at 9:20 a.m. Staff D, certified nurse aide, indicated she works day shifts, but has worked nights. Staff D stated Resident #1 will get up unassisted more frequently on the night shift. Resident #1 had been known to shut off his/her alarm or unplug the alarm. Staff D indicated she had reported her concerns to the nursing staff. During an interview with the Director of Nursing on 8/7/14 at 11:15 a.m., she reported she was not aware that Resident #1 turned off his/her alarm until after the fall on 7/25/14. Resident #1's plan of care dated 7/25/14 (post fall) indicated Resident #1 known to shut off his/her personal alarm with interventions to monitor hourly from 8:00 p.m. to 8:00 a.m. for his/her safety and to ensure the motion alarm was turned on. Resident #1 had a fall with head injury with interventions for a pressure alarm when up in chair, motion alarm when in bed (used to alert staff of resident ' s movements in motion) and a call bell next to couch when resident sitting there.

Based on record review and interviews with staff, physician and family, the facility failed to plan for and direct nursing services to ensure Resident #14 received adequate supervision to prevent accidents. Record review and interviews identified Resident #14 fell 21 times within 6 months with the fall on [DATE] resulting in head injuries which lead to the resident' s death. Additional concerns were identified for Resident # 13 and Resident #11.The sample consisted of five (5) residents and the facility identified a census of 52 (fifty two) residents. Findings include: 1. Resident #14's admission Minimum Data Set (MDS) assessment with reference date of [DATE], identified Resident #14 with a moderately impaired cognition with short and long term memory deficits. Resident #14 required extensive assistance of two staff members with transfers, bed mobility, ambulation, dressing, and toilet use. Resident #14's [DIAGNOSES REDACTED]. The MDS noted the resident exhibited physical and verbal behaviors and was resistive to cares. MDS Assessment of fall history prior to admission revealed the resident was at risk for falls due to a fall sustained prior to admit. The MDS also noted the resident had 2 falls between the date of admission ([DATE]) and the completion date of the MDS ([DATE]). Clinical record review of incident reports revealed the resident had four falls prior to [DATE]. Review of the Fall Risk collection tool dated [DATE] (at admission) revealed the resident had a score of " 19 " indicating the resident was a high risk for falls (score of "12 " or more indicates high risk for falls). On [DATE] the resident's fall score was documented as "25". The initial care plan implemented upon admission identified the resident as a fall risk due to impaired mobility, weakness, and dementia. Routine fall measures were implemented and staff was instructed to: maintain the bed in a low position; be sure the resident was wearing shoes/slippers with non-skid soles; to observe for increased unsteadiness, to transfer with the assist of ,[DATE] staff members; to keep pathways clear of clutter; to receive strengthening and balance therapy; and place a personal alarm (PA) to increase safety for the resident. On [DATE] a bed alarm and motion detector were implemented on the care plan for the resident. Record review of Facility Incident Reports noted the following falls: a). On [DATE] the resident fell in his/her bedroom when he/she attempted to self-transfer from bed to doorway. The report identified the resident's personal alarm did not sound and the evening shift reported the resident is noncompliant with PA (personal alarm) and call light. No injuries were noted. The intervention noted a PA would be place where resident cannot reach and obtain Lorazepam (antianxiety medicine) order. b). On [DATE] the resident fell in bedroom with red skin noted on his/her back. The resident removed the PA got up without assistance. The intervention identified to reapplied the PA, motion detector and continue physical Therapy (PT) strengthening. c.) On [DATE] the resident fell in bedroom when he/she attempted to self-transfer from the bed and sustained a forehead abrasion. The resident lost his/her balance when he/she reached for the walker. The report did not identify whether or not the resident ' s PA or motion detector had alerted staff. The intervention noted to check for Urinary tract infection (UTI) and make sure resident had shoes on when up. d.) On [DATE]- 6:20 a.m. the resident fell in dining room with complaint of buttock pain. The intervention noted a referral to psychiatric nurse. The investigation summary noted the resident gets up without assist and does not use the walker all the time. e). On [DATE] at 8:10 a.m. the resident fell in bedroom with no injury noted. The intervention listed to remind resident to use wheeled walker (w/w) and for aides to watch the resident closely. f). On [DATE] at 9:45 a.m. the resident fell in dining room with no injury noted. The report noted the resident refuses to use his/her walker and was unsteady. The intervention listed to remind the resident to use w/w. g). On [DATE] the resident fell in the hallway with bruise noted on forehead and right side of face. The report noted the resident had been agitated all shift. The intervention directed staff to encourage resident to use w/w and evaluate medications. h). On [DATE]- resident fell in hallway with no injury noted. The report documented the personal alarm did sound. The intervention listed Wanderguard, 1:1 activity, 1:1 staff. Possible referral to an in-patient psychiatric evaluation program. i). On [DATE] the resident fell in bedroom with no injury noted. The resident ' s family member reported the resident attempted to sit in the recliner and barely sat on the edge then slid to the floor. The interventions listed the following: decrease Haldol (anti-psychotic medication) and ask staff to use PRN (as needed) anti-anxiety medications. Staff noted the resident walks until exhausted. j). on [DATE] the resident fell in bedroom with no injury noted. The interventions listed: ask staff to use PRN medications and check for UTI. Possible referral to the same in-patient psychiatric evaluation program as mentioned before. k.) On [DATE] the resident fell in hallway with complaint of pain in the back, shoulder, neck, and head. The investigation noted the resident had an unsteady gait and attempted to sit down and fell . The intervention noted for staff to attempt to use wheelchair when resident is unsteady. l). On [DATE] the resident fell in hallway with contusions and abrasions noted. The investigation noted the resident unable to walk safely, shuffling his/her gait both before and after the incident. The interventions listed to use wheelchair, use standby assist when it appears he/she cannot walk safely, provide wheelchair. m). On [DATE] the resident fell in bedroom with contusions and back pain noted. The incident report noted the personal alarm did not sound. The interventions listed to continue PA and motion detector on bed, offer snack, and assist to toilet on schedule. n). On [DATE] the resident fell in hallway with no injury. The investigation noted the resident had increased the use of wheelchair due to unsafe walking and unsteady gait. The report noted the resident gets tired easily and had an increase dementia and unable to ask for assistance. The intervention noted to administer PRN medicine, educate resident to ask for help to ambulate. o). On [DATE] the resident fell in hallway with no injury. The report identified staff will aid in walking with walker as much as allow. The interventions listed PRN medicine given, 1:1 and offer activity. p.) An investigation noted the resident fell on [DATE] at 8 p.m. with the interventions noted to not allow the resident to push the empty (wheel) chair and to have resident in the wheelchair when restless and weak. q). On [DATE] the Resident fell in the hallway and sustained a contusion to his/her forehead. The intervention noted to look into referral to in-patient psychiatric evaluation program. (This intervention was initially suggested on [DATE] and [DATE].) r). On [DATE] the resident fell in bedroom with no injury. The interventions identified the social worker would provide education at afternoon " huddle" (meeting) regarding possible interventions and to arrange family meeting regarding possible admittance to the in-patient psychiatric program for an evaluation. s). On [DATE] the resident fell in hallway with no injury. The intervention noted multiple interventions attempted but resident continues to fall. t). On [DATE] the resident fell in hallway with no injury noted. The investigation noted the resident did not have the walker but was using the wall-railing when walking in the hallway. The investigation noted to educate staff to get the resident ' s walker and to put the resident in the wheelchair when gait is unsteady. The intervention listed a pressure call light placed on bed to alert staff when resident was getting out of the bed so staff can make sure resident had proper footwear and walker for ambulation. u). On [DATE] at 3:15p.m., Resident #14 fell in hallway and was found lying on the floor on his/her back. The resident had been walking down the hall when he/she fell to the floor. The reported noted the resident was unresponsive. The facility contacted the physician who informed staff to call for an ambulance to transport the resident to the emergency room . The investigation revealed the resident had been moving fast, and did not have his/her walker and will not stay in wheelchair. The report noted the walker makes the resident fall because he/she moves to fast. The incident report did not mention whether any alarm sounded. The interdisciplinary progress notes dated [DATE] identified the incident occurred on [DATE] (not [DATE]). The progress note identified the following: Resident walking down the hall going very fast fell on to carpet floor and rolled over. Resident would not respond, and his/her left eye dilated, right eye constricted, with a bump on his/her left forehead. The ambulance was called and arrived. The note revealed staff called the hospital on [DATE] at 9 p.m., and received report that the resident would be kept overnight. The facility reported the incident to the department and reported the CT scan diagnosed Resident #14 with a subdural hematoma. Resident #14 died on [DATE]. Resident #14's certificate of death listed the immediate cause of death on [DATE] as a left subdural hemorrhage. According to the form, the factors such as traumatic head injury and the fall lead to the underlying cause of death on [DATE]. Review of the clinical record revealed the resident had a [DIAGNOSES REDACTED]. During an interview with the resident's physician on [DATE] he stated the resident was taking Coumadin (blood thinner) for the [DIAGNOSES REDACTED]. The physician stated Resident # 14 ' s cause of death was a subdural hematoma most likely caused by the fall on [DATE] which was complicated by the resident's dementia and other diagnoses. He stated he was aware of the resident's frequent falls due to non-compliance and the resident was being seen at the Psychiatric Clinic for medication management. During an interview with Resident #14's family member on [DATE] at 11:30 a.m. he/she stated concerns regarding the facility's measures to keep Resident #14 safe from falls. The family member reported it was his/her understanding that Resident #14 would have physical assistance from staff when ambulating. The family member stated he/she entered the facility "dozens" of times and would observe the resident ambulating by his/her (self) with and without a w/w. The family member stated a facility staff member told him/her that the facility would contact them after an internal investigation of the resident's final fall on [DATE] was completed. The family member was concerned because the facility did not contact them in the following weeks after the resident's fall and subsequent death. The family member stated the family was aware of the resident's multiple falls, the resident ' s non-compliance, and impulsiveness and getting up on his/her own frequently. The family member reported at one time the resident had bed alarm and he/she had asked why the resident didn't have a personal alarm (PA) and staff could not tell why no PA. During an interview on with Staff T, CNA, on [DATE] at 1:00 p.m. she stated she worked the evening shift on [DATE]. She stated she was in another resident's room with the door closed when she heard a knock on the door and heard Resident #14 say "Hello" through the closed door. The CNA called out to Resident #14 that she would be out" in a minute". When the CNA finished with the other resident and opened the door she saw Resident #14 on the floor and the LPN was running to the resident. The CNA stated she knew Resident #14 was out in the hallway by him/herself when Resident #14 knocked on the door but the CNA was unable to immediately go to Resident #14 right away as that would have endangered the resident she was working with at the time. The CNA stated Resident #14 would frequently wander the halls with or without the wheeled walker. Staff was supposed to help him/her walk but were unable to provide the constant supervision to accomplish this. She stated there was not enough staff on evening shift to care for all the residents and to provide Resident #14 with 1:1 care. During an interview with Staff U, Licensed Practical Nurse (LPN) on [DATE] at 3:45 p.m. she stated she worked the evening shift on [DATE]. Staff U reported she was getting medication for another resident ready at the end of the hall. She stated she was starting her rounds after shift report when she saw Resident #14 ambulating very quickly at the far end of the hallway without a wheeled walker. She started towards the resident and stated the resident fell forward and "tucked and rolled forward and landed on her/his back". She stated upon assessment the resident was unresponsive and had a hematoma and abrasion on the left side of the head. An ambulance was called and the resident was taken to the emergency department. Staff U reported Resident #14 would follow her on the med (medication) pass holding onto the cart. The LPN stated the resident had been care-planned to have staff assistance when transferring or ambulating however the resident was frequently non-compliant and would ambulate without assistance. She stated the typical level of staffing on evening shift had been one nurse and one Certified Nurse's Aide (CNA) to cover Hall 300 and Hall 400. She stated she and the aide tried to keep track of the resident but could not keep the resident "down". The LPN stated she administered the PRN Lorazepam to the resident occasionally but the medicine seemed to make the resident more agitated. She stated she would also try to educate the resident to use his/her wheeled walker when ambulating and to call for assistance with the call light. She stated she and the CNA were too busy caring for all of the residents to provide 1:1 monitoring of Resident #14. A review of staffing levels on the dates Resident #14 had falls revealed 6 evening shifts where Halls 300 and 400 (the resident was on Hall 400) were staffed with one nurse and one CNA to care for an average of 17 residents. Day shift review revealed approximately ,[DATE] CNAs present on Halls 300 and 400. During an interview with the Director of Nurse's on [DATE] at 5:30 p.m. she stated it was difficult to state typical staffing levels because they are determined by the census and care levels of the residents at that time. During an interview with the Director of Nurse's (DON) and Staff F, Registered Nurse (RN), on [DATE] at 9:00 a.m. the DON revealed the resident was combative, resistant to cares, and non-compliant. She stated the resident had an unsteady gait and was care planned to have staff assist for ambulation and transfers. She stated the resident would constantly get up and ambulate independently with or without the W/W. The DON voiced great frustration was experienced by staff due to the resident's non-compliance with calling for help. The DON stated she did not have sufficient staff to monitor the resident 1:1. She stated the facility had three different social workers during the resident's stay at the facility and this could have contributed to a lack of communication between team members when evaluating interventions for the resident. The DON agreed that the interventions implemented for the resident were mostly ineffective and other interventions could have been tried. She agreed the documentation of the falls on the incident forms was not complete and it is unknown if the alarms care planned for the resident were used consistently. She stated she was not sure why the motion detector and the PA interventions were removed on [DATE]. The DON reported the care plan was hard to interpret due to so many handwritten notes and crossed off items. During an interview with Staff F, RN and Quality Assurance Nurse, on [DATE] at 1:40 p.m. she stated she reviews each fall and provides reports to the Quality Assurance Committee. She provided a map of the facility where she had documented where each fall occurred monthly, however she did not document which resident had the fall on the map. She stated she was trying to evaluate the facility for hazards that could be eliminated. She stated she was keeping a fall log for each resident who had a fall. When asked to provide the fall log for resident #14 she provided a log for [DATE] through [DATE] which listed 9 falls. She stated she did not have any additional logs for Resident #14. The facility Procedure for Fallen or Injured Residents, revised ,[DATE], was provided and the following procedure steps were reviewed and discussed with pertinent staff as listed below: a).Step #18- Communicate the fall has occurred on the 24 hour communication record. Staff F, QA RN, on [DATE] at 1:40 p.m. stated the nurses maintain a 24 hour report sheet that is used to communicate falls between shifts. b). Step #19- Up date the Comprehensive Care Plan- The DON in an interview on [DATE] at 9:00 a.m. addressed the care plan for Resident #14 and stated the Health Information employee was responsible for deleting discontinued interventions and typing the new ones on to the care plan and re-printing so it was easier for staff to interpret and review every three months.. The DON stated due to a cut back in hours this employee was unable to keep up with the task. c). #21- Monitor the resident's condition and the effectiveness of interventions put into place to prevent further falls and document in the Interdisciplinary Progress notes (nurse's notes). Review of these notes from [DATE] through [DATE] revealed nursing staff were consistently documenting the resident's physical condition after each fall, but were failing to consistently evaluate the effectiveness of interventions. d). #22- Complete the Incident trending Record and Incident Record Log. Staff F, QA RN, on [DATE] at 1:40 p.m. stated she was not currently keeping these records. Additional record review revealed the following: Review of the records from the Psychiatric Clinic revealed the following: [DATE]- Resident saw psychiatric nurse with recommendations to keep medications as they were. No new orders written. [DATE]- Resident saw psychiatric nurse with recommendations to monitor resident for constipation. No new orders written. [DATE]- Resident saw psychiatric nurse with recommendations to continue with current regimen for now. She/He had ongoing falls regardless of medication or use of walker or not. No new orders written. Record review revealed Resident #14 received physical therapy (PT) and speech therapy (ST) from [DATE] through [DATE]. The facility developed a restorative program for the resident on [DATE] to include upper extremity/lower extremity exercises with 2 pound weights, NuStep (stationary bicycle) Level 2 ,[DATE] minutes, and gait/amb (walking) training of distances up to 150 feet. The goal of the restorative exercises was to maintain strength for mobility. The program did not specify how many times a week the exercises were to be done. On [DATE] documentation revealed the restorative ambulation was to be done three times a day three to seven times a week. Documentation provided by the Restorative Nurse revealed the resident received restorative exercises 4 times in March, 11 times in April, and 5 times in May. Restorative ambulation was documented as received 7 times in May and 19 times in June. PT resumed on [DATE]. Review of clinical records revealed additional communication with the resident's spouse as follows: [DATE]- The Social worker documented she spoke with the resident's spouse and he/she did not agree to a short stay in-patient psychiatric evaluation referral for the resident at this time. [DATE]- Meeting held with Resident's spouse, Administrator, Director of Nurse's (DON), Business Office Manager, and the facility Social Worker. The spouse stated he/she did not want the resident moved to the in-patient psychiatric clinic for an evaluation as the spouse felt it would confuse the resident to change environments. [DATE]- Phone conversation with resident's spouse, administrator, and DON. Spouse stated again he/she did not want the resident moved to psychiatric clinic for an evaluation as the spouse felt the change would confuse the resident. 2. The MDS (Minimum Data Set) with an assessment reference date of [DATE] documented Resident #13 as moderately impaired cognition with short term memory loss. The MDS indicated the resident had shown consistent inattention and disorganized thinking. The MDS indicated the resident rejected care on a daily basis and exhibited wandering behaviors daily. The MDS indicated the resident required extensive to total assistance from staff for activities of daily living that included eating, toileting, and personal cares. The MDS indicated the resident had frequent incontinence of bowel and bladder. The MDS indicated the resident required supervision from staff during mobility and/or locomotion. The MDS indicated the resident's [DIAGNOSES REDACTED]. The resident's care plan instructed staff that the resident showed dependence upon staff for grooming, dressing, and assist with oral care two times a day. The staff were instructed to observe for over sedation and side effects of psychoactive medications. The care plan instructed staff to be aware that the resident had high risk for falls and attempts to transfer self. The fall data collection record dated [DATE] scored the resident at 26 which indicated the resident to be high risk for falls. A score of 12 and above indicates a high risk and advises staff to proceed to care plan approaches and revise as appropriate. Review of the resident's clinical record revealed that from [DATE] to [DATE] the resident had multiple (36) falls. The documentation revealed the resident fell from 2 to 6 times a month. The documentation revealed the majority (29) of the falls occurred during the afternoon to early evening hours and occurred as the resident had been ambulating independently or attempting to sit on a chair. Interventions to prevent falls addressed environmental factors but did not look at engaging the resident in activities to avoid the wandering behaviors. ******** Based on observation, interview and container label review, the facility failed to ensure all hazardous materials were maintained in a safe manner by ensuring the storage area of the chemicals remained locked. During the environmental tour on [DATE] between 3:40 p.m. and 4:45 p.m. with Staff D, the maintenance director and housekeeping supervisor, observation showed the following: 4. The door to the soiled utility room in the 400 hall, equipped with a push button code lock was not locked, with 2 spray bottles of Virex TB (an disinfectant licensed for institutional use) easily accessed from the doorway. Warning labels on the bottle stated "Harmful if swallowed", "Keep out of the reach of children", "contact poison control center if swallowed", "flush eyes with water for 15 minutes for contact with eyes". 5. A door in the middle hallway located between the entrance and facility dining room was labeled "Fire Door Keep Closed", "Storage", "Housekeeping Storage Room", and 4 colored diamonds (standard symbols of hazard warnings) labeled as follows: Yellow with a #3, red with a #4, and blue with a #4. The door had a push button code lock, but not locked. The room contained hazards that included at least 20 spray bottles of Virex TB. 6. The door to the soiled utility room in the 100 hall, equipped with a push button code lock was not locked, with a spray bottle of Virex TB located within reach of the door and readily accessible. Staff D reset the lock on the housekeeping storage room door from the back of the door, and stated that someone must have disabled the lock. Staff D and the housekeeping and laundry director, also on the environmental tour, both acknowledged that the soiled utility room doors should have been locked and the doors might require an adjustment to the hydraulic hinge closure.

Based on resident record review, observations, and staff interviews, the facility failed to consistently ensure residents identified as high risk for falls, remained safe in their environment and that staff used personal safety alarms correctly in an effort to reduce the number of falls. This occurred for 3 of 4 residents reviewed ( Resident #1, #3, and #5). The facility reported a resident census of 52. Findings include: 1. 1. A Medicare 30 day MDS ( Minimum Data Set Assessment Tool ) dated 10/17/12 identified Resident #1 with the following [DIAGNOSES REDACTED]. The MDS coded the resident with both short and long term memory impairment and severely impaired cognitive function related to daily decision making skills. The MDS coded the resident required extensive staff assistance for bed mobility, transfers, ambulation in the room, eating, and toileting needs. The MDS coded the resident required total staff assistance with dressing, personal hygiene, and bathing. The MDS coded the resident with functional limitation of both lower extremities. The MDS identified the resident as always incontinent of bladder function and frequently incontinent of bowel. The MDS coded the resident with occasional pain and noted the resident without any recent falls or injuries. The resident care plan dated 10/4/12 identified the resident as a fall risk related to impaired cognition and safety awareness. The intervention directed the staff use a PSA ( personal safety alarm) at all times to increase safety due to weakness upon return from the hospital and the recent hip fracture. Observations made on 11/27/12 at 9:15 a.m. and 9:55 a.m. revealed the resident resting in bed with the PSA alarm string clipped to the neck of the resident's t-shirt and the PSA box placed beside the resident's pillow on the left side not secured in any way to the bed or the bed frame. 2. 1. A significant change of status MDS ( Minimum Data Set Assessment Tool ) dated 8/29/12 identified Resident #3 with the following [DIAGNOSES REDACTED]. The resident scored 3/15 on the Brief Interview for Mental Status, indicative of severely impaired memory and cognitive function related to daily decision making skills. The MDS coded the resident required extensive staff assistance for bed mobility, transfers, dressing, personal hygiene, toileting, and bathing. The MDS coded the resident required only supervision for ambulation and eating. The MDS identified the resident with functional limitation in range of motion of 1 upper extremity. The MDS coded the resident with no pain and no recent falls. The resident care plan dated 11/21/12 identified the resident a fall risk related to impaired mobility, weakness, and dementia. The interventions directed staff apply a PSA alarm at all times, check it's function every shift, and replace batteries as needed. Observations made on 11/27/12 at 8:55 a.m., 9:50 a.m., and 2:00 p.m. revealed the resident seated in the wheelchair in the 200 hall lobby area with no PSA alarm on. 3. A quarterly MDS dated [DATE] identified Resident #5 with the following [DIAGNOSES REDACTED]., malnutrition, osteoporosis, and generalized weakness. The resident scored 9/15 on the Brief Interview for Mental Status indicative of some memory impairment and moderately to severely impaired cognitive function related to daily decision making skills. The MDS coded the resident required extensive staff assistance with bed mobility, transfers, ambulation in the room, dressing, toileting, personal hygiene, and bathing. The resident required limited assistance with eating. The MDS coded the resident with limitation of range of motion for both lower extremities. The MDS identified the resident with no recent falls. The resident care plan dated 10/4/12 identified the resident at risk for potential falls related to balance difficulties and generalized weakness. The care plan interventions failed to identify the use of the PSA alarm when up. Observations made on 11/26/12 at 2:20 p.m., 3:10 p.m., 4:10 p.m. and on 11/27/12 at 10:00 a.m. revealed the resident seated in room in a recliner chair with the foot rest elevated. A PSA alarm string attached to the shoulder area of the resident's top and the alarm box resting in the seat of the recliner chair beside the resident hip, not secured to the chair in anyway. Observations made on 11/28/12 at 11:20 a.m. and 12:45 p.m. revealed the resident seated in a wheelchair in the room and no PSA alarm attached. An interview conducted on 11/28/12 at 8:45 a.m. with the DON revealed the facility management team met daily to discuss falls and current interventions. The DON explained she hoped to push the team to do more critical thinking about fall prevention. The DON stated she felt the fall interventions needed to be more accessible for the staff to use and stated she would like to place this information at the resident's bedside. She stated currently due to the computer system used for documentation, the care plan information for the CNAs is not very accessible or user friendly. She stated staff also discussed any recent falls/interventions daily at the huddle meetings conducted at the change of shift. The DON stated she felt the facility over the past 2 -3 made some important changes in the communication of information but noted still needed to work on the system. At the time of the facility exit on 11/28/12 at 1:45 p.m., both the facility Administrator and the DON agreed not securing the alarm boxes to the chair of bed and not applying the alarms to residents requiring them compromised the resident's safety and risk for falls.

The following relates to facility self report # -I Based on record review and staff interviews, the facility failed to provide supervision to ensure against hazards from self and the environment and adequately assess and provide interventions when a resident has adverse symptoms which represent a change in a physical condition (Resident #1). The sample consisted of 4 residents reviewed at risk for falls and the facility reported a census of 52 residents. The facility had knowledge the resident just returned from a hospital stay and presented in a weak condition requiring more assist with transfers and ambulation. The facility also had knowledge the resident to be poor at decision making, short and long term memory problems, and unable to make needs known. The facility had knowledge the resident made an attempt to get up out of the dining room chair just prior to the fall and staff failed to implement any interventions for the resident ' s safety. As a result, the resident attempted to transfer self alone and fell , fracturing a hip which required surgical intervention. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 8/15/12, which identified [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assist of one staff member for bed mobility, transfers, toilet use, and personal hygiene and limited assist of one staff for dressing and eating. The MDS further indicated the resident had short and long term memory and severely impaired cognitive skills for daily decision making. The MDS identified the resident as not steady and required the assistance of staff during transitions. The MDS revealed the resident had a fall since the last assessment which resulted in a non-major injury. The Care Plan dated 8/23/12 listed the resident had a fall risk problem related to impaired cognition and safety awareness. The care plan indicated the resident to be independent with ambulation and required extensive assistance for transfers. The resident should wear well-fitting non-slip soles foot wear. The long term goal indicated the resident would remain free from injuries thru 11/16/2012. Review of the Fall Risk Evaluation dated 3/14/12, 5/13/12, and 8/14/12 identified a score of 16. A score of 12 or above identifies the resident to be at a high risk for falls. The Patient Transfer Form dated 9/13/12 indicated Resident #1 had been admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The Interdisciplinary Progress Notes dated 9/13/12 at 11:20 a.m. revealed Resident #1 had returned to the facility from the hospital. Review of a Fax Communication to Resident #1 ' s physician dated 9/13/12 at 11:45 a.m. revealed the facility reported the resident had returned from the hospital with weakness. The resident cannot transfer except with the assistance of 2 people and the resident had been independent before hospitalization . The facility requested an order for [REDACTED]. On 9/13/2012 the physician approved the order to have physical therapy evaluate and treat the resident. Review of the Facility ' s Investigation report dated 9/13/12 at 12:10 p.m. revealed Resident #1 attempted to ambulate from the dining room chair and feel to the floor landing on buttocks with knees bent and back against the wall. The resident received a skin tear to the right elbow. The investigation results revealed cause due to dementia and increased weakness. The staff applied a personal alarm after the fall and the care plan updated to include two person assistance with transfers and a wheel chair to be used. The Facility Incident Details dated 9/13/12 indicated an assessment after the fall included Resident #1 guarding right groin area. The assessment further documented ROM (range of motion) of extremities (lacked indication if ROM normal or abnormal), visual skin and audio, and documented the resident denied pain. Review of Interdisciplinary Progress Notes dated 9/13/12 at 12 10 p.m. revealed staff found Resident #1 on the floor by the dining room table and chair. It appeared the resident attempted to transfer self, lost balance and fell landing on buttocks. The resident denied hitting head and denied pain. An open area was found on his/her right elbow; area cleansed and dressing applied. The staff notified the physician. Review of the Interdisciplinary Progress Notes dated 9/13/12 at 6:30 p.m. reflected Resident #1 continually tried to get out of the recliner, complains of groin and upper thigh pain ( resident rubbed hand on area of pain), dressing dry and intact to right elbow, ate 75% of supper and drank 480 ml (milliliters) of thickened water with assist. Review of the next entry of the Interdisciplinary Progress Notes dated 9/14/12 at 6:20 a.m. revealed Resident #1 rested quietly this shift, no complaints of pain, resident required two assist with cares, vital signs 99.1, blood pressure 104/56, heart rate 76, and respirations 18. Resident assisted to bed with the use of a mechanical stand lift and the assistance of two staff members. The record lacked indications that a full assessment had been completed of the Resident #1 after the fall. The record lacked any interventions were implemented for the resident ' s safety after the resident returned to the facility in a weakened state from the prior illness and hospitalization . The facility had knowledge the resident to be a fall risk and required more assistance when he/she returned to the facility. The facility also had knowledge that the resident attempted to transfer self-prior to the fall. The facility reported the resident as unable to make his/her needs and wants known and dependent upon staff for cares. Review of the next entry of the Interdisciplinary Notes dated 9/14/12 at 9:00 a.m. revealed Resident #1 complained of right hip and back pain. Staff administered Tylenol for pain. At 9:30 a.m. the pain had not been relieved with the administration of Tylenol. The staff notified the physician and the physician indicated he would see the resident when on rounds at the facility. At 9:45 a.m. the physician saw the resident and orders were received to have x-rays of the right hip and pelvis. The facility had the resident transferred to the hospital for x-rays which revealed a right hip fracture. The resident was admitted to the hospital for surgical repair. Review of the MAR (Medication Administration Records) dated the month of September 2012 revealed an order for [REDACTED]. The MAR revealed the resident received Tylenol two times, once on 9/13/12 at 9:30 p.m. and on 9/14/12 at 8:15 a.m. On 9/26/12 at 9:12 a.m., Staff A was interviewed and stated she had been working on the day shift on 9/13/12 and had been assigned to the CCDI (Chronic Confused Dementia Illness) unit where Resident #1 lived with 9 other residents. Staff A reported Resident #1 had just returned from a hospital stay right before lunch in a weakened status requiring more assist for transfers and ambulation. Staff A stated the resident had been assisted to the unit via a wheel chair for transportation and transferred from the wheel chair to the toilet use and to the dining room chair for lunch. Staff A further reported the resident attempted to get up on his/her own after being transferred to the dining room chair. Staff A reported she assisted the resident to remain sitting and gave the resident a glass of thickened water. Staff A further reported the resident sat back down in the chair and Staff A stated she then went to the hallway and into residents ' room to finish making the beds sometime before 12:00 p.m. Staff A stated around 12:10 p.m. Staff B, cook, had been pushing the lunch cart back to the unit dining room when Staff A stopped the cart. Staff A stated she went to see why Staff B had stopped the cart. Staff B found Resident #1 on the floor in the dining room. The resident had been sitting in the dining room chair at the table prior to the fall and Staff A stated she then saw the resident sitting on the floor with back against the wall with left leg stretched out in front with right leg bent at the knee and right lower leg under left leg. Staff A stated she then hit the panic button to summon for the nurse and Staff E, RN (Registered Nurse) responded immediately. Staff A reported Staff C, RN, also responded but left shortly afterwards. Staff A stated she had been instructed to get the resident up off the floor and Staff E did no assessment on the resident prior to instructing Staff A to assist the resident up off the floor. Staff A reported Staff D, CNA (Certified Nurse Aide) assisted her to get the resident up off the floor and back into the dining room chair using a gait belt. Staff A stated the resident would not bear weight on the right leg and Staff A could tell the resident to be in pain by his/her grimacing face and the resident would touch his/her right hip and said it hurt. Staff A stated nurse Staff E had been seen and also told by Staff A that the resident would not bear weight on right leg and complained of pain. Staff A stated she came back into work the next morning and the resident complained of right pain, not bearing weight on right side and when sitting the resident would lean to his/her left side, which all is unusual for the resident. Staff A reported this to Staff G (nurse). On 9/26/12 at 11:05 a.m., Staff B (cook) was interviewed and stated she had been taking back the food cart to the CCDI Unit around 12:05 p.m. when she got to the end of the hallway. Staff B stated she stopped the cart because Staff B saw Resident #1 sitting on the dining room floor by the table with back against wall with one leg stretched out in front and the other leg with knee bent. Staff B stated she turned to go up the hallway to get help as no staff were present. Staff B stated she saw Staff A coming out of a resident ' s room and she told Staff A the resident was lying on the floor. On 9/26/12 at 11:15 a.m., Staff D (CNA), was interviewed and reported she had been in the activity room when Resident #1 fell . Staff D reported she responded to the panic button and went to the unit and observed the resident on the floor in the dining room. Staff D stated Staff E, RN, took the resident ' s blood pressure while the resident lay on the floor and asked the resident a couple questions. Staff D stated Staff E then instructed her and Staff A to assist the resident up off the floor and into the dining room chair. Staff D stated when they assisted the resident to a standing position it had been clear the resident not to be alright. The resident would not bear weight on his/her right leg, and by the resident ' s face the resident seemed to be in a lot of pain. Staff D further indicated once the resident was in a seated position in the chair, the resident would lean to his/her left side attempting to not put weight on the right side. Staff D stated she reported all the resident ' s symptoms to Staff E. Staff D stated Staff E had seen the resident when they transferred the resident to the chair and saw the resident had not been bearing weight and displayed a facial expression of pain. On 9/26/12 at 11:55 a.m., Staff E (Registered Nurse), was interviewed and stated had been working on 9/13/2012 and assigned to care for Resident #1. Staff E reported she did not see the resident before the fall and the resident had just returned from a hospital stay 20 to 30 minutes prior to the fall. Staff reported she responded to the panic button around 12:10 p.m. and went to the CCDI Unit and found Resident #1 on the floor in the dining room on his buttocks and with back against wall and legs out in front of him. Staff E reported the/she took the resident ' s vital signs (blood pressure, pulse, respirations) while resident laid on the floor and did a visual check, asked the resident if he/she had pain and did limited but not extensive ROM (Range of Motion). Staff E stated did enough to tell if the resident had pain. Staff E reported he/she felt the resident had no pain and noted a skin tear to the resident ' s right elbow. Staff E reported when the resident was assisted up, she did see the resident guarding his/her right side and lifting the right leg up some. Staff E stated that at first when she saw the resident guarding the right side/groin area she did not think anything of it. Staff E stated Staff F, LPN, (Licensed Practical Nurse) and she assessed the resident ' s right side/groin area pain and felt the pain to be caused from the muscle in the upper right thigh area. Staff E stated that in hind sight she could have always done a better job with an assessment of the resident after a fall and may have been able to prevent the fall with better supervision of the resident. Staff E further stated it had been a very crazy busy day and had been running behind with the medication administration pass to the residents. Staff E stated there was another resident that had fallen in another area of the facility. On 9/27/12 at 8:51 a.m., Staff H, CNA, stated she worked 2nd shift following Resident #1 ' s fall and assigned to care for the resident. Staff H reported it was passed along to her in report during shift change that Resident #1 had a fall and now the resident is not bearing weight and having pain of the right leg/hip area. Staff H reported during her shift the resident continued to have pain to the right hip area and would not bear weight on the right leg. Staff F, the nurse assigned to the unit on the 2nd shift had been informed of the resident ' s pain and no weight bearing. Staff H stated Staff F assisted with transferring the resident and witnessed his/her not bearing weight to the right leg. Staff H further indicated this as unusual for the resident to not bear weight or exhibit signs of pain. Staff H stated the resident does not speak much and is unable to make needs known. Staff H reported she and Staff F transferred the resident to bed using a mechanical lift (E-Z Stand) that night due to the resident not able to bear weight. Staff H stated they have never had to use a mechanical lift before to transfer this resident. On 9/26/12 at 1:57 p.m., Staff F (Licensed Practical Nurse) stated she worked 2nd shift on 9/13/12 and was assigned to care for Resident #1. Staff F stated he/she received report regarding the resident ' s fall from prior shift and she and Staff E (Registered Nurse), assessed the resident while the resident sat in a recliner. Staff F stated she assessed the resident by pushing on the resident ' s right upper leg, hip, and groin area. Staff F stated she felt the resident ' s pain to be coming from a pulled thigh muscle. Staff F reported the resident did require more assistance with transfers after the fall. Staff F reported the resident did have a change in condition after the fall. On 9/27/12 at 8:15 a.m., Staff G (Licensed Practical Nurse) reported she came into work on 9/14/12 on the day shift and had been told in report that the resident needed to be two assist for transfers now. Staff G thought it had been due to the resident ' s recent hospitalization and weakness, not from the resident not bearing weight on the right leg. Staff G stated she did not know the resident had not been bearing weight on the right leg until the staff told her that morning. Staff G stated the resident ' s physician had been in the building then and Staff G had the physician saw the resident. Staff G stated the physician ordered x-rays of the right hip area and the facility sent the resident to the hospital for the x-rays. After the x-rays, the physician admitted the resident into the hospital due to a fractured hip and needed repair.