Every finding on record at Crestview Nursing and Rehabilitation

Based on observation, record review, document review and staff interviews the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions (EBP) for 1 out of 1 resident reviewed (Resident #1). The facility reported a census of 58 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1, documented the Brief Interview for Mental Status (BIMS) scored a 13 indicating intact cognition. The MDS listed Resident #1 utilizes an external catheter. The MDS identified diagnosis as a quadriplegic, seizure disorder, and peripheral vascular disease. The MDS also documented that the resident received nutrition through a jejunostomy feeding tube (j-tube).Resident #1's Care Plan dated 7/25/25 instructed staff to wear EBP due to their indwelling j-tube and urinary catheter. On 9/17/25 at 11:10 AM observed Staff B, Registered Nurse (RN), complete a treatment to Resident #1's j-tube site. As Staff B did, they treatment, they failed to wear EBP. Interview on 9/17/25 at 12:15 PM Staff B acknowledged she should have worn EBP while doing the treatment. The facility policy named Enhanced Barrier Precautions revised 5/8/24 defined the purpose as to reduce the risk of transmission of multidrug-resistant organisms (MDRO) in the facility. High Contact activity included activities that place the resident and the person helping them in close physical contact that increases the risk of transmission of MDRO between the resident and health care provider. These activities included device care such as central line, urinary catheter, feeding tube, and tracheotomy/ventilator. Indwelling devices include any devices that are inserted into the resident and have contact with the external air such as foley catheters, central lines, tracheostomies, feeding tubes, or drains. Personal protective equipment (PPE) used to reduce the risk of exposure to and transmission of microorganisms. EBP includes the use of gowns and gloves. In instances where splashes/sprays are anticipated, face protection (mask or respirator) and eye protection (goggles or face shield) should also be applied. Interview on 9/17/25 at 12:50 PM the Director of Nursing (DON) stated they expected the staff to wear EPB for residents with feeding tubes and catheters.

Based on observations, clinical record review, staff interview and policy review, the facility failed to treat residents (Resident #6 and Resident #18) with dignity during meal service. The facility reported a census of 58 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident had diagnoses of other orthopedic conditions, cirrhosis, renal insufficiency and non-Alzheimer's dementia. The MDS documented the resident required substantial/maximal assistance with eating. The Care Plan for Resident #6, with a revision date of 10/7/24, included a focus area the resident will need help to complete Activities of Daily Living (ADL's) daily due to weakness. The Interventions instructed staff Resident #6 could eat independently after setting up. During a continuous observation of lunch service in the Chronic Confusion or Dementing Illness (CCDI) unit on 9/15/25 beginning at 12:00 PM, Staff C, Certified Nursing Assistant (CNA), stood over Resident #6 while helping her eat. Staff C brought bites of food on a fork to Resident #6's mouth and bringing the cup of fluid to the resident's mouth. Staff C did not sit next to the resident and stood over her for the entirety of the lunch service helping them eat. During an observation 9/16/25 at 11:45 AM of lunch service in the CCDI unit, Staff C stood over Resident #6 and brought food to their mouth on a fork. As Staff C assisted Resident #6 eat her lunch, they stood over her. 2. The MDS dated [DATE] documented Resident #18 had a BIMS score of 0, indicating severe cognitive impairment. The resident had diagnoses hyperlipidemia (high bad cholesterol) and non-Alzheimer's dementia. The MDS documented the resident required set-up or clean-up assistance with eating. The Care Plan for Resident #18, with a revision date of 10/7/22, included a focus area that the resident needed help to complete ADL's daily due to dementia. The Intervention instructed staff to set-up assist for eating and documented the resident as independent with eating. During a continuous observation of lunch service in the CCDI unit on 9/15/25 beginning at 12:08 PM, Staff D, CNA, stood over Resident #18 as they assisted them eat lunch. Staff D brought food to the resident's mouth with a fork and brought a cup with fluid to the resident's mouth. Staff D stood over the resident for the entire lunch service, assisting the resident with eating and drinking. During an observation 9/16/25 at 11:53 AM of lunch service in the CCDI unit, Staff C, CNA, went over to Resident #18, put food on a fork and brought it to their mouth, while standing over her. Staff C brought several bites of food to Resident #18's mouth, all while standing over her, as well as the glass for a drink. Staff C stood over the resident to assist with eating until 11:59 AM. At 12:03 PM, Staff C returned to the resident, stood over them, put food on a fork and brought it to their mouth. During an observation 9/17/25 beginning at 11:45 AM of lunch service in the CCDI unit, Resident #18 ate her meal independently. During an interview 9/17/25 at 12:35 PM, the Director of Nursing (DON) stated they expected the staff to sit down next to residents while assisting them during meal services and not hover over them as they assisted them with eating and drinking for dignity purposes. Review of the facility policy Promoting/Maintaining Resident Dignity During Mealtimes, undated, documented it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life. All staff will be seated, if possible, while feeding a resident.

Based on clinical record review, staff interviews and policy review, the facility failed to submit a Level 1 and a Level II Preadmission Screening and Resident Review (PASRR) evaluation to the appropriate state-designated authority prior to the expiration date for 2 of 2 residents reviewed for PASRR (Resident #4 and Resident #38). The facility reported a census of 58 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] indicated Resident #4 had diagnoses of anxiety disorder, depression and bipolar disorder. Resident #4's PASRR completed [DATE] provided authorization for short-term nursing facility services approved for 60-days for convalescent care. The report also indicated that re-screening must occur by or before the 60th day if the individual would remain in the nursing facility beyond the current authorized timeframe. The due date of the Follow-up level I PASRR would need done on or before [DATE]. In an interview on [DATE] at 1:05 PM Staff A, Social Worker (SW), stated PASRR assessments are typically done by the hospital before they first arrive at the facility. She typically performed them when there is a change in condition or a new diagnosis, especially for Level II PASRR residents. Staff A stated the authorized PASRR company tracked when the next PASRR is due online. Upon request of Staff A reviewing Resident #4 online, she described Resident #4 as a short term PASRR that she missed and is overdue for one now. Staff A reported the last PASRR performed as [DATE] and only approved for 60 days. Added Resident #4 should have a new level I PASRR completed just after the first of the year, and she planned to complete it soon. In an interview on [DATE] at 9:00 AM Staff A explained she currently worked on Resident #4's new PASRR level I. She stated she would expect to get a reply in 12-24 hours but expected Resident #4 would be a level II. She added that if Resident #4 received a level II indicated, someone would come out and evaluate her on site. When questioned about Resident #4's PASRR status as level I or level II, Staff A responded neither as she is out of compliance. A document titled Resident Assessment – Coordination with PASARR Program stated that the Social Services Director, or designee, shall be responsible for keeping track of each resident's PASRR screening status, and referring to the appropriate authority. 2. The MDS dated [DATE] documented Resident #38 had a BIMS score of 7, indicating severe cognitive impairment. The resident had diagnoses to include medically complex conditions, anxiety disorder and bipolar disorder. The MDS documented the resident was taking high risk drug classes to include antipsychotic and antianxiety medications in the look back period. The Care Plan for Resident #38, with an initiation date of [DATE], documented they received a short-term nursing facility approval in PASRR which expired [DATE], as a result all PASRR identified community placement supports needed addressed as part of the resident's Care Plan in addition to any specialized and rehabilitative services. Clinical record review of facility submitted Level II PASRR completed by the authorized facility for Resident #38 documented a determination of a short-term Level II approval on [DATE], with a time limited approval of [DATE]. Clinical record review for Resident #38 lacked a new Level II PASRR submission before or after the approval end date of [DATE]. During an interview on [DATE] at 2:30 PM, Staff A verified the date of the last Level II PASRR completed for Resident #38 as [DATE], with a Level II short term approval that expired on [DATE]. Staff A acknowledged another PASRR didn't get completed in November of 2023 or since then. Staff A explained they expected this completed and submitted by the expiration date in [DATE].

Based on clinical record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 2 of 16 residents (Resident #4 and Resident #38) sampled for Care Plan review. The facility reported a census of 58 residents.Findings include:1. Resident #4 had a Preadmission Screening and Resident Review (PASRR) completed on [DATE], which provided authorization for short-term nursing facility services approved for a 60-days for convalescent care. The report also indicated that re-screening must occur by or before the 60th day if the individual would be remaining in the nursing facility beyond the current authorized timeframe. Follow-up level I PASRR would be due on or before [DATE]. The Care Plan initiated on [DATE] for Resident #4 referenced PASRR level II 3 times including goals and interventions. It was noted, after speaking with Staff A, SW, that the PASRR level II references on the Care Plan were cancelled on [DATE]. In an interview on [DATE] at 1:05 PM Staff A, SW stated PASRR assessments are typically done by the hospital before they first arrive at the facility. She typically performs them when there is a change in condition or a new diagnosis, especially for Level II PASRR residents. Staff A, SW stated that Maximus tracks when the next PASRR is due online. This surveyor requested she pull up Resident #4 online. Staff A, SW stated that she was a short term PASRR that she missed and is due for one now. Stated the last PASRR performed was [DATE] and was only approved for 60 days. Added that she should have been due just after the first of this year and she plans to do soon. In an interview on [DATE] at 9:00 AM Staff A stated that 3 references to PASRR level II on the Care Plan is probably from her previous stays. When questioned if they should be on the current Care Plan given Resident #4's status, she stated no they shouldn't. An undated document titled Care Plan Revisions Upon Status Change instructed to review and revise the Comprehensive Care Plan as necessary, when a resident experiences a status change. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #38 had a BIMS score of 7, indicating severe cognitive impairment. The resident had diagnoses of medically complex conditions, anxiety disorder and bipolar disorder. Clinical record review of facility submitted Level II PASRR for Resident #38 documented a determination of a short-term Level II approval on [DATE], with a time limited approval of [DATE]. The PASRR determination explanation section documented the resident met PASRR criteria for serious mental illness which had led to significant symptoms that impact daily functioning and the need for intensive supports. The PASRR included what services and supports the nursing facility staff were required to provide, which included the following specialized services: ongoing psychiatric medication management, individual therapy by a licensed behavioral health professional, rehabilitative services and community placement supports. The Care Plan for Resident #38, with a revision date of [DATE], included a focus area for PASRR. The Care Plan documented PASRR had identified the resident was in need of specialized services due to mental illness and to assist the resident to achieve optimal functioning and recovery. The interventions/tasks section did not provide the name of the therapist or the frequency of therapy. The Care Plan further documented the resident had been given a short-term nursing facility approval in PASRR which expired [DATE], as a result all PASRR identified community placement supports needed addressed as part of the resident's Care Plan in addition to any specialized and rehabilitative services. During an interview [DATE] at 3:25 PM, Staff A stated she completed the residents' Care Plans on PASRR. In addition, she updated and revised those sections. She acknowledged Resident #38's Care Plan section didn't get updated since 2023 regarding the PASRR recommendations or revised to be person-centered. The facility used a template for PASRR, and the template didn't get updated for specific interventions for Resident #38. Staff A stated they expected that updated, revised, be person centered and comprehensive. Staff A acknowledged this didn't happen with Resident #38's Care Plan.

Based on observations, clinical chart review and staff interview the facility failed to check placement for jejunostomy tube (j-tube or a small tube inserted through the stomach to provide nutrients and potential medication) for 1 of 1 resident (Resident #1). The facility reported a census of 58 residents. Findings included:The Minimum Data Set (MDS) dated [DATE] for Resident #1, documented the Brief Interview for Mental Status (BIMS) scored a 13 indicating intact cognition. The MDS identified diagnoses of quadriplegic (inability to move their upper and lower body on their own), seizure disorder, and peripheral vascular disease (poor blood flow through the vessels). The MDS indicated Resident #1 received nutrition through a jejunostomy feeding tube. The Care Plan dated 5/20/25 indicated to check for tube placement and gastric contents/residual volume per order. On 9/17/25 at 11:10 AM observed Staff B, Registered Nurse, (RN), administer medications and fluids via the j-tube. Staff B failed to check placement of the j-tube prior to administering the medications or fluids. Interview on 9/17/25 at 12:15 PM Staff B, acknowledged she didn't check placement prior to administering the fluids. Staff B verified the nurse would check placement by pulling back the stomach contents. The facility policy dated 5/5/25 named Verifying Placement of Feeding Tube identified the practice of the facility as to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube.To verify tube placement, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube. Notify supervisor and/or physician of abnormal findings, or using a stethoscope, listen for placement. Place the stethoscope's diaphragm flat on the patient's abdomen, next to the tube site. Quickly inject air (5-10 milliliters ML) down the tube, listen for a swoosh or gurgling sound. On 9/17/25 at 12:50 PM the DON stated they expected the staff to follow the physician orders on the medication administration sheet and to check placement prior to administering fluids.

Based on observations, staff interviews, family interview, clinical record review, hospital clinical record review, facility images, hospital images and policy review, the facility staff failed to ensure residents who required assistance to move around couldn't come into direct contact with the electric baseboard heater for 1 of 3 residents (Resident #1) reviewed. Resident #1 required the staff to utilize a mechanical lift to transfer in or out of the bed, needing significant assistance from the staff for all mobility. A staff member found Resident #1 with their legs laying on top of the electric baseboard heater on 12/8/24 at 12:44 AM. Staff interviews revealed Resident #1 potentially laid on the electric baseboard heater for approximately an hour before staff discovered him. When the staff moved Resident #1, they discovered he suffered burns to both legs. An observation of Resident #1's room on 12/30/24 revealed an electric baseboard heater, without a protective device, that had a surface temperature of 124 degrees Fahrenheit (F). Review of the facility staff documentation revealed that all of the rooms in the 100, 200, and 300 hallways had electric baseboard heaters similar to Resident #1's room. The staff documented the electric baseboard heaters had surface temperatures ranging from 124 degrees F to 130 degrees F. An interview with the maintenance staff indicated they believed the electric baseboard heaters could potentially reach a maximum temperature of 180 degrees Fahrenheit. The State Agency informed the facility of the Immediate Jeopardy on 12/31/24 at 1:56 PM that began on 12/8/24. The Facility Staff removed the Immediate Jeopardy on 12/31/24 through the following actions: -Resident #1 immediately positioned away from heater - 12/8/24 -Assessment and First aid initiated, primary care provider (PCP) and wife updated - 12/8/24 -Resident #1's room rearranged with beds moved to wall without a register - 12/8/24 -Bed placement audit performed for all resident beds with electric heaters and any beds with concern were moved to safe distance of 3 feet - 12/9/24 -Safe touch surface audits done on all electric registers - 12/9/24 -Room thermostats to be set no higher than 71-degree F unless management notified - 12/9/24 - Random safe touch audits with surface touch thermometer to include every room in 100, 200 and 300 halls for the remainder of the season. The facility will follow the safe water temperature of 100 degrees per Appendix PP in the State Operations Manual. - 12/31/24 -Facility will audit safe distance of beds from heater five times a week for 3 months and then quarterly, done by maintenance or assigned person - 12/31/24 -All staff training for identifying and reporting hazards, bed positioning and thermostats. All staff assigned safety hazard in-service training videos to be completed immediately. - 12/31/24 -Purchasing designee actively looking for a safe cover or similar mechanism, if one available - 12/31/24 The scope lowered from a K to a G at the time of the survey after removing the immediacy. The facility identified a census of 60 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition. The MDS identified Resident #1 required substantial/maximal assistance with rolling left and right in bed and listed them as dependent on staff with transfers. Resident #1's MDS included diagnoses of non-Alzheimer's dementia, malnutrition (inadequate intake of nutrients), depression, arthritis, hyperlipidemia (high cholesterol) and a urinary tract infection (UTI) in the past 30 days. The MDS documented Resident #1 had a risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcer/injuries. The MDS documented Resident #1 had one unstageable pressure ulcer present on admission or reentry. The MDS documented the following skin and ulcer/injury and treatments: pressure reducing device for chair/bed, nutrition/hydration to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing and application of ointments/medications. The Care Plan revised on 12/26/24 revealed Resident #1 had a potential impairment to skin integrity related to fragile skin, history of pressure wounds and current wounds/blisters to bilateral lower extremities. The Care Plan documented contributing factors included burns, risk for malnutrition, history of deep vein thrombosis (DVT) and transient ischemic attack (TIA) causing risk with circulation to extremities, and hyperlipidemia causing increased risk with wound healing. The Interventions directed the following: a. Wound management to include skin prep (skin protectant) to the blisters, mupirocin (topical ointment) to open areas, house supplement for wound healing, air mattress, winged mattress for positioning and a wheelchair cushion. b. Resident #1 needed help to complete Activities of Daily Living due to dementia. c. Use a mechanical lift for all transfers. Resident #1 couldn't ambulate. A Fall Scene Investigation Report (FSI) dated 12/8/24 at 12:44 AM revealed the staff observed Resident #1 lying sideways on the bed with his legs out of the bed. The fall huddle findings described Resident #1 as restless due to vascular dementia and recent decrease in the medication Seroquel (antipsychotic). The findings concluded Resident #1 attempted to climb out of bed and slid his legs outside of the low bed. The FSI documented an intervention to prevent falls as to increase the Seroquel and rearrange the room. The Director of Nursing (DON) signed the form on 12/9/24 at 8:15 AM. An Incident/Accident Report dated 12/8/24 at 12:44 AM reflected the staff found Resident #1 with his legs hanging out of the bed touching the heat register, resulting in burns to his bilateral lower extremities. The report documented interventions added to the Care Plan included the following: -Rearrange room with bed across room along east wall -Elevate legs and treatment as ordered -Maintenance to check heat registers in room and also audit other registers throughout the building -Boundary board checks The Skin/Wound Note dated 12/8/24 at 12:44 AM labeled as a late entry documented a Certified Nursing Assistant (CNA) found Resident #1 lying on his stomach with his legs off the bed. Resident #1's left leg touched the heater and caused two blisters (Blister A and Blister B). Blister A measured 6 centimeters (cm) x 5 cm and popped with movement. Blister B listed as intact and measured 1 cm x 3 cm. The note lacked documentation of treatment to the burn areas at the time of discovery and lacked documentation of immediate interventions. The Skin/Wound Note dated 12/8/24 at 12:00 PM documented Resident #1 had multiple fluid filled blisters of various sizes. The left knee had two blisters. Blister A measured 4.2 cm x 3 cm and Blister B measured 6 cm x 8 cm. The note documented the open blisters had a scant amount of bloody drainage. The note revealed Resident #1's right shin had a red area that measured 7.3 cm x 3.8 cm with a fluid filled blister in the center that measured 1.1 cm x 1.2 cm. The note documented they cleaned the areas, applied skin prep to the intact blisters, mupirocin and a nonstick dressing to the open blisters. The note documented the intervention as the staff moved Resident #1's bed away from the heater and rearranged the room. The facility notified Resident #1's wife and Physician of the incident. The Non-Pressure Skin Condition Record dated 12/8/24 documented 7 burn related areas (A through G) to the left knee/shin. The record described the areas as partial thickness (affected the second layer of skin) with scant amount of serous (clear or yellow, thin, watery fluid) drainage. A - Fluid filled blister - 1.2 cm x 1.3 cm B - Open area - 4.2 cm x 3 cm C - Open area - 6 cm x 8 cm D - Blister - 1 cm x 0.8 cm E - Blister - 1.2 cm x 1.1 cm F - Blister - 5.3 cm x 3.4 cm G - Dark red area - 5 cm x 2cm The Non-Pressure Skin Condition Record dated 12/9/24 (24-hour reassessment) and facility pictures/images dated 12/9/24 of the left knee/shin documented four burn related areas and the following measurements: #1 - fluid filled - 2 x 2.5 #2 - granulation - 12 x 6 #3 - fluid filled - 5.8 x 4 #4 - red, intact - 3 x 2 A Physician Progress note dated 12/10/24 documented a physical exam identified Resident #1 had blisters to the skin of the left knee and leg. The Physician directed to apply skin prep to the intact areas and mupirocin to areas that are open, continue the treatment until resolved. The Non-Pressure Skin Condition Record dated 12/16/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - fluid filled - 2 x 2.5 #2 - scab forming, red edges - 12 x 6 #3 - fluid filled - 5.6 x 4 #4 - intact, red - 2.8 x2 The Non-Pressure Skin Condition Record dated 12/20/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - scab covering - 1.5 x 2 #2 - scab covering 90% - 11.8 x 6 #3 - flat blister, partially scabbed - 5.6 x 3 #4 - 2 x 2 The Non-Pressure Skin Condition Record dated 12/23/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - superficial scab - 1.3 x 1.9 #2 - 70% covered with scab - 10 x 3.5 #3 - scab - 5.2 x 2.5 #4 - dark pink - 1.4 x 1.2 The Non-Pressure Skin Condition Record dated 12/23/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - partial thick/superficial scab - 1 x 1.5 #2 - 70% covered with scab, scab lifting - 10 x 3 #3 - scab - 5 x 2.3 #4 - new skin, dark pink - 1.4 x 1.2 The Non-Pressure Skin Condition Record dated 12/8/24 documented a burn with a blister to the right shin. The red area measured 7.3 cm x 3.8 cm and the blister measured 1.1 x 1.2. The record documented they applied skin prep. A facility form titled Root Cause Analysis (RCA) and Plan of Correction (POC) for Resident #1 dated 12/8/24 documented the facility had audits in place to check heat register surface temperatures. The POC documented Resident #1's surface temperature for the electric baseboard heater was 124 degrees F which the facility considered was a safe temperature. A facility form/room map titled Heat Register Safe Touch dated 12/9/24 documented the electric baseboard heaters in all of the rooms in the 100, 200, and 300 hallways had surface temperatures ranging from 124 degrees Fahrenheit to 130 degrees Fahrenheit. The Non-Pressure Skin Condition Record dated 12/9/24 (24-hour reassessment) and facility pictures/images documented an intact fluid filled blister to the right shin that measured 3.6 cm (length) x 2.5 cm (width). The Non-Pressure Skin Condition Record dated 12/16/24 described the blistered area to the right shin as open at that time and measured 3.1 cm (length) x 2.6 cm (width). No signs of infection. Non-Pressure Skin Condition Record dated 12/23/24 documented the right shin area as scabbed and measured 3.4 cm (length) x 2.2 cm (width). The Communication with Family/NOK/POA Note dated 12/23/24 at 10:45 PM documented Resident #1's wife saw her husband and told the CNA she was going to call 911 to take her husband to the hospital. The note documented Resident #1's wife talked to a nurse about his burns and showed the nurse pictures she took of his knee. The wife voiced concerns about why they didn't send Resident #1 to the burn hospital right away. The wife reported Resident #1 was going to die and lose his leg. The note documented the nurse gave reassurance to the wife of the doctor's involvement and how they didn't feel he needed to go to the hospital at the time. The note documented that it takes time for the burns to heal. The wife reported the DON had voiced the Physician would be at the facility the following day. The wife reported she would be back in the morning when the Physician came. A Physician Progress note dated 12/24/24 documented Resident #1's chief complaint as his wound wasn't healing. The progress note documented Resident #1 had pain in the left knee, preferred to sit with his leg flexed at 90 degrees at the knee, had pain with extension of the knee, and had superficial wounds around the patella and left anterior knee that were not healing. The Physician ordered x-rays of the left knee/hip, a wound culture of the left knee, lab work that included a CBC (completed blood count) and CRP (c-reactive protein), and a wound clinic referral. The Communication - with Doctor dated 12/24/24 at 2:40 PM indicated the staff reviewed Resident #1's labs with the Physician, who gave new orders to continue Keflex (oral antibiotic) TID for the knee wound. The Transfer to ER Note dated 12/26/24 at 4:36 PM documented Resident #1 went to the emergency room per family request via private vehicle. The Hospital emergency room (ER) Physician Note dated 12/26/24 documented Resident #1 reason for the ER visit as a wound check and nursing home placement. The note documented Resident #1 suffered fairly severe burns on his legs 19 days before and recently started antibiotics. The note documented his legs appeared to heal okay. The wound had a large amount of eschar (dead, nonviable tissue) present. The note documented the final diagnosis as a full thickness burn (3rd degree burn that extends through all layers of skin, completely destroying the skin) of the left lower extremity with the plan to admit to the hospital. The Hospital Wound Assessment and picture/image dated 12/27/24 documented Resident #1 had a thermal burn to the anterior left knee that measured 17 cm (length) x 5 cm (width) x 0.1 cm (depth) with 100% eschar to the wound bed. The Hospital Wound Assessment and picture/image dated 12/27/24 documented Resident #1 had a thermal burn to the right lower leg that measured 3 cm (length) x 1.7 cm (width) and 0.1 cm depth with 100% eschar to the wound bed. The Hospital record titled General Surgery Consult dated 12/27/24 documented they saw Resident #1 for an assessment of his lower legs burn wounds. The consult documented Resident #1 had a very large eschar to the left knee that overlies the patella. Resident #1 also had a dark eschar distal (farther away) to this as well as on the right shin. The progress note documented they managed to debride (remove dead tissue) majority of the dry eschar at the bed side, with very adherent dry eschar remaining over the knee. The note directed to start Santyl (topical enzymatic debridement) as a treatment. The Hospital record titled Wound Debridement Documentation dated 12/27/24 documented they performed excisional debridement (removal of nonviable tissue using a sharp instrument) to his left knee. The debridement involved subcutaneous tissue (deepest layer of the skin) and removal of necrotic, devitalized (tissue not savable due to a lack of blood supply), non-viable (non-savable) tissue. They debrided the wound to viable, fresh, and bleeding tissue. They listed the estimated wound area as approximately less than 20 square cm. Review of Appendix PP in the State Operation Manual (SOM) issued 8/8/24 revealed a safe water temperature of 100 degrees F. The SOM documented the degree of injury depends on factors including temperature, the amount of skin exposed, and the duration of exposure. Table 1 in Appendix PP in the SOM illustrated damage to skin in relation to the temperature of the water and the length of time of exposure for a 3rd degree burn to occur: 155-degree F - 1 second 148-degree F - 2 seconds 140-degree F - 5 seconds 133-degree F - 15 seconds 127-degrees F - 1 minute 124-degrees F - 3 minutes 120-degrees F - 5 minutes 100-degrees F - Safe temperature for bathing An article from Geographic Pedia titled, How Hot Can A Human Touch Without Getting Burned? dated 6/22/24 documented the industry standard for safe contact is 140 degrees F, but temperatures above 100 degrees F can still cause damage to the skin with prolonged contact. Researchers found the pain threshold for heat is around 112.3 degrees F and the highest threshold was found in the foot at 112.1 degrees F. The article further documented 140-degrees F could cause third degrees burn on human skin in just one second. On 12/30/24 at 9:18 AM, Resident #1's wife requested the surveyor check all the rooms in the memory care unit to ensure the facility didn't have beds against the heat registers. She stated they had her husband's bed positioned in front of the window and only 6-8 inches from the heat register. She stated he rolled out of bed onto the heat register. She stated she didn't know for sure how long he laid there. She reported he received burns to both of his legs. She reported the heat register as hot to touch and she could not keep her fingers on it. She stated the facility notified her around 12 noon the following day of his injuries. She stated the staff told her they were treating the burns and that the areas were healing. She stated she felt the facility should have sent him to the wound center for treatment. She stated the left knee cap had a really bad burn on it. She added her husband couldn't straighten his left leg as it is too painful. She reported he had a smaller burn on his right shin. She reported she took pictures of the burns at the facility on 12/23/24. She stated she tried to see the wound several times and was not able to. She stated the staff would tell her that they just wrapped his legs. She stated on 12/23/24 she demanded to see the wounds. She stated she told the staff if they didn't unwrap his legs she would remove the dressing herself. She reported she transported her husband to the emergency roiagnom on [DATE]. She stated the hospital admitted her husband and the hospital debrided some of the burn wounds. She stated the hospital applied an ointment to the wounds to soften up the big scab on the left knee. She reported her husband couldn't move without a lot of pain and that he kept his left knee bent. On 12/30/24 at 11:38 AM, an observation of the electric baseboard heater in Resident #1's room (room [ROOM NUMBER]) revealed it as hot to touch on the side of the room Resident #1 resided. On 12/30/24 at 11:28 AM, Staff A, Registered Nurse (RN), reported Staff B, Certified Nursing Assistant (CNA), came to her and asked for help with repositioning Resident #1. She stated she thought it happened around midnight but couldn't say for sure regarding the time. She stated she thought Staff B got her right away and did not do anything in between. She stated she got in the room and observed Resident #1 laying with his lower legs off the bed with his torso and upper legs still in the bed. She described one leg on top of the other while still wearing his heel lift boots. She stated he had his right shoulder underneath him and he sort of on his stomach. She stated as soon as she got in the room, she moved his legs back into bed. She stated when she grabbed his legs, she felt moisture on his left knee and thought a blister might have popped. She stated his legs were a little warm. She stated on his right shin he had some redness like he laid on something. She stated he didn't have blisters and it didn't puff up at that point. She stated he later did develop blisters on his right leg. She stated they placed a body pillow on the bed on the side of the heater. She stated she left the areas open to air and then later that morning applied a dry dressing to the left knee. She stated the left leg was further down then the right leg and felt the left leg would have touched the heater more than the right. Staff A reported Resident #1 wiggled around a lot. She stated Resident #1 would flop his legs around and grab the hand rail to wiggle his hips. She described Resident #1 as confused and fiddled with things. Staff A reported the heat registers could get pretty warm where it could cause a burn. She stated the facility didn't have the beds right against the heater. She stated they have boards placed on the floor to create a little bit of space. She stated the boards prevent the bed from being smack against the wall/heater, prevent the bed from rubbing on the wall and to keep the blankets from being against the heater. She stated she didn't call the physician or family at the time of the incident. She stated she told the morning nurse to do the notification at a more appropriate time. She stated she text management about Resident #1 needing to be seen by the physician. She stated she continued to check on Resident #1 throughout the shift. She reported she filled out a paper for management about the incident. A hand-written staff statement dated 12/8/24 at 12:44 AM by Staff A documented a CNA came to the door and asked the nurse to help her reposition and change Resident #1. Staff A immediately came into the unit and walked down to Resident #1's room. Staff A observed Resident #1 laying across the bed almost sideways with his right arm under him leaning towards his stomach. He had his left arm up between his pillow and the side rail with his torso and stomach on the bed. He had his body pillow tucked under the fitted sheet on the side of the bed towards the door with the air mattress pad in place within the fitted sheet. Resident #1 appeared to have started on his right side with his head of the bed up and legs raised some. His legs hanged off the bed, knees flexed, between the bed, and the wall. His had his left leg underneath the right one with his heel boots in place. He had his left knee leaning on the heater and his right leg mostly lined up with the other leg but not completely. Staff A immediately ran over and lifted Resident #1's legs back into the bed while Staff B tried to pull him over more from the other side of the bed. When Staff A grabbed Resident #1's legs she felt some wetness, his blister. After Staff A and Staff B got Resident #1 positioned safely on the bed, Staff B stayed with him while Staff A grabbed measuring tools. Staff A and Staff B gently proceeded to change Resident #1's wet brief and reposition him with the body pillow on the other side of the window. On 12/30/24 at 1:15 PM, Staff A reported she left the burn open to air as she wanted the area to cool off. Staff A stated she didn't want to put anything cold immediately on it. She stated she kept going back to check on Resident #1. She described Resident #1 as restless and wiggly and would have picked off or removed a dressing. She stated she didn't want him rubbing or scratching the areas. On 12/30/24 at 2:15 PM, the Nurse Manager, Licensed Practical Nurse (LPN), reported the facility had boundary boards in the residents' room for years. She stated the boundary boards are in place to keep the beds away from the heaters. She reported she went down to Resident #1's room after the incident, measured the bed to the heat register, and it measured 3 feet away from the heat register. She stated they used a surface temperature gun to check the heat register safe touch temperatures documented in the plan of correction. She stated the facility used Occupational Safety and Health Administration (OSHA) guidelines for the safe temperatures of 140 degrees. On 12/30/24 at 2:28 PM, the Director of Maintenance stated that the heating system in the 100, 200, and 300 hallways were the electric baseboards heaters. He stated each resident room had their own thermostat that controlled the electric heaters. He stated the 400 and 500 hallways are heated by a boiler system, where hot water pumps water to a tube through the basement and produces radiant heat. He stated there are no safe temperatures with the electric baseboard heaters, he stated they could get up to 160 to 180 degrees F. He stated it's a timing thing. He stated the boundary boards on the floor are to keep everything away from the heaters, walls, and electrical outlets, he stated the boards are not the same measurement in each room because it depends on the beds, some rise up and down differently, and some have different legs on the beds. He stated staff are to keep the beds 3 feet away but sometimes the beds get moved and the staff or housekeeping have to move them back. On 12/30/24 at 3:10 PM, the Nurse Manager reported it was her idea to do the surface temperature on the heat registers. She stated she tried to come up with something else for the plan of correction. She reported she thought knowing how hot the surface temperatures of the heat registers were and monitoring periodically would help prevent further concerns. She stated the best intervention was to move the bed from the register. She stated the boundary boards are in place to keep the bed away from the heaters. She stated some rooms staff will put the bedside table in between the wall and bed. She stated if you move the bed too far out there is not enough space for the residents to live. On 12/30/24 at 4:20 PM, The Nurse Manager used the facility equipment with the surveyor present to obtain a surface temperature of the electric baseboard heater in room [ROOM NUMBER]. The surface temperature registered 124 degrees F. She took an additional surface temperature in room [ROOM NUMBER] with a temperature registered at 116 degrees F. On 12/30/24 at 4:23 PM, Staff B reported she as she did the first rounds, she made it to Resident #1's room, she observed him lying on his stomach, with his upper torso in bed, hands near the side rail, and legs off the bed by the heat register. She reported she thought it was around midnight. She stated she hadn't worked at the facility that long and didn't know about the heat register or it being on. She stated she pulled the call light in the bathroom for help. She stated the nurse came in after she pulled the light. She stated the nurse told her about the heat register. She stated they got Resident #1 off the heat register right away. She reported Resident #1 had slept during the incident. She stated she checked on Resident #1 after she got report from the second shift CNAs around 10:40 PM. She stated at that time he laid on his side facing the door and held onto the side rail. She reported after the incident she pushed the bed out, put the body pillow in place and tucked the pillow under the fitted sheet on the side of the bed with the heater. She stated after the incident she checked on him more frequently. She stated when she got him back into bed he had red marks and forming blisters on his bilateral lower legs. She stated the nurse wrapped his leg but did not remember which leg. A hand-written staff statement dated 12/8/24 by Staff B documented at midnight they went into Resident #1's room to change him for rounds. Staff B documented she did a visual check around 10:45 PM. When Staff B went into Resident #1's room, she found Resident #1 sleeping on his stomach with his legs off the bed. Staff B pulled Resident #1's call light for help. Staff B documented she didn't know he had a heat register there and on until Staff A said something. Staff B documented Staff A helped her get Resident #1 back into bed. On 12/30/24 at 4:43 PM, Staff C, RN, reported Staff A passed on in report the aide found Resident #1 with his legs out of the bed when she went in to change him. Staff C stated when Staff A went into the room to help she observed Resident #1 with his legs on the heater. Staff C stated Staff A told her Resident #1 had blisters on his legs. She stated she checked on him first and completed the needed paperwork. She stated she notified the Physician, family, nurse manager, and DON regarding the incident. She stated he had blisters and open areas on both lower legs. She stated the left knee developed a bigger wound as the areas came together. She stated the Nurse Manager obtained treatment orders to apply mupirocin to the open areas and skin prep to the unopen blisters. She stated she rearranged the room and moved the bed completely away from the heater. She stated Resident #1 had a wing mattress and an air overlay. She stated she got rid of the air overlay so the wing mattress would work better. She stated when she called the wife to report the incident, the wife wanted to know why someone didn't call her right away. She stated the wife relayed she wanted to be called anytime of the day. She stated the wife came in later that day and liked how the room rearrangement. On 12/31/24 at 9:15 AM observed a boundary board in front of the electric baseboard heater in room [ROOM NUMBER]. The board measured 7.5 inches (width) from the edge of the heater to the edge of the board. The electric baseboard heater didn't have a protective cover. The baseboard heater felt hot to touch, a person couldn't leave their hand/fingers on the electric baseboard heater for more than a couple of seconds. On 1/6/25 at 9:36 AM, the Director of Nursing (DON) reported she put the air mattress back in place the following day after the incident, once they rearranged Resident #1's bed and moved it away from the heater. A facility policy titled Accident and Supervision dated 2024 described the facility policy as to ensure the resident environment would remain free of accidents hazards as much as possible. The policy documented each resident would receive adequate supervision and assistance to prevent accidents which included: a. Identifying hazards and risks b. Evaluating and analyzing hazards and risks c. Implementing interventions to reduce hazards and risks d. Monitoring for effectiveness and modifying interventions when necessary.

Based on clinical record review, hospital clinical record review, hospital images, staff interviews and policy review, the facility failed to identify a resident with pressure ulcers/wounds and assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of ulcers/wounds for 1 of 2 resident reviewed (Resident #1). The facility reported a census of 60 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. 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. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition. The MDS identified Resident #1 required substantial/maximal assistance with rolling left and right in bed and listed them as dependent on staff with transfers. Resident #1's MDS included diagnoses of non-Alzheimer's dementia, malnutrition (inadequate intake of nutrients), depression, arthritis, hyperlipidemia (high cholesterol) and a urinary tract infection (UTI) in the past 30 days. The MDS documented Resident #1 had a risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcer/injuries. The MDS documented Resident #1 had one unstageable pressure ulcer present on admission or reentry. The MDS documented the following skin and ulcer/injury and treatments: pressure reducing device for chair/bed, nutrition/hydration to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing and application of ointments/medications. Resident #1's discharge assessment, return not anticipated MDS dated [DATE] documented they didn't have any unhealed pressure ulcer/injuries. The Care Plan Focus revised on 12/26/24 revealed Resident #1 had a potential impairment to their skin integrity related to fragile skin, history of pressure wounds, and current wounds/blisters to bilateral lower extremities.The care plan directed the following Interventions: a. Air overlay - 10/28/24 b. Heel boots at all times - 10/28/28 c. History of deep vein thrombosis (DVT) - 12/26/24 d. History of pressure ulcers from hospital stay - 12/26/24 e. Winged mattress - 10/28/24 f. Incontinent care products will be used after each incontinent episode and prn (as needed). Staff to provide nutritional supplement and protein supplement as needed. Staff to reposition Resident #1 upon arising, before meals, after meals, at hour of sleep and on rounds throughout the night and prn. Pressure relieving device to bed and chair as needed. - 7/30/24 g. Nursing to administer treatments per Physician orders and monitor for effectiveness and adverse drug reactions (ADRs). Staff to report to the Physician and family as needed. 1/4 upper side rails x 2 up as needed on bed to facilitate bed mobility and to aid with transfers. - 7/30/24 h. Staff to observe Resident #1's skin with AM (morning) and PM (evening) cares and with baths 2 times weekly. Staff to document any abnormal skin findings and report to the Physician and family if indicated. Nursing to administer treatments per Physician orders, observe effectiveness, and adverse drug reactions. Staff to consult with the wound nurse and Dietitian as needed. - 7/30/24 i. Weekly skin assessment completed by a nurse. - 7/30/24 The New Order Note dated 12/17/24 at 12:52 PM reflected the Physician came to the facility and examined Resident #1's left heel. The Physician gave a new order to start cephalexin (oral antibiotic) 500 mg (milligrams) TID (Three times a day) for 7 days. The note indicated Resident #1's wife knew of the new order due to being present during the Physician visit. A Physician Progress note dated 12/17/24 documented Resident #1 had a sore with redness around it on the left side of the posterior heel. The note identified Resident #1 as wheelchair ambulatory and often had his foot on the foot pedal. In addition, Resident #1 had a hospitalization where he spent several days inpatient with pressure on his heels. The note listed Resident #1's wife present at the visit and agreed to start antibiotic therapy with a podiatry consult. The physical exam documented the left heel had a small 0.5 x 0.5 circular area of darkened ulcer or dry scabbed. The note described the area as mildly tender to palpation with the surrounding skin had erythema (redness). The note documented the area appeared superficial with uncertainty of the depth of the ulcer. The note directed staff to start cephalexin 500 mg TID for 7 days, and the Physician would request a podiatry consult. The Skin/Wound Note dated 12/18/24 at 10:52 AM documented all of Resident #1's pressure areas from readmission resolved. Review of the facility form titled Weekly Pressure Ulcer Assessment for the left heel revealed the area resolved on 12/18/24. The Transfer to ER note dated 12/26/24 at 4:36 PM reflected the facility sent Resident #1 to the emergency room (ER) per family request via private vehicle. The Hospital emergency room (ER) note dated 12/26/24 identified Resident #1 arrived at the ER at 6:21 PM. The note documented the hospital admitted Resident #1 for a wound check and for nursing home placement. The Hospital Wound Assessment/Care Records dated 12/26/24 at 11:52 PM documented a pressure injury to Resident #1's left heel present on admission. The Wound Center Nurse assessed the pressure injury to the left heel on 12/27/24. The wound care assessment records and images revealed an unstageable pressure injury to the left heel that measured 0.7 cm (centimeters) (length) x 0.7 cm (depth) x 0.1 cm (width). The peri (around) wound listed as dry and intact. The Hospital Wound Assessment/Care Records dated 12/26/24 at 11:53 PM documented a pressure injury to Resident #1's posterior left knee present on admission. The Wound Center Nurse assessed the pressure injury to the posterior left knee on 12/27/24. The wound care assessment record and image revealed an unstageable pressure injury to the posterior left knee with 100% yellow slough (dead tissue that can be moist, stringy, or sticky to the wound bed) that measured 1.7 cm (length) x 0.7 cm (width) and 0.1 cm (depth). The Hospital Wound Assessment/Care Records and Image dated 12/27/24 documented Resident #1 had a stage three pressure area to the coccyx that measured 1.2 cm (length) x 0.5 cm (width). The assessment list the wound bed as 50% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 50% slough. A Hospital Progress Note written by the Wound Center RN (Registered Nurse) dated 12/27/24 at 10:00 AM documented they saw Resident #1 for an initial assessment of his skin. Resident #1 had a stage 3 pressure wound to his coccyx, unstageable pressure wound to his left heel, and unstageable pressure wound to his left posterior knee. Resident #1 had a wound to his left knee and right lower leg from a burn also. These wounds are 100% dry eschar (thick black dead tissue). The Wound Center RN ordered for Resident #1 to wear a mepilex sacrum (foam dressing ) over his coccyx area for protection, chair cushion in recliner, low air loss mattress, heels elevated off of all surfaces, and reposition every 2 hours. Review of Resident #1's facility clinical record lacked identification/documentation of the pressure wounds to the left heel, posterior left knee, and the coccyx. On 12/31/24 at 1:15 PM, the Nurse Manager, Licensed Practical Nurse (LPN), stated Resident #1 didn't have any other pressure ulcers/injuries after 12/18/24. She said she followed the left toe and the left heel pressure ulcers from a prior hospitalization and healed the pressure ulcers on 12/18/24. She reported Resident #1 didn't have skin sheets after 12/18/24 because he didn't have anything. On 12/31/24 1:51 PM, Staff D, CNA (Certified Nursing Assistant), stated the last time she gave Resident #1 a bath as 12/26/24 before he left the facility. She stated she had her own bath sheets that she documented baths on, she didn't document in the electronic medical record, that the girls in the neighborhoods document the baths. She stated she also documented the weights on the sheets. She stated she didn't mark any skin areas noted on the residents that she gives a bath too, because the nurses are really good and on it when she reports an area. She stated that he had an area to his left heel. She added she wouldn't describe it or make an assessment on it because that is not her area, but that he did have an area. She doesn't remember if he had an area to his bottom or the back of his left knee. She stated he did wear heel lift boots. On 12/31/24 at 3:55 PM, Staff E, CNA, reported she worked 12/25/24. She didn't recall any new areas for Resident #1. She stated she didn't see anything on his bottom or know of anything on his heel. She stated they kept the left knee wrapped up because of the burns so she didn't see anything. She stated Resident #1 started to retract his left knee around that time. She described it as a little more painful for him when changing him. She reported the retraction to Resident #1's knee as new for him. On 12/31/24 at 4:14 PM, the Nurse Manager reported they resolved Resident #1 left heel on 12/18/24. She stated he had a small scab on the heel, it lifted and revealed the heel as intact. She stated she didn't know anything about pressure areas to Resident #1's back of the left knee or buttocks. On 12/31/24 at 4:17 PM, Staff D reported she saw a little black spot to his left heel and stated she couldn't remember if she told the nurse or not, recalling it could have been a piece of lint. She reported the area to the heel as not new to her because she knew that the nurses treated the left heel. She stated if she saw something out of the normal, she would report it to the nurse, and if she didn't remember the area from before she would report it. She stated Resident #1 sat down in the bathtub, so his feet are hard to see. On 1/6/25 at 8:55 AM, the Nurse Manager reported she completed the treatments to Resident #1 on 12/26/24. She stated she concentrated on the treatment to his left knee. She stated she didn't roll him over to look at the back of the knee, buttocks or heels. She reported she had reviewed the hospital records and she acknowledged the facility didn't have any of those skin areas documented. She stated she thought the left heel received more skin damage. She stated when she did the treatment on 12/26/24 she was in a hurry to get the treatment completed as the wife was present in the room and she was not very nice. She reported the floor nurses are responsible for completing the weekly skin assessments. On 1/6/25 at 12:17 PM, the Wound Center RN acknowledged she evaluated Resident #1 in the hospital on 12/27/24. She stated Resident #1 had a small stage 3 pressure wound to his coccyx. She reported a pressure wound usually started out as a red area or a blister area. She stated she could not see a stage 3 pressure wound appearing overnight. In addition, the Wound Center RN reported Resident #1 had a pressure area to the left heel and a pressure area to the back of the left knee. She stated the left heel had a dry, small dark/reddish area. She stated it was clearly a pressure ulcer due to location, resident history, and the area wasn't a normal skin color. She stated Resident #1's wife reported the facility told her they healed the area to the left heel. She stated behind the left knee the pressure ulcer was 100% yellow slough and hard to measure as the left knee was contracted and couldn't be straightened out. She stated she didn't feel the area behind the knee could develop overnight either. She reported out of all the areas maybe the heel ulcer but that would be a stretch. She stated the left knee contracture and dressing may have contributed to the development of the wound behind the left knee. She stated you don't get a pressure wound from just a dressing unless it was wrapped too tight. On 1/6/24 at 2:28 PM, the Nurse Manager reported if a nurse identified a new pressure area, she expected the nurse to notify her and she would complete the wound assessment and/or measurements. She stated if she was not available then the floor nurse would do it. She reported the floor nurse as responsible for notifying the Physician and family of the new area. She stated they would review the Care Plan and add new interventions depending on what was already in place. A facility policy titled Pressure Injury Prevention and Management dated 2024 documented the facility as committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and service to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.

Based on record review, staff interview and policy review, the facility failed to have a Physician or a Non-Physician Practitioner (NPP) provide a face to face visit which includes a comprehensive assessment once every 60 days for 1 of 6 residents (Residents #3) reviewed for Physician Services. The facility reported a census of 60 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 3, indicating severely impaired cognition. The MDS identified Resident #3 as independent with bed mobility, transfers, and toileting. The MDS included diagnoses of hypertension (high blood pressure), hyperlipidemia (high cholesterol), other fracture, non-Alzheimer's dementia, cerebrovascular accident (CVA) (stroke), and chronic lung disease. The Clinical record revealed the Physician saw Resident #3 on 8/6/24, 9/4/24, and 10/15/24. The Clinical lacked documentation a Physician saw Resident #3 after 10/15/24. On 1/6/25 at 12:14 PM, the DON (Director of Nursing) verified they missed Resident #3 so she didn't see a Physician on rounds in December 2024 by two different Physicians who had rounded at the facility. A facility policy titled Physician Visit and Physician Delegation dated 2024 documented the facility policy as to ensure the Physician took an active role in supervising the care of the resident. The policy instructed the resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a Physician or Physician delegate as appropriate by State law.

Based on resident interview, staff interviews, record review, and manufacturer guide booklet the facility failed to ensure a resident's safety for 1 of 3 residents reviewed for accidents (Resident #27). As the staff helped Resident #27 prepare to take a bath, they failed to secure him in the chair with the seat belt. As they lifted the shower chair, Resident #27 fell from the shower chair to the floor. The facility reported a census of 59 residents. Findings include Resident #27's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #27 required partial/moderate assistance with showering/bathing. The MDS included diagnoses of renal (kidney) failure, diabetes, anemia (low blood iron) and orthostatic hypotension (sudden change in blood pressure with position changes). The Care Plan Focus revised 12/29/23, documented Resident #27 had a risk for falling due to weakness. The Care Plan Interventions dated 7/11/24 indicated Resident #27 fell out of the bathtub chair after having a coughing episode. At the time Resident #27 didn't wear his seat belt per his request. The facility educated the staff and Resident #24 regarding the need of using a bathtub strap. The Incident Note dated 7/11/24 at 9:35 AM, Staff C, Registered Nurse (RN), documented staff summoned her to the shower room. Upon arriving Staff C assessed Resident #27 as alert and oriented times four (aware of person, place, time, and situation) per his baseline. As Resident #27 got ready to take a bath in the shower room, the staff member reported while they lifted him up in the bath chair approximately one foot from the ground, Resident #27 began coughing, became pale, tipped out of the bath chair, and onto the floor. Resident #27 didn't have his seat belt on in the bath chair. Staff C initiated neurological (neuro) checks. He had vital signs within normal limits (WNL), his extremities had range of motion (ROM) WNL, he wore no footwear, dry, adequate lighting, and free of clutter. Resident #27 requested to not have a safety shower belt on after getting in the bath chair. Resident #27 had goose egg above his left eye/forehead area, and a scuffed up left knee. Staff C offered him pain medication, which he denied. Resident #27 requested a cool cloth to his forehead. Two staff assisted Resident #27 to a standing position then back into the shower chair. Staff C notified Resident #27's contacts including his provider of his fall. The provider would see Resident #27 on rounds that day. The facility implemented an intervention of staff and resident education on using the bath safety belt while in the bath. Staff C noted no further concerns. In a Provider Note dated 7/11/24 at 12:19 PM, the Nurse Practitioner (NP) documented Resident #27 sustained a fall from the shower chair that morning. He refused to wear the seatbelt provided in the past. He fell on his left side striking his left forehead on the floor. He had a 2 centimeter (cm) raised area to his left forehead with no visual bruising. He didn't take an anticoagulant. Resident #27 has a 1 cm oval intact red area below his left knee. His neuro checks are WNL and he could move all extremities. He denied pain except for a tender left forehead. He declined acetaminophen or any pain medication intervention. The nurse educated Resident #27 and the staff to ensure the shower chair seat belt is in place. Resident #27 educated during the visit and he agreed to wear the shower chair seatbelt going forward. Further detailed assessment of body systems noted, also identified as awake, alert, cooperative, clear speech, in no acute distress, at baseline cognition, and normal speech. In an interview on 10/22/24 at 4:24 PM, Resident #27 reported he fell out of the shower chair. Resident #27 stated that Staff A, Certified Nurse Assistant (CNA), forgot to put on his seat belt. Resident #27 expressed he didn't refuse, they forgot. He added all the other girls put the seatbelt on him when he sits in the bath chair. Resident #27 said he couldn't remember exactly why he fell , but he could have gotten dizzy. Resident #27 explained he received assistance right away. On 10/22/24 at 5:30 PM, Staff A, Certified Nurse Aide (CNA), recalled when she went to give Resident #27 a bath, she asked if he wanted the seat belt. Resident #27 responded, no. Staff A reported as they lifted Resident #27 up in the chair, several feet, he started coughing, went limp, and fell from the chair on to his left side hitting his head on the floor. Staff A stated she wasn't thinking and knew she should have put the seat belt on Resident #27. Staff A explained another staff member retrieved Staff C who came right away. Staff A said she got training afterwards which included all residents need to wear a seatbelt. In a joint interview/observation on 10/23/24 at 1:52 PM, the Director of Nursing (DON), and Administrator joined a tour of the whirlpool room. The observation of the tub revealed a height of approximately 3 feet tall. The Administrator and DON demonstrated how the chair went up mechanically, about 3.5 to 4 feet, to go over the tub to get the chair and resident into the tub. They also showed the straps in the chair. The Administrator voiced Resident #27 didn't want the belt on, as he often refused, as he has rights. She described Resident #27 as his own person, alert, oriented, and cognitively aware. The DON voiced she expected all residents to wear a belt and she would never recommend doing a shower without a seat belt. The Administrator agreed resident safety must be considered. In an interview on 10/23/24 at 6:02 PM, Staff C relayed the unit staff summoned her, while Staff A stayed with Resident #27, after he fell from the shower chair. Staff C stated she arrived right away, finding Resident #27 awake and alert. Staff C stated Staff A reported she pushed the pedal raising the shower chair, Resident #27 coughed. She stopped lifting the bath chair. Staff C described the bath chair lifted about a foot up and definitely not all the way up. Staff C knew that because the shower chair remained in the same level as when he fall. Staff C reported Resident #27 said he didn't want the belt. Staff C described Resident #27 after the fall had a goose egg, they started neurological assessments and did vital signs. Staff C relayed the assessment showed Resident #27 at baseline status, without complications. On 10/23/24 at 3:26 PM, Staff E, CNA, reported she gave Resident #27 a spa bath before and he never refused to wear the seatbelt. She wouldn't give a spa bath if a resident refused to wear the seatbelt. Staff E said no resident ever refused to put on the seat belt and she had training to always put on the seatbelt. On 10/23/24 at 3:30 PM, Staff F, Licensed Practical Nurse (LPN), and Staff G, RN, reported they haven't given spa baths to the residents, however, have been in the shower room during baths. Both nurses said they always need to use the seatbelt on the spa lift. When asked what they would do if a resident refused to wear the bath seatbelt, they both responded it wouldn't be ok. Staff G stated a CNA couldn't make that decision and would expect them to inform a nurse. An undated manufacture booklet for the Bath System, documented WARNING, failure to ensure the transfer seat is securely fastened to the transfer before the resident is transferred could result in injury to the operator or patient, recommended belting technique diagram pictures included. Also directed to transfer the resident into the shower chair using the proper nursing transfer techniques. Secure the seat belt around the resident, keeping the belt low fastened around the resident.

Based on staff interviews, observations and insulin pen manufacturer directive the facility failed to follow professional standards for 3 of 7 residents observed during medication administration (Residents #27, and #17). The facility reported a census of 59. Findings include: Resident #27's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS reflected Resident #27 received insulin injections during the last seven days lookback period. The MDS included diagnoses of renal (kidney) failure, diabetes, anemia (low blood iron) and orthostatic hypotension (sudden change in blood pressure with position changes). The Care Plan Focus dated 12/29/23 indicated Resident #27 had a risk for ketoacidosis (complication of high blood sugars) related to insulin therapy. The Goal listed to avoid adverse effects from insulin use. The Interventions directed staff to observe and report signs and symptoms of lab results, profound dehydration (not enough fluid in the body), elevated blood glucose, ketones (form of protein showing elevated blood sugars in urine), excessive thirst, frequent urination, nausea, vomiting, abdominal pain, weakness, fatigue, shortness of breath, fruity scented breath, confusion, rapid respirations, and elevated temperature. The October 2024 Electronic Record Order Administration directed use to use (manufacture name left out) Insulin Pen Needle. Inject one pen needle subcutaneously three times a day related to diabetes. Inject 5 unit subcutaneously (under the skin into the fatty tissue) with meals related to diabetes. On 10/22/24 at 5:07 PM observed Staff B, Licensed Practical Nurse (LPN), enter Resident #27's room. Staff B reported they had five (5) units of insulin to give Resident #27. Staff B gave Resident #27 the insulin injection in his abdomen per his choice, Staff B immediately removed the insulin pen after the injection. On 10/22/24 at 5:15 PM, watched Staff B carry a small plastic tray down the hall into the dining room. The tray contained 2 small clear plastic unlabeled medication cups, containing pills and 2 cups of clear liquid. Staff B offered 1 medication cup of pills to Resident #17 with the cup of fluid. Resident #17 took the medication and handed the empty medication cup back to Staff B. Staff B proceeded to another resident and gave them the other medication cup with the pills and the other cup of liquid. Staff B failed to complete hand hygiene before or after giving the medications. In an interview on 10/22/24 at 5:21 PM, Staff B reported they knew they should have done the task differently. Staff B explained they had professional training on medication administration and should have held the insulin syringe in place several seconds before withdrawing. Staff B, added her training included correct insulin pen administration and she realized she didn't follow the training received. Staff B confirmed she did set up medications for multiple residents, and should have administered each medication separately verses setting up medications for two residents. In addition, Staff B acknowledged she should have performed hand hygiene in between each resident medication administration. In an interview on 10/23/24 at 5:10 PM the Director of Nursing (DON), voiced Staff B knew better. The DON expected the staff to not to deliver several unlabeled medications to residents at the same time, to perform hand hygiene, and to follow the correct processes when administering insulin. The DON acknowledged Staff B shouldn't have withdrew the pen immediately after administration. The BD Autoshield Due Safety Pen Needle with Dual Automatic Protective Shields form dated 2023 insulin pen, instructed to inject insulin into the skin at a 90 degree angle, maintain constant pressure against the skin, push the dose button, and leave the needle in the skin for up to 10 seconds.

Based on observations, interviews and record review, the facility failed to serve the correct diets to 2 out of 59 residents (Resident #2 and Resident #28). During an observation of lunch service, Staff F, Cook, dished up a general diet for both Resident #2 and Resident #28. Resident #2 and Resident #28 were to receive mechanical soft diets (A type of texture-modified diet for people who have difficulty chewing and swallowing.) During the lunch service it was noted that another 6 residents were not on the Diet Type Report. Of these 6 residents, 4 of them did not have a Doctor's order for a diet (Resident's #20, #46, #64 and #65). These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 58. On 8/24/23 at 5:43 PM, the Iowa Department of Inspections and Appeals and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/25/23 and decreased the scope to D, after the facility staff completed the following: a) The two residents that were served the incorrect diets are now being served the correct mechanical soft diets. b) The resident's that did not have diet orders in PCC (Point Click Care -electronic health records (EHR)), now have diet orders. c) All resident records have been reviewed to ensure that they have the correct diet order in the EHR. d) All resident diet cards have been reviewed to ensure that the correct diet order is on the diet cards as indicated per the EHR. e) The QAPI committee reviewed/revised the facility's Nutritional Management policy on 8/24/23. The revisions made outlined the method of communication between the Nursing Staff and the Dietary Staff. f) The facility initiated in-service training for all dietary and nursing staff that were in the facility on 8/24/23. The administrator completed the training with the rest of the dietary and nursing staff per phone. All dietary staff and Nurses were trained on 08/24/23 by 7:45 PM. g) In addition, the Facility Dietician will review all resident diet orders to ensure that they are accurate, in the resident's EHR, and that there is a correct diet card in place. h) A facility created quality assurance tool will be implemented and used by the Administrator to audit the diets of all residents weekly for a month, then monthly for 3 months, then quarterly for 1 year. This tool will monitor that the facility is following the Nutritional Management Policy and the procedure for managing diet orders. The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings. Any issues identified will be immediately addressed. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #2 included cancer and Parkinson's disease. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognition. This resident required set up help only for eating. It documented that this resident had a mechanically altered diet. A Care Plan for Resident #2 documented a Focus Area revised on 1/9/23, directed staff that Resident #2 had a swallowing problem related to complaints of difficulty with swallowing related to Parkinson's disease and decreased esophagus size. An intervention revised on 6/16/23, directed staff that Resident #2's diet was to be followed as prescribed-mechanical soft ground meat with sauce/gravy/thin liquids, avoid pasta. An Order Summary Report of all of Resident #2's current orders was printed on 8/24/23. It directed that Resident #2 had a mechanical soft diet with ground meat moistened with sauce, gravy or broth. It directed to avoid pasta. The diet order was dated on 9/1/22. Results from an Esophagram (video x-ray of the swallowing function of the esophagus) performed on 7/12/23, documented that the reason for this test was dysphagia (difficulty swallowing). Findings included abnormal peristalsis (esophageal muscles contract and relax to move food). The impression was documented as likely a stricture at the distal end of the esophagus. A Gastro Procedural Note dated 8/26/21, documented that Resident #2 had an esophageal dilation. A Progress Note dated 7/21/23 at 11:40 AM, documented that Resident #2 returned to the facility after having an esophageal dilation. A Progress Note dated 2/28/23 at 12:33 PM, documented that Resident #2 returned to the facility after having an esophageal dilation. A Progress Noted dated 9/20/22, documented that the entry was a follow up to an esophageal dilation. Resident #2 reported he was feeling much better and swallowing was becoming easier. 2. A MDS dated [DATE], documented that diagnoses for Resident #28 included Cerebrovascular Accident (CVA)(STROKE) and non-Alzheimer's dementia. A BIMS documented a score of 3 out of 15, which indicated severely impaired cognition. This resident required set up help only for eating. It documented that this resident had a mechanically altered diet. A Care Plan initiated on 7/23/22 and revised on 6/8/23, directed staff that a focus area for this resident was that she had a nutritional problem which required a mechanically altered diet related to a CVA (Cerebrovascular Accident (Stroke)), and swallow. An Intervention directed staff to provide and serve diet as ordered, regular diet with mechanical soft food texture. A Doctor's Order dated 7/22/22, directed that Resident #28 was to receive a mechanical soft textured diet. A Diet Spreadsheet dated Spring/Summer 2023, Week 1 Day; 4 Wednesday, documented that a regular diet for meatloaf was 3 ounces of meatloaf. This Diet Spreadsheet documented that a mechanical soft diet for meatloaf was a #8 scoop of ground meatloaf. A Diet Type Report, dated 8/21/23 at 11:03 AM, documented that Resident #2 and Resident #28 were to receive mechanical soft diets. This report did not have Residents #20, #46, #64, and #65 names and diets on it. On 8/23/23 at 11:27 AM, Staff F, Cook started lunch service. Staff F served regular meatloaf to Resident #28. When asked why the Diet Type Report showed that Resident #28 received a mechanical soft diet, Staff F changed the meat loaf from a piece of meatloaf to ground meatloaf. The Cook then gave Resident #2 a piece of meatloaf. When asked why the Diet Type Report showed that Resident #2 received a mechanical soft diet, Staff F stated that Resident #2 was a general diet and had been switched back to this (a general diet) for quite a while. The Dietary Manager (DM) stated that Resident #28 was changed from general to mechanical soft and her liquids were changed from nectar thickened to thin liquids a year ago. The DM stated that the diet card was not updated. She stated that she would update it 'now'. The DM added that she was not working at this facility a year ago. When asked about Resident #2's diet, she said that he was supposed to be a mechanical soft diet as well. During the meal service on 8/23/23, it was noted that 6 residents were not on the Diet Type Report. Record review after the service revealed that the following 4 residents did not have diet orders: -Resident #20 was admitted on [DATE]. When the Director of Nursing (DON), was asked about this resident not having an order for a diet around 2:10 PM on 8/23/23, she stated she did not know that this resident did not have a diet order. A general diet order was then added to Resident #20's orders on 8/23/23 at 2:15 PM. - Resident #46 was admitted to the facility on [DATE]. During the lunch service it was asked why she was not on the report. A general diet order was then added on 8/23/23 at 11:49 AM. -Resident #64 was admitted on [DATE]. During the lunch service it was asked why she was not on the report. A general diet order was added on 8/23/23 at 12:09. -Resident #65 was admitted on [DATE]. During the lunch service it was asked why she was not on the report. A mechanical soft diet was added on 8/23/23 at 12:10 PM. When the Assistant Director of Nursing (ADON) was asked about this, she stated Resident #65 was admitted from home and they can downgrade a diet, they just can't upgrade a diet as nurses. On 8/24/23 at 10:55 AM, the ADON stated that she had just written the diet card out for mechanical soft because the family said he had difficulty chewing meat. The ADON stated that when a resident comes in to the facility from home as Resident #65 did, they get their medication orders from the clinic. Then they (the nurses) put the orders in to the PCC. We don't talk with a doctor because we get the medication orders from the clinic. She stated that for Resident #65, she had just filled the diet sheet out for a mechanical soft diet. She then asked if she shouldn't have taken the family's input into what diet the resident should be on. When asked if she could write a doctor's order, she stated that the doctor would put a diet order in when the resident was seen on this day. On 8/23/23 at 2:32 PM, the DM stated that she did not have a policy for individual resident's diet orders from admission to diet cards and ongoing communication. She stated the DON would have that. Asked the DON for the policy and she stated she would get it. On 8/24/23 at 10:57 AM, Resident #2 was asked if he could eat the food the facility had been serving him or if he had any difficulties eating any of the food that the facility had served to him? Resident #2 replied that he has had his esophagus stretched several times. Resident #2 stated that he couldn't eat a lot of food. He stated that some meats he could eat and some he couldn't. Resident #2 stated that he just had to look at what was served and then decide if he could eat it. Resident #2 stated that it was hard for him to eat pasta. Resident #2 stated that 'yesterday they served my meat ground and I liked that'. Resident #2 stated he was able to eat the ground meat. Resident #2 stated that the facility hadn't served him ground meat before. When asked if he was talked to about what diet he was to receive, Resident #2 stated no. When told that he had been receiving a general diet and he was supposed to be receiving a mechanical soft diet Resident #2 stated no one had talked to him about that. He repeated that he liked the ground meat. On 8/24/23 at 11:25 AM, the Nurse Consultant and the Administrator acknowledged that a doctor's order should have been obtained upon admission. The Administrator stated they could not find a doctor's order for diets for Resident #20, #46, #64, and #65. They stated that they did have a diet order for Resident #64 because she came from the apartments and had been serving her all along because the kitchen serves the meals for the residents in the apartments. The Administrator stated they cannot find an order for her though, since she was admitted to the Long-Term Care side. When told about Resident #65 being admitted from home and the ADON had stated she got the medication orders from the clinic and put the diet order on the card and the doctor was to come on this day to write the orders, the Administrator said, no the ADON should have called the doctor and got an order the day of admission. On 8/24/23 at 12:32 PM, Resident #28's daughter stated that she was unaware that her mom was on a mechanical soft diet. She said she thought she was on a general diet. She stated that her son visited her mother recently and brought in a pizza. She stated her son said this resident enjoyed the pizza but only had a couple of bites. This resident's daughter said her son did not mention her mom having difficulty with swallowing the pizza. She said her mom coughs a lot with cookies, ice cream and pop. She stated this resident used to drink a lot of pop when she lived at home. She said as far as she knew, the facility had been giving her mom a general diet. On 8/24/23 at 2:37 PM, the Dietitian stated the diet order was correct for both Resident #2 and Resident #28 but these 2 residents were served the wrong diet. She stated the cook didn't follow the diet cards. The Dietitian stated that she was in the facility on Monday. A different cook was working and that cook was following the cards. She stated that she usually goes to the facility on ce a week. She stated that when she is in the facility she looks at the orders and assesses the residents. She stated that both residents were to be on mechanical soft diets and both of them do well with those diets. She stated that she had seen before when there wasn't a diet order in PCC. She said she let the facility know when that had happened in the past and they take care of it. When asked if she had observed either resident eating a mechanical soft diet, she stated she couldn't say for sure. On 8/25/23 at 11:52 AM, the Speech Therapist was meeting with and observing Resident #2 in the dining room assessing meal consumption. On 8/25/23 at 12:04 PM, Resident #2 was sitting in the dining room with his meal in front of him. Resident #2 stated he had tried different food. The Speech Therapist was no longer with him. Resident #2 was coughing. Had ground meat and breaded shrimp (not ground) setting in front of him. A Speech Therapy SLP Evaluation and Plan of Treatment dated 8/25/23, the Speech Therapist recommended the following: Patient will independently make diet request changes to staff over x2 consecutive sessions to demonstrate understanding of safe swallowing recommendations. (Target: 9/21/2023) Baseline Patient not consistently making requests and just avoiding foods. (8/25/2023) Patient will safely tolerate least restrictive oral diet in order to optimize nutrition and hydration, minimize risk of aspiration, and facilitate safe oral intake (Target: 11/22/2023) Esophageal: Patient/medical record indicates: Towards end of meal patient with increased coughing. He reported that after eating the shrimp and taking a drink he could feel it coming back up and that it stopped at his sternum. Difficulty with esophageal phase and patient has a history of esophageal dysphagia. On 8/25/23 at 12:14 PM, the Speech Therapist was sitting across from Resident #28 in the small dining room. Resident #28 was eating a piece of shrimp. The Speech Therapist stated Resident #28 was doing good, she was just getting started. A Therapy Communication Form dated 8/25/23, documented a recommendation by the Speech Therapist of thin liquids with mechanical soft with ground meats diet. An undated Nutritional Management policy, directed the following to staff: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Nutritional Status includes both nutrition and hydration status. Compliance Guidelines: 1. A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary. 2. Identification/assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. c. A comprehensive nutritional assessment will be completed by a dietitian. Components of the assessment may include, but are not limited to: i. General appearance ii. Height/weight iii. Cognitive, physical, and medical conditions iv. Food and fluid intake v. Evidence of fluid loss or retention vi. Presence of persistent hunger, poor intake, or continued weight loss vii. Review of medication list viii. Review of laboratory/diagnostic data 3. Evaluation/analysis: a. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. b. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates. 4. Care plan implementation: a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet ii. Altered-consistency food/liquids after underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy) iii. Weight-related interventions iv. Environmental interventions v. Disease-specific interventions vi. Physical assistance or provision of assistive devices vii. Interventions to address food-drug interactions or medication side effects c. Real food will be offered first before adding supplements. d. Tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. 5. Monitoring/revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: i. Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met. ii. Directly observing the resident. iii. Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary. iv. Reviewing the resident-specific factors identified as part of the comprehensive assessment to determine if they are still relevant or if new concerns have emerged such as new diagnoses or medications. v. Evaluating the care plan to determine if current interventions are being implemented and are effective. b. The resident will be monitored for complications associated with interventions. c. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. d. The physician will be notified of: i. Significant changes in weight, intake, or nutritional status ii. Lack of improvement toward goals iii. Any complications associated with interventions. e. Nutritional recommendations may be made by the dietitian based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. f. Dietary orders may be written or modified by the qualified dietitian or other clinically qualified nutrition professional if the resident's attending physician/practitioner delegates the task. Nursing can downgrade a resident's diet for safety concern until qualified professional can address. g. Dietary orders and modifications will be communicated to the kitchen, immediately. The admitting nurse and/or the nurse manager is responsible for notifying dietary with a diet change form. The dietary manager will review the EMR diet order report, monthly, and compare it to the diet cards and make changes as needed. 6. Informed consent: a. The resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. b. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. c. The comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative. Procedure for managing Diet Orders 1. Nurse will notify kitchen staff of new admission and modifications to diet orders via diet change form and the nurse manager for that resident will follow up to ensure of the notification. 2. The Dietary Manager or Cook, if manager is absent, is responsible for immediately updating the resident's diet card in the kitchen. They must also initial and date the diet slip received and keep in a file. 3. The dietary manager will review the EMR diet order report, weekly, and compare it to the diet cards and make changes as needed. The dietary manager will compare the current censes to the EMR diet order report weekly to ensure that all residents have a diet order in place.

Based on observations, interviews, and record review, the facility failed to properly handle medications and an inhaler spacer using acceptable infection control practices for 2 of 10 residents reviewed (Resident #5 and Resident #59). The facility reported a census of 58 residents. Findings include: A Medication Administration Record (MAR) for Resident #59 for the month of [DATE], directed staff to administer Combivent Respimat Inhalation Aerosol Solution 1 puff 4 times a day related to Chronic Obstructive Pulmonary Disease. Use with spacer, use routinely now as Duonebs are on backorder. On [DATE] at 12:12 PM, Staff B administered Combivent Respimat using a spacer to Resident #59. Staff B then gathered the supplies with gloved hands, disposed of the trash and washed her hands. This resident requested assistance with putting her tennis shoes on. Staff B then assisted Resident #59 with putting her shoes on. Staff B then touched the spacer repositioning it on the small tray she carried supplies in with. Staff B left the room, picked up the spacer and the inhaler and placed them in a plastic bag, then placed the bag back into the medication cart. When asked about touching the spacer after touching Resident #59's shoes and then not disinfecting her hands and then placing the spacer in the bag in the drawer without sanitizing the spacer, The CMA stated putting this resident's shoes on threw this CMA off a bit. The IP (Infection Preventionist) acknowledged the concern. A MAR for Resident #5 for the month of [DATE], directed staff to administer Fish Oil Capsule, give 1 by mouth two times a day for hyperlipidemia. On [DATE] at 3:09 PM Staff C was setting up medications for Resident #5. Staff C was obtaining Fish Oil for this resident when 1 capsule fell on to the medication cart and 3 other capsules spilled out into the Fish Oil lid. This CMA then picked up the capsules with her hands and dropped the 4 capsules on to a small pink tray. This CMA then grabbed the bottle and was going to put the capsules back into the bottle, when the IP stopped her saying that she knew she shouldn't stop Staff C but to not put the capsules back into the bottle because Staff C would contaminate the whole bottle. A Medication Administration Policy reviewed/revised on [DATE], directed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 1. Keep medication cart clean, organized, and stocked with adequate supplies. 2. Cover and date fluids and food. 3. Identify resident by photo in the MAR (medication administration record). 4. Wash hands prior to administering medication per facility protocol and product. 5. Knock or announce presence. 6. Explain purpose of visit. 7. Provide privacy. 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 9. Position resident to accommodate administration of medication. 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. b. Administer medications at scheduled time unless otherwise ordered by physician. c. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). 12. Identify expiration date. If expired, notify nurse manager. 13. Remove medication from source, taking care not to touch medication with bare hand. If contaminated, dispose of medication. 14. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid. b. Shake well to mix suspensions. c. Crush medications as ordered. Do not crush medications with do not crush instructions. 15. Observe resident consumption of medication. 16. Hand hygiene using facility protocol and product. 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book. 19. Report and document any adverse side effects or refusals. 20. Correct any discrepancies and report to nurse manager. 21. Lock medication cart when not in view.

Based on clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed for a Level 2 PASRR evaluation (Resident #37). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS further documented the resident had diagnoses including psychotic disorder and depression. Review of the Medication Administration Record (MAR) dated August 2023 for Resident #37 revealed the resident received Risperidone (antipsychotic) two times a day for dementia with behavioral disturbance. The MAR further revealed the resident received Sertraline (antidepressant) one time a day related to major depressive disorder. The Care Plan for Resident #37 initiated 2/9/21 revealed the resident was at risk for negative side effects and at risk for changes in mental status related to psychotropic medication use with psychosis diagnoses. The Care Plan documented extrapyramidal effects of Risperdal and revealed the resident had a history of hearing people in her head and the television telling her to do things. The Care Plan further documented the resident was at risk for psychosocial well being related to depression diagnosis and the resident was at times resistive to care and directed staff to re-approach. Clinical record review in the Electronic Health Record (EHR)revealed Resident #37 had a Level 1 PASRR completed 2/8/21. The Level 1 PASRR documented the resident had no known or suspected mental health diagnosis and a Level 2 evaluation was not required. Review of Resident #37's diagnoses in the EHR documented the resident had mental health diagnoses of unspecified psychosis dated 2/9/21 and major depressive disorder dated 2/10/21. The clinical record further revealed the resident did not have a Level 2 PASRR evaluation submitted following the major depressive and unspecified psychosis diagnosis. During an interview 8/22/23 at 4:06 PM, Staff D, Social Services, revealed she did not know Resident #37 obtained the unspecified psychosis or major depressive disorder diagnosis so she did not submit a Level 2 PASRR evaluation. Staff D further revealed the facility did not have a policy related to completion of PASRR's as the expectation is to follow the PASRR protocol.

Based on clinical record review, staff interview, and policy review, the facility failed to document the administration of a prescribed medication for 1 of 1 residents reviewed for Respiratory Care (Resident #50). The facility reported a census of 58. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #50 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate impairment. The MDS further documented the resident had diagnoses including fractures and other multiple trauma, anemia, heart failure, arthritis, malnutrition, and non-Alzheimer's dementia. The Electronic Health Record (EHR) indicated radiology review of chest x-ray on 8/15/23 to include a diagnosis of unspecified bacterial pneumonia. A new order for medication was received on 8/15/23 to include Ipratropium-Albuterol Solution 0.5- 2.5 (3) MG/3 ML 1 vial inhale orally three times a day for atypical pneumonia for four days. The Medication Administration Record (MAR) for August 2023 lacked documentation for administration of the medication Ipratropium-Albuterol Solution for the date of 8/16/23 for the hour of sleep (HS) dose. During an interview on 8/22/23 at 3:20 PM, Staff E, Register Nurse (RN), acknowledged failing to document on the MAR the administration of the medication Ipratropium-Albuterol Solution for Resident #50 on 8/16/23 for the HS dose. Review of the facility policy titled Medication Administration, with a revised date of 5/5/23, documented under policy explanation and compliance guidance, sign MAR after medication administered.

Based on observation, policy review, and staff interview, the facility failed to ensure the medication cart was locked on 4 occasions when the Certified Medication Aide (CMA) responsible for the cart was not in site. The facility reported a census of 58 residents. Findings include: 1. Observation 8/21/23 at 1:13 PM revealed the medication cart was unlocked and unoccupied just outside the 200 hallway. At 1:14 PM, Staff E, RN approached the cart and acknowledged it had not been locked as expected after she was notified by housekeeping staff that it was unlocked. Staff E reported Staff A, CMA was responsible for the medication cart. 2. Observation 8/22/23 at 11:44 AM revealed the medication cart was unlocked and unoccupied just outside the 200 hallway and one resident passed the unlocked medication cart in an electric wheelchair. At 11:46 AM Staff B, CMA returned to the medication cart and acknowledged it had been unlocked. Staff B stated she thought she had locked the cart but the lock stuck and didn't lock all the way. 3. Observation 8/23/23 at 3:48 PM revealed the medication cart was found to be unlocked and unoccupied just outside the 200 hallway. At 3:50 PM, Staff C, CMA returned to the mediation cart and acknowledged it had been unlocked. Staff C stated she had been in the activity office across the hallway for 2-3 minutes prior to returning to the cart. The activity office was noted to be approximately 30 feet from the unlocked medication cart. During an interview 8/23/23 at 9:00 AM the Director of Nursing (DON) revealed a new lock had been put in place on the medication cart as the previous lock had been sticking. Review of facility policy titled Medication Administration revised 5/5/23 documented the medication cart is to be locked when not in view. During an interview 8/24/23 at 1:00 PM the DON revealed the expectation is that medication carts are locked when they are out of sight. 48886 4. On 8/24/13 at 9:55 AM observed a medication cart located in a hallway unlocked, with a drawer open at the lower section, this drawer was empty. Approximately four minutes passed in which time two residents walked next to the unlocked and unsupervised medication cart. Two staff observed sitting at a desk approximately 12 feet from the medication cart counting medication, with their backs turned away from the medication cart, the two staff could not observe or supervise the unlocked medication cart from the position and location of where they were sitting. During an Interview on 8/24/23 at 10:00 AM, Staff B acknowledged the medication cart was unlocked during the time Staff B was counting medication at the desk. Staff B opened the middle drawer of the medication cart which contained a full drawer of unsecured medication.

Based on staff interviews and facility job description review, the facility failed to employ a qualified Director of food and nutrition services. The facility reported a census of 58 residents. Findings include: During an interview 8/21/23 at 9:30 am AM, the Dietary Manager acknowledged not having a certification in dietary management, a certification as a food service manager, an Associate's or Bachelor's degree in food service management, or two or more years of experience in the position of Director of food and nutrition services in a nursing facility setting. During an interview 8/23/23 at 9:30 AM, the Administrator confirmed the Dietary Manager employed at the facility was not qualified for the position. The Administrator acknowledged the facility does not employ a full time dietitian. The administrator denied the facility has a policy for a Dietary Manager. A review of the facility job description document for Dietary Manager lacked regulatory requirements under the qualification section for the position of Dietary Manager.

Based on observation, interviews, and record review, the facility failed to ensure each resident received the 3 ounces of meatloaf per the menu approved by the facility's dietitian. An observation of the lunch meal service revealed that different size portions of meatloaf was dished up for residents on a general diet. The pieces were not measured to ensure the 3 ounces of meatloaf was provided for these residents. The facility reported a census of 58. Findings include: A Diet Spreadsheet dated Spring/Summer 2023, Week 1 Day; 4 Wednesday, documented that a regular diet for meatloaf was 3 ounces of meatloaf. On 8/23/23 at 11:36 AM, Staff F started lunch service. Staff F had cut the meatloaf into different size pieces. During this lunch service Staff F served the different portion sizes to the residents that had a general diet. When asked about the portion size of meat loaf varying throughout the meal service, Staff F acknowledged that she had served different sizes of meatloaf, stating the meatloaf was hard for her. Staff F added that it would be a lot better if the meatloaf had stayed together and didn't fall apart. On 8/24/23 at 2:37 PM, the Dietitian, when asked about the meatloaf, stated they should weigh a portion of the meatloaf to ensure they receive the correct amount and obtain a visual of how much meatloaf should be in each portion. An undated Nutritional Management policy, directed the following to staff that: The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates.

Based on observations, interviews, and record review, the facility failed to obtain physician diet orders upon admission for 4 out of 6 residents reviewed (Resident's #20, #46, #64, and #65). During an observation of a lunch service it was noted that 6 residents were not on the Diet Type Report. Further record review of the 6 residents not on the report revealed that 4 of them did not have a Doctor's diet order. The facility reported a census of 58 residents. Findings include: During the lunch meal service observation that started at 11:27 AM on 8/23/23, it was noted that 6 residents were not on the Diet Type Report dated 8/21/23 at 11:03 AM. Record review after this meal service revealed that the following 4 residents did not have diet orders upon admission and up to this day: -Resident #20 was admitted on [DATE]. When the Director of Nursing (DON), was asked about this resident not having an order for a diet around 2:10 PM on 8/23/23, she stated she did not know that this resident did not have a diet order. A general diet order was then added to Resident #20's orders on 8/23/23 at 2:15 PM. - Resident #46 was admitted to the facility on [DATE]. During the lunch service it was asked why she was not on the report. A general diet order was then added on 8/23/23 at 11:49 AM. -Resident #64 was admitted on [DATE]. During the lunch service it was asked why she was not on the report. A general diet order was added on 8/23/23 at 12:09. -Resident #65 was admitted on [DATE]. During the lunch service it was asked why she was not on the report. A mechanical soft diet was added on 8/23/23 at 12:10 PM. When the Assistant Director of Nursing (ADON) was asked about this, she stated Resident #65 was admitted from home and they can downgrade a diet, they just can't upgrade a diet as nurses. On 8/24/23 at 10:55 AM, the ADON stated that she had just written the diet card out for mechanical soft because the family said he had difficulty chewing meat. The ADON stated that when a resident comes in to the facility from home as Resident #65 did, they get their medication orders from the clinic. Then they (the nurses) put the orders in to the PCC. We don't talk with a doctor because we get the medication orders from the clinic. She stated that for Resident #65, she had just filled the diet sheet out for a mechanical soft diet. She then asked if she shouldn't have taken the family's input into what diet the resident should be on. When asked if she could write a doctor's order, she stated that the doctor would put a diet order in when the resident was seen on this day. On 8/23/23 at 2:32 PM, the DM stated that she did not have a policy for individual resident's diet orders from admission to diet cards and ongoing communication. She stated the DON would have that. Asked the DON for the policy and she stated she would get it. On 8/24/23 at 11:25 AM, the Nurse Consultant and the Administrator acknowledged that a doctor's order should have been obtained upon admission. The Administrator stated they could not find a doctor's order for diets for Resident #20, #46, #64, and #65. They stated that they did have a diet order for Resident #64 because she came from the apartments and had been serving her all along because the kitchen serves the meals for the residents in the apartments. The Administrator stated they cannot find an order for her though, since she was admitted to the Long-Term Care side. When told about Resident #65 being admitted from home and the ADON had stated she got the medication orders from the clinic and put the diet order on the card and the doctor was to come on this day to write the orders, the Administrator said, no the ADON should have called the doctor and got an order the day of admission. An undated Nutritional Management policy, directed the following to staff: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Nutritional Status includes both nutrition and hydration status. Compliance Guidelines: 1. A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary. 2. Identification/assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. c. A comprehensive nutritional assessment will be completed by a dietitian. Components of the assessment may include, but are not limited to: i. General appearance ii. Height/weight iii. Cognitive, physical, and medical conditions iv. Food and fluid intake v. Evidence of fluid loss or retention vi. Presence of persistent hunger, poor intake, or continued weight loss vii. Review of medication list viii. Review of laboratory/diagnostic data 3. Evaluation/analysis: a. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. b. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates. 4. Care plan implementation: a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet ii. Altered-consistency food/liquids after underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy) iii. Weight-related interventions iv. Environmental interventions v. Disease-specific interventions vi. Physical assistance or provision of assistive devices vii. Interventions to address food-drug interactions or medication side effects c. Real food will be offered first before adding supplements. d. Tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. 5. Monitoring/revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: i. Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met. ii. Directly observing the resident. iii. Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary. iv. Reviewing the resident-specific factors identified as part of the comprehensive assessment to determine if they are still relevant or if new concerns have emerged such as new diagnoses or medications. v. Evaluating the care plan to determine if current interventions are being implemented and are effective. b. The resident will be monitored for complications associated with interventions. c. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. d. The physician will be notified of: i. Significant changes in weight, intake, or nutritional status ii. Lack of improvement toward goals iii. Any complications associated with interventions. e. Nutritional recommendations may be made by the dietitian based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. f. Dietary orders may be written or modified by the qualified dietitian or other clinically qualified nutrition professional if the resident's attending physician/practitioner delegates the task. Nursing can downgrade a resident's diet for safety concern until qualified professional can address. g. Dietary orders and modifications will be communicated to the kitchen, immediately. The admitting nurse and/or the nurse manager is responsible for notifying dietary with a diet change form. The dietary manager will review the EMR diet order report, monthly, and compare it to the diet cards and make changes as needed. 6. Informed consent: a. The resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. b. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. c. The comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative. Procedure for managing Diet Orders 1. Nurse will notify kitchen staff of new admission and modifications to diet orders via diet change form and the nurse manager for that resident will follow up to ensure of the notification. 2. The Dietary Manager or Cook, if manager is absent, is responsible for immediately updating the resident's diet card in the kitchen. They must also initial and date the diet slip received and keep in a file. 3. The dietary manager will review the EMR diet order report, weekly, and compare it to the diet cards and make changes as needed. The dietary manager will compare the current censes to the EMR diet order report weekly to ensure that all residents have a diet order in place.

Based on observation, staff interviews, and policy review, the facility failed to ensure open items of food were dated, covered, and labeled. The facility reported a census of 58 residents. Findings include: Observation 8/21/23 at 9:30 AM, in the main kitchen with the Dietary Manager (DM) present revealed the following: a. Open undated bag of approximately 2 pounds of ham b. Undated and unlabeled zip lock bag of approximately 15 cookies of unknown origin c. Undated and unlabeled zip lock bag of approximately 10 cookies of unknown origin d. Open undated bag of approximately 2 pounds of corn dogs e. Open undated bag of approximately 3 pounds of sausage f. Box of croissants with a ripped plastic covering g. Open undated bag of approximately 1 pound of white cake mix h. Open undated bag of approximately 12 ounces of honey nut cereal i. Open undated bag of approximately 1 pound of dry pasta j. Open undated bag of approximately 2 pounds of cane sugar During an interview 8/21/23 at 9:45 AM the DM revealed the items should have been dated when opened, as well as labeled and sealed. The DM indicated the intent to keep the bag of pasta and the ham, and the rest would be thrown away. During an interview 8/23/23 at 9:30 AM, the Administrator acknowledged the items should have been dated when opened, as well as labeled and sealed. Review of the facility policy titled Food Safety Requirements, dated 3/1/23, documented food will be stored in accordance with professional standards for food service safety. The policy further documented food will be stored in a manner that helps prevent deterioration or contamination of the food.

Based on observations, interviews, and record review, the facility failed to properly dispose of garbage and refuse, as evidenced by one of one dumpster that was overflowing, with trash and debris scattered on the ground. This had the potential to affect all residents by attracting pests. The facility reported a census of 46 residents. Findings included: On 6/20/22 at 9:40 AM observed a dumpster located in the parking lot approximately 20 feet from the back door to the facility, which led to the kitchen area. The dumpster had no lid and multiple bags of trash were piled high above the walls of the dumpster. During an interview on 6/20/22 at 9:45 AM, Staff I, Dietary Aide, stated the dumpster was emptied every Monday, Wednesday, and Friday. Staff I indicated the lid had been broken for almost a year and was stored off to the side of the dumpster. Staff I stated the dumpster normally overflowed prior to being emptied because the dumpster company would charge them more if the bags were on the ground. Observation on 6/21/22 at 8:00 AM revealed the dumpster still had no lid and but the trash had been emptied. Observation on 6/22/22 at 9:15 AM revealed the dumpster had no lid, and multiple bags of trash were piled high above the walls of the dumpster, with trash debris on the ground behind the dumpster. During an interview on 6/22/22 at 9:17 AM, Staff H, Facility Driver, stated he helped Staff G, the Maintenance Director, who was off that day, with various maintenance issues. Staff H revealed that the lid to the dumpster had been broken for at least a month, and it could be a few more months before they received a new one. Staff H stated he did not think there was documentation regarding a request for a new, functioning lid. During an interview on 6/22/22 at 12:12 PM, Staff A, Administrator, stated the facility did not have a policy on maintaining the dumpster. During an interview on 6/22/22 at 2:18 PM, Staff A stated the dumpster got emptied every Monday, Wednesday, and Friday. Staff A revealed there was no trash service over the weekend, so the lid probably did not completely shut on Monday mornings. Staff A stated she would contact the trash company about bringing a new dumpster out.

Based on record review and staff interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents. (Resident #8) The facility failed to follow interventions and provide appropriate interventions and increased supervision of Resident #8 who had a history of [REDACTED]. The facility had no plan in place to increase supervision and kept the resident's room door closed due to quarantine. The fall investigation identified staff last toileted the resident 3 hours and 15 minutes prior to the 7/7/20 fall and staff last saw the resident 2 hours and 15 minutes prior to the fall in a recliner until the resident got up per self as physical therapy applied PPE outside her room immediately prior to the fall. The investigation form revealed the resident said she attempted to self transfer from recliner to the bed. The form did not identify how long the resident sat in the recliner prior to the fall. The baseline care plan directed staff to toilet every 2 hours and did not address the resident's transfer/ambulation needs. A shift report form dated night shift 7/6/20 did not identify they toileted the resident. They identified the resident as wet. The 7/7/20 fall resulted in a fractured forearm. The resident fell again on 7/16/20 at 5:15 a.m. following self transfer in an attempt to get to the toilet. The resident activated the call light but did not wait for assistance. The shift report for that date was blank and did not identify any care provided to the resident that night. The fall investigation form revealed the resident was incontinent at 2:15 a.m. (3 hours prior to fall) The investigation form did not identify when staff last saw the resident. The care plan in place 7/16/20 did not contain toileting interventions even though the resident was frequently incontinent and did not identify the resident's transfer and ambulation needs or that the resident attempted to self transfer and did not reliably use the call light. The 7/16/20 fall resulted in subdural hematoma and death. The facility census was forty-eight (48) residents. Findings include: An Admission Minimum Data Set (MDS) with observation end date of 7/7/20 revealed Resident #8 admitted to the facility 7/1/20. The MDS assessed the resident with a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The resident required extensive assistance of 1 staff for bed mobility, transfers, ambulation in room, ambulation off unit, dressing, toilet use, and personal hygiene. A balance during transition and walking test coded the resident as not steady- only able to stabilize with staff assistance in all areas of testing. The resident had no functional limitations in range of motion in the upper or lower extremities. The resident utilized a walker and wheelchair. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The resident had [DIAGNOSES REDACTED]. The MDS identified a fall history with a fall in the last 2-6 months prior to admission. The MDS coded falls since admission - one with injury (except major). Medication received during MDS look back period included: anticoagulants taken 7 of 7 days. A Nurse Practitioner note dated 7/1/20 documented a history of falls for the resident. The resident was a [AGE] year old female with a history of Alzheimer's, [MEDICAL CONDITION] fib and hypertension who (prior to coming to the facility) lived in independent living but had issues with recurrent falls and generalized weakness so moved in with a family member for short period of time and now is at facility for therapy and long term care. A Fall assessment dated [DATE] scored the resident with a score of 10. The assessment revealed a score of 10 or greater as a high risk for falls. The fall assessment identified the resident as disoriented times 3 at all times. The resident was chair bound and/or assist with elimination. The resident was unable to perform a balance test. A Baseline care plan dated 7/1/20 coded yes to cognitive loss. Bowel and bladder coded yes with assistance needed for toileting. The baseline care plan identified the resident required assistance of 1 staff with toileting. Interventions listed under bowel and bladder included: offer toileting every 2 hours, check and change every 2 hours as needed, and keep call light within reach and encourage use. Anticoagulant use coded as yes with listed [DIAGNOSES REDACTED]. Fall risk coded yes as prior history of falls. Interventions listed under fall risk included call light within reach and non skid footwear. The baseline care plan did not identify the resident's transfer/ambulation needs or need for ambulation assistance devices. Fall 7/7/20 Fractured Right Forearm: A fall scene investigation report identified a fall occurred 7/7/20 at 8:45 a.m. and revealed the resident self transferred and fell sustaining a 1 centimeter (cm.) by 2.5 cm. laceration to the right forearm. Staff last toileted the resident at 5:30 a.m. (3 hours and 15 minutes prior to fall) and last observed the resident at 6:30 a.m. in the recliner (2 hours and 15 minutes prior to fall). The resident did not use the call light and stated she attempted to get to the bed. An x-ray on 7/9/20 revealed a fracture to the right forearm. The intervention following the incident was: walker to be within reach at all times. The conclusion/fall team meeting notes identified the facility educated the resident on call light and calling for help (ineffective due to the resident's cognitive status) and a reminder sign on walker and walker in reach. (as of 7/9/20 unable to use right extremity for walker). The shift change report check off for 7/6/20 10 p.m. to 7/7/20 6 a.m. contained the documentation wet with no time listed. The form did not have any documentation listed in the area last toileted/checked/changed. A Skilled Nursing assessment dated [DATE] at 10:28 a.m. documented the resident ambulated with assist of 1 and front wheeled walker but knees buckle at times and she needs reassurance. Resident states she is scared to fall. Progress notes dated 7/8/20 at 8:34 a.m. identified a 12 cm. by 7 cm. dark purple bruise to the right hip related to the 7/7/20 fall. Progress notes dated 7/9/20 at 10:19 a.m. revealed the facility notified the physician of the right wrist bruised, painful and swollen with complaints of pain to light touch. The physician ordered an x-ray for the wrist. On the same date at 1:20 p.m. progress notes identified a 13 cm. by 12 cm. bruise to the upper right arm and 5 cm. by 2.5 cm. bruise to the right shoulder also related to the fall. At 2:04 p.m. the physician also added an order for [REDACTED]. A physician encounter note dated 7/9/20 at 6:44 p.m. identified the chief complaint as: fall. The resident fell and landed on her right shoulder. Complains of pain in her entire right arm, unable to localize. The physician identified the right hand with 3 plus [MEDICAL CONDITION], finger range of motion (ROM) limited on flexion, right wrist 2 plus [MEDICAL CONDITION] with ROM limited on extension, forearm tender, elbow tender with limited extension and right shoulder tender with limited ROM. The [DIAGNOSES REDACTED]. A Major Injury Determination Form for the 7/7/20 fall revealed the resident sustained [REDACTED]. The Nurse Practitioner identified the fracture as not a major injury. Progress Notes dated 7/9/20 at 8:35 p.m. indicated the resident transferred to the emergency room (ER) for evaluation via ambulance. Progress Notes dated 7/9/20 at 11:55 p.m. noted the resident returned to the facility with [DIAGNOSES REDACTED]. Progress notes dated 7/10/20 at 7:11 a.m. identified the resident in pain as evidenced by constantly grimacing, wincing and moaning due to pain in the right arm and new onset of pain in the right leg. No medications were given for pain last night. When in bed the resident constantly moved while grimacing and wincing due to confusion she could not verbalize ain and continued to move saying she planned to get up. Tylenol ([MEDICATION NAME]) no longer effective. On the same date at 11:24 a.m. the physician ordered [MEDICATION NAME] (narcotic) 50 milligrams (mg) every 6 hours as needed and wear immobilizer and brace at all times. A physician encounter note dated 7/13/20 at 6:41 p.m. revealed the resident's pain was controlled with [MEDICATION NAME] (narcotic) and swelling was decreased. The facility should continue with immobilization of the right forearm with wrist splint and shoulder immobilizer to keep elbow at 90 degree angle. Repeat x-ray in 7 to 10 days. A Care Plan with initiation date of 7/7/20 noted a focus area of risk for falling due to weakness and confusion. Interventions included: assure call light within reach and make sure room is free of clutter and pathways clear dated 7/7/20; keep walker within reach and reminder sign placed on walker dated 7/7/20. The care plan did not address a toileting plan even though the admission MDS identified the resident as frequently incontinent of bladder and occasionally of bowel. The care plan did not address transfer and ambulation assistance needs. There were no interventions that identified staff increased supervision of the resident. Fall 7/16/20 Subdural Hematoma: A fall scene investigation report dated 7/16/20 at 5:15 a.m. revealed the resident attempted to self transfer to the toilet and fell . The floor had urine on it. Staff last toileted the resident at 2:15 a.m. and the resident was incontinent at that time. The fall huddle findings revealed the resident had to go to the bathroom and pulled the call light but did not wait for staff. The resident possibly slipped in urine while self transferring. Progress notes dated 7/16/20 at 5:15 a.m. revealed the resident sustained [REDACTED]. each. The investigation report identified the facility later noticed a bruise on the right side of the head at 12:10 p.m. The shift change report check off for 7/15/20 10 p.m. to 7/16/20 6 a.m. contained no documentation. The form did not have any documentation listed in the area last toileted/checked/changed. Progress Notes dated 7/16/20 at 7:53 a.m. (after the fall) documented resident and all belongings moved to room [ROOM NUMBER]. A Skilled Nursing assessment dated [DATE] at 9 a.m. revealed the resident ambulated with the assistance of 2 staff pivot transfers related to altered mental status. The resident did fall at 5:15 a.m. and continues with neuros. Change in mental status noted however. Night nurse reported this was how she acted last night. Resident appears restless- wanting to get up but doesn't know what she wants to do. The resident declines pain from fall; increased incontinence noted and the resident did complain of flank pain; urine sample and lab work pending. Will continue to monitor. Progress Notes dated 7/16/20 at 12:05 p.m. documented resident appeared to have a 9 cm x 6 cm bruise/hematoma to right side of forehead-area was not observed during shower this am. Resident unable to declare pain but is extremely restless. Nurse Practitioner aware during telehealth and resident sent to ER to rule out [MEDICAL CONDITION]. Likely the forearm fracture was reinjured during fall. Progress Notes dated 7/16/20 at 3:03 p.m. revealed the resident returned from ER with [DIAGNOSES REDACTED]. Stop [MEDICATION NAME] (blood thinner) and follow up with provider in 1 to 2 days. A Major Injury Determination Form regarding the 7/16/20 fall documented subdural hematoma and contained an electronic physician signature and deemed the injury as a major injury. Progress notes dated 7/17/20 at 7 a.m. revealed the hematoma to the right side of the head measured 11 cm. by 8 cm. dark purple. The resident denied pain but moans. Progress Note dated 7/17/20 at 10:40 a.m. documented an order to repeat the right forearm x-ray in 4 weeks and keep splint on for 6 weeks. Progress Notes dated 7/17/20 at 1 p.m. revealed 2 staff transferred the resident to the bathroom and the resident's left elbow hit the grab bar. The resident obtained 2 skin tears on top of a previous skin tear that originally measured 3 cm. by 1 cm The skin tears measured 3 cm. by 0.1 cm. and 1 cm. by 1.2 cm A physician encounter note dated 7/17/20 at 2:49 p.m. documented the resident fell and sustained a subdural hematoma with a 4 mm (millimeter) shift; family chose not to pursue aggressive treatment and the resident transferred back to the facility. The resident had a hematoma to the right scalp and ecchymosis to the right face. X-rays showed no reinjury of wrist fracture. CT head or brain without contrast dated 7/16/20 at 1:30 p.m. completed due to fall with head injury, altered mental status and on [MEDICATION NAME] (blood thinner). The exam revealed: 1. Subdural hematoma along the right posterior frontal and right anterior parietal lobes with mild midline shift to the left measuring 3.9 mm. 2. Small posterior right frontal scalp hematoma. 3. No evidence of acute fracture. ER information concerning a subdural hematoma identified it as a collection of blood between the brain and its outer covering (dura). As the amount of blood increases, pressure builds in the brain. The condition is caused by bleeding from a broken blood vessel. In most cases the blood vessel ruptures due to head injury, such as from a hard, direct hit. Head injuries can happen in falls. The risk of the condition increases and is more likely to develop in older people, people who take blood thinners and have head injuries. The information revealed a person should get help right away if they take blood thinners and fall and experience minor trauma to the head. Care plan Interventions after the fall of 7/16/20 included to move Resident #8 to a room across from nurses station for more supervision, winged mattress, bed in low position while occupied, toilet/ check and change on rounds at night, ER visit dated 7/16/20. Focus area of bladder incontinence noted with interventions of assist to toilet per request and offer and assist to toilet when waking in the morning, before and after meals, at bedtime, and on rounds and as needed dated 7/17/20. Focus area of activities of daily living (ADLs) noted fracture right ulna. Shift change check off sheet updates added included, right arm brace at all times, toilet during evening rounds, bed in low position when occupied, and winged mattress date 7/17/20. Staff Interviews: On 9/15/20 at 10:53 a.m. Staff A, Licensed Practical Nurse (LPN) stated she worked with the resident when the resident fell on [DATE] at 8:45 am. Staff A stated the physical therapist PT just peeked in on her 30 seconds prior to the fall and the resident sat in the recliner. As PT applied their personal protective equipment (PPE), they heard a thud. Staff A was in the hall and ran down to her room. The resident stated she wanted to get back to bed and fell on her right side, unwitnessed. She didn't know if she hit her head so staff initiated neurological (neuro) checks. Staff A stayed with the resident for the first hour and conducted neuro checks every 15 minutes times 4, 30 minutes times 4, 1 hour times 2 and then every shift for 3 days. Staff A stated all current interventions were in place. The floor was dry, free of clutter, shoes on and call light in reach. Range of motion within normal limits The new intervention was to have her walker within reach. Staff A also worked when the second fall occurred on 7/16/20 at 6 a.m., just shortly after her fall at 5:15 a.m. When Staff A viewed the resident at 6 a.m., she sat in her recliner, alert and oriented to self and appeared restless. The overnight nurse started neuros. Staff S stated all interventions were in place, and identified the new interventions as moving the resident to a room across from the nurses station, winged mattress, bed in low position, and check and change on rounds. Staff A gave the resident a bath around 7:30 am and did not observe a hematoma to the head. Blood work and x-rays were completed. The resident transferred to ER later in the day after the Nurse Practitioner saw the resident and ordered a CT scan. The resident returned to facility a few hours later. Her [MEDICATION NAME] was discontinued at that time. She didn't have any further falls after the one on 7/16/20. On 9/16/20 at 9:25 am, Staff A LPN identified the resident as 50/ 50 with call light use. The resident required the assistance of 1 staff from the day of admission. Sometimes the resident would wait for assistance and sometimes staff would find her standing in her room with her walker. Staff would redirect and remind the resident to wait for assistance. On 9/16/20 at 8:50 a.m. Staff C, PT Assistant revealed working with Resident 3 times prior to fall on 7/7/20. Staff C stated the resident sat in her recliner and staff informed the resident they would put on the PPE and come in her room. Staff then heard a thud and yelled for the nurse who was in the hallway. The nurse went to the resident right away. Staff C did not go in the room that day. On 7/6/20 the resident ambulated 50 feet with her walker and contact guard assist of 1. According to the resident's speech therapy notes, the resident answered prompts regarding the call button with 60% accuracy and moderate verbal cues. On 9/16/20 at 1:45 p.m. Staff E, Registered Nurse (RN) revealed she did not recall if the resident was a 1 or 2 person assist when admitted since she worked overnights and did not do her assessment. Staff E stated the resident required 1 assist at times and other times 2 person assist. Some days she was stronger than others. Staff E recalled the morning of the 7/16/20 fall. They used 2 staff to get her up after the fall. Staff E did not recall the resident hitting her head but but felt pretty sure she had a skin tear to her right arm or elbow. The resident did use the call light at times and again sometimes the resident could act impulsively and get up on her own. Staff did try to watch her closely as she varied so much with her tracking and wasn't consistent. On 9/16/20 at 11:45 a.m. Staff B, CNA (certified nurse aide) stated the resident required the assistance of 1 staff from the day she admitted to the facility. She was in quarantine as she was a new admission. The resident would get up by herself and not always wait for staff to assist her. One time, Staff B found the resident standing by the air conditioner. The resident did not activate her call light. Staff B guessed the resident activated her call light about 50% of the time. Staff B stated they look at the shift report. Staff B identified shift report as a piece of paper they get at the start of the shift that contains care directives of the residents. After the resident's first fall, Staff B checked on her more often, especially since she was on quarantine with the door closed. Staff B recalled the fall on 7/7/20. PT were getting their gowns on and heard her fall. The fall occurred around breakfast and Staff B didn't recall if the resident activated her call button or not. On 9/16/20 at 12:15 p.m. the Director of Nursing (DON) revealed the resident required the assistance of 1 from the day of admission. The resident's daughter informed them the resident fell at home and needed more assistance. The resident demonstrated to the DON on admission how to use the call button. The resident would not always wait for staff to assist her once she activated the call button for help. The DON stated she makes 10 copies or so of the baseline care plan or shift report and staff get a copy when they start their shift for instructions on how to care for the residents. The DON makes changes and writes down any new interventions and then prints new updated copies for the staff. The DON expects all nursing staff to follow the care plan and ask questions if unsure. On 9/16/20 at 12:40 p.m. Staff D, Certified Medication Aid (CMA) revealed she only knew the resident after her fall on 7/16/20 when they moved her to 400 hall. At that time the resident required 2 staff and a hoyer lift for transfers. The resident could not use the call light when she moved her to her new room on the 400 hall. She had no falls after the one on 7/16/20. On 9/16/20 at 3:07 pm Staff F CNA revealed she thought the resident was a 1 person assist when she admitted to the facility. Staff F stated she never caught the resident up without assistance. Staff F stated the resident used the call button appropriately when she worked. Staff receives report when the arrive and they look at the shift change sheets printed out that contains information needed to take care of the residents, or staff asks questions. On 9/16/20 at 4:35 p.m. Staff G, CMA (certified medication aide) revealed that on admission the resident was a 1 person assist with ambulation. The resident was known to self transfer without using her call button. Staff G found the resident on the toilet before when Staff G passed pills. Staff G stated the resident did use her call button but typically she would try things on her own before using the call button. Staff knows what to do for residents by a shift report that contains all the information on how to take care of the residents. On 9/17/20 at 10:20 am the Administrator revealed she did not know what staff could have added or done differently after the 7/7/20 fall. The resident was in a 14 day quarantine and the facility was told residents in quarantine had to be in a certain area and her area was not close to the nurses station. The Administrator stated they were told this by the Iowa Health Care Association. The Administrator stated she felt staff did everything appropriately. A death certificate identified the resident's date and time of death as 8/12/20 at 4:35 p.m. The manner of death was: accident. A description of the accident injury documented as: fell at care center and struck right side of her head, scan at ER showed subdural with midline shift. The immediate cause of death: [MEDICAL CONDITION] due to or as a consequence of aspiration pneumonia of 7 days, due to or as a consequence of chronic [MEDICATION NAME] use of 27 days underlying cause subdural hematoma of 27 days.

Based on observation, record review, and interviews with resident, family and staff, the facility failed to ensure each resident received adequate supervision to prevent accidents. Concerns were noted for two of four residents (Residents # 3 & #4) that sustained falls with injuries. Resident #3's care plan revealed the resident required staff assistance for transfers and walking; and the resident used the call light to alert staff when she needed assistance with walking and transfers. On 8/31/17, Resident #3 sustained a fractured arm when she attempted to self transfer without alerting staff that she needed assistance. Observation revealed Resident #3 displayed short term memory loss and lacked the cognitive skills and ability to consistently use the call light as demonstrated by her fall history. Record review revealed Resident # 4 had several unwitnessed falls (both in her room and in the dining room) with care plan interventions not followed and or not updated to provide adequate supervision. The facility reported a census of 55 residents. Findings include: 1. According to documentation in the medical record, Resident # 3 had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 scored 14 (of 15) on the Brief Interview for Mental Status (BIMS) indicating no cognitive decline. The assessment form also indicated Resident # 3 required extensive staff assistance with activities of daily living including bed mobility, transferring, ambulation in and out of the room, dressing, toilet use and bathing. Resident #3 required limited staff assistance with personal hygiene and was able to eat independently. The care plan dated 7/11/17 identified Resident #3 resided in a secured unit due to her Parkinson ' s and Alzheimer ' s diagnoses; and she had previously lived outside the memory care unit however she did not thrive. Resident #3 walked with a scissors like gait and staff were to encourage her to keep her head up and feet strait. Resident #3 required one staff assistance when walking, and required staff assistance with bed transfers, and transfers to/from the toilet. The facility developed plan of care for Resident #3 revised date of 07-11-2017 identified the risk of falls related to Parkinson's disease, Alzheimer's disease and arthritis. The interventions included the following: * blue pressure relieving mattress to bed * call light is within reach and encourage the resident to use * inspect skin daily for redness, report to doctor as needed (prn) * lotion to arms everyday and PRN * signs posted in room to remind resident to please ask for help, use call light. The care plan revealed Resident #3 needed staff to provided assistance to identify precipitating factors(s)/stressors and she needed staff assistance to identify potential problems and solutions. Resident #3 ' s care plan for communication revealed she had impaired cognitive functioning/dementia or impaired thought processes due to short term memory loss, Alzheimer ' s. Staff were directed to monitor/document/report as needed changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness and mental status. A review of the interdisciplinary progress notes dated 6-6-17 at 10:30 p.m., revealed staff went to Resident # 3 ' s room to apply treatment to the resident ' s right ankle and found the resident sitting on the floor. According to the facility incident/accident report dated 06-06-2017, Resident #3 slid from the bed while tying her shoes at 10:30 p.m. Resident #3 did not sustain an injury. The incident report identified a new intervention of placing a floor mat next to the bed. This new intervention was not added to Resident #3's plan of care. The facility incident/accident report dated 08-09-2017 indicated a CNA heard a thud (sound) and went to the resident ' s room. Staff found Resident #3 on the floor in front of the recliner at 1:45 p.m. Resident #3 did not sustain an injury. The incident report identified a new intervention of added dicem (sic) to the recliner. The plan of care also indicated staff applied skid strips in front of the recliner. The facility incident/accident report dated 08-19-2017 indicated the nurse was called to the resident ' s room by CNA for an unwitnessed fall. Staff found Resident #3 on the floor with his/her back against the bed at 8:30 p.m. Resident #3 sustained a skin tear to his/her right hand pinky finger. The incident report and plan of care identified a new intervention of adding skid strips in front of the bed. A late entry documented on 8/21/17 in the interdisciplinary progress notes revealed the fall on 8/19/17 noted the resident reported she had been walking backyards to sit on the bed, stumbled and missed the bed. Staff revealed they reminded the resident to call for assistance to walk, use the bathroom, go to bed, etc. A interdisciplinary progress notes dated 8-21-17 revealed a new order for urinalysis (to determine if the resident had a urinary tract infection(UTI)) due to recent falls and increase in confusion. On 8-24-17, Resident #3 started an antibiotic for urinary tract infection (UTI). According to the interdisciplinary progress notes dated 8-31-17 at 8:40 p.m., Resident #3 did not use her call light to alert staff as documented by : (staff) heard a loud noise and found Resident #3 sitting on the floor. The resident stated she went to get a water pitcher and stood up and fell . The facility incident/accident report dated 08-31-2017 indicated staff found Resident #3 on the floor near the dresser with his/her walker nearby at 8:40 p.m Staff completed and documented an assessment and indicated new interventions as: 15 minute checks, neuro's, sent to ER (emergency room ) monitor for pain, remove dresser from the room. According to documentation in the interdisciplinary progress notes on 08-31-2017 at 8:40 p.m. Resident #3 sustained a spiral fracture of the right humerus. The nurse's notes dated 9-4-17 to 9-14-17 documented the resident's arm was splinted and due to swelling, surgery would occur on 9-12-17. The notes revealed on 9/14/17 at 9 a.m., Resident #3 left for right arm surgery and returned on 9/14/17. Observation/Interview on 10/4/17 at 8:58 a.m. revealed Resident #3 responded slowly and stated she knew she wasn ' t (suppose) to get up unassisted but could not/did not explain why she still did not wait for help. Resident #3 stated she had gotten up unassisted before and had fallen, but this was the first time she had broken a bone. Resident #3 talked about being frustrated but had trouble finishing her thoughts. According to documentation in the individual plan of care the only interventions added to prevent Resident #3 from falling again included: * 09-08-2017- Bilateral AFO's (ankle-foot orthotics) to feet for ankles * 09-14-2017- sling to R (sic) at all times * 09-11-17- hold AFO's until refitted. During an interview on 10-04-2017 at 10:50 a.m. the facility Administrator indicated on/or about 06-06-2017, a floor mat had been implemented but later (unknown date) it was discontinued due to potentially being a increased hazard for Resident #3 to fall. The Administrator also indicated that Resident #3 had been treated for [REDACTED]. She also acknowledged that Resident #3 scored a 14 on the BIMS, and at times was quite alert, but at other times not so alert and oriented. During the survey investigation on 10-03-2017 through 10-04-2017 no additional interventions were added to prevent Resident #3 from getting up unassisted and potentially falling again. 2. According to documentation in the medical record, Resident #4 had [DIAGNOSES REDACTED]. The facility MDS dated [DATE] indicated Resident #4 scored 3 (of 15 ) points on the BIMS indicating severe cognitive decline. The assessment form also indicated Resident #4 required extensive staff assistance with activities of daily living including bed mobility, transferring, ambulation in the room, dressing, toilet use, personal hygiene and bathing. Resident #4 was able to eat independently. The facility developed plan of care for Resident #4 initiated on 03-15-2017 and revised on 06-15-2017 identified Resident #4 at HIGH risk for falls related to confusion, Alzheimer's disease, psychoactive drug use and poor decision making skills. Interventions included the following: * be sure call light is within reach and encourage to use it for assistance as needed. Try to anticipate his/her needs if you are able. * call light attached to arm of recliner when in chair * gripper strips in front of rocker in her room * PT (physical therapy) evaluate and treat as ordered or PRN (as needed) * signs placed in room to use call light for assistance as a reminder and visual aide related to cognition fluctuations. The facility incident/accident report dated 03-19-2017 indicated Resident #4 was observed up independently in the dining room and as staff responded, Resident #4 fell before staff arrived. The incident report indicated new interventions were added of not leaving Resident #4 in the dining room unattended and Resident #4 was to be the last Resident to come into the dining room and the first to leave the dining room. The facility incident/accident report dated 04-18-2017 indicated staff found on the floor at 3:10 a.m. with his/her legs pointed toward the recliner and his/her head under the bed. The report indicated Resident #4 was alert to self only and added the intervention of keeping the call light attached to the arm of the recliner when in the chair. The facility incident/accident report dated 05-31-2017 at 8:00 p.m. indicated staff found Resident #4 in the doorway of his/her room on his/her left side and complaining of pain in his/her left arm. The intervention added was to utilize a fall mat on the left side of the bed when Resident #4 is in bed. Resident #4 was transferred to the hospital and returned later with a [DIAGNOSES REDACTED]. The Emergency Department documentation revealed Resident #4 sustained a closed comminuted fracture of right humerus. The facility incident/accident reports indicated an unwitnessed fall on 6/9/17 when the aide found Resident #4 sitting on the mat by her bed; the resident was not injured. The intervention listed: discuss room change with resident ' s son. The facility incident/accident reports indicated an unwitnessed fall on 7/8/17 when Resident #4 was walking with her wheelchair unassisted and sat down before staff could reach her. The intervention listed: remove from dining room when done eating; and staff member must be in dining room with resident. The facility incident/accident reports indicated an unwitnessed fall on 7/18/17 at 7:05 p.m. when staff found Resident #4 sitting on the floor not injured next to her recliner chair. The intervention listed: one on one when restless and 15 minute checks. The facility incident/accident reports indicated a fall on 7/19/17 at 9:00 a.m. revealed Resident #4 restless (during) 1-1 in activity. The resident stood and fell to the floor hitting her head. Staff revealed the resident should not be left alone during activity. The interventions dated 7-19-2017 revealed neuro's and not to be left alone during activity. The facility incident/accident reports indicated Resident #4 continued to fall on 07/21/2017, and 08/03/2017; and 08-21-2017 as documented in the nurses notes). According to documentation in the resident's plan of care, the following interventions were added as follows: **07-21-2017- not to be left in room alone in wheelchair. *08-03-2017- neuro's per protocol; continue with current interventions. *08-03-2017- dycem on wheelchair *08-21-2017- sent to emergency room ; continue with 15 minute checks and visual checks. According to an entry in the nurse's notes dated 06-12-2017 at 10:00 a.m., staff suggested moving Resident #4 to the memory care unit and family declined and instead requested a bed alarm to implemented. The notation indicated a bed alarm was ordered. An entry in the nurse's notes dated 07-18-2017 at 7:05 p.m. indicated staff would find a chair alarm tomorrow. During an interview on 10-04-2017 at 9:19 a.m. the facility Administrator responded to these entries and stated the facility did not use bed/chair alarms, but did have a sensor alarm on the wall. Resident #4 ' s care plan documented the sensor alarm initiated on 6/15/17 faced along bed frame and was turned on when the resident was in bed. The sensor alarm was changed to on at all times when the resident was in room alone on 7/19/17. During the survey investigation 10-03-2017 through 10-04-2017 no further interventions were put in place to ensure Resident #4 did not get up unassisted and/ or fall. During an interview on 10-03-2017 at 4:10 p.m. a family member of Resident #4 indicated that staff seem to implement interventions to prevent falls, after the fact.

Based on observation, record review and interviews with resident, physician and staff, the facility failed to prevent the development of pressure ulcers and then failed to provide the appropriate care and services to promote healing for 4 of 4 residents reviewed (Resident #3, #6, #9, #11). The facility reported a census of 60 residents. Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified the resident had a BIMS (brief interview for mental status score of 11. A score of 11 reflected the resident had a moderate cognitive impairment. The resident had no behavior problems identified such as rejection of care. The MDS indicated the resident required extensive assistance of 2 staff with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. The resident required total staff assistance with eating via a gastrostomy tube. The MDS indicated the resident to be always incontinent of bladder and frequently incontinent of bowel. The resident was not on a toileting program. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident at risk for pressure sores and did not have pressure sores or other ulcers, wounds or skin problems at the time of the MDS assessment. An admission nursing assessment dated [DATE] at 12:40 p.m. did not identify the resident as entering the facility with pressure sores. A skin breakdown risk assessment dated [DATE] identified the resident with a score of 17, (low risk for pressure sore development). The risk assessment identified the resident with the head of the bed up the majority of the day A Care Plan dated [DATE] identified the facility placed an air mattress on the bed on [DATE]. Prior to that the resident used a blue pressure relieving mattress. An intervention dated [DATE] directed staff to turn the resident side to side to back every two hours. Prior to that directive, the care plan directed staff to check and change the resident before and after meals and at bedtime and every two hours through the night. The Care Plan did not direct staff to reposition the resident at those times. An addendum dated [DATE] revealed staff could lower the head of the bed when performing care and then staff should elevate the head of the bed 30 degrees after care. Left buttock: A weekly pressure ulcer assessment revealed the resident had a Stage I 6 centimeter (cm.) by 6 cm. red area on the left buttock on [DATE]. The facility documented the area as healed on [DATE]. The MDS defined a Stage I pressure sore as intact skin with non-blanchable redness of a localized area usually over a bony prominence. A weekly pressure ulcer assessment identified a Stage II 5 cm. by 4 cm. area to the left buttock on [DATE]. On [DATE] at 9:10 a.m. the weekly pressure ulcer assessment identified the area as 5 cm. by 3 cm. and improved. The weekly pressure ulcer assessment form identified continued weekly improvement with the last measurement documented on [DATE] at 9:20 a.m. as 3.4 cm. by 2.4 cm. The MDS defined a Stage II pressure sore as 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. On [DATE] at 12:03 p.m. the Administrator identified the left buttock area as the coccyx area. A hospital assessment of a coccyx pressure sore, dated [DATE] at 11:28 a.m.identified the area as a Stage III with a 7 cm. circumference of reddened skin that did not blanch with 4 cm. open area with a 1 cm. eschar noted to the center of the wound. The MDS identified a Stage III pressure sore as 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. Right hip: A weekly pressure ulcer assessment dated [DATE] at 11:20 a.m., identified a Stage II pressure area to the right hip measuring 5 cm. by 4 cm. with no undermining or exudate. The wound was red. The [DATE] at 11 a.m. assessment identified the area as improved. The assessment revealed a Stage II pressure ulcer measuring 4 cm. by 4 cm. with no undermining or exudate. The wound was pink. The final assessment on [DATE] at 9:20 a.m. identified the area as improved. The assessment revealed a stage 2 pressure ulcer measuring 3 cm. by 4 cm. with no undermining or exudate. The wound was pink. A hospital assessment, dated [DATE] at 11:28 a.m. of the right hip pressure ulcer identified it as a Stage III with a 9 cm. circumference of reddened area with 4 cm. weeping area. Left hip: A weekly pressure ulcer assessment, dated [DATE] at 11:20 a.m. identified a Stage II pressure area to the right hip measuring 5 cm. by 3 cm. with no undermining and scant serous exudate. The wound was red. The [DATE] at 11 a.m. assessment identified the area as improved. The assessment revealed a Stage II pressure ulcer measuring 4.5 cm. by 3 cm. with no undermining and moderate serous exudate. The wound was pink. The final assessment on [DATE] at 9:20 a.m. revealed the area improved. The assessment indicated a Stage II pressure ulcer measured 4 cm. by 3 cm. with no undermining and moderate serous exudate. The wound was pink. A hospital assessment, dated [DATE] at 11:28 a.m. of the left hip pressure ulcer identified the area as a Stage III with 8 cm. circumference of reddened area with 5 cm. open weeping area. Right shoulder: Facility documentation did not identify that the facility assessed an area to the right shoulder. A hospital assessment, dated [DATE] at 11:28 a.m. of the right shoulder identified a 5 cm. reddened intact circle of skin that blanched when palpated. Orders for treatment: A telephone order dated [DATE] at 9 a.m., revealed an order for [REDACTED]. A telephone order dated [DATE] revealed the following order: Discontinue wound care to the left hip and start Dermaseptine twice a day until healed. Diagnosis: [REDACTED]. Telephone orders dated [DATE] revealed orders for the left and right hip. The PA directed staff to cleanse the left and right hip with wound cleanser, dab with gauze and apply [MEDICATION NAME] every other day and PRN until healed. Diagnosis: [REDACTED].) administer 10 ml per gastrostomy tube three times a day for 10 days. Diagnosis: [REDACTED]. Staff Interviews: On [DATE] at 3:05 p.m. Staff A (LPN-licensed practical nurse) stated the resident had an open area on his/her bottom that they applied [MEDICATION NAME] borders to and also to both hips. She stated at first they used Dermaseptine and then switched to [MEDICATION NAME] borders. She stated when she came on duty in the mornings the areas would not be covered so she would apply the [MEDICATION NAME]. She stated she didn't know why the areas were not covered. Staff A described the areas as good sized with the hip sores deeper than the buttock ulcer. She stated she never notified the physician of the areas because she kept hearing the Director of Nursing (DON) was taking care of it. She stated she made out skin sheets in the past and they have disappeared. The DON told her some of the sores she made skin sheets for were not bad enough for a skin sheet and the facility tries to heal them on their own. She identified on their own to mean the facility treats skin areas without physician notification, orders or documentation. She stated that tactic backfired for this resident. She stated the resident's pressure ulcers were bad for a little while before they got treatment. On [DATE] at 3 p.m. Staff B (CNA-certified nurse aide) stated she trained Staff C CNA (hire date [DATE]). At that time, Staff D LPN told her to turn the resident side to side because he/she had sores. She went in the room and saw the resident with uncovered sores on the hips and coccyx. She described the coccyx sore as softball sized with black in the center. It appeared infected. The hip sores looked tennis ball sized, red and bad. They were warm and inflamed. They had yellow on the open sores. The sores stuck to the sheets and Staff B went to Staff D because she did not feel comfortable turning the resident with the sores sticking to the sheets. Staff D told her to go to the DON. She informed the DON that she just saw the resident's sores and did not feel comfortable moving the resident because his/her sores stuck to the sheets. The DON stated they followed the physician's orders [REDACTED]. The DON told Staff B that the order was to have them uncovered. Staff B stated she thought that was neglect. The sores remained uncovered that night. Four days later, the facility started covering them. On [DATE] at 1:48 p.m. the Administrator identified Staff B trained Staff C on [DATE]. On [DATE] at 1:16 p.m. Staff C CNA confirmed she did see sores when Staff B trained her. The sores did not appear to have treatment and appeared moist and stuck to the bed pad. On [DATE] at 5:12 p.m. Staff E CNA stated the resident had sores for a long time. The resident's bottom was one big sore. They rolled the resident hourly. Both hips and coccyx had pretty big sores. Staff E thought the resident had sores at Christmas time. She stated there was no evidence she could see that the facility was treating the sores. On [DATE] at 4:12 p.m. Staff F CNA stated the resident had sores that started 1 to 1.5 months after the resident admitted to the facility and they never healed. The resident's hips started breaking down in the middle of December before Christmas. Staff F stated she was one of the first staff that saw the red spots on the resident's hips. She wrote it down and dated it and gave the information to Staff G LPN. After the areas got red the facility put nonstick pads on the hips. Every couple times she worked, the resident did not have the pads on the hips. At the end of December the sores started opening and staff used [MEDICATION NAME]. The sore on the resident's bottom wasn't always covered. The facility put pressure reduction on the bed a couple weeks before the resident expired. On [DATE] at 4:52 p.m. Staff H CNA stated she assisted Staff D turn the resident about 1 week before the resident expired. The resident's sores did not have covering and the resident was incontinent with urine getting in the sores. The coccyx sore appeared grapefruit size and deep with necrotic tissue in it. After they turned the resident, they covered the resident up and left the sores uncovered. On [DATE] at 11:20 a.m. Staff I CNA stated the resident had sores on his/her bottom and at first had no treatment. Staff I stated she told nurse all the time the resident had sores and they finally got a treatment. The resident's bottom started getting better and then the hips broke down. She stated she told Staff A LPN and Staff G LPN and also the Administrator and DON. She stated patches got ordered for the sores and one day the patches would be on and the next day they would be off. The nurses said the sores needed to air out. So the staff never knew for sure what to do for the sores. Before the hip sores developed, Staff I reported several times they looked red and when they got pinpoint areas prior to opening, Staff I reported that. Nothing was done. Staff I stated she was told to keep them open to air and keep the resident off the areas. Staff I stated the hip sores looked bad. The facility got a pressure reduction mattress about 3 to 4 days before the resident expired. The resident got antibiotics for the hip sores because they were red and hot. She had to holler at the nurse to get her to administer the antibiotic for the infected hips. Staff G LPN said the antibiotic wasn't at the facility but she (Staff I) knew it was. She stated she thought the resident was in pain. The resident had pained facial expressions and would say ouch. She reported it to the nurse. On [DATE] at 1:48 p.m. Staff J CNA stated she kept notes about what she reported and to whom. She stated on [DATE] she reported the resident's hips were red and sore. She stated she kept informing Staff G LPN on a daily basis after [DATE], regarding the resident's hips looking red and sore. They were not open yet. On [DATE] she reported to the Administrator that the hips had open areas. The Administrator didn't do anything. On [DATE] she and Staff I CNA showed the Administrator and they finally did something. The resident got [MEDICATION NAME]es and an antibiotic. The next day she asked Staff G LPN about the antibiotic and Staff G LPN did not give the antibiotic because it wasn't on the medication cart. Staff J stated she told the Administrator the resident did not get skin treatments. [MEDICATION NAME]es were ordered and staff didn't put them on. The resident didn't get a pressure reduction mattress until a week before he/she passed away. Staff J told nurses she thought the resident had pain. The resident would say he/she couldn't take this and complain of lower back pain. Staff J stated she thought by lower back pain the resident referred to his/her pressure sore. On [DATE] at 9:08 a.m. Staff J stated when the [MEDICATION NAME] was not on, nurses would say they left it open to air because the sore looked better without it. She stated Staff A LPN, Staff G LPN and the MDS/care plan nurse all said the previous statement regarding leaving the [MEDICATION NAME] off the sores. On [DATE] at 1:05 p.m. Staff G LPN stated the resident started with a sore on the coccyx. Staff applied [MEDICATION NAME] and turned the resident side to side and then the resident's hips got red and got blisters. The resident then got an order for [REDACTED]. She stated she was pretty sure the resident had a coccyx sore at Christmas time and she always put [MEDICATION NAME] (moisture barrier ointment) on it. On [DATE] at 3:20 p.m. Staff D LPN stated the resident had open areas for months before he/she passed away. The resident sat in a recliner all day and that is how the coccyx sore developed. Staff D LPN gave the surveyor a copy of a communication sheet dated [DATE] that revealed the resident had skin issues to both hips and buttock area and that Dermaseptine was not very effective and the resident needed a different treatment. It also revealed staff could not find any skin sheets for the hips. On [DATE] at 4:35 p.m. Staff O CNA stated she thought the resident had open areas at Christmastime. They were not covered. She reported to Staff D that the wounds were not covered, who then applied bandages. On [DATE] at 10:54 a.m. the MDS/Care Plan nurse stated she thought the [MEDICATION NAME] treatment made the buttock sore look wet and discussed it with the DON. She stated she didn't recall leaving the [MEDICATION NAME] off the hip sores, just the buttock. On [DATE] at 3:07 p.m., she stated she would leave it off for less than an hour and then put it back on. On [DATE] at 11:45 a.m. the Administrator stated the day she knew of the resident's sores was the day she got a treatment order for it ([DATE]) On [DATE] at 12:50 p.m. the DON stated she did not recall Staff B telling her the resident's sores stuck to the sheets. Regarding staff's claims that skin sheets disappear, the DON stated she didn't know about missing sheets. She stated anyone can make out a skin sheet and put it in the skin book. On [DATE] at 4:24 p.m. the pharmacist stated the pharmacy sent the first box of [MEDICATION NAME] for the resident on [DATE]. They sent a box of 5 on that date. On [DATE] they sent another box of 5 for the resident. On [DATE] at 9:05 a.m. when asked how they applied the [DATE] [MEDICATION NAME] treatment to the left buttock and right and left hips if the pharmacy didn't send supplies until [DATE], the Administrator stated she guessed they had some house supply (stock) [MEDICATION NAME] available that they used for the resident. When asked about no treatment documented to the left buttock since [DATE], she stated she thought the left hip treatment order received on [DATE] should have read left buttock and not left hip. A telephone order dated [DATE] directed staff to send the resident to the emergency room (ER). Resident care notes dated [DATE] at 8:35 a.m. revealed the resident had rales throughout lungs and thick green/yellow phlegm in mouth removed by staff. Staff notified the physician who directed staff to send the resident to the ER. On the same date at 11:31 p.m. the resident's daughter called the facility and said the resident passed away. 2. Resident #3 had a MDS assessment with a reference date of [DATE]. The MDS identified the resident had a BIMS score of 3. A score of 3 indicated the resident had a severe cognitive impairment. The resident did not have behavior symptoms which included rejection of care. The resident required extensive assistance of 2 or more staff with bed mobility, transfers, dressing, toileting and personal hygiene. The resident had functional range of motion limitations of one lower extremity. The resident had an indwelling urinary catheter and always incontinent of bowel. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident at risk for pressure sores. The MDS identified the resident did not have pressure ulcers but did have other skin problems such as [MEDICAL CONDITION] other than pressure ulcers, rashes, cuts. The resident had a pressure reducing device on the bed and in the resident ' s chair. A non-pressure skin condition report identified a 6.5 cm. by 5 cm. by 8 cm. surgical area measured on [DATE] and first observed on the right ischium on [DATE]. On [DATE] at 8:38 a.m. the DON stated the resident had an abscess to the right ischial area and the wound center performed a surgical procedure on the abscess area. A non-pressure skin condition report identified a 1 cm. abscess to the left hip first observed on [DATE]. A doctor's progress note dated [DATE] indicated the physician went to the nursing home. The physician documented the resident had an abscess or erythemia with a break in skin causing signs and symptoms of staphylococcus. A [DATE] i-heal wound center form indicated the resident had a Stage 3 pressure ulcer to the right ischium measuring 1.5 cm. by 1 cm. by 4 cm. with a large amount of purulent exudate and medium necrotic amount. The i-heal form also identified a Stage 3 pressure ulcer to the left hip measuring 1 cm. by 1.3 cm. by 1 cm. with a large necrotic amount. The MDS identified a Stage 3 pressure sore as 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. A February 2016 Medication Administration Record [REDACTED]. Cover with 4 by 4 gauze and secure with tape. The treatment schedule was 8 a.m., 2 p.m. and 8 p.m. Observations: Observation on [DATE] at 10:45 a.m. Staff C LPN in the resident's room performing a treatment to the resident's right ischium (lower buttock area). The resident lay in bed on a pressure reduction mattress. The resident had an indwelling Foley catheter (tube into bladder to drain urine) in place. Observation identified an approximate 4 -5 cm. round and deep open area on the right ischium. At that time, Staff C cleansed the wound with normal saline and packed the wound with [MEDICATION NAME] Ag packing and covered the area with [MEDICATION NAME] border dressing (foam dressing that protects wound and absorbs drainage). After completing the right ischial treatment, Staff C performed the left hip treatment. Observations Identified an approximate 1 cm. round and deep open area to the left hip. Staff C cleansed the wound with normal saline and packed the wound with packing tape soaked in Dakin ' s solution (solution to kill germs and prevent germ growth in wounds). Staff covered the wound with gauze and taped the gauze in place. Following the treatments, staff got the resident up from bed in a wheelchair with a pressure reduction cushion. Observation showed on the same date at 12 p.m., the resident sat in the wheelchair at the dining room table. Observation showed, on [DATE] at 1:30 p.m., the resident remained up. On the same date at 4 p.m., the resident remained up in the wheelchair. At that time, the surveyor asked Staff L CNA (Certified Nursing Assistant) if the resident was up in the wheelchair when she arrived at work at 3 p.m. Staff L said yes the resident was already up. At 4:30 p.m. of the same date, the resident remained up. At 4:33 p.m. of the same date, the surveyor phoned Staff K CNA who worked the previous shift. The surveyor asked the CNA if the resident lay down after they got the resident up for lunch at 11 a.m. Staff K stated no the resident did not lie down. The resident stayed up for the afternoon activity. On [DATE] at 3:50 p.m. observation revealed the resident in bed lying on his/her left side. At that time, the surveyor asked Staff L CNA when the resident laid down on [DATE]. Staff L stated she laid the resident down between 5 p.m. and 5:30 p.m. on [DATE]. (6 hours seated in wheelchair) On [DATE] at 5:15 p.m. observation showed the resident on his/her back rolled up in bed. At that time, Staff L CNA assisted the surveyor to check the date on the resident's left hip dressing. The left hip dressing contained the date and time [DATE] AM. On [DATE] at 12:44 p.m. Staff G LPN stated she did not do the resident's 2 p.m. left hip treatment dressing change on [DATE] and [DATE] because she did not have time. She stated she still signed on the Medication Administration Record [REDACTED] On [DATE] at 11:55 a.m. the wound center ARNP (advanced registered nurse practitioner) stated the sore on the left hip was from deep tissue injury changed to pressure. She stated the staff not doing treatments as ordered would affect healing and prolonged sitting would possibly affect healing. She stated the facility did not pack the wounds properly. There was a minimal amount of packing in the wounds and that is not as the wound center wants it nor is it how it is prescribed. She stated she contacted the nurses on duty and then eventually she contacted the Administrator. She stated she contacted the Administrator 3 to 4 weeks ago and the nurses before that. She stated the left hip wound was worse and may need surgical debridement. The resident would see a surgeon. A wound healing center note dated [DATE] at 9:10 a.m. directed staff to please pack wounds completely. A note from the surgeon dated [DATE] revealed no new orders apart from usual bedsore precautions (frequent turning in bed). The surgeon documented that he didn't think the resident needed orthopedic treatment or surgery. The surgeon directed the facility to continue care of the resident with the wound center. A Care Plan dated [DATE] contained a problem of has an ADL self-care performance deficit related to dementia. The Care Plan contained an intervention dated [DATE], that directed staff to reposition the resident every 2 hours and as needed. A [DATE] intervention identified the resident should sit in the wheelchair for short periods of time, not to exceed 2 hours. The Care Plan identified the resident used a blue mattress to the bed until [DATE] when staff applied an air mattress to the bed. The Care Plan [DATE] intervention directed staff to encourage and assist the resident to keep off left hip area when in bed. Observation showed, on [DATE] at 3:50 p.m. the resident in bed on the left side. Observation showed on [DATE] at 3:20 p.m. the resident in bed on the left side. The resident remained on the left side until staff got the resident up at 4:42 p.m. 3. Resident #11 had a MDS with a reference date of [DATE]. The MDS indicated the resident had a BIMS score of 15. A score of 15 identified the resident had no cognitive impairment. The resident required extensive assistance if two or more staff with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. The resident had functional range of motion limitations in both lower extremities. The resident had [DIAGNOSES REDACTED]. The resident admitted to the facility [DATE]. The MDS identified the resident at risk for pressure sore development. The MDS identified the resident with 2 venous/ arterial ulcers and infection of the foot on admission. A universal assessment form dated [DATE] revealed the primary reason for placement as treatment related to [MEDICAL CONDITION] diagnosis and the resident planned to discharge when his/her legs healed. A physician transfer order form printed on [DATE] at 9:03 a.m. identified the resident with [MEDICAL CONDITION] of the right lower extremity (LE) Discharge orders printed on [DATE] identified an order for [REDACTED]. Review of the admission physician orders [REDACTED]. Review of the February 2016 MAR indicated [REDACTED]. At that time the facility began the following treatment: Cleanse coccyx with wound cleanser and pat with gauze then apply [MEDICATION NAME] every other day until healed. A weekly pressure ulcer assessment identified the coccyx area as healed on [DATE] at 10 a.m. A skin breakdown risk assessment dated [DATE] identified the resident with a score of 19. A score of 19 identified no risk for pressure ulcer development. Observation: On [DATE] at 2:05 p.m. the resident complained of a sore bottom. The resident stated he/she sat in the wheelchair since 11:30 a.m. The resident stated he/she got weighed and the chair hurts his/her bottom. The resident stated he/she sat up too long. After the leg treatment, staff laid the resident in bed. Observation showed no pressure reduction in the wheelchair. The resident sat on a folded bath blanket. Once in bed, observation showed a very sore and red coccyx with an area on the right inner buttock. Staff did not apply any type of barrier. On [DATE], a weekly pressure ulcer assessment revealed the resident had a new Stage II pressure ulcer on the buttock coccyx area. The assessment identified the measurement of the area as 3.2 cm. by 0.5 cm. A telephone order dated [DATE] at 2:30 p.m. identified an order for [REDACTED]. On [DATE] at 9:08 a.m. observation showed the resident in bed laying on his/her back. The resident stated after the surveyor looked at his/her bottom yesterday the facility started applying cream to the area. A Care Plan dated [DATE] did not identify pressure reduction, repositioning or a potential for coccyx/buttock breakdown. 4. Resident #9 had a MDS assessment with a reference date of [DATE]. The MDS identified the resident had a BIMS score of 13. A score of 13 identified the resident had no cognitive impairment. The resident had an admission date of [DATE]. The resident was independent with bed mobility, transfers and ambulation. The resident required extensive assistance of staff with dressing, toileting, personal hygiene and bathing. The resident was occasionally incontinent of bladder. The resident had [DIAGNOSES REDACTED]. The MDS did not identify the resident with a risk for pressure sores. The resident did not have pressure sores identified on the assessment. The MDS revealed that the resident used pressure reduction in bed but not in the chair. On [DATE] at 3:07 p.m. the resident stated he/she had a sore on his/her bottom. The resident stated he/she had it about a week but didn't report it until yesterday. The resident stated they gave him/her a chair cushion today for him/her to sit on. A weekly pressure ulcer assessment identified a Stage II pressure area to the left inner buttock. A physician order [REDACTED]. Review of the February 2016 MAR indicated [REDACTED]. The resident got it once on [DATE]. The [DATE] MAR indicated [REDACTED]. On [DATE] at 3:53 p.m. the surveyor asked the resident how many times a day he/she got the treatment to his/her bottom. The resident stated it averages once a day and that the resident needs to remind staff to do it. The resident stated his/her bottom is still sore. Observation showed on [DATE] at 10:50 a.m. an approximate 3 cm. pink/red rough area on the left inner buttock with a small white open area in the pink red area. On [DATE] at 2:51 p.m. the Administrator emailed the surveyor to let her know that the resident's left inner buttocks healed and did not get worse. An email attachment contained a copy of the weekly pressure ulcer assessment. The DON documented the area healed on [DATE] at 9 a.m.

Based on clinical record review, staff, resident and family interviews and observations the facility failed to provide appropriate pressure sore interventions for 1 of 11 residents reviewed (Resident #5). The facility reported a census of 68. Findings include: Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #5 ' s Brief Interview for Mental Status (BIMS) score of 12 that indicated moderately impaired cognitive ability. The MDS indicated Resident #5 required extensive assistance of 2 staff members for bed mobility, dressing and required total dependence on 2 staff members for transfers and toilet use. Resident #5 utilized a wheelchair for mobility. Resident #5 ' s MDS identified a Urinary catheter utilized and experienced frequent bowel incontinence. Resident #5 ' s [DIAGNOSES REDACTED]. The MDS listed Resident #5 at risk for developing pressure sores and had treatments in place for pressure sores that included pressure reducing devices in the bed and chair and required the application of ointments/medications. Review of Resident #5's Care Plan dated 8/5/15, the 3 page Care Plan revealed Resident #5 had an indwelling catheter, alteration in nutrition and limited mobility. Review of the plan of care for limited mobility indicated Resident #5 had a left inner heel area that required treatment according to the physician's orders [REDACTED]. Observations on 8/20/15 at 8:30 a.m., upon entering Resident #5's room Staff A Certified Nursing Assistant (CNA), Staff B CNA and Staff C CNA prepared to complete incontinence care for Resident #5. The staff members assisted Resident #5 to roll onto his/her right side to complete cares. During the provision of incontinence cares Resident #5 noted to have 2 reddened areas on his/her right buttock and several reddened open areas and 1 linear shaped area on his/her left buttock with a scant amount of bleeding noted when the staff members cleansed the left buttock. Staff C CNA stated at this time they will have to tell the nurse to get the cream for Resident#5 ' s buttocks. Observations on 8/24/15 at 9:35 a.m., upon entering Resident #5's room Staff C CNA, Staff D CNA and Staff E CNA identified as providing incontinence cares for Resident #5 following a large incontinent bowel movement. The staff members assistant Resident #5 to roll to his/her left side for the provision of cares, observations at this time revealed a linear, open area to Resident #5's left buttocks with a darkened area next to the open area. The right buttock at this time appeared free of reddened areas. During an interview with Staff C CNA after the provision of cares on 8/24/15 at 9:35 a.m., Staff C CNA stated last Thursday, 8/20/15, during incontinence cares for Resident #5 first time she noticed the open areas to Resident #5's left buttocks, Staff C CNA indicated the areas on the left buttocks appeared open and bleeding and staff members reported it to Staff F Licensed Practical Nurse (LPN) on 8/20/15. Staff CNA indicated they thought Staff F LPN measured the reported open areas. During an interview with Staff F LPN on 8/20/15 at 10:10 a.m., Staff F LPN stated Resident #5 had a heel skin issue and an abrasion to his/her left knee. Staff F LPN revealed Resident #5 had issues in the past with redness to his/her buttocks but staff members just monitored the area. Staff F LPN revealed she was the skin nurse for Resident #5 and completed weekly skin assessments for him/her but failed to complete any skin sheet for Resident #5's buttocks. During an interview with Staff G, Director of Nurses (DON), on 8/24/15 at 9:45 a.m., Staff G DON stated the only skin sheets present for Resident #5 are for the Resident #5's heel and an abrasion of the Resident#5's left knee. Staff G DON stated everything is the same as when the surveyor inquired about Resident #5 skin sheets last Thursday, 8/20/15. During an interview with Staff F LPN on 8/24/15 at 9:50 a.m., Staff F LPN stated she entered Resident #5's room last Thursday, 8/20/15, after staff nurses received a report about an open area to Resident#5's buttocks. Staff F LPN stated on 8/20/15 she noted a small darkened, red area on Resident#5's buttocks but failed to make any skin sheets for the new areas. Staff F LPN was asked again if she made out skin sheets for the reddened areas on Resident#5's buttocks, Staff F LPN acknowledged staff failed to complete skin sheets for the buttock areas. On 8/24/15 at 10:05 a.m. Staff F LPN entered the conference room and handed the surveyor a skin sheet for a reddened area on Resident #5's right buttock, she stated staff forgot she made this skin sheet out and placed it in a folder in the medication room. Staff F LPN stated she informed Resident#5's physician and informed Resident#5's spouse of the new identified areas. On 8/24/15 at 10:25 a.m. Staff F LPN, Staff G Director of Nurses and Surveyor inspected the skin of Resident #5's left buttocks. At the time of the skin inspections staff members identified an open area, abrasion in appearance on Resident#5 ' s left buttock. Both Staff F LPN and Staff G DON described the reddened area as a Stage I pressure sore, the pressure sore measured 1.3 centimeters in length and. 5 centimeters wide. During an interview with Staff F LPN on 8/24/15 at 10:35 a.m., Staff F reviewed Resident #5's Physician order [REDACTED].#5's clinical record had a date of 8/19/15 and not related to skin issues. During an interview on 8/24/15 at 10:57 a.m. with Resident#5's Physician, the Physician stated they came to the facility on [DATE] and administered an injection into Resident#5's shoulder. The Physician stated they did not have any knowledge of a problem with Resident#5's skin to his/her buttocks and indicated if the facility staff made the Physician aware of the skin issues the Physician would have made reference to it in the clinical notes. The Physician stated they did not receive any requests for orders for Resident #5 since 8/20/15 visit and if they were made aware of the left buttock open area the Physician would have ordered a treatment. During an interview with Resident#5's spouse on 8/24/15 at 10:23 a.m., the spouse stated staff failed to inform family about any specific open areas to Resident#5s buttocks on 8/20/15 and stated it ' s a known fact Resident #5 had issues with his/her buttock skin since admission. Review of Resident #5's Nurses Notes from 8/20/15 at 10:00 a.m. thru 8/24/15 at 11:50 a.m. failed to reveal documentation related to impaired skin integrity to Resident#5's buttocks. Review of Resident #5's August 2015 Treatment Records failed to revealed skin treatment orders for Resident #5's buttocks until 8/24/15. Review of Resident#5's Resident Care Notes dated 8/24/15 at 11:50 a.m. by Staff F LPN, the notes included a statement that they updated Resident#5's physician on his/her left buttock skin issue and the Physician gave an order for [REDACTED]. Review of Resident#5's physician's orders [REDACTED].#5's buttocks twice daily for a reddened area. Review of a Skin Protocol updated on 7/1/15 directed the staff to document on the appropriate flow sheet if they identify a skin breakdown. The Protocol directed the Charge Nurse to promptly notify the resident's physician of the specific open areas and document the information reported. The Charge Nurse will notify the resident's physician and family members.

Based on observation, record review, staff and resident interviews, the facility failed to ensure that all alleged abuse, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The facility failed to protect from abuse or investigate injuries of unknown origin for 6 of 6 residents reviewed (Residents #1, #3, #11, #13, #14 and #9). Facility census was sixty-three (63) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 3/5/14 identified Resident #14 with a brief interview for mental status (BIMS) score of 11 or moderate cognitive impairment. Resident #14 was [AGE] years old and admitted to the facility on [DATE]. The MDS did not identify any behaviors. Resident #14 was independent with bed mobility, transfers, ambulation, eating and toileting. Resident #14 required limited assistance of one staff with dressing, personal hygiene and baths. The MDS listed Resident#14's [DIAGNOSES REDACTED]. A neuropsychiatric evaluation dated 12/23/14 identified Resident #14 with [DIAGNOSES REDACTED]. A geriatric psychiatric note dated 3/20/15 from the ARNP (Advanced Registered Nurse Practitioner) identified Resident #14 came to Crestview from a residential care facility. Resident #14 walked away from the residential facility and suffered frostbite to the feet and required hospitalization . When the hospital discharged Resident #14, he/she was admitted to the Crestview CCDI unit. The psychiatric note identified Resident #14 asked staff about wanting to go outside but stated he/she would wait until the facility built a fence. The ARNP identified Resident #14 verbalized appropriately but minimized and withheld information. Resident #14 answered questions asked but did not respond spontaneously. Alleged 1st incident: On 5/7/15 at 9:26 a.m. Staff E (CNA) certified nursing assistant stated she observed Resident #14's door shut. When she entered the room, she observed Resident #14 standing with his/her back to Staff E and fully facing Resident #1 as Resident #1 sat in a chair. Staff E stated could not see anything inappropriate as Resident #14's back faced Staff E when she opened the door. Staff E told Resident #1 to come out of the room and then turned around and left. Staff E stated 4/14/15 sounded like the right date the incident occurred. She did not report the incident because he/she didn't see that anything inappropriate occurred. Resident #1 didn't say anything went on. Staff E stated Resident #1 was present on the CCDI that day to get a shower. The MDS with assessment reference date of 3/9/15 identified Resident #1 ' s BIMS score of 15 (no cognitive impairment). The MDS listed Resident #1 required limited to extensive assistance for transfers, dressing, personal hygiene and toileting. On 5/5/15 at 2:15 p.m. Resident #1 stated Resident #14 exposed his/her genitals during the incident on 4/14/15 causing Resident #1 to have an anxiety attack. Resident #1 stated he/she could not move and Resident #14 wouldn't get away from him/her. According to Resident #1, Resident #14 asked Resident #1 to touch his/her genitals and perform oral sex. At that point, Staff E entered room and stopped the interaction. Second Incident: Interview on 5/5/15 at 10:35 a.m. Staff L stated she observed Resident #13 in Resident #14's room as she came out of a resident room with a food tray. Staff L took the tray to the food cart and returned to Resident #14's room to get Resident #13. When Staff L returned to the room, she observed Resident #13 in the wheelchair sitting next to Resident #14. Staff L observed Resident #14's pants unzipped with his/her genitals exposed and Resident #13's hand was on Resident #14 ' s genitals. Staff L told Resident #14 that was not acceptable behavior and removed Resident #13 from the room. She informed Staff S LPN (licensed practical nurse) of the incident. Staff L stated the incident occurred either on 4/18/15 or 4/19/15. On 5/6/15 at 12:57 p.m. Staff V CNA stated she worked the weekend of 4/18-19/15 when Resident #13 wandered into Resident #14's room. She stated Staff L immediately reported the incident to Staff S LPN. Staff V stated Resident #14's behaviors are blatant now like the facility allows Resident #14 to have the behaviors with other residents. Staff V stated Resident #3 has no family/friends and is being molested. A Minimum Data Set (MDS), with assessment reference date of 3/4/15 identified Resident #13 with a brief interview for mental status score of "0" (severe cognitive impairment). Resident #13 required extensive assistance from staff members for mobility and activities of daily living (ADL ' s). Resident #13 required a wheelchair for mobility. Third Incident: On 5/6/15 at 9:50 a.m. Staff U CNA stated Resident #14 has touched other residents. Staff U observed Resident #14 touch Resident #11's chest area as Resident #11 sat in the hallway in his/her wheelchair. Resident #11 did not react to Resident #14 touching his/her chest area. Staff U told Resident #14 he/she couldn't do that. Staff U informed Staff S LPN of the incident. On 5/13/15 at 11:20 a.m. the surveyor asked Staff U when the incident between Resident #14 and #11 occurred. Staff U stated she did not know the exact date but stated it was at "the end of April". Review of the MDS dated [DATE] identified Resident #11 with a BIMS score of "0" (severe cognitive impairment). Resident #11 required extensive assistance with transfers and ADL ' s. Resident #11 required a wheelchair for mobility. Observation showed, on 5/7/15 at 2:10 p.m. Resident #11 independently moving in the wheelchair down the hall. Resident #11 mumbled incoherently when questioned by the surveyor. Fourth Incident: On 5/5/15 at 10:08 a.m. Staff S LPN stated Resident #14 touched Resident #3. Staff S documented the incidents in the behavior book. Staff S identified those dates as 5/1/15 and 5/3/15. On 5/5/15 at 5:08 p.m. Staff S confirmed Staff G and Staff H informed her of an incident involving Resident #13. On all 3 occasions, staff separated Resident #14 from the other resident ' s and informed him/her the behavior was unacceptable. Staff S stated she marked the incidents in the behavior section of the clinical record but failed to report the issues to management. Fifth Incident: On 5/6/15 at 4:50 p.m. Staff J CNA stated she observed Resident #14 exit Resident #3's room either 5/2/15 or 5/3/15 around 7:00 p.m. When she entered Resident #3's room after Resident #14 left, Resident #3 sat in his/her chair fully clothed. Resident #14 failed to answer when Staff J asked Resident #14 what he/she did in Resident #3's room. Staff J stated she informed another CNA but failed to report the incident to the charge nurse on duty. A MDS assessment dated of 3/20/14 for Resident #3 revealed a BIMS score of "0" (severe cognitive impairment). Resident #3 required extensive to total assistance with all ADL ' s. Observation on 5/7/15 at 1:50 p.m. revealed Resident #3 seated in a chair in the corner of his/her room. Resident #3 appeared to look out the window and call for a cat. (No cat visible outside). Resident #3 was not responsive to questions. Sixth Incident: On 5/5/15 at 12:10 p.m. Staff H CNA stated Resident #14's behaviors on the unit "weren't good". Staff H stated Resident #14 sneaks in resident rooms and fondles various residents. Staff H stated yesterday or the day before, she caught Resident #14 standing in front of Resident #3 fondling his/her chest over the clothing. Staff H informed Resident #14 he/she should not do that. Resident #14 said he/she knew that and wouldn't do it again. Staff H informed the Director of Nursing of the incident. Staff H stated a couple weeks ago she observed Resident #14 fondled Resident # 11's chest over his/her clothing. Staff H informed Staff S LPN. On 5/5/15 at 4:57 p.m. the Director of Nursing (DON) stated she first became aware of an incident yesterday (5/4/15) when Resident #14 entered a room on 5/4/15 and fondled the other resident. The DON talked to Resident #14. Resident #14 stated he/she didn't mean anything by it and wouldn't do it again. The DON notified Resident #14 ' s psychiatric ARNP (Advanced Registered Nurse Practitioner) who increased Resident #14's [MEDICATION NAME] (antidepressant) dosage. On 5/5/15 at 10:08 a.m. Staff S LPN stated Resident #14 touched Resident #3. She documented the incidents in the behavior book. She identified those dates as 5/1/15 and 5/3/15. On 5/5/15 at 5:08 p.m. Staff S confirmed staff informed her of an incident involving Resident #13. According to Staff S all occasions, staff separated Resident's from Resident #14 and informed him/her the behavior was unacceptable. Staff S stated she marked the incident in the behavior book but didn't report to management. The behavior records identified Staff S marked Resident #14 had sexual behaviors that occurred on 4/20/15, 5/1/15 and 5/3/15. The record failed to identify who Resident #14 directed the behavior to and what the behavior was other than classified as sexual behavior. The behavior record identified the care plan nurse marked Resident #14's sexual behavior occurred 4/25/15 and 4/26/15. The record failed to identify who Resident #14 directed the behavior to and what the behavior was other than classified as sexual behavior. Interview on 5/7/15 at 9:36 a.m. the care plan nurse clarified the two areas documented on Resident #14's behavior record are related to Resident #14's attempts to grab breasts of the staff members. On 5/5/15 at 4:57 p.m. the Director of Nursing (DON) stated she first became aware of an incident yesterday (5/4/15) when Resident #14 entered a room on 5/4/15 and fondled the other resident. The DON talked to Resident #14. Resident #14 stated he/she didn't mean anything by it and wouldn't do it again. The DON notified Resident #14's psychiatric ARNP (Advanced Registered Nurse Practitioner) who increased Resident #14's [MEDICATION NAME] (antidepressant) dosage. Interview on 5/5/15 at 12:30 p.m. revealed Resident #14 admitted to fondling a resident's chest area. Resident #14 stated he/she didn't know the other resident's name. Resident #14 stated he/she went in the other resident's room and fondled the chest area over the top of clothing. Resident #14 stated this occurred about a week ago and a staff saw him/her. Resident #14 denied all other incidents. Resident #14 answered cognitive questions correctly related to the year, town he/she was in and the President's name. Review of Resident #14's care plan, dated 3/6/15 revealed a lack of interventions on the care plan regarding Resident #14's sexual behaviors or supervision of Resident #14 to prevent sexual behaviors. The care plan contained the following directive "report changes or declines in behavior to ARNP. On 5/5/15 at 4:57 p.m. the Director of Nursing confirmed she did not see anything on the care plan about supervising Resident #14. The facility resident to resident abuse policy was one sentence that stated if an incident occurred, the facility would take steps to remove the resident to a safe location. The policy failed to direct staff to report resident to resident abuse to the State Agency or maintain separation. 2. A MDS assessment dated [DATE] identified Resident #9's BIM ' s score of "3" (severe cognitive impairment). The MDS revealed Resident #9 ambulated independently and required extensive assistance with toileting personal hygiene and bathing. A "balance during transitions and walking" test revealed Resident #9 was unsteady but able to stabilize without staff assistance. Resident #9's MDS listed [DIAGNOSES REDACTED].#9. An Iowa emergency medical (EMS) report dated 4/20/15 revealed Resident #9 normally walked all over but the last couple days Resident #9 refused to walk. Yesterday Resident #9 rode in a wheelchair and today Resident #9 refused to get out of bed. The EMS report documented that nursing reported that from reading the nursing home paperwork, Resident #9 fell 2 to 3 days ago. EMS observed the left leg shortened and outwardly rotated due to [MEDICAL CONDITION]. An x-ray report, dated 4/20/15, showed a Varus-angulated left femoral [MEDICAL CONDITION]. Hospital records dated 4/20/15 identified Resident #9 transported from the local hospital to another hospital for surgical repair of the left [MEDICAL CONDITION]. The assessment/plan portion of the hospital records revealed Resident #9 was an inpatient due to trauma and required pain management and an invasive procedure. The history identified it was unclear whether Resident #9 fell and when. Resident #9's daughter saw him/her on 4/18/15 and Resident #9 was not his/her usual self. Resident #9 complained of pain and swelling in the knee. The left leg showed shortening and external rotation with hip pain with any movement of the left lower extremity. Review of Resident #9's record failed to contain any information regarding a fall. On 5/5/15 at 3:30 p.m., Staff M CNA stated she didn't witness the fall but Staff X LPN asked her to help with Resident #9 after locating him/her on the floor. Staff M reviewed the schedule and identified the date of the fall as 4/15/15. Staff M stated Resident #14 reported Resident #9 was on the floor and needed help. Staff X and Staff K CNA got Resident #9 off the floor and then Staff X and Staff M laid Resident #9 in bed. Staff M documented in a written statement, that Staff K went down the hall to get washcloths when Resident #14 asked for help getting a resident of the floor. Staff K got Staff X. Staff X came to Staff M as she assisted another resident and asked her to help with Resident #9. Staff X said Resident #9 was tired. Resident #9 confirmed he/she felt tired. Resident #9 stood up with Staff X and Staff M and went to bed. Staff X took Resident #9's vital signs. Resident #9 denied pain. Staff M did not see Staff X perform a range of motion assessment. Staff M stated the incident occurred between 7:30 p.m. and 8:00 p.m. On 5/5/15 at 4:10 p.m. Staff K CNA documented in a written statement, that on 4/15/15 around 7:30 p.m. Resident #14 called out for help because Resident #9 was on the floor lying on the left side. Resident #14 said Resident #9 stumbled and was fine. Staff K got Staff X (charge nurse). Staff X checked Resident #9 for bruising and redness and said everything looked OK. Staff K and Staff X transferred Resident #9 to the sofa and later to bed. Staff X did not do a range of motion assessment. On 5/5/15 at 4:27 p.m. Staff X LPN documented she did not have knowledge of Resident #9 falling or being on the floor. The Administrator gave the surveyor a paper dated 4/21/15 that contained staff names with "no" by the names indicating the staff knew nothing of Resident #9 falling. Staff K and Staff M had "no" by their names indicating they said they knew nothing of the Resident #9 falling. On 5/5/15 at 4:10 p.m. when asked about the discrepancy, Staff K stated no one asked her if she knew Resident #9 fell . On 5/5/15 at 3:30 p.m., when asked about the discrepancy, Staff M stated no one asked her if she knew anything about Resident #9 falling. On 5/5/15 at 4:42 p.m. Resident #14 stated he/she didn't see what happened. Resident just observed Resident #9 on the floor in the lounge and Resident #14 requested help for Resident #9. Other staff with "no" written by their name on facility investigation question sheet to indicate they knew nothing of Resident #9's fall: On 5/5/15 at 1:28 p.m. Staff L CNA, when asked about the discrepancy stated she didn't recall anyone asking her about Resident #9's fall. On 5/5/15 at 4:57 p.m. the Administrator and Director of Nursing stated they knew nothing about Resident #9 having a fall. After the [MEDICAL CONDITION], they asked staff if they knew anything and staff did not provide any additional information. Observation showed, on 5/4/15 at 6:50 a.m. the resident in bed with call light unavailable. The resident stated she didn't recall falling. Observation showed a large incisional area to the left hip. The resident stood up from bed with the assistance of two staff a gait belt and transferred to a wheelchair. Note: At the time of the onsite investigation the deficiency was coded at a "K" level for immediate and serious jeopardy. By May 7, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an "E" level. The facility provided a plan for reporting and investigating abuse. This statement does not denote the faciltiy has complied with prompt actions for a violation of the required standards. As of the May 20, 2015 exit conference the facility had failed to: a. To provide a safe environment that will be free from abuse against residents. b. Provide adequate supervision to allow residents to live and receive kind and considerate care free from abuse in the facility.

Based on observation, record review, resident and staff interview, the facility failed to keep residents free from abuse for 5 of 6 residents reviewed on the CCDI (Chronic Confusion and Dementing Illness unit (Resident #1, #3, #11, #13 and #14). Facility census was sixty-three (63) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 3/5/14 identified Resident #14 with a brief interview for mental status (BIMS) score of 11 or moderate cognitive impairment. Resident #14 was [AGE] years old and admitted to the facility on [DATE]. The MDS did not identify any behaviors. Resident #14 was independent with bed mobility, transfers, ambulation, eating and toileting. Resident #14 required limited assistance of one staff with dressing, personal hygiene and baths. The MDS listed Resident#14 ' s [DIAGNOSES REDACTED]. A neuropsychiatric evaluation dated 12/23/14 identified Resident #14 with [DIAGNOSES REDACTED]. A geriatric psychiatric note dated 3/20/15 from the ARNP (Advanced Registered Nurse Practitioner) identified Resident #14 came to Crestview from a residential care facility. Resident #14 walked away from the residential facility and suffered frostbite to the feet and required hospitalization . When the hospital discharged Resident #14, he/she was admitted to the Crestview CCDI unit. The psychiatric note identified Resident #14 asked staff about wanting to go outside but stated he/she would wait until the facility built a fence. The ARNP identified Resident #14 verbalized appropriately but minimized and withheld information. Resident #14 answered questions asked but did not respond spontaneously. Alleged 1st incident: On 5/7/15 at 9:26 a.m. Staff E (CNA) certified nursing assistant stated she observed Resident #14's door shut. When she entered the room, she observed Resident #14 standing with his/her back to Staff E and fully facing Resident #1 as Resident #1 sat in a chair. Staff E stated could not see anything inappropriate as Resident #14's back faced Staff E when she opened the door. Staff E told Resident #1 to come out of the room and then turned around and left. Staff E stated 4/14/15 sounded like the right date the incident occurred. She did not report the incident because he/she didn't see that anything inappropriate occurred. Resident #1 didn't say anything went on. Staff E stated Resident #1 was present on the CCDI that day to get a shower. The MDS with assessment reference date of 3/9/15 identified Resident #1's BIMS score of 15 (no cognitive impairment). The MDS listed Resident #1 required limited to extensive assistance for transfers, dressing, personal hygiene and toileting. On 5/5/15 at 2:15 p.m. Resident #1 stated Resident #14 exposed his/her genitals during the incident on 4/14/15 causing Resident #1 to have an anxiety attack. Resident #1 stated he/she could not move and Resident #14 wouldn't get away from him/her. According to Resident #1, Resident #14 asked Resident #1 to touch his/her genitals and perform oral sex. At that point, Staff E entered room and stopped the interaction. Second Incident: Interview on 5/5/15 at 10:35 a.m. Staff L stated she observed Resident #13 in Resident #14's room as she came out of a resident room with a food tray. Staff L took the tray to the food cart and returned to Resident #14's room to get Resident #13. When Staff L returned to the room, she observed Resident #13 in the wheelchair sitting next to Resident #14. Staff L observed Resident #14's pants unzipped with his/her genitals exposed and Resident #13's hand was on Resident #14's genitals. Staff L told Resident #14 that was not acceptable behavior and removed Resident #13 from the room. She informed Staff S LPN (licensed practical nurse) of the incident. Staff L stated the incident occurred either on 4/18/15 or 4/19/15. On 5/6/15 at 12:57 p.m. Staff V CNA stated she worked the weekend of 4/18-19/15 when Resident #13 wandered into Resident #14's room. She stated Staff L immediately reported the incident to Staff S LPN. Staff V stated Resident #14's behaviors are blatant now like the facility allows Resident #14 to have the behaviors with other residents. Staff V stated Resident #3 has no family/friends and is being abused. A Minimum Data Set (MDS), with assessment reference date of 3/4/15 identified Resident #13 with a brief interview for mental status score of "0" (severe cognitive impairment). Resident #13 required extensive assistance from staff members for mobility and activities of daily living (ADL ' s). Resident #13 required a wheelchair for mobility. Third Incident: On 5/6/15 at 9:50 a.m. Staff U CNA stated Resident #14 has touched other residents. Staff U observed Resident #14 touch Resident #11's chest area as Resident #11 sat in the hallway in his/her wheelchair. Resident #11 did not react to Resident #14 touching his/her chest area. Staff U told Resident #14 he/she couldn't do that. Staff U informed Staff S LPN of the incident. On 5/13/15 at 11:20 a.m. the surveyor asked Staff U when the incident between Resident #14 and #11 occurred. Staff U stated she did not know the exact date but stated it was at "the end of April". Review of the MDS dated [DATE] identified Resident #11 with a BIMS score of "0" (severe cognitive impairment). Resident #11 required extensive assistance with transfers and ADL ' s. Resident #11 required a wheelchair for mobility. Observation showed, on 5/7/15 at 2:10 p.m. Resident #11 independently moving in the wheelchair down the hall. Resident #11 mumbled incoherently when questioned by the surveyor. Fourth Incident: On 5/5/15 at 10:08 a.m. Staff S LPN stated Resident #14 touched Resident #3. Staff S documented the incidents in the behavior book. Staff S identified those dates as 5/1/15 and 5/3/15. On 5/5/15 at 5:08 p.m. Staff S confirmed Staff G and Staff H informed her of an incident involving Resident #13. On all 3 occasions, staff separated Resident #14 from the other resident's and informed him/her the behavior was unacceptable. Staff S stated she marked the incidents in the behavior section of the clinical record but failed to report the issues to management. Fifth Incident: On 5/6/15 at 4:50 p.m. Staff J CNA stated she observed Resident #14 exit Resident #3's room either 5/2/15 or 5/3/15 around 7:00 p.m. When she entered Resident #3's room after Resident #14 left, Resident #3 sat in his/her chair fully clothed. Resident #14 failed to answer when Staff J asked Resident #14 what he/she did in Resident #3's room. Staff J stated she informed another CNA but failed to report the incident to the charge nurse on duty. A MDS assessment dated of 3/20/14 for Resident #3 revealed a BIMS score of "0" (severe cognitive impairment). Resident #3 required extensive to total assistance with all ADL ' s. Observation on 5/7/15 at 1:50 p.m. revealed Resident #3 seated in a chair in the corner of his/her room. Resident #3 appeared to look out the window and call for a cat. (No cat visible outside). Resident #3 was not responsive to questions. Sixth Incident: On 5/5/15 at 12:10 p.m. Staff H CNA stated Resident #14's behaviors on the unit "weren't good". Staff H stated Resident #14 sneaks in resident rooms and fondles various residents. Staff H stated yesterday or the day before, she caught Resident #14 standing in front of Resident #3 fondling his/her chest over the clothing. Staff H informed Resident #14 he/she should not do that. Resident #14 said he/she knew that and wouldn't do it again. Staff H informed the Director of Nursing of the incident. Staff H stated a couple weeks ago she observed Resident #14 fondled Resident # 11's chest over his/her clothing. Staff H informed Staff S LPN. On 5/5/15 at 4:57 p.m. the Director of Nursing (DON) stated she first became aware of an incident yesterday (5/4/15) when Resident #14 entered a room on 5/4/15 and fondled the other resident. The DON talked to Resident #14. Resident #14 stated he/she didn't mean anything by it and wouldn't do it again. The DON notified Resident #14 ' s psychiatric ARNP (Advanced Registered Nurse Practitioner) who increased Resident #14's [MEDICATION NAME] (antidepressant) dosage. Interview on 5/5/15 at 12:30 p.m. revealed Resident #14 admitted to fondling a resident's chest area. Resident #14 stated he/she didn't know the other resident's name. Resident #14 stated he/she went in the other resident's room and fondled the chest area over the top of clothing. Resident #14 stated this occurred about a week ago and a staff saw him/her. Resident #14 denied all other incidents. Resident #14 answered cognitive questions correctly related to the year, town he/she was in and the President's name. Review of Resident #14's care plan, dated 3/6/15 revealed a lack of interventions on the care plan regarding Resident #14's sexual behaviors or supervision of Resident #14 to prevent sexual behaviors. The care plan contained the following directive "report changes or declines in behavior to ARNP. On 5/5/15 at 4:57 p.m. the Director of Nursing confirmed she did not see anything on the care plan about supervising Resident #14. The facility resident to resident abuse policy was one sentence that stated if an incident occurred, the facility would take steps to remove the resident to a safe location. Note: At the time of the onsite investigation the deficiency was coded at a "K" level for immediate and serious jeopardy. By May 7, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an "E" level. The facility provided a plan for reporting and investigating abuse. This statement does not denote the faciltiy has complied with prompt actions for a violation of the required standards. As of the May 20, 2015 exit conference the facility had failed to: a. To provide a safe environment free from abuse against residents. b. Failed to implement measures related to Resident #14's sexual behaviors. c. Provide for adequate supervision to allow residents to live and receive kind and considerate care free from abuse.

Based on observation, record review, staff and resident interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision to prevent resident to resident abuse for 5 of 6 residents reviewed for abuse. Resident #13, #11 and #3 resided on the CCDI (Chronic Confusion and Dementing Illness unit) and allegedly abused by Resident #14. Resident #1 alleged Resident #14 abused him/her upon entering the CCDI for a shower. The CCDI unit doors were left open at night when the facility scheduled 3 staff. When someone needed a nurse on the other wing, staff opened the doors of the CCDI unit so the CCDI unit (CNA) certified nursing assistant could monitor the 200 hall while the nurse was gone. Facility census was sixty-three (63) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 3/5/14 identified Resident #14 with a brief interview for mental status (BIMS) score of 11 or moderate cognitive impairment. Resident #14 was [AGE] years old and admitted to the facility on [DATE]. The MDS did not identify any behaviors. Resident #14 was independent with bed mobility, transfers, ambulation, eating and toileting. Resident #14 required limited assistance of one staff with dressing, personal hygiene and baths. The MDS listed Resident#14 ' s [DIAGNOSES REDACTED]. A neuropsychiatric evaluation dated 12/23/14 identified Resident #14 with [DIAGNOSES REDACTED]. A geriatric psychiatric note dated 3/20/15 from the ARNP (Advanced Registered Nurse Practitioner) identified Resident #14 came to Crestview from a residential care facility. Resident #14 walked away from the residential facility and suffered frostbite to the feet and required hospitalization . When the hospital discharged Resident #14, he/she was admitted to the Crestview CCDI unit. The psychiatric note identified Resident #14 asked staff about wanting to go outside but stated he/she would wait until the facility built a fence. The ARNP identified Resident #14 verbalized appropriately but minimized and withheld information. Resident #14 answered questions asked but did not respond spontaneously. Alleged 1st incident: On 5/7/15 at 9:26 a.m. Staff E (CNA) certified nursing assistant stated she observed Resident #14's door shut. When she entered the room, she observed Resident #14 standing with his/her back to Staff E and fully facing Resident #1 as Resident #1 sat in a chair. Staff E stated could not see anything inappropriate as Resident #14's back faced Staff E when she opened the door. Staff E told Resident #1 to come out of the room and then turned around and left. Staff E stated 4/14/15 sounded like the right date the incident occurred. She did not report the incident because he/she didn't see that anything inappropriate occurred. Resident #1 didn't say anything went on. Staff E stated Resident #1 was present on the CCDI that day to get a shower. The MDS with assessment reference date of 3/9/15 identified Resident #1 ' s BIMS score of 15 (no cognitive impairment). The MDS listed Resident #1 required limited to extensive assistance for transfers, dressing, personal hygiene and toileting. On 5/5/15 at 2:15 p.m. Resident #1 stated Resident #14 exposed his/her genitals during the incident on 4/14/15 causing Resident #1 to have an anxiety attack. Resident #1 stated he/she could not move and Resident #14 wouldn't get away from him/her. According to Resident #1, Resident #14 asked Resident #1 to touch his/her genitals and perform oral sex. At that point, Staff E entered room and stopped the interaction. Second Incident: Interview on 5/5/15 at 10:35 a.m. Staff L stated she observed Resident #13 in Resident #14's room as she came out of a resident room with a food tray. Staff L took the tray to the food cart and returned to Resident #14's room to get Resident #13. When Staff L returned to the room, she observed Resident #13 in the wheelchair sitting next to Resident #14. Staff L observed Resident #14's pants unzipped with his/her genitals exposed and Resident #13's hand was on Resident #14 ' s genitals. Staff L told Resident #14 that was not acceptable behavior and removed Resident #13 from the room. She informed Staff S LPN (licensed practical nurse) of the incident. Staff L stated the incident occurred either on 4/18/15 or 4/19/15. On 5/6/15 at 12:57 p.m. Staff V CNA stated she worked the weekend of 4/18-19/15 when Resident #13 wandered into Resident #14's room. She stated Staff L immediately reported the incident to Staff S LPN. Staff V stated Resident #14's behaviors are blatant now like the facility allows Resident #14 to have the behaviors with other residents. Staff V stated Resident #3 has no family/friends and is being abused. A Minimum Data Set (MDS), with assessment reference date of 3/4/15 identified Resident #13 with a brief interview for mental status score of "0" (severe cognitive impairment). Resident #13 required extensive assistance from staff members for mobility and activities of daily living (ADL ' s). Resident #13 required a wheelchair for mobility. Third Incident: On 5/6/15 at 9:50 a.m. Staff U CNA stated Resident #14 has touched other residents. Staff U observed Resident #14 touch Resident #11's chest area as Resident #11 sat in the hallway in his/her wheelchair. Resident #11 did not react to Resident #14 touching his/her chest area. Staff U told Resident #14 he/she couldn't do that. Staff U informed Staff S LPN of the incident. On 5/13/15 at 11:20 a.m. the surveyor asked Staff U when the incident between Resident #14 and #11 occurred. Staff U stated she did not know the exact date but stated it was at "the end of April". Review of the MDS dated [DATE] identified Resident #11 with a BIMS score of "0" (severe cognitive impairment). Resident #11 required extensive assistance with transfers and ADL ' s. Resident #11 required a wheelchair for mobility. Observation showed, on 5/7/15 at 2:10 p.m. Resident #11 independently moving in the wheelchair down the hall. Resident #11 mumbled incoherently when questioned by the surveyor. Fourth Incident: On 5/5/15 at 10:08 a.m. Staff S LPN stated Resident #14 touched Resident #3. Staff S documented the incidents in the behavior book. Staff S identified those dates as 5/1/15 and 5/3/15. On 5/5/15 at 5:08 p.m. Staff S confirmed Staff G and Staff H informed her of an incident involving Resident #13. On all 3 occasions, staff separated Resident #14 from the other resident ' s and informed him/her the behavior was unacceptable. Staff S stated she marked the incidents in the behavior section of the clinical record but failed to report the issues to management. Fifth Incident: On 5/6/15 at 4:50 p.m. Staff J CNA stated she observed Resident #14 exit Resident #3's room either 5/2/15 or 5/3/15 around 7:00 p.m. When she entered Resident #3's room after Resident #14 left, Resident #3 sat in his/her chair fully clothed. Resident #14 failed to answer when Staff J asked Resident #14 what he/she did in Resident #3's room. Staff J stated she informed another CNA but failed to report the incident to the charge nurse on duty. A MDS assessment dated of 3/20/14 for Resident #3 revealed a BIMS score of "0" (severe cognitive impairment). Resident #3 required extensive to total assistance with all ADL ' s. Observation on 5/7/15 at 1:50 p.m. revealed Resident #3 seated in a chair in the corner of his/her room. Resident #3 appeared to look out the window and call for a cat. (No cat visible outside). Resident #3 was not responsive to questions. Sixth Incident: On 5/5/15 at 12:10 p.m. Staff H CNA stated Resident #14's behaviors on the unit "weren't good". Staff H stated Resident #14 sneaks in resident rooms and fondles various residents. Staff H stated yesterday or the day before, she caught Resident #14 standing in front of Resident #3 fondling his/her chest over the clothing. Staff H informed Resident #14 he/she should not do that. Resident #14 said he/she knew that and wouldn't do it again. Staff H informed the Director of Nursing of the incident. Staff H stated a couple weeks ago she observed Resident #14 fondled Resident # 11's chest over his/her clothing. Staff H informed Staff S LPN. On 5/5/15 at 4:57 p.m. the Director of Nursing (DON) stated she first became aware of an incident yesterday (5/4/15) when Resident #14 entered a room on 5/4/15 and fondled the other resident. The DON talked to Resident #14. Resident #14 stated he/she didn't mean anything by it and wouldn't do it again. The DON notified Resident #14 ' s psychiatric ARNP (Advanced Registered Nurse Practitioner) who increased Resident #14's Zoloft (antidepressant) dosage. On 5/5/15 at 10:08 a.m. Staff S LPN stated Resident #14 touched Resident #3. She documented the incidents in the behavior book. She identified those dates as 5/1/15 and 5/3/15. On 5/5/15 at 5:08 p.m. Staff S LPN confirmed staff informed her of an incident involving Resident #13. According to Staff S all occasions, staff separated Resident ' s from Resident #14 and informed him/her the behavior was unacceptable. Staff S stated she marked the incident in the behavior book but didn't report to management. The behavior records identified Staff S marked Resident #14 had sexual behaviors that occurred on 4/20/15, 5/1/15 and 5/3/15. The record failed to identify who Resident #14 directed the behavior to and what the behavior was other than classified as sexual behavior. The behavior record identified the care plan nurse marked Resident #14 sexual behavior occurred 4/25/15 and 4/26/15. The record failed to identify who Resident #14 directed the behavior to and what the behavior was other than classified as sexual behavior. Interview on 5/7/15 at 9:36 a.m. the care plan nurse clarified the two areas documented on Resident #14's behavior record are related to Resident#14 ' s attempts to staff members breasts. A resident attempted elopement assessment dated [DATE] at 1:30 p.m. revealed Resident #14 eloped from the facility by going out a window. The form stated Resident #14 returned inside when directed by staff members. On 5/6/15 at 9:50 a.m. Staff U CNA stated she was in the CCDI dining room finishing lunch with residents when she looked out the window and observed Resident #14 standing outside of the locked CCDI unit by the bird feeder in the yard. On 5/4/15 at 1:40 p.m. the Administrator placed a call to the ARNP to discuss Resident #14's medications and behaviors. On 5/5/15 the ARNP returned the call and increased the Zoloft to 100 (mg) milligrams daily. On 5/5/15 at 4:57 p.m. the DON stated she first became aware of an incident yesterday (5/4/15) when Resident #14 entered a room on 5/4/15 and fondled the other resident. The DON talked to Resident #14. Resident #14 stated he/she didn't mean anything by it and wouldn't do it again. The DON notified Resident #14 ' s psychiatric ARNP (Advanced Registered Nurse Practitioner) who increased Resident #14's Zoloft (antidepressant) dosage. Interview on 5/5/15 at 12:30 p.m. revealed Resident #14 admitted to fondling a resident's chest area. Resident #14 stated he/she didn't know the other resident's name. Resident #14 stated he/she went in the other resident's room and fondled the chest area over the top of clothing. Resident #14 stated this occurred about a week ago and a staff saw him/her. Resident #14 denied all other incidents. Resident #14 answered cognitive questions correctly related to the year, town he/she was in and the President's name. Review of Resident #14's care plan, dated 3/6/15 revealed a lack of interventions on the care plan regarding Resident #14's sexual behaviors or supervision of Resident #14 to prevent sexual behaviors. The care plan contained the following directive "report changes or declines in behavior to ARNP. The care plan failed to identify any interventions related to elopement risk. Even though Resident #14 had a history of [REDACTED]. On 5/5/15 at 4:57 p.m. the DON confirmed she did not see anything on the care plan about supervising Resident #14. The facility resident to resident abuse policy was one sentence that stated if an incident occurred, the facility would take steps to remove the resident to a safe location. Observation on 5/4/15 at 4:30 a.m. the surveyor arrived at the facility. Staff A CNA and Staff B CNA came down the hall and Staff B entered the CCDI (Chronic Confusion and Dementing Illness) unit. The unit doors were closed when Staff B entered the unit. At that time, the surveyor asked Staff A what staff member covered the CCDI Unit during the time Staff B was out of the unit. Staff A stated "no one". Staff A stated she asked Staff B to help her turn a heavier resident. It took less than 3 minutes. Staff A didn't ask the CNA from the other wing because that CNA can't lift. Staff A didn't ask the nurse because the nurse appeared busy with paper work. On 5/4/15 at 4:46 a.m. Staff B stated she left the unit and helped Staff A turn a resident and wasn't gone over 5 minutes. Staff B checked everyone before she left. Staff B stated there are15 residents in the CCDI unit. Note: At the time of the incident investigation the findings of the investigation revealed an immediate and serious jeopardy with a scope of " K " identified. By 5/7/15 the facility had completed staff education. The facility implemented 1:1 supervision for Resident #14. So the grid level for the deficiency was lowered to a " E " . As of the 5/20/15 exit the facility had failed to assure compliance with policies in determining the whereabouts of wandering or behavioral residents.

Based on observation, record review, staff, resident and ARNP (advanced registered nurse practitioner) interviews, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with comprehensive assessments, plan of care updates and assessments related to pain control and change of condition for 2 of 6 residents reviewed (Resident #9 and #8). Facility census was sixty-three (63) residents. Findings include: 1. A MDS assessment dated [DATE] identified Resident # 9's BIM's score of "3" (severe cognitive impairment). The MDS revealed Resident #9 ambulated independently and required extensive assistance with toileting personal hygiene and bathing. A "balance during transitions and walking" test revealed Resident #9 was unsteady but able to stabilize without staff assistance. Resident#9 ' s MDS listed [DIAGNOSES REDACTED].#9. An Iowa emergency medical (EMS) report dated 4/20/15 revealed Resident #9 normally walked all over but the last couple days Resident #9 refused to walk. Yesterday Resident #9 rode in a wheelchair and today Resident #9 refused to get out of bed. The EMS report documented that nursing reported that from reading the nursing home paperwork, Resident #9 fell 2 to 3 days ago. EMS observed the left leg shortened and outwardly rotated due to [MEDICAL CONDITION]. An x-ray report, dated 4/20/15, showed a Varus-angulated left femoral [MEDICAL CONDITION]. Hospital records dated 4/20/15 identified Resident #9 transported from the local hospital to another hospital for surgical repair of the left [MEDICAL CONDITION]. The assessment/plan portion of the hospital records revealed Resident #9 was an inpatient due to trauma and required pain management and an invasive procedure. The history identified it was unclear whether Resident #9 fell and when. Resident #9's daughter saw him/her on 4/18/15 and Resident #9 was not his/her usual self. Resident #9 complained of pain and swelling in the knee. Resident #9 ' s left leg showed shortening and external rotation with hip pain with any movement of the left lower extremity. Review of Resident #9's record failed to contain any information regarding a fall. On 5/5/15 at 3:30 p.m., Staff M CNA stated she didn't witness the fall but Staff X LPN asked her to help with Resident #9 after locating him/her on the floor. Staff M reviewed the schedule and identified the date of the fall as 4/15/15. Staff M stated Resident #14 reported Resident #9 was on the floor and needed help. Staff X and Staff K CNA got Resident #9 off the floor and then Staff X and Staff M laid Resident #9 in bed. Staff M documented in a written statement, that Staff K went down the hall to get washcloths when Resident #14 asked for help getting a resident of the floor. Staff K got Staff X. Staff X came to Staff M as she assisted another resident and asked her to help with Resident #9. Staff X said Resident #9 was tired. Resident #9 confirmed he/she felt tired. Resident #9 stood up with Staff X and Staff M and went to bed. Staff X took Resident #9's vital signs. Resident #9 denied pain. Staff M did not see Staff X perform a range of motion assessment. Staff M stated the incident occurred between 7:30 p.m. and 8:00 p.m. On 5/5/15 at 4:10 p.m. Staff K CNA documented in a written statement, that on 4/15/15 around 7:30 p.m. Resident #14 called out for help because Resident #9 was on the floor lying on the left side. Resident #14 said Resident #9 stumbled and was fine. Staff K got Staff X (charge nurse). Staff X checked Resident #9 for bruising and redness and said everything looked OK. Staff K and Staff X transferred Resident #9 to the sofa and later to bed. Staff X failed to complete a range of motion assessment. On 5/5/15 at 4:27 p.m. Staff X LPN documented she did not have knowledge of Resident #9 falling or being on the floor. The Administrator gave the surveyor a paper dated 4/21/15 that contained staff names with "no" by the names indicating the staff knew nothing of Resident #9 falling. Staff K and Staff M had "no" by staff member names indicating unaware of the Resident #9 falling. On 5/5/15 at 4:10 p.m. when asked about the discrepancy, Staff K stated no one asked her if she knew Resident #9 fell . On 5/5/15 at 3:30 p.m., when asked about the discrepancy, Staff M stated no one asked her if she knew anything about Resident #9 falling. On 5/5/15 at 4:42 p.m. Resident #14 stated he/she didn't see what happened. Resident #14 just observed Resident #9 on the floor in the lounge and Resident #14 requested help for Resident #9. Other staff with "no" written by their name on facility investigation question sheet to indicate they knew nothing of Resident #9's fall: On 5/5/15 at 1:28 p.m. Staff L CNA, when asked about the discrepancy stated she didn't recall anyone asking her about Resident #9's fall. On 5/5/15 at 4:57 p.m. the Administrator and Director of Nursing stated they knew nothing about Resident #9 having a fall. After the [MEDICAL CONDITION], they asked staff if they knew anything and staff did not provide any additional information. Observation showed, on 5/4/15 at 6:50 a.m. Resident #9 in bed with call light unavailable. Resident #9 stated she/he didn't recall falling. Observation showed a large incisional area to the left hip. Resident #9 stood up from bed with the assistance of two staff members a gait belt and transferred to a wheelchair. Interviews with staff working between 4/15/15 (after fall) and 4/20/15 (discovery of [MEDICAL CONDITION]): On 5/6/15 at 2:52 p.m. Staff W CNA stated she worked with Resident #9 on 4/16/15 and 4/17/15. On 4/16/15 Resident #9 used a wheelchair and experienced pain even when staff slightly moved Resident #9. On 4/17/15 Resident #9 unable to walk at all. Staff W informed Staff X LPN both days. Staff X stated Resident #9 was OK. Staff W stated Resident #9 felt warm and had extreme pain when Staff X checked him/her but Staff X stated Resident #9 was fine. Staff W stated she knew something was wrong. When Staff W asked why Resident #9 unable to walk, Staff X identified Resident #9 fell . On 5/7/15 at 2:33 p.m. Staff X LPN stated staff reported Resident #9 complained of pain when transferred to bed. Staff X unable to recall what day that was. Staff X stated in the days prior to discovery of the [MEDICAL CONDITION], Staff X didn't recall Resident #9 using a wheelchair. Staff X thought Resident #9 walked to the dining room and his/her room. Resident #9 experienced a little pain. Staff X stated she assessed Resident #9 and performed range of motion. Resident #9 stated "Ow" when Staff X lifted Resident #9's leg up high. On 5/7/15 at 9:08 a.m. Staff G CNA stated she worked with Resident #9 4/16/15 and 4/17/15. Resident #9 used a wheelchair because he/she couldn't fully walk. Resident #9 stated "ow, ow" and appeared more hunched over. Staff G figured it was arthritis. Staff G reported Resident #9's condition to Staff S LPN. On 5/7/15 at 10:22 a.m. Staff D CNA stated she worked with Resident #9 on 4/16/15 and he/she used a wheelchair. Staff D couldn't recall if Resident #9 experienced pain. On 5/7/15 at 9:00 a.m. Staff H CNA stated she worked with Resident #9 prior to fracture discovery and Resident #9 used a wheelchair because he/she didn't walk very well. Resident #9 stated he/she had pain. Staff H reported it to the charge nurse. On 5/6/15 at 12:57 p.m., Staff V CNA stated she worked with Resident #9 the weekend of 4/18/15. When staff turned Resident #9 for cares, he/she screamed out with pain. When asked what hurt, Resident #9 stated, "My leg". That was different than Resident #9's usual. Just 2 weeks before, when Staff V last worked with Resident #9, he/she could ambulate independently. Staff V stated the weekend of 4/18/15 she observed swelling to Resident #9 ' s leg. Staff V informed Staff S LPN who stated Resident #9 suffered from arthritis. Staff V stated they left Resident #9 in bed all weekend and when they checked and changed Resident #9, he/she experienced pain. Even to try and get Resident #9 to sit up caused him/her extreme pain. On 5/5/15 at 10:35 a.m., Staff L CNA stated she worked the weekend of 4/18/15. Resident #9 complained of pain and Staff L reported it to Staff S LPN. The Staff members left Resident #9 in bed provided positioning along with checked and changed him/her due to Resident #9's leg appeared swollen. On 5/11/15 at 11:04 a.m. Staff S LPN stated she recalled the staff saying Resident #9 was not standing well. Staff S stated she didn't recall if Resident #9 used a wheelchair. Staff S stated she looked at Resident #9 when she helped staff get him/her out of bed. Staff S didn't recall if Resident #9 complained of pain. When asked why she didn't document anything about the Resident #9's condition. Staff S just shook her head and failed to answer. On 5/6/15 at 6:41 p.m. Staff F LPN stated one night staff reported Resident #9 had knee pain. That was not uncommon. Staff F thought she administered Tylenol ([MEDICATION NAME]) to Resident #9. Review of the Resident #9's April 2015 Medication Administration Record [REDACTED]. If Staff F knew of the fall, she would have checked Resident #9 thoroughly for signs of injury when he/she complained of pain. Review of the April 2015 Medication Administration Record [REDACTED]. On 5/5/15 at 3:30 p.m. Staff M CNA stated she worked with Resident #9 on Friday 4/17/15 and Resident #9 used a wheelchair. Staff M stated she didn't believe Resident #9 had pain when he/she stood up. Staff M stated Resident #9 wasn't 100% on 4/16/15 either. On 5/6/15 at 12:33 p.m. the care plan nurse stated she worked the weekend of 4/18/15 and the CNA ' s told her Resident ' 9 didn't act right. Resident #9 recently received a [DIAGNOSES REDACTED].#9 didn't act per usual due to that. Staff didn't say anything to her about Resident #9's decreased mobility or pain. The care plan nurse never heard Resident #9 fell . Review of the Resident #9's clinical record revealed a lack of documentation from 4/13/15 until 4/20/15 at 12:30 p.m. when Staff S LPN documented she received an order from the physician. The entry did not identify why she contacted the physician or any type of assessment. A urinary tract infection [MEDICAL CONDITION] flow sheet identified a column "pain". On 5/11/15 at 11:04 a.m. Staff S LPN stated the pain on the UTI flow sheet referred to urinary pain symptoms only. On 5/7/15 at 2:33 p.m. Staff X LPN stated the pain column on the UTI flow sheet was for urinary pain only. On 5/7/15 at 2:00 p.m. Staff C LPN stated the pain column on the UTI flow sheet referred to urinary pain only. On 5/7/15 at 2:15 p.m., the care plan nurse stated the pain column on the UTI flow sheet referred to urinary pain only. On 5/7/15 at 2:55 p.m. Staff I RN (registered nurse) stated the pain column on the UTI flow sheet referred to urinary pain only. On 5/6/15 at 10:00 a.m. the surveyor spoke with the physician who works with Resident #9's ARNP. The physician reviewed Resident #9's office file with the surveyor and said the facility reported a skin tear to the right elbow on 4/15/15. He stated there was nothing about a fall reported in the file. On 5/18/15 at 2:49 p.m. the DON emailed the surveyor. The DON stated she conducted interviews after the surveyor asked her about the skin tear report the physician identified in the file. No staff knew anything about the skin tear. Staff F filled out the form but failed to recall anything about it. No one knows who sent it. The DON stated she checked Resident #9's arm and failed see evidence of a skin tear. A fax to the physician, dated 4/15/15 at 2:50 a.m. identified a 1.5 centimeter (cm) by 0.5 cm skin tear to the right elbow. The DON stated in a 5/18/15 2:49 p.m. email that she obtained the fax report from the physician's office. On 5/5/15 at 2:12 p.m., Resident #9's daughter stated someone from the facility called her on 4/17/15 at 11:00 a.m. and reported Resident #9 fell . On 5/7/15 at 3:00 p.m. Resident #9's ARNP stated she would agree the fracture was due to trauma. She stated she did not evaluate the x-ray herself but she would go along with what the hospital physician documented about trauma. She stated she would have wanted the facility to call her sooner when Resident #9 experienced pain and mobility changes. She would have ordered testing sooner. The ARNP stated the first time she was contacted about the resident was 4/20/15. No one reported Resident #9 fell . She saw Resident #9 on 4/20/15 at 6:00 p.m. The progress note revealed Resident #9 was in bed and had [MEDICAL CONDITION] to the left leg and discomfort with movement. She ordered an x-ray of the hip and femur. Observation on 5/4/15 at 6:50 a.m. revealed Resident #9 in bed call light unavailable. Resident #9 stated she didn't recall falling. The call light was not available. Observation showed a large incisional area to the left hip. Resident #9 stood up from bed with the assistance of two staff members a gait belt and transferred to a wheelchair. Facility accident policy identified if a fall occurred an assessment for falls form is completed on the resident. The form included documentation of any injury sustained and treatment provided. The charge nurse would review the care plan and complete a 24 hour follow up. 2. The MDS assessment dated [DATE] identified Resident # 8 " s BIMS score of "12" (moderate cognitive impairment). Resident #8 required limited staff assistance with ambulation and extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #8 ' s MDS listed functional range of motion limitations of the lower extremities and used a wheelchair and walker for mobility. Resident #8 ' s [DIAGNOSES REDACTED]. Resident #8 had shortness of breath and used oxygen. On 5/5/15 at 2:40 p.m. Resident #7 (interviewable and former roommate of Resident #8) stated Resident #8 had a condition change at 3:10 p.m. on 4/9/15. Resident #7 tried to get help for Resident #8. He informed Staff X LPN Resident #8 needed help. Twenty minutes went by and Staff X (charge nurse) did not show up. At 3:50 p.m. Staff X still did not show up to check Resident #8. Resident #7's friend arrived and intervened getting Staff X. Resident #7 stated it took 45 minutes for Staff X to come to the room. Resident #7 looked at a clock on the wall to monitor the time. He/she stated the resident went to the hospital. The next day he/she reported the incident to the Director of Nursing and stated he/she was sure nothing was done about it. Review of Resident #8's history and physical dated 4/9/15 revealed Resident #8 arrived at the emergency room unresponsive. The impression was acute [MEDICAL CONDITION]. The local hospital transported Resident #8 to a larger hospital for care. On 5/11/15 at 8:48 a.m. the surveyor completed a telephone interview with Resident #8. He/she stated if a resident needed something, the response time was atrocious. If he/she could give the facility a score on a scale from 1 to 10, he/she would give it a minus 5. Resident #8 stated he/she didn't recall the incident in detail. Review of nurse ' s notes dated 4/9/15 at 4:40 p.m. revealed staff called the physician about a condition change and received orders. At 4:45 p.m. staff called 911 to transport Resident #8 to the hospital. There was no documentation of assessments or what was going on with Resident #8 prior to transport. On 5/13/15 at 9:00 p.m. the surveyor spoke with a friend of Resident #7 and Resident #8 (that intervened to get Staff X LPN to come to the room). The friend stated he went to visit the residents and when he entered the room, Resident #8 appeared blue with jerking as if having a [MEDICAL CONDITION]. Resident #7 appeared very upset and said he/she called 40 minutes ago. The friend yelled for help and ran to the nurse ' s station. The friend thought Resident #8 was dying. Staff X sat at the nurse ' s station and didn't appear concerned and seemed very "put out". Staff X went to the room in no big hurry and started checking Resident #8's blood pressure. The friend asked Staff X if she should call 911. Staff X got upset and told the friend to get out of the room. The friend and Resident #7 believed Staff X failed to do her job and could have cared less about the change of condition for Resident #8. On 5/7/15 at 2:33 p.m. Staff X LPN stated she prioritized and had 3 things going on at once. Staff X stated she was aware Resident # 8 had issues immediately after she came in to work at 3:00 p.m. Staff X stated she was told Resident #8 was alert and felt funny. At that time, the surveyor showed Staff X an employee reprimand the Administrator gave the surveyor, dated 4/9/15 and unsigned by Staff X. It stated the Administrator spoke with Staff X about the need to prioritize and ask for help. When a resident comes to her and needs something, Staff X needs to respond immediately. Staff X denied ever seeing the reprimand before and stated no one had talked to her about the incident. On 5/20/15 at 11:00 a.m. the acting Administrator stated when the ambulance arrived to transport Resident #8 to the hospital, Resident #8 was awake and yelling. An EMS (emergency medical services) report dated 4/9/15 revealed when EMS personnel arrived at the facility they found Resident #8 unresponsive and slumped down in his/her recliner with the roommate saying he/she was this way for 40 minutes. EMS assessed Resident #8's lungs as coarse and wet throughout with respirations 24 and labored. Resident #8's eye pupils appeared constricted. Both legs wept at the calves with 4 plus [MEDICAL CONDITION] observed in the ankles and jugular distention was documented.

Based on record review, staff and resident interviews, and review of facility policy/procedures, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, failed to ensure against hazard from elements in the environment and the facility health facility supervisor failed to supervise the implementation of the plan of care for two of five residents (Residents #5 and #2.) reviewed. The facility reported a census of 55 residents. Resident #2 received a whirlpool bath. Resident #2 had a [DIAGNOSES REDACTED]. The whirlpool manufacturer ' s recommendations directed staff to not release the safety belt until ready to transfer. The CNA did not follow the manufacturer ' s instructions and released the safety belt before drying the resident. The resident urinated and defecated in the chair and slid out of the chair. The CNA could not catch the resident. The staff sent the resident to the hospital due to groin/leg pain. The resident had a fractured hip. Resident #5 required the assistance of 2 people with transfers. The care plan directed staff to transfer with 2 people and to remove the foot pedals before transferring the resident. One CNA transferred the resident from the toilet. The resident began to fall and was lowered to the floor. The resident stated he/she had hit ankle on the foot pedal. Findings include: 1. A Minimum Data Set (MDS) assessment with a reference date of 4/12/2012 documented Resident #2 required extensive assistance of two people for bed mobility, transfers and bathing. The assessment noted the resident had impaired balance and experienced incontinence of bowel and bladder. A 60-day evaluation by a PA dated 4/17/12 assessed this resident with [DIAGNOSES REDACTED], congestive heart failure, hypertension, Parkinson's Disease, depression, a history of pulmonary embolus and cancer. A Resident Care Note (nurse's progress note) dated 3/29/12 at 6:20 a.m. noted a Certified Nursing Assistant (CNA) reported the resident as diaphoretic, involuntary body movements and color pale. The nurse noted the resident sitting in a wheelchair making rocking movement repeatedly with body. The plan of care dated 4/25/12 identified a problem with alteration in care status as related to needing assistance with cares. The plan of care directed the staff to provide extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The plan of care identified the resident's risk for injury as related to falls due to Parkinson's disease. A PA (Physician Assistant) progress note dated 5/15/12 noted the [AGE] year-old resident complained of not feeling well, headaches and feeling dizzy. A fall risk assessment tool dated 6/28/12 noted the resident's fall risk to be related to balance difficulties and a mental status impairment. The Resident Care Notes found in this resident's clinical record revealed one note dated 6/26/12 addressing family notification of a new physician's orders [REDACTED]." The Resident Care Notes lacked any documentation of any fall or an assessment of the resident's change in condition to warrant an emergency room visit. The next entry dated 7/6/12 at 1:45 p.m. noted the nurse called the hospital. Resident #2 was admitted to the hospital for the treatment of [REDACTED]. A Resident Fall Assessment sheet dated 7/6/12 at 11:15 a.m. noted the resident in a whirlpool chair, started to urinate and have a bowel movement, and then slid out of the chair. The CNA could not grab him/her to keep the resident from sliding from the chair. The resident complained of pain in the left groin/hip and the left leg externally rotated. An Admission History and Physical report dated 7/6/12 assessed this resident with a left hip fracture due to a fall. On 7/24/12 at 11:15 a.m. Staff E (CNA) was interviewed and stated Resident #2 required the assistance of two people for all transfers. On 7/6/12 she gave Resident #2 a whirlpool bath. Staff E stated after bathing the resident, she raised the whirlpool chair out of the tub, swung the chair/resident around and lowered the chair. Staff E stated she then unfastened the whirlpool seatbelt to dry off the resident. Staff E stated she dried the resident's legs and placed the resident's pants on up to his/her thighs. She covered the resident's top half with towels. She then began to dry off the resident's arm when the resident urinated and defecated. The resident then slid out of the chair. Staff E stated she could not stop the resident, due to the resident no longer had the seat belt fastened, the resident was not wearing anything on the top half and his/her skin was wet, so she had nothing to grab onto to stop the resident from falling out of the chair. Staff E stated had the whirlpool seat belt been fastened, the resident would not have fallen out of the chair. The resident cried out in pain when he/she fell out of the chair. Staff E stated she called for a nurse. Staff E stated it took four staff members to pick the resident up off the floor with the use of a gait belt. The resident complained of pain with movement. Staff E stated the whirlpool seat belt should be fastened the entire time except for transfers. The Whirlpool Manufactures Instructions (kept in the whirlpool room) noted The Superior Sit-Bath 6300 as designed to significantly improve the efficiency and environmental safety of nursing care operation. However, the benefits designed into the Sit-Bath System will be realized only if the system is operated and cared for properly. The purpose of the manual is to provide staff with a recommended procedure to help obtain the maximum efficiency and safety from the Sit-Bath System. Warning on page 6 read, "WARNING, Only personnel who have been thoroughly trained in the operation of the Superior Sit-Bath System 6300 should operate this equipment. Operation of this equipment by untrained personnel could result in injury to the operator or patient. Step 4 page 9 read, "Transfer the resident into the Penner Transfer using the proper nursing techniques. Secure the seatbelt around the resident, keeping the belt low and fastened around the resident's lap. Page 11, WARNING, Failure to secure the resident properly with the seatbelt could result in injury to the resident or operator. Transfer from Bath to Bed, page 20 included: Raise the resident until the bottom of the chair is two inches above the tub rim. Pat the resident dry with a soft towel. No rubbing is necessary. Use the towel to dry and clean the underside of the chair. This will prevent water from dripping on the floor and residue buildup under the seat. Before you rotate the resident out of the tub, make sure the lower extremities have been towel dried so the bathroom floor stays dry. Rotate the resident slowly out of the tub, lifting the resident's feet as you do this. The last step, step 16, read, "Release the seat belt from around the resident and transfer the resident using proper nursing techniques." When interviewed on 7/23/12 at 2:00 p.m. the resident complained of severe pain in the pelvic area. The resident stated the pain was from a fall in the shower room when he/she stood up and fell . On 7/30/12 at 8:30 a.m. the Director of Nursing (DON) was interviewed and stated she did the investigation of this incident and found the aide acted correctly in this situation and she found no fault with the aide removing this resident's safety seat belt prior to drying and dressing the resident. The DON stated the facility routinely has one aide teach another aide about how to use the whirlpool correctly. The DON stated the staff does not dry the resident off. The DON stated they lift the resident from the water, swing the chair around, lower the resident then dry the resident. The DON stated the staff removes the safety seat belt when drying the resident. The DON stated she felt it was alright for the aide to remove this resident's safety seat belt prior to drying/dressing the resident and prior to the second staff member entering the whirlpool room in preparation for the assisted transfer from the whirlpool 2. The face sheet for Resident #5 identified a date of admission into the facility as 12/30/2005. A physician History and Physical report dated 4/21/12 identified Resident #5 had diabetes, hypertension and atrial fibrillation. The physician assessed this resident with pitting edema of the lower extremities. A Physician's Assistant (PA) progress note dated 3/6/12 noted the resident weighed 166.9 pounds, lower extremity edema with a history of cellulitis and gout. A Level of Assistance Form (not dated) completed by the physical therapist noted the resident required the assistance of two people with a wheeled walker for transfers. An occupational therapy assessment dated [DATE] noted the resident required the assistance of two people at times, and at times required the assistance of only one person. This assessment noted the resident presented with decreased strength and endurance. A Physical Therapy assessment note dated 5/2/12 assessed this resident with decreased strength and functional mobility secondary to asthmatic bronchitis. The therapist assessed this resident with poor control while sitting in a chair, due to the resident "plopped" into the chair. A Resident Care Note dated 5/30/12 (written by a Registered Nurse) noted the resident would be discharged from skilled level of care on 6/1/12 due to physical therapy and occupational therapy assessed this resident at his/her highest level of functioning. The nurse noted the resident required extensive assistance with most cares, except eating. A CNA (Certified Nursing Assistant) care plan (not dated), unit instruction sheet, found at the nurse's station during the investigation, instructed the staff that the resident required the extensive assistance of two people for transfers, to use the EZ Stand as needed, and instructed the staff to remove the resident's foot pedals on the wheelchair prior to transfers in and out of the wheelchair. The Minimum Data Set (MDS) assessment tool with a reference date of 6/1/12 documented the resident required extensive assistance of two persons for transfers, walking, dressing and toilet use. The MDS assessed the resident as not steady while moving from a seated to a standing position, walking, turning and moving on and off the toilet. The Plan of Care dated 6/6/12 instructed the staff to provide extensive assistance with bed mobility, transfers, personal hygiene, dressing and toilet use. The plan of care also instructed the staff to remove the foot pedals from the wheelchair prior to transfers. A Resident Skin Injury assessment dated [DATE] noted Resident #5 had a 4 centimeter (cm) by 3 cm raised area and faint purple eccymotic area, pain to touch to the right inner ankle area. The nurse documented the application of an ice pack for approximately 20 minutes. The Explanation of how the injury occurred, read, "Resident states wheelchair leg dropped on my ankle when C.N.A. removing prior to transfer." On 7/24/12 the nurse documented the C.N.A. reported the resident was lowered to the floor with assistance of one person on 7/23/12. A Non-Pressure Skin Condition Report assessed the resident with a new 4 cm by 3 cm raised area on 7/23/12, and a 4 cm by 4 cm faint purple raised area on 7/24/12. The July 2012 MAR (Medication Administration Record) indicated the nurse gave Resident #5 two MAPAP (acetaminophen tablets) on 7/24/12 at 12:30 a.m. for complaints of right ankle pain and again on 7/24/12 at 5:15 a.m. The note indicated the pain " better " at 1:30 a.m. and again better at 6:15 a.m. The July 2012 MAR also noted the staff sometimes would hold the resident's Metoprolol 25 milligrams (helps to lower blood pressure, helps with heart pain and an abnormal rhythm of the heart) due to a low heart rate. The heart rate ranged from 50-56 beats per minute. Review of this resident's clinical record revealed the lack of documentation in the Resident Care Notes (nurse's progress notes) of the resident's fall and/or any assessment of a new painful, raised, bruised area on the right inner ankle. The Resident Care Note dated 7/24/12 indicated the PA examined left leg/ankle. A Resident Fall Assessment sheet completed on 7/24/12 indicated the resident stated he/she was getting off the toilet and felt him/herself going to fall. The Aide then lowered him/her to the floor and somehow, something bumped his/her ankle. The resident stated the foot pedals on the wheelchair were still on the wheelchair. The nurse documented she/he elevated the resident's ankle on a chair, applied ice to the left inner ankle area, pain to touch. The nurse documented on 7/24/12 that the nurse documented staff assisted the resident with the transfer with assistance of two. The resident complained of pain during the transfer and stated "It does hurt to stand on it." An Employee Reprimand dated 7/24/12 noted the facility reprimanded C.N.A., Staff A for carelessness and violation of safety rules. Explanation of the offense included: need to remove foot pedals before transfers, need to use gait belt for transfers and completely report details to nurse of incidents. A Crestview Nursing and Rehabilitation In-Service dated 7/25/12 noted: 1) Nursing assistants are expected to follow the care plans when providing cares to residents. The C.N.A. worksheets provide a reference for this information. This includes but is not limited to the number of staff required to assist with transfers. 2) When transferring a resident who requires any more assistance than stand-by or contact guard assist a gait belt must always be used unless you have been directed by the Director of Nursing or Assistant Director of Nursing differently. 3) When transferring a resident with foot pedals on their wheelchair, the pedals need to be removed prior to transfer. If the care plan/C.N.A. worksheet states the pedals must be removed, then they must be even if they swing. 4) If a resident falls, is found on the floor, or is lowered to the floor, the nursing assistant must immediately reported to the charge nurse. The charge nurse must follow the safety program and complete a fall report and investigation. On 7/23/12 at 4:05 p.m. the resident was interviewed. The resident sat in a wheelchair in the hallway with feet elevated on a chair and an ice pack noted on the resident's right ankle. The resident stated had hurt ankle when a staff member assisted him/her off the toilet and then lowered him/her to the floor. Observation on 7/23/12 at 4:25 p.m. revealed two C.N.A.'s assisted Resident #5 to the bathroom. The resident then assessed his/her pain in the right ankle at a 7 on a scale of 1 to 10 with 10 being the most severe. On 7/24/12 at 9:40 a.m., Staff B (Licensed Practical Nurse), was interviewed and stated on 7/23/12 at about 9:00 a.m. Staff A came and informed her that she lowered Resident #5 to the floor. Staff B stated they had worked at the facility for nine years and they did not consider "lowering" a resident to the floor as a fall. Staff B stated at about 10:00 a.m. on 7/23/12, she noted Resident #5 had a bruise on the ankle, and noticed a raised area. Staff B stated she applied ice to the resident's ankle. The nurse denied assessing the resident and/or the resident's ankle at the time of the fall and did not document her later assessment of the resident and the resident's ankle. The nurse stated she later documented the incident on a skin assessment sheet. Staff B stated the resident complained of pain in the ankle. The nurse stated she did not complete an incident report due to the resident did not fall. When interviewed on 7/24/12 at 9:55 a.m., Resident #5 sat in a wheelchair with his/her feet elevated on a chair. Observation revealed a raised, purple area on the inner right ankle. The resident rated his/her pain at a "5" at this time. The resident denied the ability to bear weight on the right ankle due to terrible pain with any weight bearing attempt. When interviewed on 7/25/12 at 4:00 p.m. Resident #5 stated his/her right ankle remained swollen and painful to the touch. On 7/24/12 at 10:20 a.m. Staff A (C.N.A), was interviewed and reported assisting Resident #5 to the bathroom on 7/23/12. Staff A stated they assisted Resident #5 to the bathroom by walking the resident to the bathroom, by herself without the use of a gait belt. When walking the resident out of the bathroom, to the wheelchair located in the resident's bedroom, the resident began to fall to the right. Staff A stated was unable to stop the resident's fall, and attempted to guide the resident by holding onto the resident's left arm with her left hand and placed her right hand on the resident's left thigh as the resident fell to the right. The resident fell to the floor and onto the foot pedals of the wheelchair. Staff A denied using a gait belt. Staff A denied using the assistance of two persons for the transfer/walking and she denied removing this resident's wheelchair foot pedals prior to the transfer. Staff A stated they left the resident on the floor and went and reported the fall to the nurse, Staff B. After reporting the fall to the nurse, Staff A assisted the resident up off the floor with the assistance of another aide, prior to the nurse assessing the resident. On 7/24/12 at 11:10 a.m. the Administrator stated the facility did not have a policy and/or procedure for gait belt use and/or transfers. The Administrator stated the staffs are not required to complete an incident report when a resident is lowered to the floor and it is not required for the nurse to document the incident in the nurse's progress notes. The Administrator stated the facility does not consider "lowering" a resident to the floor a fall. The Administrator stated that Staff B had told her she was going to complete an incident report for this resident from the incident on 7/23/12. On 7/24/12 at 12:15 p.m. Staff C (CNA) was interviewed and stated the facility had oriented Staff A. Staff C stated she had instructed Staff A to use a gait belt for all assisted transfers during her orientation. Staff C reported checking the CNA instruction/unit sheets when there was a change, such as a resident returning from the hospital. Staff C denied referring to these instruction sheets on a routine basis. Staff C reported Staff A had transferred Resident #5 by herself on 7/23/12. Staff C reported normally using a gait belt with Resident #5; however she denied removing the wheelchair foot pedals prior to the transfer. On 7/23/12, Staff A came and requested her assistance. Staff C stated she found Resident #5 sitting on the floor, in his/her bedroom, sitting on the footrest of the wheelchair. They lifted the resident off the floor without the use of a gait belt. Staff C stated the resident complained of pain in the right ankle with standing. Staff C reported always transferring this resident alone. Staff C stated Resident #5 told her of his/her pain in the right ankle when he/she stood. Staff C stated Resident #5 normally did not complain of pain. On 7/24/12 at 2:10 p.m. Staff D (CNA) was interviewed and reported working for the facility for four years and reported always following the CNA care plan/instruction sheets. Staff D reported when assisting Resident #5, the staff would transfer the resident alone on the resident's good days and use the assistance of two persons on the resident's bad days. Staff D reported Resident #5 had good days and bad days. On 7/24/12 at 2:40 p.m. the ADON (Assistant Director of Nursing) was interviewed and stated the CNA care plan instruction sheet was not an official document and the aides were free to deviate from the instruction sheet. The ADON stated although the instruction sheet instructed the staff to use the assistance of two for transfers with this resident, she believed it was alright for the staff only used one. The ADON stated new aides were trained proper techniques by other aides. On 7/24/12 at 11:15 a.m. Staff E (CNA) was interviewed and stated had worked at the facility for [AGE] years. Staff E stated she has deviated from the CNA care plan instruction sheet when she transferred a resident by herself when the resident needed to use the bathroom. Staff E stated although she does go by the CNA instruction sheet, a lot of it is common sense and she will go by how the resident is doing on any given day. If the resident has a good day, she will transfer Resident #5 by herself. On 7/30/12 at 8:30 a.m. the Director of Nursing (DON) was interviewed and stated she considered all incidents of lowering a resident to the floor a fall. The DON stated she would expect the nurse to always assess the resident for injury prior to the staff moving the resident after a fall. The DON stated she also would have expected this nurse to complete an assessment of Resident #5 after their fall on 7/23/12, she would have expected her to document this assessment on a fall incident report sheet at the time of this fall and she would have expected the aide to use a gait belt for this transfer and to remove the foot rests as directed.

Based on observation, record review and interviews with residents, staff and family, the facility failed to assess and treat a skin injury (Resident #5) and failed to assess and provide interventions for nausea and pain which represented a change in activities of daily living (Resident #2). Twelve residents were reviewed. The facility reported a census of fifty three residents. Findings included: 1. The Medication Administration Record for Resident #5 dated June 2011 identified [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment with a reference date of 6/9/2011 indicated the resident had severely impaired cognitive function and required extensive assistance of two staff for transfers. The MDS indicated Resident #5 did not ambulate. A Resident Skin Injury Assessment document dated 6/1/2011 reflected the resident had received a 24.4 centimeter area of abrasions to the front of the left shin when the resident put leg under the foot rest of the recliner chair. The assessment indicated the area was cleansed with soap and water and wrapped with a clean dry dressing. On 6/29/2011 at 6:38 a.m., observation revealed the resident seated in a wheelchair in the dining room. The resident ' s left lateral leg had superficial open areas evident with a one inch circular area of bright red blood on the resident ' s sock. During an observation on 6/29/2011 at 2:24 p.m. the resident sat in the recliner. The resident had the right leg off the right side of the footrest. The resident had the left knee bent with his/her foot pushed down between the right leg and the mechanical/metal parts which attach the footrest to the chair. The foot rest itself had been padded, but the lower portion of the resident ' s lateral left leg was in contact with the metal parts. The surveyor obtained a photograph of the chair. On 6/30/2011 at 6:41 a.m. the resident ' s record lacked documentation which indicated staff had assessed or treated the new skin injuries to the left lateral leg. After being told of the injury, staff documented the area to the outer, left, lower leg measured 27 centimeters by 5 centimeters. 2. Resident #2 had a Minimum Data Set assessment with a reference date of 5/26/2011. The MDS indicated the resident had severely impaired cognitive function and required total assistance of staff for transfers. Resident #2 did not ambulate. A History and Physical report dated 3/22/2011 reflected the resident was admitted to the hospital with [REDACTED]. The document further reflected the resident had apparently had trauma to the shoulder 2 or 3 months prior. A Physician ' s Progress Note dated 3/24/2011 indicated the cause of the pain to be septic arthritis. The NP (Nurse Practitioner) examined the resident on 5/17/2011 and identified one ecchymotic (subcutaneous hemorrhage under the skin-purple bruise) area on the left shoulder which the resident voiced from a fall. The note indicated the resident sat up in the chair while the spouse gave ice water. The resident had a small emesis of clear liquids. On 6/28/2011 at 2:30 p.m., a resident ' s family member stated the resident would get nauseated and vomit when sat up in a chair. The family member continued to state the resident had been in the bed most of the time for about a month. On 6/29/2011 at 10:26 a.m., Staff I1 and staff G, Certified Nursing Assistants assisted the resident to transfer from the bed and positioned the resident in the wheelchair. At 11:31 a.m., the resident laid in bed. The resident stated he/she had to lie down due to being sick to stomach. The resident stated had pain in the left shoulder and thought that may have caused the nausea. During an interview on 6/29/2011 at 3:51 p.m., the resident ' s family member stated the resident had slipped in a tub chair and hit the shoulder. The shoulder had been painful every day since then. On 6/30/2011 the Administrator provided an incident report form dated 12/3/2010 and stated this was the incident the resident and family member had made reference to. During an observation on 6/29/2011 at 2:15 p.m. the Restorative Aide assisted the resident with range of motion exercises. The aide assisted the resident with left arm exercises and the resident grimaced and winced with each movement. The Restorative Aide moved the resident ' s arm through ten repetitions of raises, abduction/adduction and elbow bends. The Restorative Aide stated in a sympathetic voice, " This hurts a little doesn ' t it? " The Restorative Aide stated the resident usually did have some pain with Range of Motion to the left shoulder. The resident ' s June 2011 MAR (Medication Administration Record) documented the resident had an order for [REDACTED]. The resident also had an order for [REDACTED]. Staff documented the Tylenol had been given ten times in June 2011, but not on June 29, 2011. The MAR indicated the physician had ordered [MEDICATION NAME] (used to treat nausea). The MAR revealed the staff administered the medication 5/21/2011, 5/22/2011 and 5/23/2011. The medication had not been administered in June 2011 and crossed off. The staff reported on 6/29/2011 of the resident ' s nausea to the physician and received a new order for [MEDICATION NAME] 8 milligrams every six hours as needed and to give 15 minutes before getting the resident up. The Director of Nursing was interviewed on 6/30/2011 at 2:21 p.m. and stated the [MEDICATION NAME] had been crossed off of the June MAR and should not have been because it had not been discontinued. During an interview on 6/29/2011 at 2:34 p.m. the resident laid in bed with the family member present. The resident stated the shoulder only hurt with movement, but that it always hurt with any movement. Both the resident and family member denied any staff member had ever discussed any pain management strategy such as routine administration of pain medication. They both knew the resident could have a pain pill but stated the resident had to ask for it and only one nurse ever asked about pain or offered a pain pill. The resident ' s family member stated, " We ' re open to any suggestions " . On 6/30/2011 at 1:13 p.m., Staff I1 stated the resident became pale and nauseated each time when gotten out of bed. This occurrence usually occurred about 10 minutes after sitting up and the resident had to be returned to bed. The resident ' s Care Plan lacked any direction to staff in regard to the resident ' s on-going problem with pain. On 7/1/2011 the PA (Physician Assistant) provided a typed note that the resident ' s nausea resulted from a heart condition and not from pain. Although the PA provided a statement report, the staff had not assessed the nausea and provided additional interventions until the surveyor informed the staff the resident had not received the medication for nausea since May 2011.

Based on clinical record review and staff interviews, the facility failed to adequately assess 1 of 5 residents reviewed who experienced an onset of adverse symptoms which represented a change in physical condition (Resident #4). Resident #4 experienced nausea, vomiting, and diarrhea during a 6 day period of time; on the early morning of the 6th day, the resident was sent to the local hospital emergency room for evaluation of no intake of solids or fluid for 24 plus hours, fever of 99.6, and lethargic. The admission [DIAGNOSES REDACTED]. The resident died at the hospital on [DATE]. The facility reported a census of 54 residents at the time of the investigation. Findings include: 1. Resident #4 had an admitted to the facility as [DATE]. The Minimum Data Set (MDS) assessment, with a reference date of [DATE], indicated [DIAGNOSES REDACTED]. The MDS indicated the resident could participate in the Brief Mental Status Assessment and had no cognitive or short/long term memory impairment. The resident required limited assist of one staff member for bed mobility, transfer, walk in room/corridor, locomotion on and off unit, dressing, toilet use and personal hygiene. The resident utilized a walker for ambulation by self. The Gastrointestinal Infection Flow Sheet dated [DATE] documented by the nurse at 5 AM indicated the resident had had the following during her/his shift: nausea, 3 episodes of vomiting, and 2 episodes of diarrhea and complaint of hurting all over. At 9 AM on [DATE] the flow sheet indicated nausea, 2 episodes of vomiting and 3 episodes of diarrhea and a check mark in the columns for physician and family notification. There was no narrative in the nursing notes or the Gastrointestinal Flow Sheet documenting what the physician or family were told by the nurse The resident continued to experience nausea, and 3 additional episodes of vomiting and 2 episodes of diarrhea. According to the same flow sheet, the resident experienced episodes of nausea, vomiting and diarrhea three times on [DATE] with a check mark 1 time for physician and family notification. There was no narrative in the nursing notes or the Gastrointestinal Flow Sheet documenting what the physician or families were told by the nurse. On [DATE] the flow sheet identified the resident experienced nausea and experienced 3 episodes of vomiting. On [DATE] there is a check mark for family notification. There was no narrative in the nursing notes or the Gastrointestinal Flow Sheet documenting what the family was told by the nurse related to the resident's medical condition. On [DATE] the flow sheet revealed documentation for nausea for 2 shifts. After [DATE] the Gastrointestinal Flow Sheet revealed no documentation of additional vomiting, or diarrhea and there was no documentation in the nursing notes until [DATE] at 7:20 AM when the physician was contacted to report the resident had a fever of 99.6, has not had any intake of solids or fluid for 24 plus hours, just had a large amount of diarrhea and very lethargic. An order was received to transport the resident via ambulance to the local hospital emergency room . On [DATE] at 4:00 p.m. the flow sheet identified the resident ' s oxygen saturation at 91 percent. This was a decline since the oxygen saturation was identified at 96 percent on [DATE]. The Iowa EMS (Emergency Medical Services) Report narrative dated [DATE] documented the 911 dispatch to above noted address (Crestview Manor) with a report of patient with altered level of consciousness. Responded to scene without difficulty and were directed to patient room by staff. Staff reported that patient had not been taking any by mouth nourishment or hydration for the past 24 hours and had also experienced several episodes of loose stools. Staff reported they were unable to arouse patient this AM and contacted primary care physician for ambulance order. Upon assumption of care, patient presents unresponsive to other than vigorous stimuli. Assessment as noted below with vital signs as noted: [DATE] at 7:28 AM level of consciousness: Lethargic/Altered Left and right pupil: reactive Left and right lung: breath sounds decreased Heart: normal Upper left and right extremity: weakness Lower left and right extremity: weakness Skin: dry and pale. Patient moved from the bed to the cot, secured with straps x 3, head of bed elevated 30 degrees for patient comfort, IV (Intravenous) access attempts, 02 (oxygen) therapies and monitoring as noted. Transport initiated per basic patient care protocol with pre-arrival telephone report given in route. An interview was conducted on [DATE] at 1:30 p.m. with the ambulance crew primary care giver who responded to the facility to transport Resident #4 to the hospital on the morning of [DATE]. The crew responded to the call at 7:27 AM and arrived at the nursing home at 7:28 AM (hospital is very close to the nursing home). The ambulance primary care giver stated when he/she entered the room of Resident #4 and called out the resident ' s name. The resident did not respond and only opened eyes and then closed them. The resident then responded to vigorous stimuli. The crew member stated had transported this resident to the hospital many times so became familiar with the resident. The crew member described this resident as very talkative, high strung (nervous) and interacts easily. The resident would only open eyes one time when transported from the nursing home to the hospital. The primary care giver ambulance member continued to state he/she believed the cold temperature outdoors could have prompted the resident to open his/her eyes. The local hospital emergency room Report documented Resident #4 presented to the emergency department via rescue squad from Crestview Senior Living on [DATE] with report that the patient has not been responding and unresponsive for the last 24 hours. The resident had nausea, vomiting, and diarrhea yesterday and had poor oral intake. The emergency room Report indicated upon arrival, the resident presented as unresponsive except to painful stimuli. Note, the patient is familiar in the emergency room , normally is very talkative. The report identified the resident ' s past medical history as significant for [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], heart failure,[MEDICAL CONDITION]([MEDICAL CONDITION]-[MEDICAL CONDITION] reflux disease), [MEDICAL CONDITIONS] disorder, and [MEDICAL CONDITION]. The resident could not answer review of systems at this time secondary to level of consciousness. The report identified the Resident as unresponsive to verbal stimuli, responded to pain, opened eyes and no diaphoretic. Diagnostic testing performed revealed the following: Sodium 128 (normal ,[DATE]), potassium of 2.2 (normal 3XXX,[DATE].2), chloride of 78 (normal,[DATE]), CO 2 of 22 (,[DATE]), BUN is 134 (normal ,[DATE]) and creatinine of 5.9 (normal0XXX,[DATE].3). The urinalysis, obtained from a catheter placed in the bladder revealed as turbid, moderate bilirubin, trace [MEDICATION NAME], greater than 300 mg/dL of protein; large blood small amount of leukocytes. Bacteria 4+ (normal is described as yellow and clear in color without blood, bacteria, keotones, cells etc.). The assessment determined a urinary tract infection, [MEDICAL CONDITION] and possible urosepsis. The assessment included hypokalemia (low potassium level), acute heart failure, [MEDICAL CONDITION] (low sodium level) and [MEDICAL CONDITION] (low [MEDICAL CONDITION] level). The Physician Assistant (PA) on duty at the hospital on [DATE] and cared for the resident in the emergency room was interviewed on [DATE] at 2:45 PM. The PA noted had provided service to this resident in the past and described the resident as normally very talkative. The resident opened his/her eyes when the resident ' s blood was drawn and when an IV (intravenous line) was started. The resident did not pull back from him/her during these procedures and did open and then close his/her eyes. The lab results of this blood draw revealed acute [MEDICAL CONDITION]. The PA continued to state with his/her experience with the elderly, signs and symptoms of acute [MEDICAL CONDITION] would be exhibited by the patient within hours of the onset in order to have laboratory values this high (BUN 134 and Creatinine 5.9). The PA stated the time period would be less than 12 hours. The physician History and Physical Report dated [DATE] indicated the following: The resident presented to the hospital after found unresponsive at the nursing facility. The resident had been experiencing [MEDICAL CONDITION] symptoms with diarrhea over the weekend. A blood workup in the emergency room by PA revealed the patient to be unresponsive, with a creatinine of 5.9, BUN 134 indicative of severe acute [MEDICAL CONDITION] with BNP at 22,305. The history/physical determined an impression of: unresponsiveness, acute [MEDICAL CONDITION], severe hypokalemia, [MEDICAL CONDITION], and pleural effusion, history of [MEDICAL CONDITIONS] and diarrhea. On [DATE] at 12:45 p.m. the physician was interviewed (not resident ' s primary physician but physician who handled care at hospital). The physician was questioned if a resident did not consume fluids when he/she would wish to be notified. The physician confirmed this would depend on the situation and if the resident had dementia, lethargy, [MEDICAL CONDITION] infection or diarrhea, then would like to be notified at some point. The physician stated if the resident had diarrhea and vomiting and unable to consume fluids, then would want to know the output amount. The physician was questioned if a resident showed signs of a change in cognition (lethargy or not responsive) and vomiting would want to be notified as soon as possible. The physician voiced would like to be notified as soon as possible with a change of cognition. The physician was questioned how long prior to becoming unresponsive due to kidney failure the symptoms of kidney failure would be noticeable. The physician stated this would be a judgment call and whether the patient could communicate with staff. This would depend upon lack of urine output, lethargy and blood work actual values. Also if the patient is not usually lethargic, then would like to be notified as soon as possible. The physician stated the blood work performed in the emergency room at the hospital on [DATE] revealed the patient had a creatinine of 5.9, BUN 134 which is indicative of severe acute [MEDICAL CONDITION]. Patient also had critically low potassium of 2.2. The hospital progress note dated [DATE] at 2:28 a.m. revealed Resident #4 had no respiration or heartbeat. The family requested to spend some time with the resident before sent to the funeral home. The physician Discharge Summary documented the resident was admitted to the hospital on [DATE] with admitting and discharge [DIAGNOSES REDACTED]. The chief complaint for present illness and admission was acute [MEDICAL CONDITIONS], urinary tract infection, and unresponsive. The family made the decision to admit the patient with no heroic measures. The physician received a call shortly after 2:30 AM on [DATE] from the nurse to notify him/her that the patient had passed away. Staff D (Licensed Practical Nurse), was interviewed [DATE] at 11:40 PM and stated she worked the 11 PM to 7 AM shifts on [DATE], [DATE], [DATE] and [DATE]. At 5 AM on [DATE] she/he initiated the Gastrointestinal Flow Sheet due to the assessment of Resident #4. Resident #4 exhibited signs and symptoms of a flu like infection. On [DATE] at midnight, Staff D stated she/he charted the resident's temperature and bowel sounds and further stated the assessment of the resident did not indicate the need to contact the physician or the family. Staff D described Resident #4 as alert and was assisted to the bathroom on [DATE] and took fluids. Staff D recalled giving the resident a Sierra Mist soda per his/her request. Staff A (Registered Nurse), was interviewed [DATE] at 11:10 AM and [DATE] at 10:40 AM, and stated she/he worked the 6:45 AM to 3:15 PM shift on ,[DATE], 22, ,[DATE]. Staff A stated she/he changed incontinent pads on Resident 4's bed two times on Saturday [DATE] and on Sunday [DATE]. Staff A stated she/he did an entire bed change because of the resident ' s urine output. Staff A stated the last time she/he observed the resident was between 2:30 PM and 3 PM on [DATE]. The resident could answer questions, open eyes and sat in bed but not in his/her chair. The resident would answer questions like, "yes,", "no", or " did not want any more " . Staff A stated she/he assisted the resident with hydration needs during her shift on [DATE] and also directed the nursing assistants to push fluids as the resident only took 2 to 3 sips of fluid at one time. Staff A stated at no time during her/his shift on [DATE] did she observed Resident #4 as unresponsive. Staff B (Licensed Practical Nurse), was interviewed on [DATE] at 4 PM and stated had worked 3 PM to 11 PM on ,[DATE], 22, ,[DATE]. On [DATE] she/he went to the resident's room and observed Resident #4 sitting up in bed and responding, but not like usually did. For supper Resident #4 took sips of hot tea and questionable if the resident actually took sips of broth but did take sips of water throughout the evening as offered by Staff B and nursing assistants. The resident was lethargic but not unresponsive, not feeling well and not as talkative. The resident ' s usually continent but now incontinent and putting out urine and taking sips of water. Staff B did not feel any documentation she/he made on the Gastrointestinal Flow Sheet warranted calling the physician or family and both had been notified prior to his/her shifts. Staff D (Registered Nurse),was interviewed on [DATE] at 11:28 PM and stated during the first interview she/he could not remember anything about Resident #4 but just know he/she was a resident for several years got sick then died . Staff D stated she/he would need to check the resident's clinical record to remember anything about Resident #4. During the second interview on [DATE] at 11:15 PM Staff D stated she worked the 11 PM to 7 AM shift on [DATE] and [DATE] and did charting on the Gastrointestinal Flow Sheet for Resident #4. Staff D did not recall any assessment/charting indicators on this flow sheet that would indicate she should contact the physician and cannot recall the name of the nurse who followed her shift that day. Staff D stated The Director of Nursing would come in early, 6:45 AM but Staff D could not remember if the Director of Nursing still on duty when the physician was contacted regarding Resident #4 and orders received to transport the resident to the hospital. Staff J (Certified Nursing Assistant), was interviewed on [DATE] at 11 AM, and stated she/he worked the day shift on [DATE]. Staff J stated she/he assisted with a bed change and also offered Resident #4 a drink of water and pop. Staff J estimated the resident received ,[DATE] of a glass (90 cc) at a time and the resident consumed this amount of fluid 3 or 4 times. Resident #4 was described as alert, could answer questions however he/she was more alert on [DATE] (Saturday) but was still alert on [DATE] (Sunday) Staff J could not recall if she/he assisted the resident to the bathroom on [DATE] but knew she/he voided urine on [DATE]. Staff K (Certified Nursing Assistant), was interviewed on [DATE] at 11:10 AM and stated she/he worked on [DATE] during the 6 AM to 2 PM shift. Staff K stated she/he took care of Resident #4 on [DATE]. The resident had the flu, was not feeling the best but voided, drinking and responding. Staff could not remember if the conversations she/he had with the resident were spontaneous or were answers to her questions. Staff K could not remember if the resident used the bathroom or just stayed in bed that day. Staff K did remember changing the bed a couple of times that day because the resident had voided in the bed. Staff K stated Resident #4 would open her eyes and respond to her on [DATE]. Staff L, (Certified Nursing Assistant) was interviewed on [DATE] at 7:30 PM and stated she/he worked [DATE] from 3 PM to 9 PM and assisted with the cares for Resident #4. Staff L stated she/he repositioned the resident, provided peri care and gave him/her sips of water. Staff L could not recall how many times she offered the resident fluids. Staff L stated the resident was in bed her entire shift on [DATE] because the resident did not feel well. Staff L could not recall if the resident talked to her/him any time during the worked shift on [DATE]. Staff M, (Certified Nursing Assistant) was interviewed on [DATE] at 8:15 PM and stated she worked 3 PM to 9 PM on [DATE] and provided cares for Resident #4. Staff M stated she/he repositioned the resident every 2 hours, provided peri care and gave the residents sips of water. Staff M provided peri care because the resident had urine output. Staff M further stated the resident was in bed during her entire shift on [DATE] because Resident #4 did not feel well. Staff M stated she/he could not remember if the resident ever talked to her/him on [DATE] during the worked shift. Staff H (Certified Nursing Assistant) was interviewed on [DATE] at 11:10 PM and stated worked the 11 PM to & AM shift on ,[DATE] to ,[DATE] and had no recall of taking care of Resident #4 Staff I (Certified Nursing Assistant), was interviewed on [DATE] at midnight and stated had worked the 11 PM to 7 AM shift on [DATE]. Staff I could not recall if she/he took care of Resident #4 during the shifts on [DATE] to ,[DATE]. The Director of Nursing (DON) and the Administrator were interviewed at [DATE] at 10:30 AM, and stated the facility had no formal procedure for nurses to get report between the change of shift. Pertinent resident information would be written in the communication book. The communication books for [DATE] and [DATE] have been destroyed. Once the nurse looks at the book for the shift, then the sheet would be removed out of the book and that sheet would be shredded. After an interview on [DATE] at 11:30 AM the Director of Nursing provided a written statement. The statement indicated the following " The DON stated on [DATE] at 6:45 AM another staff member asked him/her to check on Resident #4. The DON stated she/he entered the room and found 2 nursing assistants providing perineal care after an incontinent large bowel movement. The resident laid in bed with eyes open. The incontinent stool had a watery appearance and fowl odor. The DON then checked the night shift communication. The night nurse had documented on the infection flow sheet vital signs from 1:30 AM to 5:10 AM. The DON stated had noted at 1:30 AM the resident had a fever so she/he called the local medical center. The physician returned the call and was notified of the resident ' s fever during the night hours and had just had a large incontinent stool. The physician gave an order to send the resident to the emergency room by ambulance. The DON stated she/he telephoned one family member but got an answering machine so left a message to call the facility. Another family member was notified and informed of sending the resident to the emergency room at the hospital. The family member stated they would go the emergency room and check on the resident. The written statement by the DON indicated the DON had made a mistake on the transfer sheet regarding the amount of intake Resident #4 had taken in the 24 hours prior to the transfer to the hospital. The resident had taken sips of fluids during the day on [DATE] so it was closer to 12 hours the resident had not taken fluids. Resident #4 had a [MEDICAL CONDITION] that started on [DATE] and the Advanced Registered Nurse Practitioner was contacted on [DATE], [DATE] and [DATE] regarding the resident' status. After [DATE] the resident did not have any further episodes of vomiting or diarrhea and his/her condition appeared to be improving. The resident took small amounts of fluids and urinating but due to some complaint of nausea he/she was not taking much solid food. The resident's condition changed again during the night with a fever and then started having diarrhea which is the reason why the physician was contacted. The clinical record for Resident #4 lacked assessment and intervention documentation of the onset, duration and intensity of vomiting episodes, collection and measurement of emesis, abdominal distention, and type of vomiting (projectile, coffee ground consistency etc.). The clinical record also lacked assessment and intervention documentation of the fluidity of the diarrhea, measurement of liquid stool, measurement of fluid intake and daily weights and evaluation of diet to avoid spicy, high-fiber foods, caffeine and milk. The clinical record lacked assessment and intervention documentation for dehydration; poor skin turgor, reduced urine output, dry mucous membranes, decreased sensorium or confusion, and concentrated urine. The clinical record lacked assessment and intervention documentation for urine output, amount, color, odor or consistency. During a meeting with the facility to discuss the findings on the afternoon of [DATE], the Administrator stated the Gastrointestinal Flow Sheet is considered a quick way for the nurses to chart. The web site for CDC (Centers for Disease Control), www.cdc.com <http://www.cdc.com>, identified a [MEDICAL CONDITION] gastroenteritis as a serious illness for the elderly which makes them at risk for dehydration from loss of fluids. The web site www.webMD.com <http://www.webMD.com>, identified symptoms of acute [MEDICAL CONDITION]. The symptoms include little or no urine output, thirst, dry mouth, rapid heart rate, feeling dizzy when standing, loss of appetite, nausea, vomiting, swelling, especially of the legs and feet, feeling confused, anxious, restless or sleepy and pain on one side of the back, just below the rib cage and above the waist.The facility provided information from the Web identified as MedlinePlus medical encyclopedia. This website identified symptoms of dehydration. The symptoms identified were dry or sticky mouth, low or no urine output, concentrated urine, not producing tears, sunken eyes, lethargic or comatose (with severe dehydration).