Every finding on record at Denison Care Center

Based on clinical record review, facility investigation review, personnel file review and staff interviews, the facility failed to provide adequate assistance to a resident to prevent a fall that resulted in a fracture for 1 of 3 residents reviewed (Residents #3) and failed to reeducate the staff after a resident had a suicide attempt for 1 of 1 residents reviewed (Resident #14). The facility reported a total census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of vitamin D deficiency, disorientation and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Review of the MDS dated [DATE] revealed the resident was dependent (helper does all of the effort. The resident does none of the effort to complete the activity, or the assistance of 2 or more helpers for the resident to complete the activity) on staff to go from sit to lying position, lying to sitting on side of bed, sit to stand and chair or bed to chair transfer. Review of the Care Plan with a revised date of 6/03/26 revealed the following: Mobility- does not ambulate- utilizes a wheelchair that staff propels Transfers- 2 person assist Toileting- 2 person assist, provide peri-care with every incontinent episode and as necessary Dressing and undressing- 2 person assist Review of the resident Progress Notes revealed the following: 7/25/26 at 11:01 p.m., this nurse was called into the resident room by CNA. Upon arrival the resident was observed sitting on the floor legs facing the wandrop, shower chair behind her. The resident was awake and responsive. Head to toe assessment was done and the resident was complaining of severe pain of the ankle. Assessment revealed swelling and tenderness on the left ankle. This nurse called 911 and the resident was transported to the hospital for further evaluation. PCP was faxed, DON notified and the family was called but didn't answer the call. 7/26/26 at 4:24 a.m., resident back to facility via ambulance with no incident. 7/26/26 at 3:14 p.m., continues monitoring related to left tibia fibula fracture. Resident complain of pain 8-10 throughout this shift. Unable to access as soft cast in place. 7/26/26 at 3:14 p.m., resident continues to complain about pain 10/10 to left leg. Resident voiced severe muscle spasms. This nurse elevates the leg with a pillow and notes that dressing has drainage to the area. Soft cast removed to observe with stabilization provided by the second nurse. Deep purple bruising noted to lower inner calf. Open area with scant amount of drainage noted inside of bruising. 7/28/26 at 12:33 a.m., resident continues to be monitored for being lowered to the floor. Resident states pain is at 0/10 on the pain scale right now. The resident states it only hurts when I move around. The resident remains in bed. Observed tired. 7/28/26 at 6:50 a.m., spoke with resident regarding an appointment with orthopedic this morning. Resident tearfully stating I know my leg is broken and I don't know what's going on Reassured resident that her sister would be meeting her at the hospital and a staff member would be riding with her to the appointment and back to the facility. A review of the facility provided incident report dated 7/25/26 at 8:30 p.m., revealed this nurse was called into the resident room by CNA. Upon arrival the resident was observed sitting on the floor legs facing the wandrop, shower chair behind her, resident was awake and responsive. The resident was noted to have a gait belt on her and gripper socks on. The resident stated my legs gave up and I had to sit down. This nurse did head to toe assessment and the resident was complaining of severe pain on the ankle. Assessment revealed swelling, tenderness of the ankle. This nurse called an ambulance and the resident was transferred to the hospital. DON was notified, PCP faxed and the family was called but didn't answer the call. Injury noted was a skin tear on the left inner ankle. Review of written statement dated 7/25/26 by Staff E, CNA revealed Staff E was assisting Staff G, CNA toilet another resident. Staff E and Staff G sat her down and left. Staff E and Staff G were walking down the hallway wondering where Staff F was at. While waiting on the other resident to pull their light we sat down on our charting table to chart when Staff G saw Staff F and said oh there is Staff F, but we didn't see what room she went into. So we kept charting when a couple minutes Staff F comes down the hallway saying Resident #3 had fallen and that she thinks her leg might be broken. Then we got up to go see her with the nurse. Review of written statement dated 7/25/26 by Staff G, CNA revealed her and Staff E had just got done putting another resident onto the commode. Staff G and Staff E came out to the dining room to sit at the table to chart while we waited for the other resident. While at the table we saw Staff F but did not see where she went into. A couple minutes later Staff F appeared and said Resident #3 just fell and I think her leg is broke. Interview on 8/19/26 at 9:41 a.m., with Staff G revealed she was not in the room when the fall occurred. Staff G revealed Staff F came out of the room and stated Resident #3 had just fallen and broke her leg. Staff G explained she thought Staff F was joking. Staff F was in the room by herself and was unsure why she didn't ask for help with the transfer. Resident #3 has been a 2 assist for a long time. Staff G revealed Staff F had missed report that evening as she came in late. Interview on 8/18/26 at 3:24 p.m., with Staff M, Registered Nurse (RN) it was around 8 or 9 o'clock when Staff F called me to Resident #3's room. She was transferring her to the shower chair and stated the resident's leg gave out. Resident #3 was sitting on the floor and when she started her assessment she was in a lot of pain. Staff M called 911 and Resident #3's leg looked like a bone had poked out. Resident #3 went to the Emergency Room. Review of written statement dated 7/25/26 by Staff F, Certified Nursing Assistant (CNA) revealed she was getting Resident #3 ready for her bath, she was sitting on the edge of the bed and she applied her gait belt for the transfer. She had gripper socks on. Staff F assisted her to stand, and she stated she needed to sit down. Staff F lowered her down because she missed sitting back on the edge of the bed. During the lowering, she went down slowly to her knees, she put all her weight on them and then sat down with her legs folded back (calf, shin, ankle) on the floor. She started she felt her ankle break. I told her to not move but she began to reposition her legs to sit more comfortably and her foot appeared twisted. I called for the other CNA's to come assist and then Staff F notified the nurse immediately. She then called 911 we did not move Resident #3. We waited for the ambulance to arrive. Review of facility provided documentation titled Corrective Action dated 7/30/26 revealed Staff F was given a final written warning for performance or behavior revealed details of issue dated 7/25/26. On the date listed above, you were involved in transferring a resident using improper transfer technique. During the transfer the resident sustained a major injury. An internal review determined that the transfer was not performed in accordance with established facility policies, resident care procedures and safe transfer practices. Employees are expected to follow all resident care plans, use proper body mechanics and transfer techniques and utilize required equipment and assistance when necessary to ensure resident safety. Failure to follow these procedures places residents at significant risk of harm. Due to the seriousness of this incident and resulting to the resident, you are receiving a final written warning. This disciplinary actions reflect the severity of the policy violation and the expectation that all safety procedures will be followed without exception. Review of facility provided document titled 5 day Investigation Summary undated revealed the following information: Description of the Incident: On July 25, 2026, at approximately 8:30 p.m., the Resident #3 was being assisted from her bed to a shower chair by Staff F using a gait belt. The resident was wearing non-slip gripper socks. The resident's care plan identified her as requiring a two-person weight-bearing transfer. However, during CNA shift report, the off-going day shift CNA communicated that the resident was a pivot transfer. The CNA providing care that evening stated she sought clarification from the nurse prior to the transfer and understood the resident to be a pivot transfer. During follow-up interviews, the nurse stated that the resident required a two-person pivot transfer, not a one-person transfer. The CNA reported that she asked the resident if she felt comfortable completing the transfer with only one staff member. According to the CNA, the resident stated that she did. During the transfer, the resident took a step down to pivot toward the shower chair but stated that she needed to sit down. As the resident attempted to sit, she missed the edge of the bed. The CNA maintained use of the gait belt and lowered the resident to the floor as safely as possible. The resident landed on both knees, bearing her weight through them. Immediately afterward, the resident stated, I think my ankle broke. The CNA instructed the resident to remain still; however, the resident began repositioning her legs, at which time staff observed that her foot appeared twisted. The CNA immediately called for assistance from two additional CNAs and notified the nurse. The resident's left ankle was noted to be significantly swollen with purple discoloration. Staff also observed an open area at the injury site. The resident was transferred to the emergency department for evaluation. At approximately 11:26 pm, the facility was notified that diagnostic imaging confirmed a fracture. The resident returned to the facility with a soft cast and physician orders for Celebrex 200 mg twice daily, acetaminophen three times daily, and gabapentin three times daily. On July 28, 2026, the resident was evaluated by CHI Orthopedics. The soft cast was replaced with a cam boot. Additional orders included non-weight-bearing status to the left lower extremity, wound care, skin assessments every six hours (to take the boot off and look to ensure there are no sores), hydrocodone for pain management, and Bactrim twice daily for five days. Orthopedic providers requested wound therapy due to the nature of the fracture and associated skin injury. The resident's primary care physician has since assessed the wound and documented that the area is now an abrasion. The resident's next orthopedic follow-up appointment is scheduled for August 11, 2026. Interviews: Staff F, who was transferring Resident #3 stated that on Friday she was running late and had missed shift report but she did hear a CNA say that resident was changed to a pivot transfer. Staff F said she wasn't sure if she heard correctly so she asked the nurse how she transferred and she said pivot transfer. Before transferring the resident, Staff F stated the resident was sitting at the edge of the bed coloring, CNA asked resident if she would like to take a bath now and resident said yes. CNA moved everything so there was room for the shower chair next to the bed to get ready for the pivot transfer. Before putting the gait belt on, CNA asked the resident Do you feel comfortable with just me transferring you? The resident said yes. CNA then starts to transfer her. Staff E and Staff G- When they entered the resident room it appeared to be that her ankle was bruised, swollen and twisted. Review of the Final Report for x-ray results of left tibia and fibula signed and dated 7/25/26 at 10:53 p.m., revealed there are comminuted and mildly displaced fractures of the distal tibial and fibular metaphyses. Review of the Emergency Department discharge instructions dated 7/25/26 revealed diagnoses from today's visit included fracture of distal end of left tibia and fracture of distal end of left fibula. Review of facility provided document titled Major Injury Determination Form signed by the physician on 7/26/26 at 12:30 p.m., revealed an x in front of: after reviewing the circumstances of the incident causing the injury, the previous functional ability of the patient, and the patient's prognosis, I believe the injury sustained is a major injury. Review of facility provided document dated 7/28/26 from orthopedic appointment revealed summary of concerns listed fracture to left tibia fibula. Physician Reports/orders/notes revealed non-weight bearing to left lower extremity, every 6 hour skin checks, wound care to evaluate and treat, hydrocodone-acetaminophen tab 5mg/325mg every 6 hours and Bactrim DS tab twice a day for 5 days. Next appointment scheduled 8/11/26. Review of the facility provided policy titled Safe Resident Handling Transfers dated 2025 revealed the following: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized depending upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. Resident lifting and transferring will be performed according to the resident's individual plan of care. Interview on 8/18/26 at 2:28 p.m., with the Administrator revealed the staff should not have been transferring the resident with 1 assist if the resident was to be a 2 person assist. Interview on 8/19/26 at 3:17 p.m., with the Director of Nursing (DON) revealed the CNA should not have been transferring the resident with 1 assist when she was to be a 2 assist. 2. Review of Resident #14's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognitive functioning. The MDS further revealed Resident #14 had diagnoses of anxiety disorder, depression, and Post Traumatic Stress Disorder (PTSD). Review of Resident #14 Electronic Healthcare Record (EHR) page titled, Progress Notes revealed an entry dated 6/10/26 at 8:41 AM indicating a dietary aide had notified the nurse that Resident #14 was in his room and had an electrical cord wrapped around his neck stating, I just want to end it all. The entry further revealed that the nurse went directly to the room and upon entering observed Resident #14 with an electrical cord around his neck and standing while attempting to throw the cord over the doorway. The nurse then removed the cord from Resident #14's neck and convinces Resident #14 to sit down in his wheelchair. Review of a document titled, Psychiatric Evaluation assessment dated [DATE] revealed Resident #14 was a moderate risk, and this was Resident #14's first lifetime suicide attempt. The document further revealed that Resident #14 informed the psychiatric provider at the outside emergency department, I tried to hang myself; it was stupid. Interview 8/17/26 at 2:54 PM with Resident #14 revealed that he did have a suicide attempt. Resident #14 then revealed that he had never attempted to commit suicide before this incident. Resident #14 further revealed that he was feeling down related to having no family members around or visiting. Resident #14 then indicated that he is doing better. Resident #14 then indicated that he was moved to the room by the nurses station. Interview 8/18/26 at 1:57 PM Staff H Licensed Practical Nurse (LPN) confirmed she was working on the day Resident #14 had his attempted suicide. Staff H revealed that Resident #14 was acting per his norm that morning. Staff H proceeded that the dietary aide came to the nurses station and stated that Resident #14 had something around his neck. Staff H then indicated that she went down to Resident #14's room, and Resident #14 was standing by his door with an auxiliary cord around his neck loosely. Staff H further revealed that she helped assist the resident to sit down, and helped take the cord from around his neck. Staff H revealed that she sent the dietary aide to go get the Director of Nursing (DON), and she stayed with Resident #14. Staff H indicated that it was decided that Resident #14 would be one to one staffing, and he would be sent to the emergency room to be evaluated. Staff H indicated that Resident #14 was a one to one when he returned, and was moved closer to the nurses station. Staff H then revealed that Resident #14 had no previous attempts at suicide. Interview 8/18/26 at 2:35 PM with Staff J LPN revealed that she had never heard of Resident #14 stating he wanted to commit suicide. Staff J further revealed that he has been very happy lately, and has not voiced any concerns to her. Interview 8/19/26 at 9:50 AM Staff I Dietary Aide revealed that she was working the day of the incident with Resident #14. Staff I revealed that she was taking breakfast to Resident #14, and when she went to deliver the breakfast she noticed Resident #14 wasn't talking to her like he normally did. Staff I then revealed that Resident #14 had a cord wrapped around his neck loosely, and was trying to tie it to the door handle in his room. Staff I further revealed that she tried talking to the resident, but he didn't stop and he was trying to slide himself out of his chair and tie the cord to the door knob. Staff I then indicated that she ran down the hall and got the nurse who came back and helped the resident who stayed one to one with Resident #14. Staff I then revealed that she really didn't get any training after the event, but was talked to by her supervisor in the kitchen about the situation. Staff I further revealed that when she ran to the nurses station she had left the resident in his room for about a minute or two from the time she got the nurse to when the nurse got back to the resident. Follow up interview 8/19/26 at 9:58 AM with Staff H LPN revealed that she was given education on what to do after an event like this that happened, and it was also talked about in a meeting. Interview 8/19/26 at 10:03 AM with the DON revealed that there was education provided to staff, and that she would provide this information. Review of a facility provided document titled, All-Staff Meeting dated 6/22/26 revealed no information about suicide attempts or what to do if a resident does have an attempt. The document further revealed no signature from Staff I. The document did provide information regarding identifying a change in condition and all staff to report changes in condition which can be physical, mental, emotional, or behavioral. Another follow up interview 8/19/26 at 11:41 with staff H LPN revealed that she was given some education, but could not recall all what was in the education. Staff H then revealed that in a situation where there was a suicide attempt she would stay with the resident, and make sure they were safe and stay with the resident until more staff could come. Staff H then indicated she would also yell down the hall or hit the call light to get more staff to where the concern was. Interview 8/19/26 at 11:46 AM with Staff D LPN revealed that she was here on shift when the suicide attempt occurred. Staff D further revealed that she was given education, but it was about change of condition and to report to the doctor or correct people. Staff D then indicated that she did not recall anything specifically about suicide attempts, but she would stay with the resident and make sure they were ok and safe, and then would call for help while staying with the resident by either using the call light or hollaring for staff. Interview 8/19/26 at 11:55 AM with Staff K Certified Nursing Assistant (CNA) revealed that there was no education provided that she could remember. Staff K revealed that she would stay with the resident to make sure they were safe in a suicide attempt, and would use the call light to get ahold of other staff to assist. Staff K then confirmed she had no education on what to do in a situation like this. Interview 8/19/26 at 11:59 AM with Staff L Laundry Services revealed Staff L was just given education on videos when she started about suicide attempts. Staff L further revealed there was a small meeting, but could not recall anything about what to do in a situation where there was a suicide attempt. Staff L then revealed that she would stay with a resident who was attempting to commit suicide to ensure their safety, and would yell out for staff to come help. Interview 8/19/26 at 1:01 PM with the DON revealed that proper education should have been provided, and staff should have stayed with the resident during the attempt to make sure the resident was safe. Review of a facility provided policy titled, Suicide Prevention with a copy right date of 2026 indicated all staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. The policy further indicated the resident will not be left alone. Further review of the policy indicated all staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide adequate nursing supervision for 1 of 3 residents (Resident #1) reviewed. A non-ambulatory resident with a history of attempting to self-transfer, fell when left unsupervised in the dining room, which resulted in a head injury, nasal fractures and cervical fractures. The facility reported a census of 28. Findings include:Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severe cognitive impairment. The MDS list of diagnoses included non-Alzheimer's dementia, diabetes mellitus and paroxysmal atrial fibrillation (irregular heart rhythm). The MDS indicated Resident #1 dependent for chair/bed-to-chair transfers, and required a manual wheelchair for mobility. Review of the Care Plan, dated 12/2/2024 revealed a Focus area to address [name redacted} has potential for falls r/t (related to) self-transfers. Review of a facility reported incident submitted on 10/10/25 at 4:16 PM revealed an Incident Summary: On 10/09 [2025] at approximately 7:00 PM, the resident attempted to stand from her wheelchair and sustained a fall The resident was transported to the emergency room via ambulance, At approximately 11:43 PM the Director of Nursing was notified that the resident had multiple fractures and was life-flighted to [name of hospital redacted} for further evaluation and treatment. The resident returned to the facility on 10/10 [2025] at approximately 10:30 am.Review of a document titled, Major Injury Determination Form, dated 10/10/25 signed by the [physician name redacted] at 10:45 AM documented, in part: Participant name: [name reacted, Resident #1]. Date and time of the injury: 10/9/25, 1854 (6:54 PM) Notified of Injuries at 2343 (11:43 PM). Description of Injury: odontoid fracture (a small bone in the neck that connects the skull to the second cervical vertebrae), head injury nasal fracture, cervical fractures. Circumstances of the incident causing the injury: Fall. The physician checked the statement After reviewing the circumstances, injury and prognosis of the patient. I believe the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 67.4(1)(a)(3). Review of a document, dated 10/5/25 at 11:50 PM titled, Fall revealed, in part: Resident: [name redacted Resident #1]. Incident Location: Dining Room. Nurse Description: At 2350 (11:50 PM) this nurse went to turn off commons area TV in hopes that resident will be redirected. This nurse hears chair legs moving on floor and observed resident falling backwards out of chair. Resident landed on back, chair landed on top of resident. This nurse running to resident in the process, Resident complaints of left elbow pain. Vitals obtained, apart from BP (Blood pressure) to which resident reuses and WNL (within formal limits) for resent. Neuros initiated and WNL for resident. PERRLA (pupils, equal, round, reactive to light, accommodation - an assessment for neurological changes). Active and passive ROM (Range of Motion) WNL. NO swelling or facial grimacing noticed while performing ROM to left arm. Resident continues to yell, spit and hit at this nurse and staff while assisting resident. Hoyer sling placed under resident, transferred to wheelchair, resident transferred into bed, Call light within reach. Will continue to monitor and support per facility protocol. Was this incident witnessed: N (no). Predisposing Environmental Factors: no boxes checked. Predisposing Physiological Factors: Confused, Non compliance, Agitated/Anxious, Delusions, Resident to care, Combative, Hallucinations boxes checked. Predisposing Situation Factors: no boxes checked. Other Info: Incident: observed on floor. why: Resident had self transferred to regular chair; why: Resident was scooted chair backward and chair tipped over with resident; why: Resident had had increased behaviors and hallucinations; why: cognitive status; why: Disease progression. Review of the electronic health record (EHR) revealed a General Progress Note entered on 10/8/25 at 3:03 PM by Staff E, Registered Nurse (RN)/Assistant Director of Nursing (ADON) which documented This nurse asked to sit with resident at the dining room table, Resident [Resident #1] attempts to stand up from her wheelchair. This nurse educates the importance of staying seated in her wheelchair. Resident voices understanding but becomes tearful. She starts tearing apart a Kleenex box and states I don't want to be part of this club anymore. They are just mean to me. This nurse comforts resident and resident calms down. This nurse continues to sit the resident until another nurse came back into the dining room. Review of October 2025 schedule revealed Staff A, RN (Registered Nurse); Staff B, CNA (Certified Nursing Assistant); Staff C, CNA and Staff D, [NAME] worked the evening of 10/9/25.During an interview on 10/22/25 at 11:14 AM, Staff A, Registered Nurse (RN) acknowledged she was working the night of 10/9/25 when Resident #1 fell in the dining room. Staff A explained she was starting her night time medication pass and was walking down the hall at the time of the fall. Staff A explained that Staff B, CNA and Staff C, CNA were taking residents back to their room from dinner. Staff A stated there was no staff in the dining room when she entered the dining room and found Resident #1 lying on the floor. Staff A explained Resident #1 was seated in a wheelchair prior to fall. Staff A stated she did not know what Resident #1's level of supervision was at the time. Staff A stated after Resident #1 left for the ER, a CNA, whose name she did not recall, informed her that Resident #1 was supposed to have been taken to her room after she was done eating. Staff A stated that did not happen. Staff A reported prior to the fall no staff informed her that Resident #1 was trying to get up. Staff A stated this was her first shift at the facility, and she had a two-hour orientation on 10/9/25. She stated she had not been told that Resident #1 needed to be in line of sight if she started to have increased behaviors, that she had sundowners, or that she tried to stand up. During an interview on 10/22/25 at 12:03 PM, Staff B, CNA stated she was familiar with Resident #1. Staff B acknowledged she was working the evening shift on 10/9/25 when Resident #1 fell. Staff B stated at the time of the fall, she was putting another resident to bed. Staff B stated Resident #1 would get very anxious and delusional at times especially in the last couple weeks. Staff B stated after Resident #1 had a fall on 10/5/25, the staff decided to put her down first after dinner. Staff B stated before the fall on 10/9/25 Resident #1 was not to be left alone in the dining room, but she could be left alone in her room. Staff B stated that evening she did not know what to do because after dinner, all the residents wanted to go to bed at the same time. Staff B stated Resident #1 was kind of supervised but it is not documented anywhere. Staff B stated management had told her that Resident #1 could not be left alone in the dining room because she might fall. Staff B stated Resident #1 attempted to stand on her own frequently, and that this was a new behavior in the last couple weeks with Resident #1's change in medications. Staff B acknowledged she did not tell Staff A, RN that Resident #1 needed to be supervised. Staff B stated she told the nurse after Resident #1 had fallen that she was not supposed to be left unsupervised in the dining room. Staff B stated prior to Resident #1 fall on 10/9/25 no staff came to find her to let her know the resident was trying to stand up. During an interview on 10/23/25 at 4:31 PM, Staff C, CNA acknowledged she was working on the evening shift of 10/9/25. Staff C stated she was with Resident #1 in the dining room prior to the fall that evening. Staff C stated she had asked Resident #1 if she was ready to go to bed and Resident #1 said she was not ready to go to bed. Staff C stated Resident #1 was playing with facial tissue, when she left to answer a call light. Staff C stated there were no other staff present in the dining room when she left. Staff C stated the nurse [Staff A, RN] was down the hall passing medications. Staff C stated Resident #1 was not having behavioral issues, sundowners, or attempting to transfer or stand on her own at the time. Staff C stated Resident #1 had not had any behavioral issues that day. Staff C stated she was working with Staff B, CNA that evening who was in a room assisting another resident to bed. Staff C stated no staff came to tell her that Resident #1 was trying to stand up before the fall on 10/9/25. Staff C stated Resident #1 had a fall a couple day earlier and thought the nurse was going to have Resident #1 put to bed right after dinner because of that fall. Staff C stated she was not sure if putting Resident #1 to bed first was on the care plan. Staff C explained when Resident #1 tried to stand, self-transfer, showed signs of sundowners, or had a behavior the staff were expected to have Resident #1 in line of sight and/or sit next to her. Staff C stated it was just a known thing and did not think it was charted anywhere. Staff C stated the nurses had told her to make sure to keep a close eye on Resident #1 if she was trying to stand, trying to self-transfer, showing signs of sundowners, or having a behavior. Staff C stated during those times staff would sit next to Resident #1, have Resident #1 sit at the nurse's station, or deliver snacks with the staff to prevent her from falling. During an interview on 10/22/25 at 1:22 PM Staff D, [NAME] stated he had worked at the facility for over two years, and worked on the evening of 10/9/25. Staff D stated the evening of 10/9/25Resident #1 was rocking like she was trying to stand up. Staff D explained he asked Resident #1 to stop or she was going to fall and get hurt. Staff D stated Resident #1 was sitting at the table fine when he left the dining room. Staff D stated about 5 minutes later he heard yelling and ran out to the dining room. Staff D stated he found Resident #1 face down on the floor and bleeding. Staff A stated when he got to the dining room Staff A, RN was present and shortly after that Staff B, CNA and Staff C, CNA appeared. Staff D stated he did try to find a CNA after Resident #1 tried to stand up and tell them to make sure Resident #1 was okay. Staff D stated he did not remember which staff he told. Staff D stated he notified the CNA and went back to the kitchen to continue his work. On 10/22/25 at 1:50 PM Staff E, Registered Nurse (RN)/Assistant Director of Nursing (ADON) recalled sitting with Resident #1 on 10/8/25. She stated a nurse asked her to sit with Resident #1 in the dining room because Resident #1 was agitated. Staff E stated at the time there was no staff in the dining room to sit with Resident #1. She explained staff generally kept their eyes on Resident #1. Staff E stated if Resident #1 attempted to stand up the staff would have her sit behind the nurse's station to keep better eyes on her. Staff E stated she does not have a lot of experience with care plan development. Staff E stated she could not answer if it should be care planed that there is a change in supervision when Resident #1 became agitated or tried to stand up. Staff E stated on 10/5/25 the physician was notified and there was an increase in medications. Staff E stated she entered [into the EHR] there was a medication review and this was added to the care plan as the intervention in place for that fall [on 10/5/29]. Staff E stated the other staff knew to keep Resident #1 in line of sight or close to the nurse's station when she attempted to stand up or became agitated. Staff E stated if Resident #1 attempted to stand up on 10/9/25, a staff member should have been in line of sight of that resident. Staff E stated the kitchen staff probably did not know that someone should have been in line of sight of Resident #1 if she was trying to stand up. Staff E stated if someone that was not nursing staff found Resident #1 attempting to stand, she would expect them to stay with the resident until a nursing staff came to the dining room. Staff E stated she expected all the staff to know Resident #1 needed to be supervised because kitchen and maintenance cannot read the care plan. During an interview on 10/23/25 at 10:54 AM, the Director of Nursing (DON) DON stated Resident #1 had an increase in behaviors such as delusions, anxiety, restlessness, verbal and physical aggression to staff, self-transferring, and standing on her own. The DON stated if the resident was trying to stand up or have any of the behaviors, she would expect the staff to respond to the behavior appropriately. The DON stated the staff should attempt to redirect and if that was ineffective would talk to the ADON for other interventions. The DON stated taking the resident to pass snacks, sitting with Resident #1 at the table, sitting with her behind the nurse's station or keeping her in line of sight was part of the job. The DON stated the staff know to do these redirections without having them in the care plan. The DON stated she would have expected the care plan to reflect the interventions prior to the fall on 10/9/25. The DON stated her expectation was that staff that were not nursing staff would stay with the resident and alert the appropriate staff if Resident #1 was attempting to stand on her own. Stated she would have expected the Staff D to stay with Resident #1 until nursing staff were notified. Review of the Care Plan, dated 6/9/24, revealed a Focus area to address [Name redacted] has impaired cognitive function r/t Dementia. Interventions included, in part: Provide one-to-one or line-of-sight supervision as clinically indicated to ensure resident safety. Date Initiated: 10/15/25. On 10/23/25 at 12:07 PM, the Administrator stated any staff that observed Resident #1 to be agitated or self-transferring should have stayed with the resident for her safety. Review of policy dated 2001 revised 3/22 titled, Care Plans, Comprehensive Person-Centered documented the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their cause, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of policy dated 2021 and revised 3/18 titled, Assessing Falls and Their Causes documented when a resident falls, the following information should be recorded in the resident's medical record: completion of a falls risk assessment and appropriate interventions taken to prevent future falls.

Based on clinical record review, facility policy review and staff interviews, the facility failed to accurately assess and provide appropriate interventions after a resident had an unwitnessed fall for 1 of 3 residents (Resident #1) reviewed. Staff attempted to move Resident #1 after they found her prone (face down), bleeding, and in pain. The facility reported a census of 28 residents.Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated a severe cognitive impairment. The MDS list of diagnoses included non-Alzheimer's dementia, diabetes mellitus, and paroxysmal atrial fibrillation (irregular heart rhythm). The MDS indicated Resident #1 dependent for transfer chair/bed-to-chair transfer, and required substantial/maximal assistance to roll from right to left.Review of the Care Plan, dated 12/2/2024 revealed a Focus area to address [name redacted} has potential for falls r/t (related to) self-transfers. Review of a facility reported incident submitted on 10/10/25 at 4:16 PM revealed an Incident Summary: On 10/09 at approximately 7:00 PM, the resident attempted to stand from her wheelchair and sustained a fall. The resident was transported to the emergency room via ambulance, At approximately 11:43 PM the Director of Nursing ass notified that the resident had multiple fractures and was life-flighted to [name of hospital redacted} for further evaluation and treatment. The resident returned to the facility on 10/10 at approximately 10:30 am.Review of a document titled, Major Injury Determination Form, dated 10/10/25 signed by the [physician name redacted] at 10:45 AM documented, in part: Participant name: [name reacted, Resident #1]. Date and time of the injury: 10/9/25, 1854 (6:54 PM) Notified of Injuries at 2343 (11:43 PM). Description of Injury: odontoid fracture (a small bone in the neck that connects the skull to the second cervical vertebrae), head injury, nasal fracture, cervical fractures. Circumstances of the incident causing the injury: Fall. The physician checked the statement After reviewing the circumstances, injury and prognosis of the patient. I believe the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 67.4(1)(a)(3). Review of October 2025 schedule revealed Staff A, RN (Registered Nurse); Staff B, CNA (Certified Nursing Assistant); Staff C, CNA and Staff D, [NAME] worked the evening of 10/9/25.During an interview on 10/22/25 at 11:14 AM, Staff A, Registered Nurse (RN) stated she worked the evening of 10/9025. Staff A stated during the night time medication pass she heard yelling from the dining room, and ran to the dining room. Staff A explained two of the Certified Nursing Assistants (CNA's) were taking residents back to their rooms after dinner. Staff A stated she found Resident #1 lying prone (face down) on the floor in the dining room. Staff A stated she completed an assessment and determined that Resident #1 was in pain. Staff A stated Resident #1 was not able to move her head. Staff A stated she could not tell if anything was broken. Staff A stated Resident #1 could move her extremities but not very much. Staff A stated Resident #1 could move her right arm but could not move it above her head. Staff A stated Resident #1 could move the left arm but even less than the right arm. Staff A stated she had no reason to suspect Resident #1 had a neck fracture. Staff A explained blood came from Resident #1's nose. Staff A stated after her assessment she and the CNA's attempted to roll Resident #1 over onto her back a couple of times but were unable to turn the resident on to her back. Staff A then stated 911 was called. Staff A explained after Emergency Medical Services (EMS) entered the facility they turned the resident onto her back without a C-collar. Staff A stated Resident #1 was sent to the ER (emergency room). Staff A explained Resident #1 was seated in a wheelchair prior to fall. On 10/22/25 at 12:03 PM Staff B, CNA stated she was familiar with Resident #1. Staff B acknowledged she was working the evening shift on 10/9/25 when Resident #1 fell. Staff B stated she was putting another resident to bed when the incident occurred. Staff B stated Resident #1 was in the dining room with other residents. Staff B stated the resident that she was putting to bed required a full body mechanical lift and there were only 2 CNA's. Staff B stated the other CNA working that night was Staff C. Staff B stated she and Staff C were in the resident who required the mechanical lift when Resident #1 fell. Staff B stated she heard yelling and ran down to the dining room and found Resident #1 lying face down on the floor and there was blood under her face. Staff B stated Resident #1 must have tried to stand up and fell. Staff B stated the nurse tried to turn Resident #1 over a couple of times but Resident #1 was hurting too bad to turn over. Staff B explained they tried to turn her over because Resident #1 could not do it on her own, and she was crying. Staff B stated 911 was called and once EMS arrived 2 EMT (Emergency Medical Technician) and 3 staff flipped Resident #1 onto her back. Staff B acknowledged Resident #1 was in a lot of pain at the time and did a lot of screaming. During an interview on 10/23/25 at 4:31 PM Staff C, CNA acknowledged she was working on the evening shift of 10/9/25. Staff C stated she worked with Resident #1 that evening. Staff C stated she was with Resident #1 in the dining room as the resident said she was not ready to go to bed. Staff C stated Resident #1 was playing with facial tissue when she left the dining room to answer a call light. Staff C stated there were no other staff present in the dining room when she left. Staff C stated she assisted Staff B, CNA with getting another resident to bed. She explained after she was done, she exited the room when she heard screaming and ran to find Resident #1 lying on the floor face down. Staff C stated Resident #1 had blood coming out of her face, which she thought was coming out of the resident's nose. Staff C explained she yelled for the nurse (Staff A, RN) who was in the hall and she came running to the dining room. Staff C stated Staff A completed an assessment with Resident #1's extremities and then they made a couple attempts to roll Resident #1 onto her back. Staff C stated Resident #1 was screaming and would not roll onto her back. Staff C stated the nurse called 911 and the ambulance arrived. Staff C recalled Staff D, [NAME] stated Resident #1 was rocking in her chair trying to stand up earlier and thought that was what may have led to the fall. Staff C stated Staff D did not come to find her to let her know Resident #1 was trying to get up. On 10/22/25 at 1:22 PM Staff D, [NAME] acknowledged he was worked the evening of 10/9/25 when Resident #1 fell in the dining room. Staff D stated Resident #1 was sitting at the table fine when he left the dining room. Staff D stated she was rocking like she was trying to stand up. Staff D explained he asked Resident #1 to stop or she was going to fall and get hurt. Staff D stated he did try to find a CNA after Resident #1 was trying to stand up and tell them to make sure she was okay. Staff D explained he did not remember which staff he told that Resident #1 was trying to get up. Staff D stated about 5 minutes later he heard yelling and ran out to the dining room. Staff D stated he found Resident #1 lying face down on the floor and bleeding. Staff D stated when he got to the dining room Staff A was there and shortly after Staff C arrived. Staff D stated the nurse and CNAs were trying to roll Resident #1 over but were unable to. Staff D stated Resident #1 was yelling.On 10/22/25 at 1:50 PM Staff E, RN/Assistant Director of Nursing (ADON) stated if a resident falls on the floor and is found lying in the prone position she would check their ROM. Staff E stated if the assessment showed any changes with ROM or any decrease in ROM she would not move the resident and would just call 911. Staff E stated if there was a lot of blood around the head she would not move the resident and just call 911. Staff E stated the reason she would not move a resident lying prone with a head injury is because the resident could have spinal injury. On 10/23/25 at 12:07 PM the Administrator stated she would not want a resident moved if found bleeding from the head, decreased sensations in extremities, or change in extremities ROM. On 10/23/25 at 10:54 AM the Director of Nursing (DON) explained if a resident is found face down she expected an assessment of the resident. The DON stated in the situation with Resident #1 blood was on the floor. The DON stated she would have shipped the resident to the emergency room immediately. The DON stated during her investigation she did not find any concerns with Resident #1's transfer to the emergency room immediately. The DON stated she was glad that they did not move Resident #1. The DON stated what Staff A said to her was that they could not move the resident because of her position. The DON stated Staff A assumed the blood was coming from Resident #1's nose. The DON acknowledged if a resident is found with blood present face down, they should not be moved and sent directly to the emergency room. Review of policy dated 2021 and revised 3/18 titled, Assessing Falls and Their Causes directed if a resident had just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. Obtain and record vital signs as soon as it is safe to do so. If there was evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.

Based on record review, family interview, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 1 of 3 residents (Resident #18) reviewed. The facility reported a census of 27 residents. Findings include: Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had reentered into the facility from a short-term general hospital stay 5/6/25. The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of Resident #18's Electronic Healthcare Record (EHR) revealed that Resident #18 was in the hospital from [DATE] through 5/6/25. Further review of the EHR page titled Clinical Census, confirmed that Resident #18 was in the hospital on these dates. Interview 7/1/25 at 12:29 PM with Resident #18's family member revealed that Resident #18 had gone to the hospital for surgical repair of the right femur. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman dated April 2025 revealed that Resident #18 was not on the form. Interview 7/1/25 at 1:59 PM with Social Services, and the Administrator confirmed Resident #18 was not on the Ombudsman Notification, and that their expectation would be for the Ombudsman to be notified when residents are transferred or discharged . Interview 7/2/25 at 7:58 AM with the Administrator revealed the facility does not have a policy for reporting to the Ombudsman. The Administrator then revealed the facility just abides by the state and federal regulations.

Based on observation, policy review, and staff interviews the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility reported a census of 33 residents. Findings include: An initial tour of the kitchen on 5/21/23 at 10:15 AM revealed the following: a. Freezer #3 contained - no thermometer to check its temperature. - an unlabeled and undated bag of frozen pink meat that looked freezer burnt. - an unlabeled, unsealed, and undated bag of frozen strawberries. - an undated frozen ham that appeared freezer burnt b. Freezer #2 contained - an unsealed open bag of frozen French fries. - an unlabeled, undated, and uncovered open bag of items that looked like frozen cookie dough on a clear plastic tray. - an undated open bag of frozen carrots. - un undated open bag of frozen corn. c. Refrigerator #1 contained - an undated covered tray of fruit cups. - a basin with undated, uncovered, and unlabeled glass of white milk, two glasses of chocolate milk, and what looked like a glass of apple juice. - an undated open bag of cooked sausage links - an unsealed open package of ham slices on the third shelf dripping juice down near an unsealed bag of shredded cheese. - an open undated container of peach yogurt. - an open undated bottle of grape juice. - an open undated bottle of thicket hydrolyte (liquid thickener). - an open undated cranberry juice - an open undated apple juice - an open undated grape juice - an open undated gallon of chocolate milk - an open undated 12-ounce (oz) bottle of Coke a third full without a name. - an open undated 16.9 oz bottle of Coke half full without a name. - an open undated bottle of Cranberry thicket juice (thickened cranberry juice) - an open undated bottle of Apple thicket juice - an open undated and unsealed bag of shredded cheese - an open undated and unsealed bag of cheese slices - an undated and unlabeled plastic container that looked like a casserole. - an open undated metal can of peach chunks with lid still attached. - an uncovered compote (fruit preserved) of what appears to be two small pancakes - an open undated plastic container containing what looked like salsa. - an open undated of French dressing - an open undated can of tomato juice c. Random items around the kitchen - an open undated box of coffee cake mix. - an open undated bag of brown sugar spilled in a drawer with two spoons laying in it - the inside of the microwave had food splatter, debris, and dried liquid of multiple colors. - the cupboard had a half of a jar of caramel, a half of a jar of strawberry topping, and three-fourths of a bottle of chocolate toppings that indicated they required refrigeration after opening. The May 2023 Refrigerator/Freezer Temperature logs lacked the following temperatures: - 5/5/23 all day - 5/6/23 evening - 5/13/23 evening - 5/19/23 morning - 5/20/23 all day - 5/21/23 morning On 5/22/23 at 11:45 AM observed Staff B, Cook, begin serving lunch without taking the temperature of the food on the steam table. On 5/22/23 at 12:47 PM after lunch service, asked Staff B to check the final food temperatures. Staff B checked the temperature of the foods without cleaning the thermometer between items. One pan of regular meatloaf had three servings removed from it, had a temperature of 123.3 degrees Fahrenheit (F). On 5/22/23 at 1:10 PM the food temperature logs reviewed from 4/10/23 to 5/22/23 lacked the following temperatures: - 4/12/23 Supper - 4/14/23 Supper - 4/18/23 Breakfast and lunch - 4/19/23 Supper - 5/5/23 Breakfast, lunch, and supper - 5/6/23 Supper - 5/9/23 Supper The Sanitation and Food Production policy dated June 2015 directed to take food temperatures during preparation, cooking, meal service, and storage. In addition, the policy instructed to record the temperatures on the menu spreadsheet for each meal, including alternates, and special orders. On 5/22/23 at 1:55 PM the Administrator stated she expected the staff to check the temperature of food prior to serving the meal. On 5/23/22 at 2:35 PM when question about the initial kitchen tour concerns, the Administrator responded that she expected staff to follow the policies, date, and label foods after opening.

Based on clinical record review, the Centers for Medicare and Medicaid Services (CMS) website, and staff interview, the facility failed to give 2-day notification of the CMS form #10123 Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 residents reviewed (Resident #9). In addition, the facility failed to provide a complete CMS form #10055 Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) of Non-coverage (SNFABN) for 2 of 3 residents reviewed (Residents #9 and #15). Findings Include: 1. Resident #9's NOMNC form listed that his showed skilled nursing coverage would end on 8/11/22. The form included an electronic signature from Resident #9 dated 8/10/22. The facility failed to provide documentation that showed Resident #9 received notification of skilled nursing cover ending within the two calendars as required. Resident #9's SNFABN dated 8/10/22 lacked a reason why Medicare may not pay and the estimated cost of services. 2. Resident #15's SNFABN dated 3/10/22 form lacked the estimated cost of skilled nursing care. The facility's CMS Guidelines on Notification of Non-Coverage revised 6/10/21 instructed that upon decision by the clinical staff that the resident is no longer meeting skilled criteria, a facility appointed individual will deliver a NOMNC (CMS-10123) two days prior to coverage termination. The guideline failed to instruct staff to complete all areas of the form including the reason Medicare may not pay and the estimated cost of services. The CMS website titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 visited on 5/25/23 at 1:12 PM, listed the following information: The facility must deliver the NOMNC at least two calendar days before their Medicare covered services end or if the resident does not receive services daily, on the second to last day of service. The Centers for Medicare and Medicaid Beneficiary Notices website (https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN), last modified on 12/1/21 at 8:00 PM, provided the link to the undated document titled Form Instructions Advance Beneficiary Notice of Non-coverage that provided instruction for SNFABN estimated cost of services. The form instructed that notifiers must complete the column under Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether to obtain potentially non-covered services. Notifiers must make a good faith effort to insert a reasonable estimate for all the items or services listed under Blank (D). In general, CMS expects that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since it would not harm the beneficiary if the actual costs were less than predicted. A single cost estimate can include a bundle of multiple items or services routinely grouped. For example, a group of laboratory tests can have a single cost estimate, such as a basic metabolic panel (BMP). An average daily cost estimate is also permissible for long term or complex projections. As noted above, providers may also pre-print a menu of items or services in the column under Blank (D) and include a cost estimate alongside each item or service. If a situation involves the possibility of additional tests or procedures (such as in laboratory reflex testing), and the notifier cannot determine a reasonable cost estimate associated with such tests at the time of ABN delivery, the notifier may enter the initial cost estimate and indicate the possibility of further testing. Finally, if for some reason the notifier is unable to provide a good faith estimate of projected costs at the time of ABN delivery, the notifier may indicate in the cost estimate area that no cost estimate is available. We would not expect either of these last two scenarios to be routine or frequent practices, but the beneficiary would have the option of signing the ABN and accepting liability in these situations. On 5/24/22 at 1:41 PM, the Administrator acknowledged that residents need the areas on the SNFABN regarding the reason Medicare may not pay and the estimated cost of services, to make an informed decision to pay out of pocket for continued services. The Administrator reported that the Social Worker is responsible for completing and reviewing the information for NOMNC, SNFABN, and for obtaining the resident's signatures within two calendar days of benefits ending. On 5/24/22 at 3:29 PM, the Administrator reported that she followed up with the Social Worker. The Social Worker reported that she did review the information with the residents prior to two calendar days but failed to document the specific details. The Administrator reported that she reviewed the forms and required documentation with the Social Worker.

Based on clinical record review, staff interview, and policy review, the facility failed to revise and update the Care Plan to include and address oxygen usage in 1 out of 15 sampled residents reviewed for comprehensive Care Plans (Resident #18). Findings include: 1. Resident #18's Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of pneumonia. The MDS indicated that Resident #18 experienced shortness of breath with exertion and received oxygen therapy. The Clinical Physician's Order included an order dated 4/21/23 of Oxygen 2 liters per minute (L) administered continuously via a nasal cannula (NC). The Care Plan revised 4/26/22, lacked information regarding Resident #18's oxygen usage. Resident #18's May 2023 Medication Administration Record (MAR) listed an order for Oxygen 2L continuously via NC. On 5/21/23 at 1:52 PM observed Resident #18's Oxygen concentrator set at 3L per (/) NC. On 5/22/23 at 8:21 AM witnessed Resident #18's oxygen concentrator set at 3L/NC. On 5/23/23 at 10:04 AM observed Resident #18's oxygen concentrator set at 3L/NC. The Care Plan Development policy revised August 2015 instructed the staff to review and revise the Care Plan as needed, when the staff notice a significant change in condition, when the resident did not achieve their outcomes, or when the resident completed their outcomes, and at least every 92 days. On 5/24/22 at 2:48 PM the Assistant Director of Nursing (ADON) reported that she failed to add oxygen usage to Resident's #18's Care Plan. The ADON acknowledged the Care Plan needs revised to include oxygen usage. On 5/24/22 at 3:22 PM the Administrator reported that she expected the Care Plan to contain oxygen usage.

Based on clinical record review, staff interview and policy review, the facility failed to manage Oxygen usage in 1 out of 15 sampled residents reviewed (Resident #18). Findings include: Resident #18's Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of pneumonia. The MDS indicated that Resident #18 experienced shortness of breath with exertion and received Oxygen therapy. The Clinical Physician's Orders included the following orders: a. Dated 4/17/23: Administer Oxygen 2-4 liters per minute (L) for Oxygen saturations (sats) below 90% as needed. b. Dated 4/21/23: Administer Oxygen 2L continuously via nasal cannula (NC). The facility failed to clarify if Resident #18 could receive additional Oxygen if needed. Resident #18's May 2023 Medication Administration Record (MAR) listed the following orders: a. Oxygen 2L continuously via NC. i. Documented as complete. b. Oxygen 2-4L per (/) nasal cannula (NC) if Oxygen sats dropped below 90%. i. Lacked documentation to indicate administration of as needed Oxygen. The Care Plan revised 4/26/22, lacked information regarding Resident #18's Oxygen usage. The Oxygen Saturation Summary for April and May 2023 for Resident #18 lacked documentation of when Resident #18's Oxygen saturation fell below 90%. On 5/21/23 at 1:52 PM observed Resident #18's Oxygen concentrator set at 3L per (/) NC. On 5/22/23 at 8:21 AM witnessed Resident #18's Oxygen concentrator set at 3L/NC. On 5/23/23 at 10:04 AM observed Resident #18's Oxygen concentrator set at 3L/NC. The Progress Notes dated 4/19/23 to 5/17/23 lacked documentation that Resident #18's Oxygen saturation fell below 90%. In addition, the Progress Notes lacked when and why Resident #18's Oxygen administration increased from 2 to 3L. On 5/24/22 at 2:41 PM the Director of Nursing (DON) reported that during rounds the facility's Nurse Practitioner (NP) noticed Resident #18 did not have continuous Oxygen ordered after her readmission from the hospital. The DON added that despite Resident #18's having Oxygen saturations 90% the NP called the primary provider and determined that Resident #18 should be on 2L of continuous Oxygen. The DON reported she did not know when or why the staff increased Resident #18's continuous Oxygen administration from 2L to 3L.

Based on observations, clinical record review, policy review, and staff interviews, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents reviewed (Residents #13 and #30). This resulted in a medication error rate of 5.26%. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS indicated that Resident #13 required extensive assistance of one person with bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The MDS included diagnoses of heart failure, anemia, atrial fibrillation, arthritis, non-Alzheimer's dementia, anxiety disorder, and psychotic disorder. Resident #13's Care Plan Focus revised 12/16/22 identified that she used an antidepressant medication (Fluoxetine) for excoriation related to a skin picking disorder. On 5/22/23 at 7:20 AM observed Staff C, Certified Medication Aide (CMA), pass the morning medications to Resident #13. Resident #13's medication card listed Fluoxetine 20 milligrams (MG). Staff C punched one capsule into the medication cup. Resident #13's Clinical Physician Orders listed an order dated 11/14/22 for Fluoxetine 60 MG daily. On 5/22/23 at 8:40 AM, reviewed Resident #13's Fluoxetine order with Staff C. Staff C replied that she only gave one capsule and should have given three to equal 60 MG. 2. Resident #30's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS indicated that Resident #30 required extensive assistance of one person with bed mobility, off unit locomotion, and toilet use. Resident #30 is non-ambulatory and uses a wheelchair for mobility. The MDS included diagnoses of renal insufficiency (poor kidney function), anemia (low blood iron level), diabetes, arthritis, anxiety, depression, asthma, left below the knee amputation, and obsessive-compulsive disorder (mental disorder characterized by repetitive actions that seem impossible to stop). On 5/22/23 at 7:26 AM, watched Staff C pass morning medications to Resident #30. Staff C removed one folic acid 400 micrograms (MCG) from a stock bottle and put into Resident #30's medication cup. Resident #30's Clinical Physician Orders listed an order dated 4/28/23 for folic acid 1 MG daily. On 5/22/23 at 8:40 AM reviewed Resident #30's folic acid order with Staff C. Staff C explained that the Nurse Practitioner said she was changing the order. On 5/23/23 at 8:40 AM the Director of Nursing reported that she expected that the staff gave the medications as ordered.

Based on observations, policy review and staff interview, the facility failed to secure two resident insulin pens in a locked storage area to prevent access by unauthorized personnel, visitors, or residents. The facility reported a census of 33 residents. Findings include: On 5/22/23 at 7:08 AM witnessed Staff D, Registered Nurse (RN), placed two insulin pens on top of Staff C's, Certified Medication Aide (CMA), medication cart while Staff C prepared a resident's medications for administration. Staff C finished preparing the resident's medications, locked the medication cart, and left the insulin pens on top of cart while administering the resident's medications. After administering the medications, Staff C returned to the medication cart and put the insulin pens away. On 5/23/23 at 8:40 AM the Director of Nursing reported that she expected the insulin return to the locked medication cart before leaving the medication cart unattended.

Based on observation, staff interviews, and record reviews, the facility failed to ensure food was stored and prepared under sanitary conditions. The facility failed to ensure appropriate temperatures while washing dishes in the dishwasher to efficiently clean dishes that the residents and staff use for meals. The facility reported a census of 30 residents. Findings include: 1. On 12/20/21 at 9:58 AM noted a white liquid on the salsa bottle in the refrigerator. On 12/20/21 at 11:30 AM Staff A, Cook, noted to have her face mask below nose. On 12/20/21 at 11:31 AM Staff A opened the window and moved her face mask over her nose. Without hand hygiene, Staff A gave a Certified Nurse's Aide a cup. On 12/20/21 at 11:32 AM Staff A adjusted her mask and without hand hygiene Staff A got a plate. Then she placed sandwiches on plates with tongs and places in window for two residents. On 12/20/21 at 11:45 AM Staff A removed her mask to speak to the Director of Nursing (DON), then got the DON and the Administrator's food. After handing the DON the food, Staff A opened the drawer and got out some plastic forks for them to use. On 12/20/21 at 11:48 AM Staff A opened the refrigerator doors and placed lids on two glasses of drinks. On 12/20/21 at 11:52 AM Staff A pulled her mask up and applied face shield then delivered meal to a resident without hand hygiene. On 12/20/21 at 12:02 PM Staff A washed her hands for first time during the kitchen observation. On 12/20/21 at 12:10 PM Staff A washed her hands again. On 12/21/21 at 10:15 AM Staff A explained that she only needed three puree sandwiches but makes four in case someone wanted some more. Staff A reported that she added six ounces of milk to the sandwiches before pureeing them. Staff A buttered the sandwiches with gloved hands, applied cheese, and two ounces of turkey. Staff A reported that two slices of turkey for each sandwich, then changed her gloves. Staff A removed her gloves after putting the sandwiches into the blender and put the gloves into garbage. Without hand hygiene Staff A walked over to the fridge and got milk then added measured six ounces into the blender. On 12/21/21 at 10:22 AM Staff A gathered three bowls and picked up the scoop. Staff A took the scoop to the dishwasher and placed in the dishwasher, starting the cleaning cycle. The thermometer read a temperature of 100. Once the dishwasher completed the cycle, Staff A got a paper towel and dried the scoop. Staff A washed her hands then got the coleslaw and began to scoop into the measuring cup. Staff A used her bare hand to prevent coleslaw from falling out of the container. As Staff A added mayo and milk noted white debris on her hand. Infection Control interview On 12/21/21 at 8:30 AM the Director of Nursing (DON) said that her expectation was for someone to sanitize their hands after touching their face shield or mask. 2. On 12/20/21 at 11:58 AM the dishwasher thermometer noted a temperature of 90 during the wash cycle and then 95 on the rinse cycle. The Dietary Manager showed the sign on the dishwasher that the temperature should be 120 for wash and rinse. The Dietary Manager opened the dishwasher and pulled out a rack of plate covers and water pitchers. On 12/20/21 at 12:10 PM the dishwasher thermometer while running showed a temperature of 115. On 12/20/21 at 12:14 PM the dishwasher thermometer showed a temperature of 120 while running a dish load. The Dietary Manager tested the chemical level while the load ran. The Dietary Manager showed the chemical strip with a level of 400 for chemicals and explained that it was between 400 and 500. Administration interview On 12/21/21 at 12:18 PM the Dietary Manager said that she didn't have a policy for the hand hygiene after touching a face mask or a face shield. She said they don't have to wear the face shield in the kitchen but if the staff did wear the face shield she was okay if they didn't wash their hands. They are the only ones that were touching the face shield, so they were clean. If the Cook was actively working with food, the Dietary Manager would expect them to wash their hands. The Dietary Manager explained that it took a few washes with the dishwasher for it to come up to the correct temperature so they have to run it twice for the first couple of loads to get it up to temperature. After it is up to the correct temperature they can wash them just once. She would expect the Cook to wash the scoop twice to ensure it was the Dishwasher was the correct cleaning temperature. Policies review The Dishmachine policy For Low Temperature Dishmachines dated 11/17 explained that before washing anything, the staff were to check the sanitizer level. A. For chlorine sanitizers, the level should be 50 ppm B. For Quat sanitizers, the level should be 200 ppm The Nutrition Services Manual: Sanitation dated 6/15 indicated that the facility strived to promote good sanitation practices in order to protect its residents and employees form foodborne illness. The facility sanitation system would ensure a clean, safe environment for its residents and staff. The Nutrition Services staff follow infection control procedures including maintaining personal hygiene and handling foods to prevent contamination. Staff were to wash their hands after the following activities, including, but not limited to: A. After touching the hair, face, or body B. After touching anything that may contaminate hands, such as unsanitized equipment, work surfaces, or wash cloths

Based on employee records, staff interviews, and policy review the facility failed to ensure new hires completed Dependent Adult Abuse training within six months of initial employment for two of five employees reviewed. The facility reported a census of 30 residents. Findings include: The employee record for Staff C, Dietary Aide showed a hire date of 3/4/21. The employee record for Staff C lacked documentation of completion of the Dependent Adult Abuse training. The employee record for Staff D showed a hired date of 2/22/21. The employee record for Staff D lacked documentation of completion of the Dependent Adult Abuse training. On 12/21/21 at 12:01 PM the Business Office Manager reported she could not find certificates of completion for Dependent Adult Abuse Mandatory Reporter training. She said that she attempted to reach each of them to see if they can come in to complete it. On 12/21/21 at 1:13 PM the Administrator stated she expected staff to complete Dependent Adult Abuse Mandatory Reporter training within six months. The Abuse Prevention Program and Reporting Policy dated 8/19 revealed Iowa Specific Instructions required each employee to complete two hours of Dependent Adult Abuse training related to the identification and reporting of dependent adult abuse within six months of initial employment.

Based on staff interview, observation and record review the facility failed to update resident care plans in a timely manner and ensure resident's individual needs were communicated accurately for 2 of 13 residents reviewed. Resident #28 had a large mass on the side of her face that was growing in size, the care plan lacked information about any special cares required. Resident #22 had a change in code status from CPR to DNR the beginning of December and the care plan did not reflect this change. The facility reported a census of 30 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #28 with a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severe cognitive deficits. Resident #28 required limited assistance of one staff for dressing, toileting and was independent with transfers and bed mobility. The care plan dated [DATE] identified Resident #28 with self-care deficits related to dementia and identified the resident at risk for complications related to occasional bowel and bladder incontinence. The care plan directed staff to observe and report any changes in condition. The care plan revealed the resident at risk for impaired skin integrity related to diabetes mellitus. Observation showed on [DATE] at 11:38 AM, Resident #28 sitting at the table in the dining room with a large purple and red growth (mass) on right side of her face between the right eye and ear. The care plan lacked information about the mass, when it was first discovered or if there were any directives to staff on treatment or cares for the area. 2. A MDS dated [DATE] assessed Resident #22 with a BIMS score of 10 out of 15 (moderate cognitive impairment. The MDS showed that the resident required extensive assistance of one staff for transfer, dressing, locomotion and toileting. The care plan updated on [DATE] identified the resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation showed on [DATE] at 11:20 AM a binder with a title of IPOST (Iowa Physicians Orders for Scope of Treatment) and contained a copy of the IPOST documents for all of the residents. These documents identified the resident's wishes for resuscitation in the case of [CONDITION(S)]. A care plan updated on [DATE],revealed Resident #22 requested CPR/full code and directed staff to provide chest compressions if/when the heart stopped. The care plan also showed that on [DATE], the family for Resident #22 chose hospice care services for the resident. An IPOST document from the Hospice organization, dated [DATE] identified Resident #22 with a Do Not Resuscitate (DNR) order. On [DATE] at 8:26 AM the Assistant Director of Nursing (ADON) and Nurse Consultant (NC) said that they conducted a monthly audit of the code status of residents. The NC said she completed an audit on [DATE] just before Resident #22 started Hospice services and changed status to DNR on [DATE]. They said that when there is a change in code status the Director of Nursing (DON) usually makes sure that the information is transferred to the IPOST binder and in the care plan.

Based on staff and Hospice interviews and record review the facility failed to accurately document the code status for 1 of 13 residents reviewed. Resident #22 requested Cardiopulmonary resuscitation (CPR) initiated if she experienced [CONDITION(S)]. Upon a change of condition, the resident changed her code status to Do Not Resuscitate (DNR) but staff change facility documentation. The facility reported a census of 30 residents. Findings include: A MDS dated [DATE] assessed Resident #22 with a BIMS score of 10 out of 15 (moderate cognitive impairment. The MDS showed that the resident required extensive assistance of one staff for transfer, dressing, locomotion and toileting. The care plan updated on [DATE] identified the resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation showed on [DATE] at 11:20 AM a binder with a title of IPOST (Iowa Physicians Orders for Scope of Treatment) and contained a copy of the IPOST documents for all of the residents. These documents identified the resident's wishes for resuscitation in the case of [CONDITION(S)]. A care plan updated on [DATE],revealed Resident #22 requested CPR/full code and directed staff to provide chest compressions if/when the heart stopped. The care plan also showed that on [DATE], the family for Resident #22 chose hospice care services for the resident. A review of the electronic chart on [DATE] revealed that the resident had active orders for both CPR and DNR and the face page indicated the code status to be CPR. An IPOST document from the Hospice organization, dated [DATE] identified Resident #22 with a Do Not Resuscitate (DNR) order. On [DATE] at 8:26 AM the Assistant Director of Nursing (ADON) and Nurse Consultant (NC) said that they conducted a monthly audit of the code status of residents. The NC said she completed an audit on [DATE] just before Resident #22 started Hospice services and changed status to DNR on [DATE]. They said that when there is a change in code status the Director of Nursing (DON) usually makes sure that the information is transferred to the IPOST binder and in the care plan.

Based on observation, record review, and staff interview the facility failed to assure a resident with a catheter received necessary care and services to prevent infection for 1 of 5 residents reviewed (Resident #8). The facility reported a census of 30 residents, Findings include: A Minimum Data Set (MDS) dated [DATE] assessed Resident #8 with a Brief Interview for Mental Status score of 10 (moderate cognitive impairment). The resident depended on staff for toilet use and personal hygiene. The resident had an indwelling urinary catheter and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Current Care Plan revised 3/3/21 identified the resident had an indwelling catheter. The goals included the resident would show no signs and symptoms (s/sx) of urinary infection. The interventions included positioning the catheter bag and tubing below the level of the bladder, monitoring/recording/reporting to the physician for s/sx of urinary tract infection. Observation showed on 12/21/21 at 1:46 p.m. Staff B Certified Nursing Assistant (CNA) and Staff E CNA transfer the resident to bed with the total mechanical lift. The dignity bag covering the catheter bag had no bottom to it. During the transfer Staff E held the catheter bag at the residents head height (above the bladder). After they transferred the resident to bed, Staff B obtained a wet washcloth. Staff E prepped the resident and performed perineal care and cleaned down the catheter tubing. Staff B placed a barrier on the floor, and a graduate on the barrier. She performed hand hygiene before gloving, and removed the drain port and wiped with an alcohol prep. She emptied the catheter bag, then let go of the drain and it touched the graduate at the upper rim while she changed gloves and performed hand hygiene. She then wiped and replaced the drain. On 12/23/21 at 8:36 a.m. the Assistant Director of Nursing (ADON) stated the catheter bag should remain below the level of the bladder, and when emptying the catheter bag, the drain should not be in contact with the graduate. The facility policy for Indwelling Catheter Care dated 01/13 documented the procedure included positioning the catheter and drainage bag below the level of the bladder to facilitate flow of urine, and emptying the gravity drainage bag every shift or more often, and not allowing the end of the drainage spigot touch the floor, collection container, or other surface. The Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) found on the CDC website, last updated June 6, 2019 included proper techniques for urinary catheter maintenance on page 13 of 61. They included keeping the collecting bag below the level of the bladder at all times and not resting the bag on the floor. When emptying the collecting bag, preventing contact of the drainage spigot with the nonsterile collecting container.

Based on observations, staff interviews and record review, the facility failed to ensure staff implemented appropriate infection control measures when providing care for 3 of 13 residents reviewed. Resident #14 had an indwelling catheter and the catheter bag was resting on the floor. While providing cares to Resident #15 and #81, staff failed to use adequate and safe hygiene methods. The facility reported a census of 30 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #14 with a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). The MDS revealed the resident used a wheel chair for mobility, had an indwelling catheter, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan updated on 8/9/21 identified Resident #14 with an indwelling catheter and the goal was that the resident would remain free from catheter related trauma. Observation showed on 12/20/21 at 2:32 PM the resident in bed sleeping with the urinary catheter bag resting on the floor next to the bed. Observation revealed a puddle of fluid on the floor next to the catheter bag. On two separate observations: 12/20/21 at 12:17 PM and 12/21/21 at 1:05 PM, the catheter bag sat on the floor next to the resident's bed. On 12/22/21 at 08:16 AM the Assistant Director of Nursing (ADON) and Nurse Consultant (NC) said that they had been aware of the catheter bag resting on the floor and discussed how to change that situation with his bed being in the low position. They said that they thought about putting the catheter bag in a tub that could be sanitized on a regular basis. They were also aware that there was some concern about drainage from the penis/catheter area on Monday and agreed that there could have been some leakage onto the floor. According to the Center for Disease control and Prevention (CDC) in order to help prevent Catheter-associated urinary tract infections (CAUTI) the collecting bag should be kept below the level of the bladder at all times and the bag should not rest on the floor. (Retrieved on 12/22/21 from the Center for disease control and prevention CAUTI Guidelines | Guidelines Library | Infection Control | CDC) 2. A MDS dated [DATE] assessed Resident #15 with a BIMS score of 15 (no cognitive impairment). The resident required limited assistance of one staff with transfers and walking and extensive assistance of one staff for dressing and toileting. The care plan dated 10/29/21 identified the resident with impaired skin integrity related to fragile skin and bladder incontinence. On 12/21/21 the care plan revealed the resident started on antibiotic therapy for a urinary tract infection. Observation showed on 12/21/21 at 11:15 AM Staff B Certified Nursing Assistant (CNA) assist Resident #15 to the bathroom. Staff B removed the soiled brief with ungloved hands. She then went to the dresser, opened the drawer and gathered towels and clothing. Following that, she used hand sanitizer. On 12/22/21 at 08:14 AM, the ADON and NC agreed the CNA should have used gloves when removing the soiled brief and then completed hand hygiene before touching any other surfaces. 3. A MDS dated [DATE] assessed Resident #81 with a BIMS score of 13 (no cognitive impairment). The resident admitted to the facility on [DATE] from an acute hospital. The resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation On 12/21/21 at 9:03 AM Staff B, Certified Nurses' Aide (CNA) brought the resident his meal. Staff B stated she used to work the novel Coronavirus 2019 (COVID19) unit at the hospital and the rules were different here than at the hospital. At the hospital she would put on gloves, gown, then another pair of gloves. Staff B entered the isolation area and opened the isolation drawer, she took out a gown, then took the plastic bag and placed it into the garbage can. The gown brushed the garbage can as she placed the bag into it. Then she removed her face shield and face mask. She laid the face mask on the hand rail behind the isolation supplies got out another face mask and applied it. Then she opened the drawer to get gloves. After getting the gloves, she dropped one glove. Staff B stopped and picked it up then tossed it towards the garbage can where it bounced off the garbage can to the floor. Without hand hygiene, she opened and reached into the drawer to get another glove. Staff B applied the gloves, picked up the tray of food and went into the resident's room. No hand hygiene completed through entire observation. Record review The Baseline Care Plan - Version 4 - V 3 dated 12/10/21 stated the list of other dietary interventions was that the resident ate in his room for the next 14 days then the resident would go to the dining room for meals. The Infection Control section said the resident required standard precautions. Infection Control Interventions section reported not applicable. The Nursing Daily Skilled Assessment v.8 - V 4 dated 12/21/21 at 9:07 AM stated under the COVID/Isolation section that the resident warranted droplet isolation. The resident required a private isolation room. Administration interview On 12/21/21 at 8:30 AM the Director of Nursing (DON) said that her expectation was for someone to sanitize their hands after touching their face shield or mask. Policy review The Infection Control Manual: Handwashing policy dated 3/20 revealed the facility would follow the Center for Disease Control (CDC) Guidelines for handwashing. Handwashing is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident/patient contact to prevent the spread of infection. Hands must be washed after the following, including, but not limited to: A. Contact with contaminated items or surfaces B. Contact with resident/patient C. Initiating a clean procedure D. Removal of gloves

Based on observation, clinical record review and interview, the facility failed to ensure that all residents received treatment and care in accordance with professional standards and failed to provide professional nursing assessments and timely intervention for 4 of 5 residents reviewed (Resident #1, #2, #3, #4.) The facility reported a census of 30. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 required extensive assistance with the assistance of 2 staff for transfers, dressing, bathing and toileting. The MDS assessed the resident with a Brief Interview for Metal Status (BIMS) score of 9 out of 15 (moderate cognitive deficit). The MDS indicated that the resident had [DIAGNOSES REDACTED]. According to the resident census in the electronic chart, Resident #1 admitted to the facility on [DATE] and hosptalized on [DATE] with acute kidney failure and readmitted to the facility on [DATE] with a Foley urinary catheter in place. Nursing notes dated 9/14/20 at 12:10 PM indicated the resident readmitted to the hospital on [DATE] with foot ulcers and kidney failure. While at the hospital, he was admitted to Hospice services and returned to the facility on [DATE] on Hospice. According to the nursing notes the resident passed away on 9/18/20. A Braden Scale assessment (used to determine risk for development of pressure ulcers) completed on 9/12/20 and dated 7/11/20 identified the resident with no impairment in sensory perception or ability to respond meaningfully to pressure-related discomfort. The assessment indicated the resident did not have sensory deficits to limit his ability to feel or voice pain or discomfort. The chart lacked any follow up Braden Scale assessments until the resident returned from the hospital on [DATE] and on that date the assessment identified the resident at very high risk for development of pressure sores. A nursing admission assessment dated [DATE], identified the resident at mild risk for pressure development and at that time, the only skin issues recorded revealed bruising on the left elbow, right hand and left hand and discoloration to the right 3rd toe. A pressure injury weekly assessment form 7/18/20 identified an unstageable pressure area on the right heel measuring 4.2 centimeters (cm) length x 5.4 cm width x 0 depth. The left heel contained an unstageable pressure ulcer that measured 2.0 cm x 3.1 x 0. A third area identified as the outer left great toe revealed a 2.4 cm. by 2.5 cm. by 0 stage 1. A physician order [REDACTED]. According to a skin assessment dated [DATE], the left heel had healed and the right heel measured 3 cm x 3.5 cm. A skin assessment completed on 8/19/20 revealed an area discovered on the right great toe measuring 4.2 cm x 3.0 cm. From 8/26/20 until the resident's hospitalization on [DATE], the chart lacked measurements on any of the previously mentioned ulcers. According to a nursing note dated 9/17/20, when the resident returned from the hospital on [DATE] the right heel ulcer measured 4 cm x 3.5 cm, right great toe was 1 cm x 1.5 cm., and one additional ulcer on the side of the right great toe measured 2 cm x 1.5 cm x 0. According to a physician's orders [REDACTED]. The order directed staff to insert a catheter as needed if the resident did not have any output for a 12 hour period. According to the electronic documentation of output for the resident, on 9/8/20 and 9/12/20 the resident did not have any urinary output. The chart lacked any information regarding follow up on those two days with no documented urine output. An intake/output entry made on 9/15/20 at 1:00 PM revealed the resident ate 76%-100% of his breakfast meal, however the resident was in the hospital at that time. Nursing notes dated 9/14/20 at 12:10 p.m. revealed the resident admitted to the hospital. Nursing notes dated 9/17/20 revealed the resident readmitted from the hospital on [DATE] at 12:45 p.m. On 10/1/20 at 8:10 AM, Staff A RN (registered nurse) remembered providing care for Resident #1 and stated she assessed him upon admission on 7/4/20 and then again on 7/5/20 when he returned from the hospital. She said that in that one day he was a different person. Initially he had been very interactive and independent but after the hospital stay he slept more and his speech was slurred. She said that initially he was continent of bowel and bladder but was incontinent of both when he came back on the 5th. On 10/12/20 at 12:30 PM the doctor that treated Resident #1 during his hospitalization s, stated that he remembered the resident and stated the resident had a severe decline in health. The doctor said the resident had little feeling in his feet and due to his dementia the resident could not express his pain and discomfort. When asked about the [DIAGNOSES REDACTED]. hours without voiding. The doctor said he would have wanted to have been contacted if/when the resident went longer than 12 hours without voiding but he could not say for sure if that would have made a difference in the outcome due to the resident's total decline in health. 2. A MDS dated [DATE] assessed Resident #2 with a BIMS score of 0 out of 15 (severe cognitive impairment). The MDS revealed the resident admitted to the facility on [DATE]. The MDS identified, that upon admission, the resident required extensive assistance of 2 staff for bed mobility, dressing and toileting and required limited assistance two staff for transfers. A fall assessment completed on 4/6/20 at 10:05 AM, but dated 3/31/20 at 9:25 AM, revealed an unwitnessed fall on 3/31/20 at 9:25 PM. The facility contacted the family and physician. Nursing notes dated 3/31/30 identified the resident with complaints of lower back pain at 3:55 p.m. and Staff administered Tylenol ([MEDICATION NAME]). A later entry at 7:57 p.m. identified the Tylenol as effective. A pain evaluation completed on 4/6/20 at 2:53 AM, but dated 4/1/20 2:48 PM. identified the resident with severe pain at fracture site and a change in behavior. The pain evaluation form identified the resident with a [MEDICAL CONDITION] 2 and healing [MEDICAL CONDITION]. The chart lacked any documentation of physician notification until nurses notes revealed a notification on 4/5/20 at 5 p.m. A pain assessment dated [DATE] at 7:57 AM revealed the resident rated her pain at 6 out of 10 (with 10 being the worst imaginable pain). According to a nursing note on 4/2/20 at 6:18 PM, the resident refused her evening meal and on 4/3/20 at 1:05 PM she refused fluids. A nursing note dated 4/4/20 at 3:11 indicated the resident refused to eat and reported lower back pain. A nursing note dated 4/4/20 at 5:00 PM documented the nurse observed swelling to coccyx and lower lumbar and an unsteady gait. The nurse documented she notified the doctor at that time and the resident went to the emergency room (ER). According to the hospital documentation dated 4/5/20, the resident suffered a Lumber 2 fracture. The resident returned to the facility on [DATE] at 5:46 PM. On 10/1/20 at 3:15, Staff E CNA (certified nurse aide) revealed she and the nurse found the resident on the floor in the bathroom. She remembered the resident told them she did not have pain at that time but that a couple of times, days after the fall she said that her back hurt and Staff E noticed the resident walked slower slower. Staff E said she reported the pain to the nurses and assumed that they followed up. 3. An MDS dated [DATE] assessed Resident #3 with a BIMS score of 15 (no cognitive impairment) and [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of two staff with bed mobility, and toileting and the resident required limited assistance of one staff with transfers, locomotion and hygiene needs. In a series of observation on 9/28/20 at 2:10, 3:30, 4:00 and 4:30, observation revealed the resident in the same position in bed on her back. According to meals eaten documentation on 9/28/20 at 10:55 AM and 1:40 PM the resident did not eat and at 6:43 PM for the evening meal it indicated that she was not available. The Fluids with Meals documentation on 9/28/20 at 10:58 AM and 1:22 PM indicated no fluid intake at the morning or lunch meal and the evening meal documented as not applicable at 9:26 p.m. A nursing daily skilled assessment dated [DATE] at 12:24 AM revealed the resident remained in bed the entire shift with good appetite and fluid intake. The assessment did not contain documentation of urine output. A nursing note dated 9/29/20 at 5:54 AM identified the resident as flushed and hot to touch. Vitals taken and found with a temperature of 103.4 degrees, heart rate (HR) 108, blood pressure 100/54 and oxygen saturation 90% on room air. The facility notified the physician and the resident transferred to the hospital. According to the ER report dated 9/29/20 at 7:14 AM the resident reported she felt ill for the previous 5 days and she admitted to the hospital with [REDACTED]. On 9/29/20 at 9:43 AM, Staff A, RN stated she provided care for the resident during the day on 9/28/20 and she did not notice anything different or concerning about the residents skin color, or any lethargy. Nursing documentation dated 9/28/20 at 6:37 PM identified the resident's appetite as good and fluid intake good and resident alert. In an interview on 9/29 at 10:04 AM Interview with CNA Staff E worked on 9/28 she that when she emptied the urine bag that day, she noticed the urine to be darker than normal. She noticed that the resident hadn't eaten much, and that normally she would eat almost all of what is put in front of her. CNA staff E said that she also worked on 9/27/20 and noticed that the urine was darker on that day and that the resident appeared to be sleepier. She said that she had reported to this to the nurse. In an interview on 9/29/ 10:15 AM, CNA Staff G said she had worked with Resident #3 on 9/28 and had noticed that the urine was a little dark with sediment and that the resident had been sleeping more than normal. She also stated that the resident would usually drink her entire pitcher of water before the end of the day, but on 9/28 the resident drank about half as much water. Staff G stated that the resident told her that she was not feeling well at supper time, and had an upset stomach. Staff G said that she reported to nurse that the resident wasn't herself. Staff G was unsure if there was any follow up from the nurse. 4. A MDS dated [DATE] assessed Resident #4 with a BIMS score of 15 out of 15 (no cognitive impairment). The resident had [DIAGNOSES REDACTED]. According to the MDS, the resident was independent with transfers, eating, toileting and bed mobility. Observation on 9/28/20 at 10:30 AM revealed the resident in his room in a wheel chair and appeared to be sleeping with a protective boot on his right foot and his left leg absent from above the knee. A skin assessment dated [DATE], revealed the resident had a non-pressure skin tear on the top of his left lower leg. Follow up skin assessments dated 9/15, and 9/29 also referred to a skin tear on the left leg. A follow up skin assessment on 10/6/20 indicated that this skin tear was on his right leg. Observation on 10/1/20 at 9:45 AM, showed Staff A RN provide treatment to a pressure area on the resident's toe. Staff A asked the resident when he had gotten the skin tear and stated this was the first time she observed it. According to the nursing notes, Staff A RN cared for Resident #4 on 9/24/20 and 9/29/20. On 10/13/20 at 2:40, the Administrator said Staff A did not work on the floor on 9/29/20 so would not have done patient cares. When asked about nurse to nurse report if she would expect new skin tear information passed on, she said she expected nurses would share it in report. According to the policy titled: Skin Care and Wound Management, staff are directed to identify residents at risk for developing pressure ulcers and implement prevention strategies to minimize the developing of pressures ulcers and skin integrity issues with weekly monitoring of skin status and daily monitoring of existing wounds.

Based on record review and interview the facility failed to review and revise care plans in a timely manner for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 30 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 required extensive assistance with the assistance of 2 staff for transfers, dressing, bathing and toileting. The MDS assessed the resident with a Brief Interview for Metal Status (BIMS) score of 9 out of 15 (moderate cognitive deficit). The MDS indicated that the resident had [DIAGNOSES REDACTED]. According to the resident census in the electronic chart, Resident #1 admitted to the facility on [DATE] and hosptalized on [DATE] with acute kidney failure and readmitted to the facility on [DATE] with a Foley urinary catheter in place. According to the nursing admission assessment dated [DATE] Resident #1 had no pressure ulcers upon admission. A skin assessment dated [DATE] identified the resident with a pressure ulcer of the right heel measuring 4.2 centimeters (cm) length x 5.4 cm width x 0 depth, and one on the left heel that measured 2.0 cm x 3.1 x 0. According to a physician's orders [REDACTED]. The order directed staff to insert a catheter as needed if the resident did not have any output for a 12 hour period. The care plan lacked focus areas and interventions to address the monitoring of urinary output or monitoring of foot ulcers. The care plan lacked details regarding the pressure ulcers on his feet and had no interventions related to pressure prevention. In an interview with the Administrator on 10/13/20 at 1:10 PM she said that they have been without a designated staff person to update care plans.

Based on observation, clinical review and interview the facility failed to provide care to prevent the development and worsening of pressure ulcers for 2 of 5 residents reviewed (Residents #1 and #3). The facility reported a census of 30 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 required extensive assistance with the assistance of 2 staff for transfers, dressing, bathing and toileting. The MDS assessed the resident with a Brief Interview for Metal Status (BIMS) score of 9 out of 15 (moderate cognitive deficit). The MDS indicated that the resident had [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE], identified the resident at mild risk for pressure development and at that time, the only skin issues recorded revealed bruising on the left elbow, right hand and left hand and discoloration to the right 3rd toe. A Braden Scale assessment (used to determine risk for development of pressure ulcers) completed on 9/12/20 and dated 7/11/20 identified the resident with no impairment in sensory perception or ability to respond meaningfully to pressure-related discomfort. The assessment indicated the resident did not have sensory deficits to limit his ability to feel or voice pain or discomfort. The chart lacked any follow up Braden Scale assessments until the resident returned from the hospital on [DATE] and on that date the assessment identified the resident at very high risk for development of pressure sores. A nursing admission assessment dated [DATE], identified the resident at mild risk for pressure development and at that time, the only skin issues recorded revealed bruising on the left elbow, right hand and left hand and discoloration to the right 3rd toe. A pressure injury weekly assessment form 7/18/20 identified an unstageable pressure area on the right heel measuring 4.2 centimeters (cm) length x 5.4 cm width x 0 depth. The left heel contained an unstageable pressure ulcer that measured 2.0 cm x 3.1 x 0. A third area identified as the outer left great toe revealed a 2.4 cm. by 2.5 cm. by 0 stage 1. A physician order [REDACTED]. According to a skin assessment dated [DATE] at 7:22 AM the left heel had healed and the right heel was 3 cm x 3.5 cm., and an area was discovered on the right great toe measuring 4.2 cm x 3.0 cm. A skin assessment dated [DATE] at 1:00 PM included the right heel measuring 3 cm x 3 cm and the outer great toe 2.5 cm x 2 cm. From 8/26/20 until the resident's hospitalization on [DATE], the chart lacked measurements on any of the previously mentioned ulcers. According to a nursing noted dated 9/17/20 at 1:00 PM, the resident returned to the facility with the following ulcers: Right heel 4 cm x 3.5 cm. side of the right great toe was 2 cm x 1.5 cm. and the top of the right great toe measured 1 cm x 1.5 cm. The care plan lacked focus areas and interventions to address the monitoring of foot ulcers. The care plan lacked details regarding the pressure ulcers on his feet and had no interventions related to pressure prevention. 2. A MDS dated [DATE] assessed Resident #3 with a BIMS score of 15 (no cognitive impairment) and [DIAGNOSES REDACTED]. The MDS revealed the resident required extensive assistance of two staff for bed mobility, and toileting. The resident required limited assistance of one staff for transfers, locomotion and hygiene needs. According to the care plan dated 2/5/20 the resident required assistance to reposition every two hours. Observation showed on 9/28/20 at 2:10 p.m., 3:30 p.m., 4:00 p.m. and 4:30 p.m., the resident in the same back lying position in bed at all observations. According to weekly pressure assessments dated 7/3/20 at 11:37 AM a chronic ulcer on the left gluteal fold measured 6.9 cm x 1.7 cm x 1.4 cm depth. On 8/19/20 it measured 4.4 cm x 1.8 cm x 0.1 cm. On 9/1/20 it measured 5.1 cm x 2.0 cm x 1.8 cm. The chart lacked any other measurements up until her hospitalization on [DATE]. According to a nursing note on 9/29/20 at 5:54 AM the resident appeared flushed and hot to touch. Staff obtained vital signs. The resident's temperature measured 103.4 degrees, heart rate 108, blood pressure 100/54 and oxygen saturation 90% on room air. Staff notified the physician and the resident transferred to the hospital. According to the emergency room report the resident reported that she felt ill for the last 5 days and she admitted to the hospital with [REDACTED]. Nursing notes dated 9/8/20 11:48 AM, 9/18/20 3:42 PM and 9/25/20 3:42 PM indicated that the resident refused one of the twice a day treatments to the wound. Nursing notes dated 9/18/20 3:42 PM and 9/25/20 3:42 PM indicated the resident refused skin assessment on those dates. The chart lacked documentation of any other attempts at assessment. According to the hospital records dated 9/30/20 at 8:35 AM the wound on bottom in left buttock crease measured 10 cm x 3 cm and observed a superficial small slit open area at the top of coccyx. On 10/13/20 at 1:15 PM the Administrator stated Resident #3 often refused cares and could change positions per self in bed. According to the policy titled: Skin Care and Wound Management, staff are directed to identify residents at risk for developing pressure ulcers and implement prevention strategies to minimize the developing of pressures ulcers and skin integrity issues with weekly monitoring of skin status and daily monitoring of existing wounds.

Based on record review and staff interview, the facility failed to maintain medical records that were accurate for 3 of 5 residents reviewed. The facility had conflicting information regarding Resident #1 and #3 intakes. The facility inaccurately documented the location of Resident #4's leg wounds. Facility census was thirty (30) residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 required extensive assistance with the assistance of 2 staff for transfers, dressing, bathing and toileting. The MDS assessed the resident with a Brief Interview for Metal Status (BIMS) score of 9 out of 15 (moderate cognitive deficit). The MDS indicated that the resident had [DIAGNOSES REDACTED]. An intake/output entry made on 9/15/20 at 1:00 PM revealed the resident ate 76%-100% of his breakfast meal, however the resident was in the hospital at that time. Nursing notes dated 9/14/20 at 12:10 p.m. revealed the resident admitted to the hospital. Nursing notes dated 9/17/20 revealed the resident readmitted from the hospital on [DATE] at 12:45 p.m. 2. An MDS dated [DATE] assessed Resident #3 with a BIMS score of 15 (no cognitive impairment) and [DIAGNOSES REDACTED]. According to meals eaten documentation on 9/28/20 at 10:55 AM and 1:40 PM the resident did not eat and at 6:43 PM for the evening meal it indicated that she was not available. The Fluids with Meals documentation on 9/28/20 at 10:58 AM and 1:22 PM indicated no fluid intake at the morning or lunch meal and the evening meal documented as not applicable at 9:26 p.m. A nursing daily skilled assessment dated [DATE] at 12:24 AM revealed the resident remained in bed the entire shift with good appetite and fluid intake. Nursing documentation dated 9/28/20 at 6:37 PM identified the resident's appetite as good and fluid intake good and resident alert. In an interview on 9/29 at 10:04 AM Interview with CNA Staff E worked on 9/28 she that when she emptied the urine bag that day, she noticed the urine to be darker than normal. She noticed that the resident hadn't eaten much, and that normally she would eat almost all of what is put in front of her. 3. A MDS dated [DATE] assessed Resident #4 with a BIMS score of 15 out of 15 (no cognitive impairment). The resident had [DIAGNOSES REDACTED]. According to the MDS, the resident was independent with transfers, eating, toileting and bed mobility. Observation on 9/28/20 at 10:30 AM revealed the resident in his room in a wheel chair and appeared sleeping with a protective boot on his right foot and his left leg absent from above the knee. A skin assessment dated [DATE], revealed the resident had a non-pressure skin tear on the top of his left lower leg. Follow up skin assessments dated 9/15, and 9/29 also referred to a skin tear on the left leg. A follow up skin assessment on 10/6/20 indicated that this skin tear was on his right leg.

Based on interviews with residents and staff, record review, and facility policy review, the facility failed to: investigate allegations of possible abuse, failed to immediately report allegations of abuse to the State Survey Agency; and failed to report the outcome of the investigation to the State Survey Agency. This deficient practice represented a systemic failure by management that resulted in a determination of Immediate Jeopardy, that directly affected two (2) of eleven (11) residents (Resident #11 and Resident #12) in the sample; and had the potential to affect other residents due to management's lack of reporting and investigating. The Immediate Jeopardy (IJ) was identified during the investigation on 7/13/17 at 12:57 p.m. The facility reported a census of 36 residents. Findings include: 1. According to the Minimum Data Set with assessment reference date 6/19/17 Resident #11 had a BIMS score of 14, which meant he/she had intact cognitive skills for daily decision making. The resident had not displayed any behavior symptoms, hallucinations or delusions. Resident #11 required extensive assist of two staff for bed mobility, transfers, ambulation and toilet use. During an Interview with Resident #11 on 7/11/17 at 3:20 p.m. he/she stated one night he/she had a lot of leg pain and Staff F, certified medication aide (CMA) made the comment, Do I need to hang you from your neck? Resident #11 stated he/she had spoken of the situation to the Administrator. During interview on 7/11/17 at 4:25 p.m. the prior Administrator stated about three weeks ago Resident #11 and the resident's family member had called him to the resident's room to visit. The resident had told him about Staff F who the resident had called into the resident's room several times the night before because the resident had leg pain. Resident #11 told the Administrator that Staff F had stated to the resident, I am going to hang you by your neck or stand you on your head. Resident #11 said Staff F and the resident had a rough night but the resident did not feel it was an appropriate response. The Administrator stated he asked the resident if he/she wanted to file a grievance report and the resident did not want to. The Administrator stated he did not report the allegation of abuse and did not investigate the incident. The Administrator stated it was an error in judgement and at a loss of what to do now. He stated he would start an investigation and file a late, late report. 2. According to the Minimum Data Set with assessment reference date of 5/15/17, Resident #12 had a BIMS score of 9, which revealed moderate impaired cognitive skills for daily decision making. The resident had not displayed any behavior symptoms, hallucinations or delusions. Resident #12 required limited assist of one staff for bed mobility, transfers, ambulation and toilet use. During interview on 7/12/17 at 4:28 p.m. Staff G, certified nurse aide (CNA) stated Resident #12 had told her that Staff H (Registered Nurse) had seen him/her standing up with his/her walker and told the resident, Better sit down because I do not want to pick your sorry ASS off the floor if you fall. Staff G stated she had told the prior Director of Nursing (DON) directly because she thought it was critical. Staff G stated the prior DON said they are working on it, we do not have a lot of Registered Nurses and Staff H is a Registered Nurse. Staff G stated she told the DON we have to do something and the prior DON responded the Administrator thinks we are picking on Staff H. During interview on 7/13/17 at 9:30 a.m. Resident #12 stated staff treated him/her good when he/she is doing right and when not doing right staff are rude. The resident stated he/she had been told, if you fall down I am not going to pick your sorry ASS up. Resident #12 stated it was Staff H that said that to him/her. Resident #12 then asked if that staff member was standing behind him/her. The resident was assured Staff H was not in the building. The resident stated Staff H had helped him/ her with medications and cares since making the statement. Resident #12 felt like Staff H did not like him/her denied being afraid of Staff H. Resident #12 then began to cry softly. The resident was unable to state when (approximate date) the incident had occurred. Resident #12 stated she had told Staff G of the incident. During interview on 7/17/17 at 11:25 a.m. the prior Director of Nurses (DON) stated she had heard from Staff G that Staff H had made the comment to Resident #12, (you) better sit down because I do not want to pick your sorry ASS off the floor if you fall. The prior DON stated she thought she heard it last month, guessing, since after Resident #12's last fall on 6/18/17. The prior DON stated she had not had a chance to talk to Staff H or Resident #12 about it. The prior DON stated she knew it needed to be investigated and then if it was valid would report it after the investigation. The Abuse Prevention Program and Reporting Policy with revised date 04/17 noted the facility acknowledges the following Federal definition of Verbal Abuse; oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy included Reporting, directing staff to report the incident immediately to the Administrator and Director of Nursing. Any staff member with knowledge of the event is responsible for notifying the Administrator and/or DON. Notify the appropriate State agency immediately by fax, telephone or on-line reporting after identification of alleged/suspected incident. The facility abated the IJ on 7/13/17 when they completed the following: The Interim Administrator began education with staff regarding the facility Abuse Program and Reporting Policy on 7/12/17. On 7/13/17, the facility started on going education with staff on the Abuse Prevention Program and Reporting policy and facility Grievance Process. Staff were not allowed to work until they were educated. Staff were given a copy of the abuse policy and acknowledged a shared knowledge of understanding of what to do if there is an allegation of abuse, unkind or inconsiderate care towards a resident that they will report it to the Administrator and DON immediately. The facility provided training documentation to the State Agency (Department of Inspections and Appeals) which showed employees scheduled to work had been educated. The education provided by the management staff revealed the Administrator or designee daily will ensure prompt and appropriate follow-up in accordance with the facility's abuse and grievance policy. The facility would have departments heads meet with assigned residents on a regular basis using the Guardian Angel tool to proactively address concerns with residents as a part of the facility ongoing quality assurance process. Staff F was suspended by the prior Administrator at 10:00 p.m. on 7/11/17 pending an investigation. The prior Administrator was suspended by the interim DON, regional nurse consultant the evening of 7/12/17. These actions lowered the IJ from K severity to D with ongoing monitoring of the facility policy for reporting and investigating abuse.

Based on interviews with residents and staff, review of the facility policy, the facility failed to implement their abuse policy and procedure to report and investigate all allegations of possible abuse; and failed to carry out reporting requirements to the State Survey Agency. This deficient practice represented a systemic failure by management that resulted in a determination of Immediate Jeopardy. The Immediate Jeopardy (IJ) was identified during the investigation on 7/13/17 at 12:57 p.m. The facility reported a census of 36 residents. Findings include: The Abuse Prevention Program and Reporting Policy with revised date 04/17 noted when the facility received an allegation of abuse, they must report immediately, (as soon as possible, but not to exceed 24 hours); separate the alleged perpetrator from all potential victims and begin their investigation. Under Protection, staff are directed to immediately separate the resident from the alleged perpetrator. In the case of a direct care giver being suspected of alleged abuse the Administrator,(in their absence, the DON, ADON, Charge Nurse, in that order) must immediately relieve the individual of their duties without pay (suspend) until the investigation is complete. The policy included Reporting, the policy directed staff to notify the shift supervisor if suspected abuse, neglect, mistreatment or misappropriation of property occurs. Report the incident immediately to the Administrator and Director of Nursing. Any staff member with knowledge of the event is responsible for notifying the Administrator and/or DON. Notify the appropriate State agency immediately by fax, telephone or on-line reporting after identification of alleged/suspected incident. During an Interview with Resident #11 on 7/11/17 at 3:20 p.m. he/she stated one night he/she had a lot of leg pain and Staff F, certified medication aide (CMA) made the comment, Do I need to hang you from your neck? Resident #11 stated he/she had spoken of the situation to the Administrator. During interview on 7/11/17 at 4:25 p.m. the prior Administrator stated about three weeks ago Resident #11 and the resident's family member had called him to the resident's room to visit. The resident had told him about Staff F who the resident had called into the resident's room several times the night before because the resident had leg pain. Resident #11 told the Administrator that Staff F had stated to the resident, I am going to hang you by your neck or stand you on your head. The Administrator stated he asked the resident if he/she wanted to file a grievance report and the resident did not want to. The Administrator stated he did not report the allegation of abuse and did not investigate the incident. The Administrator stated it was an error in judgement and at a loss of what to do now. He stated he would start an investigation and file a late, late report. During interview on 7/11/17 at 10:05 p.m. Staff F stated she still works with Resident #11 whenever he/she turns on call light. 2. During interview on 7/12/17 at 4:28 p.m. Staff G, certified nurse aide (CNA) stated Resident #12 had told her that Staff H (Registered Nurse) had seen him/her standing up with his/her walker and told the resident, Better sit down because I do not want to pick your sorry ASS off the floor if you fall. Staff G stated she had told the prior Director of Nursing (DON) directly because she thought it was critical. Staff G stated the prior DON said they are working on it, we do not have a lot of Registered Nurses and Staff H is a Registered Nurse. Staff G stated she told the DON we have to do something and the prior DON responded the Administrator thinks we are picking on Staff H. During interview on 7/13/17 at 9:30 a.m. Resident #12 stated staff treated him/her good when he/she is doing right and when not doing right staff are rude. The resident stated he/she had been told, if you fall down I am not going to pick your sorry ASS up. Resident #12 stated it was Staff H that said that to him/her. The resident stated Staff H had helped him/ her with medications and cares since making the statement. Resident #12 stated she had told Staff G of the incident. During interview on 7/17/17 at 11:25 a.m. the prior Director of Nurses (DON) stated she had heard from Staff G that Staff H had made to Resident #12. The prior DON stated she thought she heard it last month, guessing, since after Resident #12's last fall on 6/18/17. The prior DON stated she had not had a chance to talk to Staff H (nearly a month later) or Resident #12 about it. The prior DON stated had not investigated the allegation and if it was valid, she knew she should report it (to the State Agency) after the investigation. This deficient practice represented a systemic failure that resulted in a determination of Immediate Jeopardy on 7/13/17 at 12:57 p.m. The facility abated the IJ on 7/13/17 when they completed the following: The Interim Administrator begun education with staff regarding the facility Abuse Program and Reporting Policy on 7/12/17. On 7/13/17, the facility started on going education with staff on the Abuse Prevention Program and Reporting policy. Staff were not allowed to work until they were educated. Staff were given a copy of the abuse policy and acknowledged a shared knowledge of understanding of what to do if there is an allegation of abuse, unkind or inconsiderate care towards a resident that they will report it to the Administrator and DON immediately. The facility provided training documentation to the State Agency (Department of Inspections and Appeals) which showed employees scheduled to work had been educated. The prior Administrator, and Staff F was suspended on the evening of 7/12/17. The management staff began education staff on the Grievance Process on 7/12/17. The education provided by the management staff revealed the Administrator or designee daily will ensure prompt and appropriate follow-up in accordance with the facility's abuse and grievance policy. The facility would have departments heads meet with assigned residents on a regular basis using the Guardian Angel tool to proactively address concerns with residents as a part of the facility ongoing quality assurance process. These actions lowered the IJ from K severity to D with ongoing monitoring of the facility policy for reporting and investigating abuse.

Based on record review and staff and resident interviews, the facility failed to ensure residents were free from abuse and failed to be treated with consideration and respect (Residents #1, #2, #3). The sample consisted of 3 residents and the facility reported a census of 42 residents. Findings: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 6/2/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the BIMS (Brief Mental Status) had a score of 10. A score of 10 represented moderate cognitive problems. The resident used a wheeled walker with the oversight of one staff. The Care Plan with a focus area dated 11/25/14, identified the resident had a history of [REDACTED]. The intervention directed the staff to place a pad alarm under the resident at all times. A focus area for risk of elopement/wandering dated 10/8/15, established interventions dated 3/14/16. The interventions directed the staff to approach calmly and be flexible and non-resistive when trying to redirect the resident. An intervention dated 4/27/16 directed the staff to check the functioning of a Wanderguard (device to alert staff when resident attempts to leave facility). On 3/14/16 the intervention directed staff to place personal items of clothing, recognized by the resident, on the entrance to the resident's room. On 3/14/16, the interventions directed the staff to provide activities the resident may enjoy. A focus area with a revision dated 9/2/15 identified episodes of increased temper with possible physical aggression. The interventions dated 3/4/16-8/15/16 directed the staff to notify the physician of increased behaviors, administration of [MEDICAL CONDITION] medications, intervene before agitation escalates, redirect and separate the resident from other resident(s) when there are inappropriate interactions. The Progress Notes dated 2/20/16-8/15/16 indicated incidents of physical aggression toward other residents, staff and wandering in and out of resident's rooms and lying in their beds. Facility records indicated on 7/12/16, the staff were to make hourly checks for five days to limit wandering from inappropriate areas in the building. The Progress Notes dated 8/13/16 at 9:08 p.m. documented the resident wandering into and out of other resident ' s rooms and walking the halls with walker and supervision of staff. An Incident Report dated 8/14/16, documented on 8/13/16 at 10:00 p.m. Resident #1 entered the room of Resident #3. On 8/13/16 at approximately 10:00 p.m. Resident #3 reported he/she had told Resident #1 twice he/she was in the wrong room and to get up and go to his/her room. After Resident #3 told Resident #1 to leave the second time, Resident #1 punched him/her in the right and left leg. The facility records identified the staff initiated 1 hour checks on 8/14/16 at 4:00 p.m. An Incident Report, dated 8/15/16 at 12:30 p.m. identified the resident attempted to leave the dining room and became agitated with another resident's walker in the way. Resident #2 reported he/she told Resident #1 to wait for staff and they would help. Resident #1 told Resident #2 to fuc (expletive) himself/herself. Resident #2 told Resident #1 Not to talk that way. Resident #2 reported Resident #1 tried to push him/her, dodged and Resident #1 pushed his/her right arm. Resident #2 reported a staff person stood in the area and escorted Resident #1 back to his/her room. The staff person asked Resident #2 if he/she was hurt but the resident reported not hurt and didn't want to get Resident #1 into trouble because he/she knew the resident had dementia. 2. Resident #2 had a MDS assessment with a reference date of 7/24/16. The MDS identified the resident had a history of [REDACTED]. The resident ' s BIMS score of 10 indicated moderate cognitive impairment. The Care Plan with a focus dated 7/1/16, identified the resident needed the assistance of one staff when using a wheelchair for mobility, transfer and bed mobility. The Progress Notes dated 8/15/16 at 12:25 p.m. documented the resident on the receiving end of aggressive behavior by another resident (Resident #1). The incident had been witnessed by a staff member. Another resident (Resident #1) walked by the resident's table, stopped and stated something the resident couldn't understand and then struck the resident on the left forearm with the backside of his/her hand. Staff redirected the resident who had initiated the aggressive behavior toward the resident. Staff completed an assessment with no injury noted. On 8/23/16 at 2:00 p.m., Resident #2 was interviewed and confirmed the aggressive behavior from Resident #1 on 8/15/16 at 12:25 p.m. The resident walked by his/her table, complained of a walker being in the way and when the resident told Resident #1 staff would help, Resident #1 struck his/her on the forearm. The resident reported Resident #1 to be in his/her room on a couple of occasions and would try and sleep in the empty bed across the room. The resident's family member reported Resident #1 came into the resident's room on 8/19/16 at 10:00 p.m. and attempted to sit on the edge of the bed while the resident lay in bed. Resident #2's family member reported Resident #1 believed he/she is the resident's spouse. 3. Resident #3 had a MDS assessment with a reference date of 7/20/16. The MDS identified the resident had [DIAGNOSES REDACTED]. A BIMS identified a score of 15. A score of 15 reflected the resident to not have cognitive problems. The MDS identified the resident dependent upon staff for transfers and mobility. The Care Plan, with a focus area dated 5/18/16, identified the resident immobile and had bilateral humerus fractures. The Progress Notes dated 8/14/16 at 1:32 p.m. documented the resident reported to the staff that Resident #1 had entered his/her room early in the morning, sometime before 2:00 a.m. and sat on his/her Foley catheter (indwelling) while in bed. The resident reported Resident #1 pulled on the catheter slightly because the catheter site felt uncomfortable. The resident told Resident #1 it was not his/her room. Resident #1 replied this is my F-ing (expletive) room and proceeded to punch the resident. When asked where Resident #1 had punched him/her, the resident reported somewhere on the legs. The resident reported it didn't hurt but didn't like it. On 8/23/16 at 3:00 p.m. Resident #3 confirmed the events of 8/14/16, when Resident #1 entered his/her room, sat next to him/her in bed and sitting on his/her Foley catheter; pulling the catheter and causing the catheter to hurt. Resident #3 stated she told Resident #1 to leave and Resident #1 swore at him/her and hit one of his/her legs. The resident reported the hit from Resident #1 caused immediate pain. The resident reported she reported the incident to staff and the resident hasn't been in the room since the event. The resident reported he/she has continued to worry about his/her safety and whether the resident would return to his/her room again

Based on facility policy review and staff interviews, the facility failed to plan, direct the nursing care and provide safety for (Residents #2, #3) in order to prevent Resident #1 from abusing the residents. The facility identified Resident #1 wandered and had behaviors of mistreating other residents and the staff did not prevent the continued mistreatment to others. The sample consisted of 3 residents and the facility reported a census of 42 residents. Finding include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 6/2/16. The MDS identified the resident had [DIAGNOSES REDACTED]. A Brief Mental Status (BIMS) documented a score of 10. A score of 10 represented moderate cognitive problems. The resident used a wheeled walker with oversight of one staff with mobility and transfer. The Care Plan with a focus area dated 11/25/14 identified a history of falls with an intervention dated 5/9/16 of placing a pad alarm under the resident at all times. A focus area for risk of elopement/wandering dated 10/8/15, established interventions dated 3/14/16 directing staff to approach calmly and be flexible and non-resistive when trying to redirect the resident, an intervention dated 4/27/16 to check functioning of a Wanderguard, on 3/14/16 to place personal items of clothing recognized by the resident on the entrance to the resident's room and on 3/14/16 to provide activities the resident may enjoy. A focus area with a revision dated 9/2/15 identified episodes of increased temper with possible physical aggression. The interventions dated 3/4/16-8/15/16 directed the staff to notify the physician of increased behaviors, administration of [MEDICAL CONDITION] medications, intervene before agitation escalates, redirect and separate the resident from other resident(s) when there are inappropriate interactions. The Progress Notes dated 2/20/16 at 9:42 a.m. revealed Resident #1 had sat in another resident's chair in the dining room. The other resident asked Resident #1 to get up. Staff assists Resident #1 from the chair and Resident #1 yelled at the other resident and proceeded to hit the other resident in the left arm. The other resident hits Resident #1 back. Progress notes dated 3/5/16 at 7:17 a.m. revealed the resident yelling at a tablemate. Staff asks the resident what h/she is yelling about, redirect the resident to talk about something else but the resident continues on the same subject. Staff tells the resident to stop talking and to stop yelling. The resident hits the nurse in the stomach. Progress notes dated 3/15/16 at 2:49 p.m. revealed an incident occurred of alleged abuse by Resident #1 toward another resident. The incident report dated 3/13/16 at 5:00 p.m. revealed Resident #1 had hit another resident prior to supper on 3/13/16. The facility notified the Department and an investigation was completed. Progress notes dated 4/8/16 at 3:44 a.m. revealed the resident wandering throughout the facility; walking down hall without h/her walker. Staff attempted to redirect resident to h/her room to go to sleep but the resident refused all attempts and continues to walk in the dining room and living room area. Progress notes dated 4/11/16 at 1:59 p.m. revealed during room checks staff noted the resident sleeping in another resident's bed. Staff wakens the resident and assists the resident back to h/her room. Progress notes dated 4/15/16 at 9:43 p.m. revealed the resident set off the front door alarm three times but didn't go outside. The resident also set off the alarm on a door by the kitchen. Staff redirected the resident each time. Progress notes dated 4/19/16 at 5:30 a.m. and again on 4/22/16 at 2:37 a.m. revealed the resident wandering throughout the facility. Progress notes dated 4/23/16 at 9:48 p.m. revealed the resident walking in the lobby area and pushed h/her walker into a recliner that another resident way lying in. The resident lying in the recliner raised h/her hand and Resident #1 pushed against the other resident's hand. Progress notes dated 4/24/16 at 6:32 a.m. revealed the resident agitated and pushing h/her walker into staff and asking what the hell are you doing. Progress notes dated 4/25/16 at 10:48 a.m. revealed Resident #1 the director of nursing reviewed the resident's behavior with an advanced registered nurse practitioner who ordered inpatient hospitalization in a psychiatric behavioral unit. Progress notes dated 4/25/16 at 4:28 p.m. revealed the hospital contacted by the facility reported they could not admit the resident at this time. The facility contacted another behavioral unit and was waiting for a response from them. Progress notes dated 4/28/16 at 1:48 p.m. revealed the behavioral unit contacted on 4/25/16 reported they were unable to accept the resident for inpatient hospitalization . Progress notes dated 5/28/16 at 9:00 p.m. revealed the resident walking down a hall with staff. Staff tells the resident they are going to head back toward the dining. The resident becomes upset, curses at staff and pushes h/her walker against staff and hits staff on the left hand. Staff attempted to discuss the behavior with the resident but the resident curses at staff. Staff documented they were unable to educate the resident. Facility records revealed on 7/12/16 hourly checks for five days to limit wandering from inappropriate areas in the building. Progress notes dated 7/17/16 at 11:50 a.m. revealed the resident showed more signs of aggression after breakfast. Resident #1 saw another resident wheeling himself/herself from the dining room to a hallway. Resident #1 walked over to the resident and ran h/her walker into the back of the other resident's wheelchair, possibly pushing the other resident. Staff intervened by separating the two residents and redirected Resident #1 back to the dining room. The Progress Notes dated 7/17/16 at 12:44 p.m. indicated the resident attempted to sit in another resident's chair in the dining room when the other resident told Resident #1 he/she was at the wrong table. Resident #1 got angry and started raising his/her walker in front of the other resident. The staff walked by and redirected the resident. The Progress Notes dated 8/3/16 at 3:15 p.m. indicated the staff found Resident #1 sleeping in another resident's bed (Resident #2). Staff noted Resident #2 also sleeping in bed. Staff redirected Resident #1 back to his/her room. The Progress Notes dated 8/8/16 at 10:46 a.m. revealed the resident wandered throughout the facility and into other resident's rooms. Staff redirected the resident from the other resident's room. Staff reported the resident had wandered into another resident's room and again redirected to the dining room. The Progress Notes dated 8/13/16 at 9:08 p.m. documented the resident wandered into and out of other residents rooms and walked the halls with his/her walker with staff supervision. An incident report dated 8/14/16 documented on 8/13/16 at 10:00 p.m. Resident #1 entered Resident #3's room on 8/13/16 at approximately 10:00 p.m. Resident #3 reported he/she had told Resident #1 twice he/she was in the wrong room and to get up and go to his/her room. After Resident #3 told Resident #1 to leave the second time Resident #1 punched him/her in the right and left leg. Facility records indicated the staff initiated 1 hour checks on 8/14/16 at 4:00 p.m. An incident report dated 8/15/16 at 12:30 p.m. indicated the resident attempted to leave the dining room and became agitated as another resident's walker was in his/her way. Resident #2 reported he/she told Resident #1 to wait for staff and they would help. Resident #1 told Resident #2 to Fu (Expletive) his/herself. Resident #2 told Resident #1 not to talk that way. Resident #2 reported Resident #1 tried to push his/her, dodged and Resident #1 pushed his/her right arm. Resident #2 reported a staff person stood in the area and escorted Resident #1 back to his/her room. Staff asked Resident #2 if he/she hurt but the resident reported he/she wasn't hurt and didn't want to get Resident #1 into trouble because he/she knew the resident had dementia. During an interview on 8/22/16 at 2:30 p.m. Staff A, a certified nursing assistant (CNA) reported the resident had a pad alarm for the past two weeks and the resident continued to set off the alarm. Prior to that a pad alarm had not been used and the resident would wander continuously all the time in every hall and would go into other resident's rooms. The resident would always go into Resident #2's room. During an interview dated 8/22/16 at 2:40 p.m. Staff B, CNA reported Resident #1 liked to wander, goes into other resident's room and lies in their beds. The facility initiated the use of a pad alarm but used it only for a couple of days after she first started and then the facility stopped using the pad alarm. The facility started using the pad alarm again in the last two weeks. The resident went into Resident #3's room at night (8/14/16) and Resident #3 reported Resident #1 had hit him/her. She stated the pad alarm hadn't been used until this event occurred. During an interview dated 8/22/16 at 2:55 p.m. Staff C, a licensed practical nurse (LPN) reported staff are to assist the resident at all times; at meals, for staff to keep visual contact with the resident at all times and to use a pad alarm when the resident is sitting or lying down. The resident previously had a bed and floor alarm but the resident knew how to turn the alarms off. The resident was allowed to wander throughout the facility and found in other resident's room. The staff found Resident #1 in Resident #2 ' s room often and believed the resident to be his/her spouse. Staff C reported she heard of incidents of aggression toward other residents. Staff had been directed to keep the resident away from other residents at all times. This intervention had been long standing and for the last four months staff were to provide 1:1 with the resident. During an interview dated 8/22/16 at 4:00 p.m. Staff D, a certified medication aide (CMA) reported Resident #1 had a history of [REDACTED]. The resident wandered independently but now has a pad alarm and 1:1 staff supervision. However, staff allowed the resident wander last Friday night 8/19/16 for about 10 minutes because staff were busy assisting other residents. The resident went into Resident #2's room. Resident #1 believes Resident #2 is h/her spouse. Staff are aware of the resident's wandering and going into Resident #2's room. She reported someone must have turned off the chair alarm because she didn't hear the pad alarm sounding. The facility policy/procedure titled Abuse Prevention Program & Reporting Policy; Resident to Resident Abuse, with a revision date of 4/2014, directed the facility to provide ongoing staff training that included appropriate interventions to deal with aggression and reactions of residents, ensure prevention techniques are implemented that included ongoing supervision through visual observation, recognition of signs of resident conflict and aggressive behavior, assign staff demonstrating knowledge of the resident's needs and identify appropriate behaviors. The policy directed staff to identify events, patterns and trends that may constitute resident to resident abuse and conduct investigations.

Based on record review and staff, family and resident interviews, the facility failed to adequately supervise Resident #1 to ensure the resident did not harm other residents (Resident #2, #3). The sample consisted of 3 residents and the facility reported a census of 42 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 6/2/16. The MDS indicated the resident had [DIAGNOSES REDACTED]. A Brief Mental Status (BIMS) identified a score of 10. A score of 10 represented moderate cognitive problems. The resident used a wheeled walker with oversight of one staff for mobility and transfer. The Care Plan with a focus area dated 11/25/14 identified a history of falls with an intervention dated 5/9/16 of placing a pad alarm under the resident at all times. A focus area for risk of elopement/wandering dated 10/8/15, established interventions dated 3/14/16. The interventions directed the staff to approach calmly, be flexible and non-resistive when trying to redirect the resident. An intervention dated 4/27/16 directed the staff to check functioning of a Wanderguard. On 3/14/16 the intervention directed the staff to place personal items of clothing recognized by the resident on the entrance to the resident's room. On 3/14/16, the interventions directed staff to provide activities the resident may enjoy. A focus area with a revision dated 9/2/15 identified episodes of increased temper with possible physical aggression. The interventions dated 3/4/16-8/15/16 directed the staff to notify the physician of increased behaviors, administration of psychotropic medications, intervene before agitation escalates, redirect and separate the resident from other resident(s) when there are inappropriate interactions. The Progress Notes dated 2/20/16 at 9:42 a.m. - 3/15/16 at 2:49 p.m. indicated Resident #1 had incidents of wandering throughout the facility and into other resident rooms. The Notes indicated the resident had physical aggression and an incident of alleged abuse by Resident #1 toward another resident. An incident report dated 3/15/16, identified an alleged resident on resident abuse had been investigated by the Department. The Progress Notes dated 4/19/16 at 5:30 a.m. and again on 4/22/16 at 2:37 a.m. indicated the resident wandered throughout the facility. The Progress Notes dated 4/23/16 at 9:48 p.m. indicated the resident walked in the lobby area and pushed his/her walker into a recliner that another resident laid in. The resident laid in the recliner, raised his/her hand and Resident #1 pushed against the other resident's hand. The Progress Notes dated 4/24/16 at 6:32 a.m. identified the resident as agitated and pushing his/her walker into staff and asking what the hell are you doing. The Progress Notes dated 4/25/16 at 10:48 a.m. indicated the Director of Nursing reviewed the resident's behavior with an Advanced Registered Nurse Practitioner (ARNP). The ARNP ordered inpatient hospitalization in a psychiatric behavioral unit. The Progress Notes dated 4/25/16 at 4:28 p.m. indicated the hospital contacted by the facility reported they could not admit the resident at this time. The facility contacted another behavioral unit and was waiting for a response from them. The Progress Notes dated 4/28/16 at 1:48 p.m. indicated the behavioral unit was contacted on 4/25/16 and reported they were unable to accept the resident for inpatient hospitalization . Facility records indicated on 7/12/16, staff performed hourly checks for five days in order to limit wandering from inappropriate areas in the building. The Progress Notes dated 7/17/16 at 11:50 a.m. indicated the resident showed more signs of aggression after breakfast. Resident #1 saw another resident wheeling himself/herself from the dining room to a hallway. Resident #1 walked over to the resident and ran his/her walker into the back of the other resident's wheelchair, possibly pushing the other resident. Staff intervened by separating the two residents and redirected Resident #1 back to the dining room. The Progress Notes dated 7/17/16 at 12:44 p.m. indicated the resident attempted to sit in another resident's chair in the dining room when the other resident told Resident #1 he/she was at the wrong table. Resident #1 got angry and started raising his/her walker in front of the other resident. Staff walked by and redirected the resident. The Progress Notes dated 8/13/16 at 9:08 p.m. documented the resident wandered into and out of other resident rooms and walking the halls with his/her walker with supervision of staff. An incident report dated 8/14/16 documented on 8/13/16 at 10:00 p.m. Resident #1 had entered Resident #3's room on 8/13/16 at approximately 10:00 p.m. Resident #3 reported he/she had told Resident #1 twice he/she was in the wrong room and to get up and go to his/her room. After Resident #3 told Resident #1 to leave the second time, Resident #1 punched him/her in the right and left leg. The facility records identified 1 hour checks were initiated on 8/14/16 at 4:00 p.m. An incident report dated 8/15/16 at 12:30 p.m. indicated the resident attempted to leave the dining room and became agitated as another resident's walker was in his/her way. Resident #2 reported he/she had told Resident #1 to wait for staff and they would help. Resident #1 told Resident #2 to Fu (Expletive) self. Resident #2 told Resident #1 not to talk that way. Resident #2 reported Resident #1 tried to push his/her, dodged and Resident #1 pushed his/her right arm. Resident #2 reported a staff person stood in the area and escorted Resident #1 back to his/her room. Staff asked Resident #2 if he/she was hurt but the resident reported he/she wasn't hurt and didn't want to get Resident #1 into trouble because he/she knew the resident had dementia. During an interview dated 8/22/16 at 2:30 p.m. Staff A, a certified nursing assistant (CNA) reported the resident had a pad alarm for the past two weeks and the resident continues to set off the alarm. Prior to that, a pad alarm had not been used and the resident would wander continuously all the time in every hall and would go into other resident's rooms. The resident would always go into Resident #2's room. During an interview dated 8/22/16 at 2:40 p.m. Staff B, CNA reported Resident #1 likes to wander, goes into other resident's room and lies on their beds. The facility initiated the use of a pad alarm but used only for a couple of days after she first started and then the facility stopped using it. The facility starting using the pad alarm in the last two weeks. The resident went into Resident #3's room at night (8/14/16) and Resident #3 reported Resident #1 had hit him/her. She stated the pad alarm hadn't been used until this event occurred. During an interview dated 8/22/16 at 2:55 p.m. Staff C, a licensed practical nurse (LPN) reported staff are to assist the resident at all times; at meals, for staff to keep visual contact with the resident at all times and to use a pad alarm when the resident is sitting or lying down. The resident previously had a bed and floor alarm but the resident knew how to turn them off. The resident was allowed to wander throughout the facility and found in other resident's room. The staff found the resident in Resident #2 ' s room often and believed the resident was his/her spouse. Staff C reported she had heard of incidents of aggression toward other residents. The staff were directed to keep the resident away from other residents at all times. This intervention had been long standing and for the last four months staff were to provide 1:1 (staff to resident) with the resident. During an interview dated 8/22/16 at 4:00 p.m. Staff D, a certified medication aide (CMA) reported Resident #1 had a history of [REDACTED]. The resident wandered independently but now had a pad alarm and 1:1 staff supervision. However, staff allowed the resident to wander last Friday night 8/19/16 for about 10 minutes because staff were busy assisting other residents. The resident went into Resident #2's room. Resident #1 believes Resident #2 is his/her spouse. Staff are aware of the resident's wandering and going into Resident #2's room. She reported someone must have turned off the chair alarm because she didn't hear the pad alarm. During an interview dated 8/23/16 at 2:00 p.m., Resident #2 confirmed the aggressive behavior from Resident #1 on 8/15/16 at 12:25 p.m. The resident had walked by his/her table, complained of a walker being in the way and when the resident told Resident #1 staff would help him/her Resident #1 struck his/her on the forearm. The resident reported Resident #1 had been in his/her room on a couple of occasions and would try and sleep in the empty bed across the room. The resident's family member reported Resident #1 came into the resident's room on 8/19/16 at 10:00 p.m. and attempted to sit on the edge of the bed while the resident lay in bed. Resident #2's family member reported Resident #1 believed he is the resident's spouse. During an interview dated 8/23/16 at 3:00 p.m. Resident #3 confirmed the events of 8/14/16, when Resident #1 had entered his/her room, sat next to him/her in bed and sat on his/her Foley catheter; pulling the catheter and causing the catheter to hurt. She told Resident #1 to leave and Resident #1 swore at him/her and hit one of his/her legs. The resident reported the hit from Resident #1 caused immediate pain. The resident stated she/he reported the incident to staff and the resident hasn't been in his/her room since the event. The resident reported he/she continued to worry about his/her safety and whether the resident would return to his/her room again.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision and monitoring to protect residents against potential hazards from self, others or elements in the environment. Record review identified Resident #1 displayed exit seeking behaviors and staff failed to provide adequate supervision on [DATE] when Resident #1 left the facility through the unalarmed front door without staffs' knowledge. Staff interviews revealed the facility had no system in place to monitor the front door for Resident #1 and the additional 9 residents with moderate risk for wandering/elopement. The facility failed to address the wandering risk on the plan of care for Residents #1, #5, #7, #8, #9, #10 and #11). The findings constituted an immediate jeopardy to residents' health and safety. The facility identified a census of 42 residents. Findings included: 1. A Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], revealed Resident #1's [DIAGNOSES REDACTED]. The same MDS identified the resident's mental status as fully intact, the resident reported little interest or pleasure in doing things and felt down, depressed or hopeless during the previous 2 weeks. The resident had verbal behaviors symptoms (threatening, screaming or cursing) directed towards others that occurred 1 to 3 days. The resident had not wandered during the assessment period and independently walked/ambulated without assisted devices. A Wandering and Risk for Elopement form dated [DATE], identified Resident #1's mental status as moderately impaired and identified the resident at moderate risk for wandering/elopement. On [DATE] at 2:12 P.M., staff documented the resident verbally aggressive toward his/her Medical Care Provider the resident wanted to have his/her Wandergaurd bracelet removed, and the Medical Care Provider informed the resident he/she needed to continue to wear the bracelet. Staff documented the resident as periodically confused. On [DATE] at 1:00 P.M., staff documented the resident stated he/she felt as if imprisoned due to wearing a Wandergaurd bracelet and other rules. On [DATE] at 10:30 A.M., staff documented a facility corporate nurse, the MDS nurse and the facility Social Worker met with the resident and discussed his/her Wandergaurd bracelet device. The resident stated the Wandergaurd bracelet made it seem like prison and voiced at times he/she just wanted to go outside for fresh air. Staff documented the resident's Wandergaurd bracelet as removed. Resident #1's care plan, with a date initiated dated of [DATE], had included a focus for the resident being at risk for elopement due to impaired cognitive function/dementia or impaired thought processes. The same care plan included a goal for the resident to not leave the building and included interventions such as attempt to redirect the resident if exit seeking, re-direct when trying to leave the building and placed a Wandergaurd bracelet placed on the resident's left wrist. Further review of the care plan revealed staff resolved or discontinued the resident's risk for elopement care plan on [DATE]. Review of a Wandering and at Risk for Elopement form dated [DATE], identified the resident continued at moderate risk for elopement. Even though the resident remained at moderate risk for elopement, the facility discontinued the resident's care plan for risk of elopement on [DATE]. Review of a Wandering and at Risk for Elopement form dated [DATE], the resident remained at moderate risk for wandering/elopement. Ongoing review of the resident's care plan with an initiated date of [DATE], revealed a focus for the resident being under the care of Hospice services due to COPD. Review of Resident #1's Progress Notes revealed nursing staff documented the following: On [DATE] at 10:41 A.M. - the resident had increased anxiety and anger throughout the shift. Wants to leave and go home. On [DATE] at 3:44 A.M. - came to the dining room with his/her coat looking for the barn. The resident proceeded to the front door caught by staff and brought back. Staff returned the resident to his/her room and administered Ativan (for restlessness). The resident removed his/her coat and the nurse left the resident's room. Within a few seconds later the resident returned to the dining room with his/her coat on asking for his/her O2. On [DATE] at 4:18 A.M. - the resident returned to the dining room carrying his/her coat. On [DATE] at 1:12 P.M. - the resident had increased anger throughout the shift and continued to exit seek. On [DATE] at 8:19 p.m., the resident wandered in and out of other residents' rooms on Dear Road. The resident wandered throughout the dining room and lobby area. The resident needed reminders to wear O2 (oxygen) on most of the shift. On [DATE] at 1:34 A.M. - the resident attempted to go out the dining room exit door. The resident did not go out but sets off alarm and walked away waving his/her arms in the air. The resident reported he/she had been looking for his/her room. On [DATE] at 4:44 P.M. - the resident continued to be up on own, unsteady and needed one-to one attention. Continued to have anxiety related to dying. On [DATE] at 12:17 P.M. - Staff administered the resident a PRN (whenever necessary )Ativan medication due to the resident's air hunger, restlessness and agitation, The resident attempted to stand and ambulate, stumbled and the nurse steadied the resident to a chair. The resident did not remember to leave O2 in place, became anxious and hard to redirect. On [DATE] at 1:11 A.M. - the resident wandered in and out of other residents' rooms multiple times. Has been restless and up and down the hall several times. On [DATE] at 10:17 A.M.- Staff administered PRN Ativan to the resident due to anxiousness and unable to settle down. The resident paced and his/her gait identified as unsteady. Hospice (staff) sat with resident to calm down provided 1: 1. On [DATE] at 6:52 P.M. - the resident had been very restless today. On [DATE] - 8:31 A.M. - the facility Director of Nursing (DON) documented the resident with increased restlessness and staff aware to continue to watch the resident. On [DATE] at 5:08 A.M. - the resident was up wandering all night, moving furniture and trying to get outside. On [DATE] at 6:10 P.M. - the resident was found outside the front door near the parking lot. An untitled document (with a scanned date of [DATE]) identified Resident #1 left the faciity on [DATE] and staff were to provide monitoring of residents in the dining room and front lobby area. All staff left the area without making sure a staff member stayed to provide supervision of the resident. Resident #1 had been left unsupervised for about 5 minutes before being returned to the building. The facility identified on [DATE] the resident's Wanderguard/SecureCare bracelet had been removed as the resident had not exhibited behaviors since the end of October (2015); and had not exhibited exit seeking behaviors until [DATE]. During interview on [DATE] at 12:20 P.M., the DON confirmed all of the other 4 exit doors in the facility (aside from the front doors) had alarms on the doors that alarmed when the door opened. The DON confirmed at the time Resident #1 left the building on [DATE] through the front door, the front door lacked an alarm system other than a Wanderguard alarm system. During interview on [DATE] at 8:30 A.M., the facility DON stated on the morning of [DATE], she wrote a note in a communication book (for staff to review & be passed between shifts) and verbally advised staff to provide constant supervision due to the resident being unsteady on his/her feet. The DON presented a copy of the above note in a communication book. The note contained no documented date or time as to when the constant observation of the resident began. During interview on [DATE] at 10:40 A.M., the DON confirmed a facility policy included to always have 1 person in the dining room at all times due to resident's at risk for choking. During interview on [DATE] at 12:40 P.M., Staff D, RN, confirmed working on the evening of [DATE]. Staff D stated not being aware of Resident #1's need to receive constant supervision. Staff D stated on [DATE] at an unknown time he saw Resident #1 sitting at a dining room table with 2 other residents. Staff D stated he went outside to take a break at approximately 6:05 P.M. and a short time later Staff B, Certified Medication Aide, CMA came outside to tell Staff D that the resident had been outside without staffs knowledge. During the same interview, Staff D showed the Surveyor where the resident stood outside, approximately 21 steps from the front door and stood approximately 62 steps from a street with a 25 miles per hour speed limit. During interview on [DATE] at 1:25 P.M., Staff B confirmed working the evening of [DATE]. Staff B stated on that evening she last saw the resident sitting at a dining room table at approximately 5:40 P.M. Staff B stated she went on break in a break room of the facility at approximately 5:50 P.M., and a short time later heard pounding on the break room door. Staff B reported another resident's family member pounded on the break room door and reported Resident #1 had been outside of the facility. Staff B stated she left the break room and went outside to get the resident. Staff B reported the weather as nice and stated the resident wore long pants, long sleeve shirt and shoes. Staff B confirmed no staff had been in the dining room with the resident. Staff B stated she had been aware 1 staff should have been in the dining room at all times when residents were present. (Note: Review of Staff B's time card on [DATE] revealed she punched out for a break at 5:43 P.M., and punched in after her break at 6:15 P.M.). During interview on [DATE] at 1:15 P.M., Staff F, Certified Nurse Aid/CNA stated one week prior to the incident is when she heard 1 staff member needed to remain in the dining room at all times when residents were present. Staff F identified a problem with that as the facility being short staffed at times. During interview on [DATE] at 8:45 A.M., Staff G/CNA stated one week prior to the incident is when she heard 1 staff member needed to remain in the dining room at all times when residents were present. Staff F identified a problem with that as the facility being short staffed at times. Staff G confirmed working the evening shift of [DATE], stated she had not read the communication book when she arrived to work and no staff passed on in report that Resident #1 needed constant supervision. During interview on [DATE] at 11:35 A.M., the facility Administrator stated he had no knowledge of the reason for no alarm (other than a Wanderguard alarm) on the front door of the facility prior to the resident leaving the facility on [DATE]. During interview on [DATE] at 10:40 A.M., the DON confirmed no staff monitored the front door of the facility prior to an alarm being implemented after the resident left the building on [DATE]. Record review revealed the main entrance door did not have an alarm other than a Wanderguard alarm system (electronic device that signals an alarm at the time a resident passes through the door wearing a electronic bracelet) to alert staff if any mobile (ambulatory or self-propelling with a wheelchair) residents left the building. The facility identified they had 9 independently mobile residents that did not use a Wanderguard. 2. Record Review for Residents #5, #7, #8, #9, #10 and #11 identify the following: a. According to an Admission Record, Resident #5's [DIAGNOSES REDACTED]. The admission record identified the resident's admission to the facility as [DATE]. A facility Assessment Scoring Report dated [DATE], included the resident's Brief Interview for Mental Status (BIMS) and identified the resident's mental status at fully intact. A Wandering and at Risk for Elopement form dated [DATE], identified the resident at moderate risk for elopement. Review of the resident's care plan revealed no goal and/or interventions in regards to the resident being at risk for elopement until [DATE] (1 week after Resident #1 left the building without staffs knowledge). b. According to an Admission Record, Resident #7's [DIAGNOSES REDACTED]. The admission record identified the resident's admission to the facility as [DATE]. A Wandering and at Risk for Elopement form dated [DATE], identified the resident at moderate risk for elopement. Record review revealed no temporary or other care plan on the resident's record and lacked any reference to the resident's risk for elopement. c. According to Resident #8's most recent care plan, the resident's [DIAGNOSES REDACTED]. According to a MDS assessment dated [DATE], the facility identified the resident's mental status as severely impaired. A Wandering and at Risk for Elopement form dated [DATE], identified the resident at moderate risk for elopement. Review of the resident's care plan revealed no goal and/or interventions in regards to the resident being at risk for elopement until [DATE] (1 week after Resident #1 left the building without staffs knowledge). d. According to Resident #9's most recent care plan, the resident's [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] identified the resident had difficulty with short and long term memory and had severely impaired decision making skills. A Wandering and at Risk for Elopement form dated [DATE], identified the resident at moderate risk for elopement. Review of the resident's care plan revealed no goal and/or interventions in regards to the resident being at risk for elopement until [DATE] (1 week after Resident #1 left the building without staffs knowledge). e. According to Resident #10's most recent care plan, the resident's [DIAGNOSES REDACTED]. A facility Assessment Scoring Report dated [DATE] BIMS identified the resident's mental status at fully intact. A Wandering and at Risk for Elopement form dated [DATE], identified the resident at moderate risk for elopement. Review of the resident's care plan revealed no goal and/or interventions in regards to the resident being at risk for elopement until [DATE] (1 week after Resident #1 left the building without staffs knowledge). f. According to Resident #11's most recent care plan, the resident's [DIAGNOSES REDACTED]. A facility Assessment Scoring Report dated [DATE] BIMS identified the resident's mental status as moderately impaired. A Wandering and at Risk for Elopement form dated [DATE], identified the resident at moderate risk for elopement. Review of the resident's care plan revealed no goal and/or interventions in regards to the resident being at risk for elopement until [DATE] (1 week after Resident #1 left the building without staffs knowledge). During interview on [DATE] at 11:00 A.M., the facility MDS nurse stated Resident's at moderate risk for elopement needed to be care planned as such, unless the resident is non-mobile. During interview on [DATE] at 12:20 P.M., a facility Corporate Nurse confirmed she instructed the MDS nurse to update Residents care plans who were at moderate risk for elopement or higher after Resident #1 left the building without staffs knowledge on [DATE]. She reported another temporary care plan would be completed since Resident #7 ' s care plan could not be located. A facility policy for Elopement Prevention & Management included a procedure for all residents to be evaluated at risk for elopement and interventions needed to be put in place. The policy instructed staff to implement interventions of any resident at risk for elopement. The facility Administrator implemented a pad alarm at the front door of the facility after Resident #1 left the building on [DATE]. The facility abated the IJ on [DATE] when they activated the alarm to make an audible sound each time the door is opened unless a code is manually entered to silence the alarm. Staff were re-educated to provide supervision as indicated and reminded to communicate with each other to verify who is responsible to provide supervision. The facility identified Resident #1 had been on 1:1 supervision when out of the room prior to the elopement incident on [DATE] and this would be continued. Resident #1's care plan initially added a pull cord alarm to the front door on [DATE] and a pad alarm on [DATE]. Additional residents who were at moderate risk for elopement or higher care plans were updated to include and alarm on front door and exit doors & reassessments as needed.

Based on staff interview and facility policy review the facility failed to develop and implement written policies that prohibit mistreatment, negligence and abuse of residents and provide appropriate guidance to staff regarding reporting alleged abuse according to regulatory standards. The facility reported a current census of 40 at the time of the investigation. Findings include: Review of the undated facility Abuse policies for, resident protection during an investigation, investigation of alleged abuse, abuse prevention and resident abuse, neglect and mistreatment directed alleged violations of abuse will be investigated thoroughly by the Administrator with assistance from the Director of Nursing. An investigation of the reported allegation will be completed and steps taken to prevent further potential harm to the identified resident or others. Any employee suspected will be suspended pending the completion of an investigation. The Administrator will report incident or suspected incidents immediately to the Regional Nurse Consultant and Regional Vice President. Allegations will be reported immediately to appropriate State agencies in accordance with State law. Upon completion, a final report will be sent to the State agency within 5 working days of the incident. The report will include whether abuse was validated and any appropriate actions taken. Review of the facility coporate associate handbook with a revision date of 9/14/12 revealed under the section for Resident Rights and Disciplinary Action. a. All residents have the right to be treated as individuals with consideration, respect and dignity. b. Your behavior must reflect your beleif in this right in your dealings with residents. Failure to behave in an acceptable manner will result in disciplinary action and possible termination. c. Resident abuse (verbal or physical) or neglect or failure to report resident abuse. (Classified as a Catergory 1 serious offense) On 3/5/15 at 11:50 a.m. the Administrator stated Staff T did not work with Resident #3 since the alleged incident. According to the Administrator Staff T directed to return tonight for work. He stated the corporate nurse okayed Staff T to work with Resident #3. At that time, the Director of Nursing (DON) stated she was coming to the facility at 10:00 p.m. tonight to train with Staff T and watch her provide cares. According to a comment from the DON, Resident #3 stated he/she was OK with Staff T working with him/her if accompanied by another staff member as a witness. On 3/10/15 at 3:05 p.m. the Administrator stated the facility intended to bring Staff T back to work but not assist with Resident #3. He stated not aware the facility needed to maintain separation between Resident #3 and Staff T until investigation by the Department of Investigations was completed. On the same date at 3:22 p.m. the DON stated they did not know for sure what they intended for Staff T when she returned to work on 3/5/15. The DON stated not confident ok for Staff T to work around Resident #3. The DON stated she planned to discuss with Staff T upon arrival at work that night. Review of the undated Facility policy titled Resident Protection During Abuse Investigation section 5, identified a suspected employee involved in the incident is immediately suspended and unable to enter the facility until the investigation was complete. The Administrator wrote and initialed he interpreted that to mean facility investigation. Note: At the time of the onsite investigation the deficiency was coded at a L level for immediate and serious jeopardy. By April 10, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an F level. The facility provided comprehensive policies related to Abuse that directed staff regarding the investigation and reporting requirements. This statement does not denote the faciltiy has complied with prompt actions for a violation of the required standards. As of the March 11, 2015 exit conference the facility had failed to: a. To provide a safe environment free from abuse against residents. b. Complete training related to the investigation and reporting of abuse. c. Provide adequate supervision to allow residents to live and receive kind and considerate care free from abuse in the facility. d. Provide comprehenisive written policies regarding the investigation and reporting of abuse.

Based on resident and staff interviews and facility policy review the facility failed to provide kind and considerate care at all times, adequate supervision and shall be free from abuse related to 5 of 14 residents reviewed (Resident #1,#2, #3, #6 and #10. The facility reported a current census of 40. Findings include: Review of the undated facility Abuse policies for, resident protection during an investigation, investigation of alleged abuse, abuse prevention and resident abuse, neglect and mistreatment directed alleged violations of abuse will be investigated thoroughly by the Administrator with assistance from the Director of Nursing. An investigation of the reported allegation will be completed and steps taken to prevent further potential harm to the identified resident or others. Any employee suspected will be suspended pending the completion of an investigation. The Administrator will report incident or suspected incidents immediately to the Regional Nurse Consultant and Regional Vice President. Allegations will be reported immediately to appropriate State agencies in accordance with State law. Upon completion, a final report will be sent to the State agency within 5 working days of the incident. The report will include whether abuse was validated and any appropriate actions taken. 1. According to Resident #2's Minimum Data Set (MDS)dated [DATE] revealed a Brief Interview for Mental Status (BIMs)score of 13 of 15 that indicated no cognitive impairment. During an interview with Resident #2 on [DATE] at 12:30 p.m. revealed Resident #2 heard an inappropriate interaction between Staff T certified nursing assistant (CNA) and his/her roommate (Resident #3). According to Resident #2 Staff T CNA, said mean things and hit his/her roommate (Resident #3). Resident #2 indicated he/she did not inform staff but heard the interaction between Staff T CNA and the cries of Resident #3 after hearing a slapping noise and the statement Ouch from his/her roommate (Resident #3). Resident #2 expressed fear of Staff T CNA. On [DATE] at 10:40 a.m. follow up interview with Resident #2 stated he/she heard a punch and Resident #3 got quiet, said ouch and began to cry. Resident #2 stated Staff T said shit before she punched Resident #3 and always curses at Resident #3. Resident #2 stated she did not inform anyone in the facility. On [DATE] at 10:40 a.m. Resident #2 stated he/she heard Staff T talk in a mean tone to Resident #3, and recalled five (5) instances that Resident #3 cried while Staff T provided personal assistance to him/her. 2. According to the MDS dated [DATE] identified Resident #3's BIMS score of 15 of 15 that indicated no cognitive impairment. Resident #3 had the following signs of [MEDICAL CONDITION]: inattention, altered level of consciousness and disorganized thinking that comes and goes in severity. According to the MDS Resident #3, required extensive assistance of two or more staff members for all activities of daily living (ADL's). Resident #3 utilized a walker and wheelchair to move about the facility. The MDS listed Resident #3's [DIAGNOSES REDACTED]. According to the Care Plan updated [DATE], interventions for Resident #3 are as follows: a. Assistance with activities of daily living with an intervention to provide 2 staff members to assist with toileting. b. Interventions ambulate/transfer with 2 staff and gait belt, wheelchair for locomotion. c. Approach resident in a warm and positive manner. On [DATE] at 12:45 p.m. Resident #3 stated Staff T hit him/her on the stomach. Resident #3 stated he/she informed Staff T no but Staff T was mad about things and reached across his/her bed and put her open hand on his/her stomach. Resident #3 indicated this occurred a couple of times that Staff T hit Resident #3 ' s arms after he/she told Staff T no. 3. Resident #1 ' s MDS assessment with a reference date [DATE] reflected a BIMs score of 11 out of 15 that indicated moderate impairment of cognition. The MDS reflected Resident #1 required extensive assistance of two or more staff with transfers, ambulation, toileting, personal hygiene and ambulation on and off the unit. The MDS listed Resident #1 ' s [DIAGNOSES REDACTED]. The Care Plan initiated [DATE] indicated limited mobility for Resident #1 due to a fractured left femur. The Care Plan, initiated [DATE] identified Resident #1 at risk for skin tears and/or bruising with the following interventions: assess environmental conditions and remove potential dangers that cause skin tears or bruises. The resident took anticoagulant medication. The Care Plan initiated [DATE] for Resident #1 identified extensive assistance of two staff members required for activities of daily living such as bed mobility due to acute pain and a healing femur fracture. Interview on [DATE] at 3:03 p.m. revealed Resident #1 stated Staff T was grumpy and talked to herself. Resident #1 stated Staff T repeatedly leaned on his/her sore leg during personal cares which caused increased pain. Follow up interview on [DATE] at 12:35 p.m. Resident #1 stated Staff T, leaned on his/her sore leg after Resident #1 had surgery in December, 2014 for a fractured femur. According to Resident #1 Staff T continued to lean on the injured leg even after Resident #1 told Staff T it hurt. 4. Review of the MDS for Resident #6 dated [DATE] revealed a BIMs score of 14 that indicated intact cognition. Resident #6 required extensive assistance of two staff members for ADL ' s. Resident #6 used a walker and wheelchair for mobility. The MDS listed [DIAGNOSES REDACTED]. The Care Plan dated [DATE] identified Resident #6 at risk for bruising and skin tears due to use of anticoagulation therapy and required two staff member assistance with a gait belt for transfers. Review of the Progress notes for Resident #6 dated [DATE] revealed identified bruising to the right inner thigh of 2.5 centimeter (cm) by 1.5 cm purple in color and the left lower leg area bruise measured 4.5 cm by 3.0 cm red/purple in color. Staff questioned Resident #6 on the cause of the bruising and according to Resident #6 ' s statement Staff T was rough on him/her. On [DATE] at 1:15 p.m. Resident #6 stated Staff T hangs on to him/her too tight which causes discomfort. Resident #6 confirmed she complained about Staff T because she pushed him/her up, and demonstrated how he/she crossed the arms across his/her chest, then Staff T dropped the Resident #6 onto the bed. Staff T then fell on top of Resident #6 which hurt his/her stomach. Resident #6 stated Staff T laughed and commented you're doing well. Resident #6 Staff T is always pushing and it hurt when Staff T fell on top of him/her. Resident #6 stated he/she sustained a bruise after Staff T was rough with a transfer. Resident #6 stated it required a dressing because the bruised area bled. 5. Review of the MDS for Resident #10 dated [DATE] revealed a BIMs score of 15 that indicated Resident #10 as cognitively intact. According to the MDS Resident #10 required extensive assistance of 2 staff members for ADL ' s and used a wheelchair for mobility. [DIAGNOSES REDACTED]. The Care Plan for Resident #10 dated [DATE] indicated a need for staff assistance for transfers and ADL ' s. Review of the Nurse Progress Notes dated [DATE] at 12:48 p.m. revealed Resident #10 utilized two staff members for transfers with a mechanical sit to stand device to relieve weight bearing on the left leg. Interview with Resident #10 on [DATE] at 1:15 p.m. revealed a comment that Staff T was rough and mouthy towards Resident #10. According to Resident #10 Staff T not aware how to properly use the mechanical lift and it caused Staff T to strike Resident #10 ' s elbow into the door causing pain. On [DATE] at 10:55 a.m. Resident #10 confirmed Staff T was unkind from his/her first day at the facility. Resident #10 stated he/she informed the Social Services Designee (SSD) because she had been with him/her since admission and was a good friend. Resident #10 indicated the SSD was aware of resident complaints regarding Staff T. On [DATE] at 9:48 a.m. Resident #10 clarified his/her statement made at Group Interview and stated Staff T was always rough and bumped his/her arm on the door because Staff T just jammed ya through the door to the bathroom. Resident #10 stated other staff members are careful, but not Staff T. Resident #10 stated he/she didn't always get a bruise but it sure hurt. Resident #10 unable to recall who he/she informed of the concerns besides the SSD. Weekly Skin Assessment sheets identified Resident #10 s bruised extremities (arms/legs) on the following dates: a. On [DATE] bruised areas identified on the Resident #10's left pinky finger and on top of the knuckles. b. On [DATE] bruised areas identified on the back of Resident #10's right hand that measured 2.0cm by 1.75 cm and the right elbow area that measured ,[DATE]cm by 1.75 cm. The documentation also noted bruising to the front of Resident #10 ' s left thigh that measured 0.5cm by 1.5 cm. c. On [DATE] bruised areas identified on Resident #10's right elbow that measured 1.9cm by 1.8cm, the back of the right hand measured 2.0cm by 2.0 cm and the front of the left thigh measured 0.5cm by 1.4 cm. Staff interviews as follows: Interview on [DATE] at 10:14 a.m. with Staff A, CNA revealed Resident #1 and Resident #3 commented to Staff A that Staff T yells and is rude during cares. Staff A stated she reported resident complaints to nurses and once wrote a note for the Director of Nursing (DON) however nothing occurred following the report. On [DATE] at 10:55 a.m. Staff D, CNA, interviewed and stated Resident #3 complained about Staff T being rude and rough hitting him/her in the stomach. Staff D indicated Residents #3 refuse to allow Staff T to provide cares due to fear. According to Staff D concerns reported to a former nurse however nothing occurred following the report. Interview on [DATE] at 2:05 p.m. with Staff F, CNA, stated previously residents stated Staff T not allowed in various resident rooms and complained that Staff T is rough. Staff F verbally reported the resident complaints to a previous Director of Nursing however nothing further occurred regarding the reported concerns. Interview on [DATE] at 1:50 p.m. with Staff G provided general comments and stated Staff T was very huffy with residents and stated when a resident requests assistance, Staff T responded with an attitude and was very rude to residents. Staff G stated she observed Staff T pulled a pillow from under a dying resident's head and the resident's head flopped (This resident died [DATE]). Staff T apologized to the sleeping resident then laughed about it. Staff G reported her observation to the DON and thought the DON provided counseling. Staff G stated Resident #2 commented Staff T was very huffy and made fun of Resident #3. According to an interview on [DATE] at 3:50 p.m. the facility SSD stated she was alerted to an incident after Resident #2 informed Staff N CNA of concerns. The SSD interviewed roommates Resident #2 and Resident #3 separately. Resident #3 indicated Staff T punched him/her in the stomach. Resident #3 clenched his/her fist to describe how Staff T hit him/her. The SSD stated both Resident #2 and Resident #3 provided the same allegation that Staff T punched Resident #3 as he/she turned the call light off. The SSD indicated awareness of residents that refused to have Staff T ' s assistance with activities of daily living because she's rough. The SSD stated she informed the Administrator of the concerns. Interview on [DATE] at 5:50 a.m. with Staff K, LPN, indicated awareness of 1 resident (Residents #3) that refused to allow Staff T in his/her room because Staff T is rough and rude. During an interview on [DATE] at 8:59 a.m. with Staff L CNA, indicated Resident #3 informed her that Staff T got mad and punched him/her in the arms. Staff L CNA, stated Resident #3 seemed upset and requested Staff L not inform Staff T because she will get mad. Staff L informed Resident #3 that she was required to inform the Director of Nursing, and did. Staff L stated Resident #10, refused to allow Staff T in his/her room. Interview on [DATE] at 11:33 a.m. the SSD stated she first became aware of residents' complaints regarding Staff T when she began employment at the facility approximately 3 years prior. The SSD stated it was understood there was a problem when she reported resident concerns to the DON. The SSD had no documentation of resident complaints or concerns because her flash drive broke and she had a different computer. The SSD stated she first became aware of residents' complaints of Staff T during morning meetings 3 years ago. She then clarified Morning Meetings occurred daily with the Administrator, Director of Nursing, Assistant Director of Nursing and department heads mentioned resident complaints regarding Staff T. The SSD stated the Administrator at that time is the current Administrator, but the Director of Nursing is no longer employed by the facility. Review of the facility investigation notes completed by SSD revealed the following information. a. On approximately [DATE] at 8:30 a.m. the SSD received information that Resident #6 reported bruising located on his/her body followed cares provided by Staff T. According to Resident #6 ' s comments Staff T hugs Resident #6 so tight that it hurts. Resident #6 explained that Staff T yells during cares and this upsets Resident #6. b. According to the documentation on [DATE] at 1:52 p.m. the Administrator directed the SSD to initiate contact with Resident #6 related to the concerns expressed related to cares provided by Staff T. c. Information obtained on [DATE] at 11:00 a.m. by the SSD regarding concerns Resident #10 had related to cares. According to Resident #10 ' s comments Staff T jammed him/her into the bathroom area during cares and Staff T appeared upset and agitated with Resident #10 during the cares. Resident #10 expressed fear of being hurt by Staff T during these times of personal cares. d. On [DATE] at 12:10 p.m. Staff N CNA informed the SSD concerns Resident #2 stated in regards to rough care provided by Staff T to Resident #3. According to Resident #2 Staff T hit Resident #3 and the response heard by Resident #2 after the incident was for Resident #3 to say Ow stop hitting me. According to the facility information Resident #3 confirmed Staff T punched him/her at night in the stomach and was rude to Resident #3 and it hurts him/her. e. The facility investigation on [DATE] revealed at 1:20 p.m. the SSD reported the incidents of rough behavior and treatment towards Resident #3, #6 and #10 to the Administrator and Director of Nursing. Note: At the time of the onsite investigation the deficiency was coded at a K level for immediate and serious jeopardy. By [DATE] the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an E level. The facility terminated the employment of Staff T. This statement does not denote the faciltiy has complied with prompt actions for a violation of the required standards. As of the [DATE] exit conference the facility had failed to: a. To provide a safe environment free from abuse against residents. b. Remove Staff T from access to residents identified in the deficiency. c. Provide for adequate supervision to allow residents to live and receive kind and considerate care free from abuse.

Based on resident and staff interview and facility policy review the facility failed to report suspected abuse as required. The facility reported a current census of 40 at the time of the investigation. Findings include: Review of the undated facility Abuse policies for, resident protection during an investigation, investigation of alleged abuse, abuse prevention and resident abuse, neglect and mistreatment directed alleged violations of abuse will be investigated thoroughly by the Administrator with assistance from the Director of Nursing. An investigation of the reported allegation will be completed and steps taken to prevent further potential harm to the identified resident or others. Any employee suspected will be suspended pending the completion of an investigation. The Administrator will report incident or suspected incidents immediately to the Regional Nurse Consultant and Regional Vice President. Allegations will be reported immediately to appropriate State agencies in accordance with State law. Upon completion, a final report will be sent to the State agency within 5 working days of the incident. The report will include whether abuse was validated and any appropriate actions taken. According to facility investigation documentation on approximately 1/23/15 at 8:30 a.m. the Social Service Designee (SSD) received information from a staff member that Resident #6 reported bruising and rough treatment during cares provided by Staff T. Resident #6 stated Staff T hugs him/her so tight that it hurts. Resident #6 explained that Staff T yells during cares and this upsets Resident #6. The facility investigation notation revealed on 1/23/15 at 1:52 p.m. the Administrator directed the SSD to initiate contact with Resident #6 related to the concerns expressed related to cares provided by Staff T. Information obtained on 1/23/15 at 11:00 a.m. by the SSD involved concerns Resident #10 expressed related to cares provided by Staff T as she jammed Resident #10 into the bathroom during cares. Resident #10 expressed Staff T appeared upset and agitated with Resident #10 during the cares. Resident #10 expressed fear of injury. On 2/25/15 at 12:10 p.m. Staff N CNA informed the SSD concerns Resident #2 stated in regards to rough care provided by Staff T to Resident #3. Resident #2 reported Staff T hit Resident #3. Following the incident Resident #2 reported hearing a comment from Resident #3 Ow stop hitting me. The facility staff questioned Resident #3 and received confirmation Staff T was rude, punched Resident #3 that caused pain. According to Resident #3 the incident occurred during the night shift. Interview on 3/11/15 at 8:59 a.m. Staff L, certified nursing assistant (CNA), revealed Resident #3 reported Staff T CNA, gets mad and punches me. Staff L stated Resident #3 reported Staff T hit his/her arms when he/she turned the call light on to get up and Staff T got mad. Resident #3 did not provide a specific date of the allegation. Interview on 3/11/15 at 10:20 a.m. with the Director of Nursing (DON) confirmed she completed an investigation regarding an incident with Staff T and a resident on 1/22/15. On 3/11/15 at 11:57 a.m. the DON stated the SSD completed the interview and she (DON) completed the write up of the incident. The DON confirmed Resident #6 reported that Staff T was rough with cares and sustained a bruise. Staff T was suspended pending facility investigation. The DON then stated Staff T was suspended 2 or 3 times since she began employment at the facility. The DON stated her employment began April, 2014. During an interview with the Administrator on 3/11/15 at 12:45 p.m. confirmed Staff T was suspended upon notification of the abuse allegation related to the incident from 1/22/15 and 2/25/15, The Administrator stated the facility investigation lacked evidence of an injury to residents involved so Staff T was allowed to return to work. Note: At the time of the onsite investigation the deficiency was coded at a K level for immediate and serious jeopardy. By April 10, 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 March 11, 2015 exit conference the facility had failed to: a. To provide a safe environment free from abuse against residents. b. Complete training related to the investigation and reporting of abuse. c. Provide adequate supervision to allow residents to live and receive kind and considerate care free from abuse in the facility.

Based on observation, clinical record review and interview, the facility failed to adequately assess changes in physical conditions for 3 of 10 residents reviewed (Residents #1, # 6 and #10). Staff failed to assess Resident #1 on two separate occasions with no bowel movements (BM) for six consecutive days with resultant bowel movement impaction and failed to assess Resident #1's rectal bleeding. Staff failed to assess Resident #6's signs of symptoms of impaired respiratory status. Staff also failed to document assessment of Resident #10 during his/her last hours of life. The facility reported a census of 38 residents. Findings included: 1. (A) According to an Order Report Summary dated 6/1/14 - 6/30/14, Resident #1's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment with a reference date of 4/29/14 listed the Brief Interview for Mental Status (BIMS) score of 5 that identified Resident # 1's mental status as severely impaired. The same assessment revealed the resident required extensive assistance from staff with toilet use and personal hygiene, always incontinent of bowel with constipation present. Review of the same Order Report Summary described above and dated 6/1/14 -1 6/30/14 included the following Physician orders: a. Milk of Magnesia (MOM) suspension, give 30 milliliters (ml) by mouth as needed for constipation per the facility protocol. (start date 4/23/13) b. [MEDICATION NAME] Suppository, insert 1 suppository rectally as needed for constipation per the facility protocol. (start date 4/23/14) c. Sodium [MEDICATION NAME] enema, insert 1 rectally as needed for constipation per the facility protocol. (start date 4/23/14) d. Senna-S Tablet 8.6-50 milligrams (mg), give 1 tablet by mouth two times a day related to Unspecified Constipation. (start date 5/28/14) Review of Resident #1's facility protocol admission orders [REDACTED] MOM, 30 ml, whenever needed, per protocol day 3 (after no BM for 2 days, administer MOM on the third day) [MEDICATION NAME] suppository, per rectum, whenever needed, per protocol day 4 (after no BM for 3 days, administer a suppository on the 4 the day) Fleets enema or soap suds enema per rectum, whenever needed, per protocol day 4 (after no BM for 3 days, administer an enema on the 4th day). Review of Resident #1's bowel records revealed staff documented the resident had no BM for 6 days between 5/17 - 5/22/14 and no BM for 6 days between 6/6 - 6/11/14. Review of Nurses Notes between the dates of 5/10/14 and 5/28/14, lacked any notation of the resident inability to have a bowel movement. Furthermore the record lacked any assessment of the resident's inability to have a bowel movement such as bowel sounds, abdominal palpation, rectal digital exam, pain in the abdomen etc. The nurse's notes lacked any assessment or follow up of the resident's condition or bowel results after the administration of MOM on 5/22/14. Ongoing review of nurses notes dated 5/28/14 at 3:32 P.M. revealed staff documented the resident received 2 Fleets enema's, 1 hour apart with only small BM results. Staff documented the resident's medical provider ordered Senna -S (stool softener) 2 times a day for constipation. Ongoing review of Nurses Notes between the dates of 5/28/14 and 6/12/14 lacked any further follow up assessment of the resident's constipation. The nurses notes revealed no notation of the resident inability to have a bowel movement between the dates of 6/6 - 6/11/14 or assessment of the resident's inability to have a bowel movement such as bowel sounds, abdominal palpation, rectal digital exam, pain in the abdomen etc. On 6/13/14 at 11:28 A.M., staff documented the resident as not having a BM for several days. Staff documented completing a rectal exam and noted the resident full of bulging hard BM. Staff documented a large amount of hard BM being manually removed with resultant rectal bleeding. Staff documented a large amount of stool remained in the rectal vault. Staff documented the need for the resident to rest and a re-evaluation of the resident would be completed after lunch for further intervention. Ongoing review of nurses notes after 6/13/14 at 11:28 A.M., through 6/16/14, revealed staff failed to make any further assessment of the resident's difficulty with constipation or BM's. Because facility staff failed to assess Resident #1's BM's, staff failed to follow the facility protocol for BM management as follows:Review of a Medication Administration Record [REDACTED]. Staff administered MOM only 1 time between the dates of 6/6- 6/11/14 and failed to administer a [MEDICATION NAME] suppository or Fleets or Soap Suds enema between the dates 6/6 -6/11/14. During interview on 6/18/14 at 10:50 A.M., Staff A (Registered Nurse/RN), confirmed she checked Resident #1 on 6/13/14 after she noticed the lack of BM's on the resident's BM record. Staff A states she wanted to make sure the resident had not been "impacted". Staff A described the resident as indeed impacted on digital rectal exam. 1. (B) According to a Medication Administration form dated June 2014, Resident #1 received [MEDICATION NAME] (an anticoagulant medication) with a 0.5 milligrams (mg), 1 time a day on Monday, Wednesday and Friday and [MEDICATION NAME] 1 mg, one time a day on Sunday, Tuesday, Thursday and Saturday. Review of [MEDICATION NAME] drug website (www.[MEDICATION NAME] .com) included important safety information about [MEDICATION NAME] and the risk of bleeding involved. The information web site documented the bleeding can be serious and sometimes lead to death. Review of a laboratory report form dated 6/16/14, Resident #1's [MEDICATION NAME] time (PT- a blood test used to check blood clotting time for people who take [MEDICATION NAME]) test results revealed a high level of 111.8. According to the same laboratory report form, a normal PT time ranged between 9.3 - 11.4). Review of the same laboratory report form dated 6/16/14, Resident #1's International normal ratio (INR- a blood test standardizes the results of a PT test) revealed a high test result of 10.1. According to the laboratory form, a normal INR ranged between 0.1 - 1.1. According to a Physician telephone order form dated 6/16/14, the resident's medical provider ordered the resident to receive a one-time dose of Vitamin K (used to help the blood clot and prevent excessive bleeding) 10 mg, subcutaneous injected. The same order form revealed orders to hold the resident's [MEDICATION NAME] on Monday, Tuesday and Wednesday of the same week. Observation on 6/17/14 at 7:15 A.M. revealed Staff B (Certified Nurse Aid/CNA) and Staff C (CNA) performed Resident #1's perineal cares. Staff B and Staff C rolled the resident to his/her left side. Further observation revealed a moderate amount (approximately 3-4 inches in diameter) of red blood on the resident's bed pad, as well as blood smeared on the resident's rectal area. During the same observation, Staff C reported the resident had a history of [REDACTED]. Observation on 6/17/14 at 10:40 A.M revealed Staff B and Staff C checked Resident #1 for bowel incontinence. Staff rolled the resident to his/her left side. Further observation revealed a moderated amount (approximately 4 inches in diameter) of bright red blood with small clots on the resident's bed pad. Observation revealed an approximate 6 inch area of serosanguinous drainage surrounded the blood spot on the bed pad. During interview on 6/17/14 at 11:00 A.M., Staff C confirmed Resident #1 with rectal bleeding on one other occasion. During interview on 6/17/14 at 1:55 P.M., Staff E (CNA) confirmed Resident #1 with rectal bleeding, approximately quarter size, on one occasion. Observation on 6/17/14 at 4:00 P.M., Staff E and Staff F (CNA) checked Resident #1 for bowel incontinence. Staff rolled the resident to his/her right side. Further observation revealed a moderated amount of dark, semi dried blood with small clots, approximately 5 inches by 2 inches in diameter in the resident's brief near his/her rectal area. Review of nurse's notes between the resident's time of admission on 422/14 - 6/18/14, revealed staff documented on 5/28/14 at 6:30 P.M., CNA's reported no rectal bleeding. At no time in the previous nurse's notes had staff documented any assessment of Resident #1 with rectal bleeding. On 5/29/14 at 8:35 A.M., staff documented the resident's medical provider as notified in regards to some rectal bleeding. The note lacked any further assessment of the rectal bleeding such as amount or color or any further assessment of the resident's physical condition such as visual exam of the rectal area, abdominal palpation, or vital signs such as temperature, pulse or respirations (TPR). The surveyor made 3 observations on 6/17/14 of Resident #1 with rectal bleeding beginning at 7:15 A.M., nursing staff failed to make any assessment of the resident's rectal bleed such as visual or digital exam, abdominal palpation or bowel sounds. The resident ' s laboratory PT/INR test results as noted above revealed the resident was at risk for excessive bleeding and presented with rectal bleeding. The nursing staff failed to perform assessment and notify the resident's Medical Care Provider of the rectal bleeding. Not until 6/17/14 at 4:10 P.M.(approximately 9 hours after the first observation of rectal bleeding) did staff notify the resident's Medical Provider of the resident's rectal bleeding. During telephone interview on 6/18/14 at 10:10 A.M., Resident #1's Medical Provider confirmed the resident's use of a [MEDICATION NAME] (narcotic medication) increased the resident's risk of constipation. The Medical Provider stated she expected nursing staff to be aware of the increase risk of constipation with narcotic use and expected facility nursing staff to follow the BM protocol for assessment of BM's and resultant need for MOM, [MEDICATION NAME] suppository or enema use as ordered after three days with no BM ' s. The Medical Provider stated she would expect to be informed right away in regards to a resident with rectal bleeding. During interview on 6/18/14 at 2:45 P.M., the facility Assistant Director of Nursing (ADON) stated facility nursing staff had difficulty with documentation of assessment. The ADON stated the facility currently worked on education nursing staff in regards to bowel assessment and expected nurses to follow the BM protocol. The ADON stated she expected staff to perform a physical assessment of a resident with a rectal bleed and call the Medical Provider. 2. According to a MDS with an assessment reference date of 5/27/14, Resident #10's [DIAGNOSES REDACTED]. The same MDS revealed the resident required extensive assistance from staff with bed mobility, transfer, toilet use and personal hygiene. A Physician Telephone Order dated 5/27/14, revealed the resident admitted to Hospice care due to a change in the resident's Physical condition. According to a Hospice Nursing Visit note date 6/9/14, the Hospice nurse described Resident #10 as lethargic with no response to verbal stimuli. The note described the resident as had no signs or symptoms of pain and no oral intake. The Hospice nurse documented a follow up visit scheduled for Hospice on 6/10/14. According to a facility social worker progress dated 6/10/14 at 3:36 P.M., the social service designee documented she sat with the resident's family to provide emotional report as the family watched the resident slowly pass away. A nurse's progress note dated 6/10/14 at 11:06 P.M. revealed a nurse documented a medication the resident received as effective. Further review of the nurses notes, revealed no further assessment of the resident's physical and/or mental status during the resident's dying process. According to a facility Record Of Death form with a signature date of 6/11/14, Resident #10 passes away on 6/11/14 at 2:10 A.M. Again, record review lacked any assessment and/or progress noted about the resident's status during the last hours of his/her life. During interview on 6/18/14 at 2:43 p.m., the facility ADON confirmed Resident #10's record lacked any assessment and/or progress note in regards to his/her death. The ADON stated she asked the nurse on duty at the time of the resident's death to document the circumstances leading up to his/her death, but the nurse on duty failed to do so. Review of a facility Charting and Documentation policy form included a purpose to provide a multidisciplinary record and communication of the physical and mental status of a resident. The purpose included a record of concise account of treatment, care, response to care, signs and symptoms and progress of a resident's condition. The policy included direction for staff to document symptoms complained of by a resident as well as those visualized by the nurse (whether complained of or not). 3. The quarterly MDS assessment dated [DATE] for Resident #6 identified [DIAGNOSES REDACTED]. The assessment documented the resident required the assistance of 2 persons for bed mobility, transfers, walking in room, and dressing. The MDS revealed the resident experienced shortness of breath (SOB) with exertion and utilized oxygen therapy. The resident's care plan dated 3/26/14 identified a problem area of inability to do ADL's (activities of daily living) independently related to recent hospitalization with pneumonia and related weakness and need to have O2 continuous. The care plan approaches instructed to give meds as ordered. The medication review report dated 4/23/14 listed the following orders: a. [MEDICATION NAME] sulfate nebulization solution (2.5 milligrams per 3 milliliters) (mg/ml) 0.083% 1 vial inhale orally via nebulizer as needed (PRN) for asthma related to wheezing, may give up to twice each day (BID); order start date documented 9/15/13 b. Proair HFA aerosol solution 108 (90 base) mcg/act 2 puffs inhale orally every 4 hours as needed for wheezing; order start date documented 9/15/13 c. Proair HFA aerosol solution 108 (90 base) microgram/actuations (mcg/act) 2 puffs inhale orally every 6 hours as needed for wheezing; order start date documented 9/15/13 The April 2014 Medication Administration Record [REDACTED] a. [MEDICATION NAME] sulfate nebulization solution (2.5mg/3ml) 0.083% 1 vial inhale orally via nebulizer as needed for asthma related to wheezing, may give PRN up to BID each day; medication documented as not given during the month b. Proair HFA aerosol solution 108 (90 base) mcg/act 2 puffs inhale orally every 4 hours PRN for wheezing; medication documented as given 4/25/14 at 7:16 a.m. and 4/26/14 at 6:50 a.m. c. Proair HFA aerosol solution 108 (90 base) mcg/act 2 puffs inhale orally every 6 hours PRN for wheezing; medication documented as given 4/25/14 at 3:57 p.m. The weekly weights documented weight changes as follows: 3/30/14 to 4/6/14 280.0 pounds (#) to 289.0# (9# weight gain in 7 days) 5/4/14 to 5/10/14 286.0# to 291.0# (5# weight gain in 6 days) 5/11/14 to 5/23/14 289.0# to 299.0# (11# weight gain in 12 days) The nurse's progress note dated 3/22/14 at 11:45 a.m. documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The nurse's progress notes dated 3/22/14 at 12:19 p.m. through 3/28/14 2:01 p.m. lacked documentation of full nursing assessments (head-to-toe health examination that assesses all body systems). The nurse's progress note dated 3/28/14 at 9:11 p.m. documented the resident's lung sounds diminished bilaterally (both sides); the notes lacked documentation of a full nursing assessment. The nurse's progress notes dated from 4/1/14 - 4/20/14 lacked documentation of full nursing assessments and lacked assessments of weight gain or [MEDICAL CONDITION]. The nurse's progress note dated 4/22/14 at 3:39 p.m. documented the resident remained lethargic with faint wheezes present in all lung fields, the resident complained of feeling icky, SOB at rest and with exertion, and the resident utilized a [MEDICAL CONDITION] machine (mask worn that supplies positive airway pressure to assist keeping the airway open). No nurse's progress notes charted from 4/22/14 at 3:40 p.m. to 4/23/14 at 1:18 p.m. The nurse's progress note dated 4/23/14 at 1:19 p.m. documented the resident remained lethargic and difficult to arouse, [MEDICAL CONDITION] on as ordered, O2 sat 89-91% with O2 at 4 liters per nasal cannula (4L/NC), remained in room for breakfast, and came out to dining room for lunch. The nurse's progress note dated 4/23/14 at 3:19 p.m. documented the resident sent to the emergency room (ER) to be seen for [MEDICAL CONDITION] exacerbation/aspiration pneumonia at 12:30 p.m. via ambulance. The nurse's progress note dated 4/23/14 at 3:37 p.m. documented the resident returned to the facility via ambulance at 3:37 p.m. No nurse's progress notes charted from 4/23/14 at 3:38 p.m. to 4/24/14 at 2:26 a.m. The nurse's progress notes lacked documentation of the completion of a full nursing assessment upon the resident's return from the hospital. The nurse's progress notes dated from 4/25/14 at 3:57 p.m., 4/25/14 at 3:58 p.m., 4/26/14 at 6:50 a.m., and 4/26/14 at 7:10 a.m. documented administration of Proair HFA aerosol solution 108 (90 base) mcg/act 2 puffs inhale PRN for wheezing. The notes lacked documentation of full nursing assessments. The nurse's progress notes dated from 5/4/14 - 5/25/14 lacked documentation of full nursing assessments and lacked assessments of weight gain or [MEDICAL CONDITION]. The nurse's progress noted dated 5/19/14 at 7:03 p.m. documented the resident commented she/he thought she/he was going to die soon. The note lacked documentation of a nursing assessment. The 10 page weights and vitals summary report with the date range of 3/22/14 - 6/18/14 lacked documentation of full set of vital sign assessments (blood pressure, temperature, pulse, and respirations readings) from 3/24/14 - 4/4/14; 4/7/14 - 4/21/14; 4/25/14 - 5/4/14; 5/7/14 - 6/3/14; 6/6/14; 6/9/14; and 6/11/14 - 6/15/14. During an interview on 6/18/14 at 2:45 p.m. the Assistant Director of Nursing (ADON) stated when weight gain and SOB exhibited in a resident the nursing staff is expected to perform a full nursing assessment. The ADON stated a full nursing assessment should include lung sounds, a full set of vital signs, O2 Sats (oxygen saturation test), and check for [MEDICAL CONDITION].

ased on clinical record review and interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision to protect against hazards in the environment. The facility reported a census of 45 residents. Findings included: A hospital note dated 3/15/12 documented [DIAGNOSES REDACTED]. A fall risk Care Plan originated on 12/19/11, updated every three months through 1/10/13 listed the following safety interventions: a. Complete a Fall Risk Assessment quarterly (every 3 months) to determine risk factors. b. Physical Therapy (PT) and Occupational Therapy (OT) to screen as needed. (PT/OT had been discontinued 5/29/12.) c. Attempt to determine cause of falls and intervene to prevent further falls. d. Monitor frequently. e. Remove potential hazards from environment. f. Encourage restorative nursing. g. Wear proper fitting shoes with no-slick soles or no slip stockings. h. Resident independent in room and required assistance of one outside the room (hand written under approaches, highlighted in yellow on the care plan to indicate the intervention stopped), and the intervention lacked a start and stop date. The same Care Plan identified a problem with Activities of Daily Living (ADL's) 2/19/11 and documented an intervention on 4/20/12 the resident independent with a walker in room and required assistance from one staff, a walker, and gait belt for meals and activities. A previous intervention (not date when initiated) revealed the resident had been independent in room, however this intervention had been discontinued on 3/15/12. Fall Risk Assessments completed 3/12/12 and 6/20/12 documented the resident scored 10 (10 or above indicated the resident high risk). The Fall Risk Assessment completed 8/22/12 documented the resident scored 12. The ADON completed the assessment and noted Resident #1 had a change in gait pattern when walking though doorway(s). The ADON did not assess a point for balance problems while walking. During an interview with the ADON on 4/24/12 at 2:55 p.m., she reported a Fall Risk Assessment had not been completed during October or November 2012 (quarterly as indicated by the care plan). During an interview with the DON on 4/24/13 at 12:45 p.m., she was asked when Resident #1 became independent and the DON informed the surveyor to check with the Physical Therapy Assistant (PTA). On 4/24/13 at 3:45 p.m., the DON stated she found a note from 5/4/12 in the nurse's notes which indicated Resident #1 had been independent in room. The DON maintained Resident #1 had been independent in his/her room after that time. When asked if the resident had a change from when discharged from PT on 5/29/12 until he/she fell on [DATE], the DON did not reply. During an interview with the Physical Therapy Assistant (PTA) on 4/24/13 at 2:40 p.m., she reported the resident started services after the fall on 3/15/12 with fracture. The PTA reviewed the following documents Physical Therapy (PT) and Occupational Therapy (OT) progress updates with the surveyor: a. An OT-Therapist Progress Report and Discharge Summary sheet, dated 5/22/12, had an entry dated 5/10/12 that documented the resident achieved Mod I (modified independence) with toileting and able to manage clothing, walker, and walker for the task. During the interview the PTA stated modified independence meant on 5/10/12 the resident had the ability to toilet independently with the use of a walker and without staff assistance. b. An OT Therapy Communication note written 5/22/12 documented the resident discharged from OT, the resident required assistance with dressing task, inconsistent with safe functional transfers, and visual cues utilized for safety in room. The written visual cues included a sheet to remind the resident to use the call light when needed, directions for the resident to use to get out of a chair, and a visual to take the walker along at all times. c. A PT-Therapist Progress Report and Updated Plan of Care dated 5/14/12 documented the resident required stand by assistance to transfer sit to stand and required contact guard assistance for ambulation safety. d. A PT-Assistant Progress Update dated 5/21/12 documented the resident had modified independence in room, demonstrated increased safety awareness with the walker, increased strength, increased balance, and precautions required because the resident at risk for falls due to a recent hip fracture. During the interview with the PTA she stated she wrote the above note on 5/9/13. e. A PT Therapist Progress Report and Discharge Summary dated 5/29/12 documented the resident required supervision to transition from supine to sitting position, supervision to ambulate safely, and supervision to transfer from sit to stand. The report documented the resident required verbal cues for walking due to safety. The PTA stated Resident #1 did not receive therapy services after being discharged on [DATE], until the 10/2/12 fall with fracture. The Nursing Daily Skilled Documentation forms revealed the following: a. on 5/28/12 during the 6-6 shift, staff provided the assistance of one (1) for toileting, for bed mobility and for transfers. b. on 5/29/12 time unreadable, staff provided the assistance of one (1) for toileting, for bed mobility and for transfers. c. on 5/29/12 during the 6 to 2 shift, staff provided the assistance of one (1) for toileting, for bed mobility and for transfers. d. on 5/30/12 during the 10- to 6 shift, staff provided the assistance of one (1) for toileting, for bed mobility and for transfers. A quarterly Minimum Data Set (MDS) assessment tool, with an Assessment Reference Date (ARD) of 5/30/12, documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of six out of 30, and indicated severe cognitive impairment. The MDS documented the resident independent with bed mobility and ambulation in room, required supervision with transfers, and extensive staff assistance with ambulation in the corridor. The MDS documented the resident not steady but able to stabilize without staff assistance with balance during transitions and walking, had lower extremity impairment on one side, and used a walker and wheel chair. A quarterly MDS with an ARD of 8/16/12 documented the resident with a BIMS score of six out of 30, independent with bed mobility, transfers, and ambulation in the room, and required limited staff assistance with ambulation in the corridor. The MDS documented the resident not steady but able to stabilize without staff assistance with balance during transitions and walking and used a walker. The MDS documented the resident had one fall without injury since the prior assessment period. Facility Incident Reports documented the following: a. On 7/25/12 at 6:50 a.m., staff found the resident sitting on the floor and back against the roommates bed, the resident unaware of what happened. The resident ' s roommate reported Resident #1 appeared unsteady when walked toward the closet to get something out, the walker within reach, and the resident without injury. The report documented the resident alert with confusion prior to the fall. A new intervention documented on the report and on the Care Plan revealed staff should encourage the resident to call for assistance if felt unsteady. An entry on the Incident Report, dated 7/30/13 documented the resident remained independent in the room with the walker. b. On 8/16/12 at 6:40 a.m., a staff member observed the resident in the bathroom without walker, the resident turned and lost balance, hit left shoulder against the door jam when slid down the wall to the floor, had a 10.5 centimeter (cm) by 3.5 cm purple bruise on the left forearm, and a red area on the left mid back and upper left hip. A new intervention documented on the Care Plan revealed Resident #1 is independent in his/her room and to keep the walker in reach at all times and remind resident to use (walker) at all times. An undated entry on the Incident Report, written by Staff A, documented the resident remained up ad lib in room, reminded to use the walker, and the resident had poor safety awareness. c. On 9/6/12 at 1:00 p.m., a staff member observed the resident on the floor in room leaning against the bed. The resident had no pain with range of motion and a 1.5 cm. and 1.0 cm bruises on the right elbow. The report documented the resident used walker and aware of his/her name prior to the fall. Under new interventions, staff documented the resident up ad lib (as desired) in room with a walker, often left the walker behind, gripper socks worn, and the call light within reach. The Care Plan documented all interventions in place and lacked documentation of any new intervention after the fall. An undated entry on the Incident Report, written by the DON, documented the staff frequently reminded the resident to take the walker, alarms attempted in the past and the resident hid, broke, and threw the alarms away. d. On 10/2/12 at 1:15 p.m., staff found the resident on the floor in room with the walker located against the sink, the resident sat against the recliner, slippers on, the right elbow with a 1 cm skin tear and a 5.0 cm by 4.0 cm bruise, unable to bear weight on right leg when stood, and the resident transferred to the hospital. The report documented the resident alert times one prior to the fall. A 10/2/12 hospital physician's note documented the resident fell at the nursing home and since then has had severe pain in the right hip and in ability to ambulate. Resident #1 had been referred to this hospital for definitive orthopedic care. The x-rays showed a right hip fracture (femoral neck fracture with the head rolled posteriorly). On 4/24/13 at 3:45 p.m., the DON stated she found a note from 5/4/12 in the nurse ' s notes which indicated Resident #1 had been independent in room. The DON maintained Resident #1 had been independent in his/her room after that time. When asked if the resident had a change from when discharged from PT on 5/29/12 until he/she fell on [DATE], the DON did not reply. During an interview with the DON on 4/25/13 at 9:50 a.m., she presented radiology and physician progress notes [REDACTED]. She reported she called the surgeon's office to find out if this history contributed to the resident's fractures. The DON stated the office nurse stated there was no way to know if the fracture came first and caused the fall.

Based on observation, record review and staff interviews, the facility failed to provide the nursing care services to meet the needs of the resident by failure to timely identify an avoidable heel pressure sore, provide adequate assessment and timely intervention to promote healing and prevent infection for 1 of 2 residents reviewed (Resident #5). The facility reported a census of 42 residents. Findings include: Resident #5 was admitted into the facility on [DATE] with bilateral leg stasis ulcers and pressure ulcers on the buttocks region. Although the staff performed treatments and assessed the stasis ulcers and buttocks pressure ulcers, the heel pressure ulcer had not been identified and assessed promptly. The nurse ' s notes indicated staff occasionally floated the heels off the mattress; however, the plan of care didn ' t provide adequate interventions for staff to follow (routine floating of heels, assessment of ulcers or additional devices to prevent the development of pressure ulcers to the heels). On 8/22/2011 the nurse ' s notes revealed a blister was noted on the resident ' s left heel (no assessment performed). A treatment was ordered on [DATE] after the resident was seen at the physician ' s office. Staff did not assess the heel ulcer until 9/16/2011 (The skin assessment form identified the heel ulcer as a Stage III with yellow slough and maceration. On 9/23/2011 the resident was admitted into the hospital for the stasis leg ulcers. The consultation assessment report dated 9/25/2011 indicated an admission date of [DATE] and identified the left heel decubitus ulcer as gangrenous and unstageable. The hospital operative report indicated the resident had a chronic necrotic heel wound on the left foot and a debridement and a partial calcanectomy (portion of left heel) was removed. A wound vac was placed on the lower leg. 1. Resident #5 had an admission Minimum Data Set (MDS) assessment with a reference date of 08/26/11. The assessment reflected Resident #5 scored 13 on the Brief Interview for Mental Status (BIMS) which identified cognition ability as intact. Resident #5 required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and totally depended upon staff for bathing services. The MDS identified Resident #5 as not at risk for the development of pressure ulcers, but, the resident had 2, Stage II pressure ulcers. The MDS reflected the resident had a pressure reducing devices located on the chair and bed and the staff began a turning and reposition program. The MDS did not identify pressure relieving devices for the foot or heels. A Braden Scale For Predicting Pressure Sore Risk scored Resident #5 at 15 with a score of 16 or less indicating the risk of developing pressure ulcers. An Emergency Department Record dated 08/19/11 indicated Resident #5 had stasis [MEDICAL CONDITION], cellulites and pressure ulcers. The nursing assessment documented Resident #5 had multiple pressure ulcers to the bilateral buttocks and the backs of the bilateral legs, in various stages from Stage I to Stage III. The record identified open areas throughout with bleeding and a gross amount of blood to the bilateral lower legs. The admission orders [REDACTED]. The orders directed staff to keep the resident ' s legs elevated and to be seen in the office in 1 week or as needed. The Care Plan dated 08/19/11 identified Resident #5 with impaired skin integrity related to immobility. Resident #5 had Stage II pressure ulcers on the buttocks and stasis ulcers on the lower legs. The goal plan indicated the pressure ulcers would heal without signs and symptoms of infection, and skin problems would be promptly identified and interventions initiated. The approaches directed staff to : a. Follow house protocol/regime for treating breaks in skin integrity/pressure ulcers. b. Pericares when resident incontinent as needed. c. Pressure relief mattress on bed. d. Pressure relief cushion in wheelchair. e. Encourage and assist resident to change position every hour as needed. f. Medications as ordered. g. Braden scale with comprehensive, quarterly assessments and as needed. h. Wet to dry dressings every shift as ordered, i. Treatment as ordered to buttock. An Admission Nursing assessment dated [DATE] at 3:40 p.m. indicated Resident #5 had pressure ulcers of the buttocks as marked on a body chart. The same body chart indicated stasis ulcers on the lower legs. The general skin condition section directed to indicate location, size, depth, color, drainage, of all body marks such as pressure ulcers, abrasions, bruises, soft heels, moles, skin tears, cancer [MEDICAL CONDITION], surgical wounds, scars. The Nurse's Notes dated 08/19/11 at 3:40 p.m. identified Resident #5's admission. The notes documented Resident #5 showed many open areas on the bilateral buttocks and lower extremities. The left lower leg lateral aspect open area measured 39 by 14 cm, partially crusted, partially weeping, with a very foul odor noted. The left lower leg medial aspect open area measured 4 by 2 cm. Resident #5 denied pain from the open areas on the legs. At 6:00 p.m. dressings were on Resident #5's legs as ordered. The admission record lacked identification of skin issues to the resident ' s heels. The Nurse's Notes dated 08/20/11 at 12:00 a.m. identified the resident ' s dressings clean, dry and intact to the bilateral lower legs; elevated, heels floating. At 9:00 a.m. the staff changed the dressings to the bilateral lower extremities. The left lower leg appeared pale, skin thickened and deeply wrinkled. The outer aspect had many scabbed areas over the lower leg and ankle with skin sloughing around scabs. The Nurse's Notes dated 08/21/11 at 10:00 a.m. indicated the left lower leg wounds were much more extensive, especially the outer leg and posterior. The Nurse's Notes dated 08/22/11 at 4:00 am. indicated the dressing change to the bilateral lower extremities as wrapped with Kling from the knee to the ankle. The Nurse's Notes dated 08/22/11 at 1:00 p.m. identified a blister on the resident ' s left heel. The clinical record lacked any documentation of an assessment of the blister of the left heel including size, color, or surrounding skin. A Physician Clinic Sheet dated 08/23/11 documented a summary of Resident #5's problem. The sheet asked if the physician would like PT and OT to evaluate and treat for strengthening. The sheet also questioned if Resident #5 would benefit from seeing a wound care specialist or nurse. The sheet also questioned if they should continue daily whirlpool baths. The physician responded: a. PT (physical therapy) and OT (occupational therapy) to evaluate and treat. b. Wound care protocol, saline dressings, keep moist, change every shift. c. Whirlpool 3 times a week or more often. d. Recheck in 1 week to 10 days. e. Ensure or other supplement between meals. A Progress Note dated 08/23/11 documented Resident #5 had been at the facility for a few days. The resident lived at home but could not take care of the sores on the feet. Resident #5 had some improvement since starting daily whirlpools and elevating feet. They wondered if Resident #5 needed some advanced wound healing procedures, but with good nutrition, saline soaks initially and if there were some deeper [MEDICAL CONDITION] they could try some silver therapy. Resident #5 had extensive ulcers on the left leg and superficial ulcers of the right leg and buttocks area. The Nurse's Notes dated 08/23/11 at 1:00 a.m. documented the dressing change to the bilateral lower extremities. The skin on the posterior left lower leg. Saline soaked gauze to all areas lower legs and covered with a foul odor from areas left lower leg. On the 6 to 2 shift, staff redressed the bilateral leg wounds. On the 2 to 10 shift the physician checked the leg ulcers and reapplied dressings. The Nurse's Notes dated 08/25/11 at 12:15 a.m. documented Resident #5 complained of pressure on the left heel, and staff repositioned with heels floating. Dressing to Resident #5's bilateral lower legs done by the DON after the whirlpool, just to the legs. The Nurse's Notes dated 08/26/11 at 4:10 a.m. documented wet to dry dressings applied to Resident #5's bilateral lower legs as ordered. His/her feet were up on 2 pillows. At 4:00 p.m. the treatment to Resident #5's lower legs continued per order. A facsimile (fax) dated 08/26/11 requested an increase in pain medication due to Resident #5 having a lot of pain especially when changing the dressings to his/her lower legs. The physician responded with new orders. The Nurse's Notes dated 08/28/11 at 2:15 a.m. documented Resident #5 continued to complain of much discomfort with the dressing changes to bilateral lower extremities. Staff noted a foul odor from the left lower leg ulcers. The Nurse's Notes dated 08/29/11 at 8:00 p.m. documented the left lower leg wound areas appeared yellow/tan with red surrounding. The Nurse's Notes dated 08/30/11 at 8:30 p.m. documented the treatment to Resident #5's bilateral lower legs continued as ordered. The Nurse's Notes dated 08/31/11 on the 6 to 2 shift documented the wound to Resident #5's left leg had increased bleeding after the dressing removal. At 7:00 p.m. Resident #5 received [MEDICATION NAME] (pain medication) prior to the treatment to the lower legs The Nurse's Notes dated 09/02/11 at 4:00 p.m. documented the treatment to Resident #5's lower legs done per order. The Nurse's Notes dated 09/03/11 on the 2 to 10 shift documented the treatment to Resident #5's lower legs done as ordered. The Nurse's Notes dated 09/04/11 on the 2 to 10 shift documented Resident #5 received pain medication prior to the treatment to his/her lower legs. The Nurse's Notes dated 09/06/11 on the 2 to 10 shift documented the treatment to Resident #5's bilateral lower legs done per order. The Nurse's Notes dated 09/07/11 at 4:00 p.m. documented Resident #5 received medication 1 hour before the dressing change. Resident #5 cried when the dressings were removed from the left leg. The Nurse's Notes dated 09/08/11 at 9:00 a.m. documented an appointment scheduled with the physician for a recheck of Resident #5's leg ulcers progression/condition. The Nurse's Notes dated 09/09/11 on the 2 to 10 shift documented Resident #5 experienced extreme pain during treatment to his/her lower legs. Resident #5 had an appointment scheduled 09/12/11 to look at his/her bilateral lower legs. New orders received regarding pain medication. The Nurse's Notes dated 09/11/11 at 10:00 a.m. documented Resident #5's dressings changed with extreme pain, the pain medication given earlier not decreasing the pain. Resident #5 cried with taking off and applying the dressing. The left leg appeared deep and bleeding more today. The Nurse's Notes dated 09/12/11 at 2:00 p.m. documented Resident #5 to see the physician for a recheck of wounds. Communication sent regarding bowel care in conjunction with narcotic use. A History and Physical dated 09/12/11 documented Resident #5 had been in the nursing facility receiving whirlpools and therapies and slowly improving some of the shallow ulcers although the deep ulcers were still quite deep. The [DIAGNOSES REDACTED]. The Nurse's Notes dated 09/13/11 on the 6 a.m. to 2 p.m. shift documented they wrapped Resident #5's left leg with saline soaked gauze and covered with dry gauze. Throughout the dressing process Resident #5 cried uncontrollably. Pain medication administered after the whirlpool bath. At 2:00 p.m. the RN spoke with the physician regarding the dressing orders, a specialized dressing to be used on the deepest wounds of the left leg. The nurse requested increased pain control and the physician agreed. At 4:00 p.m. the physician ordered a pain patch for Resident #5. The Nurse's Notes dated 09/15/11 at 10:30 a.m. documented the dressing change done to Resident #5's bilateral lower legs. A fax dated 09/16/11 notified the physician Resident #5 continued to cry due to pain in his/her legs and had not been coming out for meals due to increased pain. The wounds also had a foul smell. The nurse requested an order for [REDACTED]. A Physician's Telephone Order dated 09/16/11 directed the staff to talk with the family and the resident and if they agree, to consult a wound nurse for treatment of [REDACTED]. The Nurse's Notes dated 09/17/11 on the 2 to 10 shift documented the treatment to Resident #5's lower legs intact. The Nurse's Noted dated 09/18/11 at 10:00 a.m. documented the left leg dressing also very bloody and bleeding through to the pillow underneath. Large clotted tissue piece removed from his/her posterior left ankle. The left leg was wrapped and covered. At 3:00 p.m. Resident #5 cried with even the slightest touch to his/her lower legs. The Nurse's Notes dated 09/19/11 documented an appointment made with the Wound Nurse for 09/22/11. The Nurse's Notes dated 09/20/11 documented the treatment to Resident #5's lower legs done. The Nurse's Notes dated 09/22/11 at 10:30 a.m. documented Resident #5 out to a doctor's appointment. The Nurse's Notes dated 09/23/11 documented the physician called and Resident #5 would be admitted to the hospital. The Weekly Ulcer Assessment described MDS staging of pressure ulcers: Any lesion caused by pressure resulting in damage of underlying tissue. An ulcer cannot be staged with eschar (black), stage when eschar sloughed off. The document described the stages: Stage I: A persistent area of skin redness (without a break in the skin) that does not disappear when pressure relieved. Stage II: A partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater. Stage III: A full thickness of skin is lost, exposing the subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue. Stage IV: A full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone. The Weekly Ulcer Assessment documented Resident #5's ulcer located on the bilateral lower extremities with numerous stasis ulcers at various stages. a. On 08/19/11 the resident had Stage III with odor and yellow slough with serosanguinous drainage. The resident had pain. b. On 08/26/11 the resident had Stage III with odor present and green (infected) and yellow (slough), serosanguinous drainage, maceration to the surrounding skin and pain. c. On 09/02/11 the resident continued to have Stage III, odor present, serosanguinous drainage, maceration of the surrounding skin and pain. d. On 09/09/11 the resident had Stage III, with odor present, serosanguinous drainage, maceration of the surrounding skin and pain. e. On 09/16/11 the resident had Stage III in the lower heels and the heel with the areas not connected. Odor was present, yellow in color and serosanguinous drainage, maceration to the surrounding skin, and pain. The clinical record lacked any documentation of an assessment of the heel area. f. On 09/23/11 Resident #5 was hospitalized . g. On 10/07/11 the drawing showed the lower leg and back of the foot with a 6 by 6 by 0.2 cm area to the heel. The assessment indicated 34 staples and a wound vac (device to remove drainage) to the left heel. The Daily Wound Documentation for the bilateral lower extremities from 09/13/11 through 09/23/11 documented Resident #5 had no necrotic tissue present and no signs and symptoms of infection present. A Wound Clinic Progress Note dated 09/22/11 documented the chief complaint: Multiple chronic venous stasis ulcers to bilateral lower extremities. The wound assessment documented venous ulcers to the lower left leg with a large amount of light green/serosanguinous drainage with mild odor. Seventy five percent of the wound base appeared beefy red, with the remaining 25% tanish slough. The assessment identified a non-stageable pressure ulcer to the left heel. Eschar (black) covered 75% of the wound base, with 25% pink-yellow edges. The surrounding wound appeared bright pink. The right lower leg venous ulcers appeared 100% red, moist. The assessment indicated 1/4 to 1/2 inch [MEDICAL CONDITION], which appeared to be more [MEDICAL CONDITION], mainly to the left lower leg. The comments included: Ulcerations to the left lower leg were severe. Resident #5 also had a large necrotic pressure ulcer to his/her left heel, described as boggy and moist. Surgical debridement recommended if the arterial/venous blood supply proved adequate. The wound nurse explained to the physician her concern for infection with moist necrotic tissue. The wound nurse consulted a physician at a local hospital regarding Resident #5's wound status, who viewed photos. The physician recommended Resident #5 be transferred to a larger hospital due to the wounds being very severe and extensive. A Patient Transfer Form dated 09/23/11 from the facility to the hospital documented the primary [DIAGNOSES REDACTED]. The additional information documented Resident #5 had stasis ulcers to the bilateral extremities. Resident #5 saw the Wound Nurse 09/22/11 with recommendations to be admitted to the hospital for surgical debridement. An Infectious Disease Consultation dated 09/25/11 documented Resident #5 reported a long history of venous stasis ulcers that had been worse over the past several weeks. A physical exam of the extremities revealed a gangrenous (decayed body tissue) unstageable wound of Resident #5's left heel. There were multiple ulcers on the left leg, especially on the back and lateral side with a significant amount of foul smelling drainage. A hospital Consultation dated 09/27/11 documented Resident #5 presented to the hospital for evaluation of multiple stasis wounds and a chronic ulcer to the left heel. Podiatry/orthopedics consulted foe evaluation of a necrotic wound and possible surgical intervention. Resident #5 received compression therapy for the ulcers from wound care. The physical exam included a large 4 centimeter necrotic ulceration at the plantar aspect of the left heel. They noted a fair amount of redness and swelling around the area, as well as fluctuance (indication of presence of pus in a bacterial infection) underneath the lesion. The assessment: Chronic ulceration with gangrenous/necrotic changes of the left heel. An Operative Report dated 09/28/11 documented the preoperative [DIAGNOSES REDACTED]. The procedure involved wound debridement with partial calcanectomy of the left foot. A hospital physician's orders [REDACTED]. The note documented Resident #5 had left heel osteo[DIAGNOSES REDACTED] (infection of the bone) [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) and Proteus. During an interview on 11/03/11 at 11:06 a.m. the Wound Nurse stated she was surprised when she saw Resident #5. The Wound Nurse stated she expected to assess the stasis ulcers to Resident #5's lower legs, but she did not expect the ulcer to the left heel. The wound nurse stated the ulcer to the left heel was a pressure ulcer. The Wound Nurse stated intervention should have been taken sooner. The Wound Nurse continued to state she understood the physician tried some different things, however, she would not have ordered the whirlpools; the warmth increased circulation which increased [MEDICAL CONDITION], and a source of infection. The Wound Nurse stated the blister to the left heel documented on 08/22/11 indicated a Stage II pressure ulcer. As long has the blister was clear then the facility could have watched the blister and kept all contact from it, and then saw how it progressed. The wound to the back of the left calf was about 3 inches above the ankle bone. The outer ankle showed island type open areas. The Wound Nurse noted intact skin surrounding the left heel pressure ulcer. The Wound Nurse did not get the ulcers measured, she made calls to get Resident #5 admitted to the hospital. When discussing the surgical report concerning the left heel, the Wound Nurse stated it indicated Resident #5 had a Stage IV pressure ulcer to the left heel. On 11/02/11 at 1:45 p.m. the Director of Nursing (DON) was interviewed and stated Resident #5 came in with wounds on the front and the back of the legs. When questioned about the heel ulcer, the DON stated it was all over and the facility tried everything. When questioned about the lack of documentation regarding the heel ulcer except on 08/22/11, only noting a blister to the heel and nothing else until Resident #5 was admitted to the hospital with [REDACTED]. During findings with the facility staff on 11/03/11 at 10:25 a.m., the DON stated she did not measure the leg wounds because the wounds all ran together. The DON thought when the blister to Resident #5's heel popped there may have been some slough tissue. When asked where she documented it, the DON shook her head. When asked why they did not document the left heel wound, no one responded. The DON acknowledged the lack of interventions on the care plan regarding the left heel pressure ulcer. The DON thought Resident #5 had Rook Boots (protective boots for the heel), but no documentation in the clinical record reflected Rook Boots used. During additional findings at 2:00 p.m. the DON stated Resident #5 didn't have Rook boots prior to the hospitalization . During the Exit Conference on 11/04/11 at 11:00 a.m. the DON stated she realized the staff did not document the heel involvement. The DON went on to say when staff documented the lower extremities that encompassed everything. During an interview on 11/03/11 at 5:15 p.m. Staff G Registered Nurse (RN) stated she measured the wounds to Resident #5's legs. Staff G stated she did not think Resident #5 had an ulcer to his/her left heel when he/she came in. Staff G stated she would have documented if Resident #5 had an ulcer to the left heel. Staff G did not remember Resident #5 having eschar, but thought he/she had some yellow slough. Staff G stated she didn't usually change the dressing but sometimes assisted the charge nurse by holding the leg during the dressing change. She asked the DON about requesting a consult with the Wound Nurse. The DON stated she could request it but she wouldn't get it. The physician did agree to the consult. Staff G stated she didn't know if she knew Resident #5 had a pressure sore to the left heel until he/she saw the Wound Nurse and was admitted to the hospital. Staff G stated they didn't use Rook Boots for Resident #5 because she didn't think they would work very well. She stated they tried to float Resident #5's heels as best they could given the circumstances. She did not assess or measure the wounds after initially doing so on admission. She stated the DON did the weekly assessments and measuring. She stated if Resident #5 had an ulcer on his/her heel on admission she would have documented it. She stated the heel may have been dark or discolored. During an interview on 11/03/11 at 9:55 a.m. the Assistant DON (ADON) stated she remembered when Resident #5 came in and she assisted with his/her admission. The ADON thought there was something to the left heel. She could not remember what it looked like but thought maybe it appeared dark. The ADON acknowledged the lack of documentation regarding the heel. The ADON stated the wound care ordered for the resident's legs were used on all the wounds. During an interview on 11/03/11 at 12:30 p.m. Staff A (Registered Nurse) stated she remembered Resident #5 had skin coming off of the leg. Staff A stated she couldn't remember if it came off the heel. Staff A stated when she did the dressing changes she padded the left heel. Staff A stated she always floated Resident #5's heels and thought the other staff was good about doing that. Staff A stated Resident #5 complained about pain if the heel was not floating and they would reposition. Staff A could not remember, but thought Resident #5's heel may have been turning black the last time she changed the dressing (according to the Daily Wound Documentation she last changed the dressing on 09/20/11 and documented no necrotic tissue present). Staff A stated she didn't think the heel ulcer was as bad as the other ulcer. Staff A stated she used the same dressings to the heel as she used on the legs. During an interview on 11/03/11 at 4:00 p.m. Staff F (Registered Nurse) stated Resident #5 was admitted in poor condition. Staff F stated the wound started at the top of the calf and down. Staff F thought the wound was on Resident #5's heel as well. Staff F did not remember Resident #5 having a blister to the left heel. Staff F stated there was probably black eschar on different parts of the wound (according to the Daily Wound Documentation Staff F documented no necrotic tissue present 09/23/11, the day she admitted to the hospital for surgical debridement). Staff F thought everyone tried to keep Resident #5's heels floating for the most part, but it proved difficult because of the pain he/she experienced in the lower legs. Staff F stated being very upset, because she thought something should be done. Staff F stated she asked the physician for a wound consult and he declined. When she asked again she was basically shamed by administration for asking again when he already said no and was told she needed to ask the DON before doing that. Staff F stated she finally obtained the okay for a consult and she sent the nurse's notes so the Wound Nurse would know what was going on. When told the Wound Nurse expected stasis ulcers to the lower legs, and her surprise by the pressure ulcer to the left heel, Staff F stated she didn't know why she didn't use the word heel. During an observation on 11/01/11 at 11:56 a.m. Resident #5 laid in bed with a Wound Vac attached to the left heel (dressing). Resident #5 also had an intravenous PICC (peripherally inserted central catheter) line in his/her left arm. During an observation dated 11/02/11 at 9:55 a.m. the DON prepared to do the dressing change to Resident #5's left heel. The DON removed the gauze dressings. The DON removed the Wound Vac dressing. The open area covered the entire heel. The heel had a flat rather than a round appearance. The facility policy regarding pressure ulcers dated 10/27/2010 identified pressure ulcers as an injury usually caused by unrelieved pressure that damages the skin and underlying tissue. The policy directed staff to assess the areas prone to pressure ulcers and immediately address any pressure ulcers. The intervention also directed staff to protect the skin against the effect of pressure, friction and shear and provide positioning devices between skin and surfaces (heel protectors, pillows, etc.)