Every finding on record at Dunlap Specialty Care

Based on clinical record review, observation, staff interviews, and manufacturer recommendations the facility failed to ensure the residents were free of significant medication errors to 1 of 5 residents reviewed (Resident #1). The facility reported a census of 31 residents.Findings include:Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was admitted to the facility on [DATE]. The MDS further revealed Resident #1 had diagnoses of end-stage renal disease, and diabetes mellitus. Review of Resident #1's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Humulin R U-500 subcutaneous solution 500 units per milliliter to inject 115 units subcutaneously two times a day with an order date of 8/4/26.Observation on 8/5/26 at 7:55 AM of Staff A Registered Nurse (RN) completing med pass for Resident #1. Observed Staff A obtain Resident #1's insulin pen, and set the pen to the dosage without utilizing 2 units to prime the insulin pen. Staff A then cleansed the tip of the pen with alcohol, and placed the needle. Staff A then handed Resident #1 the insulin pen and Resident #1 administered the insulin. Interview on 8/5/26 at 8:15 AM Staff A revealed that she has never primed insulin pens as she did not know to do this. Interview on 8/5/26 at 8:20 AM with the Director of Nursing (DON) revealed that she would expect staff to prime insulin pens. Review of the manufacturer's website for Resident #1's insulin Kwikpen https://uspl.lilly.com/humulinru500/humulinru500.html#ug1 on 8/6/26 revealed:a. Prime before each injection.Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly.If you do not prime before each injection, you may get too much or too little insulin.b. To prime your pen, turn the dose knob to select 5 units.c. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. d. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly.You should see insulin at the tip of the needle.

Based on observation, staff interviews, and facility policy review the facility failed to use universal infection control measures while completing medication pass for 1 of 3 Residents (Resident #1) reviewed. The facility reported a census of 31 residents. Findings include:Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was admitted to the facility on [DATE]. The MDS further revealed Resident #1 had diagnoses of end-stage renal disease, and diabetes mellitus. Review of Resident #1's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for blood sugar checks three times a day with an order date of 7/10/26. On 8/5/26 at 7:55 AM, observed Staff A Registered Nurse (RN) getting two pairs of gloves from Resident #1's bathroom, and placing one pair into her scrubs pocket. Staff A then donned the other pair of gloves. Staff A further proceeded to complete Resident #1's blood sugar check. Staff A then doffed the set of gloves, and without hand hygiene grabbed the pair of gloves in her scrub pocket and donned them. Staff A then obtained Resident #1's insulin pen and set the pen to the dosage. Staff A then cleansed the tip of the pen with alcohol and placed the needle. Resident #1 was then handed the insulin pen by Staff A for administration. Interview on 8/5/26 at 8:15 AM with Staff A revealed that she should not have placed the gloves into her pocket, and then revealed there could have been hand hygiene in between the glove changes. Interview on 8/5/26 at 8:20 AM with the Director of Nursing (DON) revealed that she would expect hand hygiene between glove changes as well as not putting gloves to be used in pockets of clothing before use. Review of a facility provided policy titled, Handwashing/Hand Hygiene with a revision date of August 2019 indicated staff should complete hand hygiene before and after glove usage. The policy further indicates staff should remove one glove at a time from the container for usage.

Based on Electronic Health Records (EHR) review, observations, resident interview, family interview, staff interviews, and policy review the facility failed to provide the residents with a comfortable/clean homelike environment by not cleaning resident rooms or common space in a timely manner. The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. On 5/19/25 at 11:17 AM Resident #6's daughter stated there was a spider in the dining room by the nurses station for about a week. The resident's daughter stated her mothers room gets spiders at times. She stated she had told the administration. The daughter stated she killed a large spider in the chapel and explained to look behind the door in the chapel where she killed the spider about a week ago. The daughter stated there were a lot of dead bugs in the chapel when she was there last. On 5/19/25 at 11:40 PM observation of numerous dead bugs in the chapel and in the hallway on center hall. Observation of a large spider dead where Resident #6's daughter described. 2. The MDS dated [DATE] for Resident #24 documented a BIMS of 15 indicating no cognitive impairment. On 5/20/25 at 5:02 PM Resident #24 stated the housekeeping rarely comes in to clean the room less then twice a month. Resident #24 stated it did bother her and she has mentioned it to several nurses. 3. The MDS dated [DATE] for Resident #27 documented a BIMS of 13 indicating no cognitive impairment. On 5/19/25 at 12:57 PM Resident #27 stated he had to clean his room on his own before on his hands and knees. Resident #27 stated he filed a grievance about how the room was not cleaned in several days. Resident #27 stated he can go days without his room being cleaned. Resident #27 stated it did bother him that his room was not cleaned for days at a time. Observations on 5/19/25 at 11:30 AM of numerous dead insects on the floor around the nurses station and on the center hallway baseboards. Review of document Grievance/Concern Investigation Form for the last 3 months documented concern that room had not been cleaned since the resident had admitted to the facility dated 4-7-25. A concern that housekeeping was asked to clean the bathroom because the resident thought the bathroom smelled like urine. The resident wanted it mopped and cleaned. The housekeeper opened the bathroom door, said it was fine and left the room. A concern that the resident's room had not been cleaned for a few days. The resident attempted to clean the floor himself. Actions and follow-up in place for all of the grievances with Staff K, Housekeeping Aide, spot checks for effectiveness, and follow-up inspections. On 5/22/25 at 8:50 AM Staff K, housekeeping aide stated he had worked at the facility since 8/31/23. Staff K stated there were 3 people in the housekeeping then one went to the kitchen and the other became the Manager. Staff K explained about a month ago the Manager moved to Missouri. Staff K stated he worked every day, about 6 hours every day, to keep it under 40 hours. Staff K stated the facility had not allowed overtime in the past. Staff K stated the facility allowed overtime over the last five days since surveyors have been in the facility. Staff K stated on 5/21/25 there were 3 extra housekeeping brought to the facility. Staff K stated they were brought to help out during the survey. Staff K stated the facility had never in the past since he had worked at the facility pulled staff from another building for help at this facility. Staff K acknowledged that he had been spoken to about the grievances. Staff K stated he was the only person in housekeeping and he could not complete all the tasks. Staff K stated the plan that was developed had little to no follow up because there simply was not enough staff at the facility to complete all the tasks. Staff K stated he usually cleaned every single room every day. Staff K stated he usually cleaned the dining rooms and resident rooms daily. Staff K stated in the residents room he would at least sweep the room daily. Staff K acknowledged he did not feel he was completing all the tasks in the housekeeping department because he just simply does not have the time to complete all the required cleaning. Staff K stated he missed areas like the chapel, hallways and the nurses station. Staff K stated he cleaned every bathroom, toilets and the floors every day. Staff K stated he was just thrown into the position and was not oriented to the expectations. Staff K stated he had no orientation besides computer training such as dependent adult abuse. Staff K stated he had spoken to the Administrator about not being able to complete his tasks and he was told they tried to hire staff but the facility never did. Staff K stated he did not remember any follow ups from the management related to grievances. On 5/22/25 at 8:51 AM Staff L, Maintenance Supervisor and Temporary Housekeeping Supervisor stated the previous housekeeping supervisor quit that was why he started being the supervisor. Staff L stated when the residents or staff saw spiders or ants they would report them. Staff L stated it seems when the pest control spray they will try to clean up the dead when the insect is present when sprayed. Staff L stated Resident #7's daughter had reported a spider in the hall and in Resident #7's room. Staff L stated the facility was not cleaned appropriately. Staff L stated there were not enough hours. Staff L stated the halls are not being cleaned daily and the housekeeping staff were limited to 40 hours. Staff L explained the housekeeping department was short 2 full time people and did not have anyone in the laundry either. Staff L stated laundry takes priority over maintenance. Staff L stated maintenance had tasks that took priority as well. Staff L stated it was brought to his attention and he had brought it to the Administrator multiple times requesting more employees in the department or overtime. Staff L stated neither overtime or new hires had been provided. Staff L stated yesterday there were 3 staff from another facility brought in for housekeeping. Staff L stated he had not had any staff from other buildings come help in the housekeeping role. Staff L stated the grievances were written prior to him taking the position and he put together a schedule to ensure the cleaning would have been completed appropriately. Staff L stated the cleaning schedule that was being implemented related to the concerns on the grievances were not being followed because by Wednesday he had too many hours. Staff L stated the Administrator was aware of the concerns. Staff L stated he had that conversation many times with the Administrator. Staff L stated the follow up only happened for 2 days. Staff L stated the Administrator stated he could not have over 40 hours so that was stopped. Staff L stated after the plan was developed there was very little to no followup to how the issues/concerns would be addressed. Staff L stated the resident had very bad incontinence and urinated all over the room and the department was supposed to clean his room [ROOM NUMBER] times a day. Staff L stated he originally cleaned the residents room twice a day but does not think it was currently being cleaned that often. On 5/22/25 at 11:15 AM Staff M, area Administrator stated housekeeping was brought in from other facilities to help out for housekeeping at that facility. Staff M stated there was someone from the department who quit last Tuesday. Staff M stated he would expect the insects would have been cleaned up in a timely manner around the facility. Review of policy revised 8/13 titled, Cleaning and Disinfecting Residents' Rooms documented housekeeping surfaces will be cleaned on a regular basis. Environmental surfaces would be disinfected on a regular basis. Clean personal use items such as lights, phones, call buttons, bedrails etc with disinfectant solution at least twice weekly.

Based on observations, staff interview, and policy review the facility failed to store food in accordance with professional standards by not dating open food items or disposing of expired food items. The facility reported a census of 33 residents. Findings include: On [DATE] at 8:24 AM an observation during the initial kitchen tour revealed a 3 door refrigerator with 3 bags of lettuce (one bag open) with the expiration date of [DATE]. A second 3 door refrigerator had a bag containing 8 hard boiled eggs that were open and undated, 8 individual yogurt containers with expiration of [DATE] and cheese in a large clear plastic container with an open date of [DATE]. Dry storage contained a bag of gravy mix, a bag of lemonade mix, a 2 pound bag of gluten free flour, a 5 pound bag of egg noodles, a 10 pound bag of tri colored noodles and a 5 pound bag of white cake mix open and undated. On [DATE] at 10:23 AM Staff E, Certified Dietary Manager (CDM) stated the facility's expectation was that all open food items would be dated with the date the item was opened. Staff E stated she would have expected the cheese with the date of [DATE] would have been discarded before [DATE]. Staff E stated all expired food should have been discarded once it was expired. Staff E explained the yogurt and lettuce should have been discarded before [DATE]. During a continuous observation on [DATE] from 11:17 AM - 12:15 PM of the lunch meal service revealed Staff F, CDM using metal tongs to remove buttered bread from a metal container. Observation revealed Staff F moving between the tongs and bare hands to replace the lid using the handle of the lid to cover the bread throughout the entire lunch service. Observation on [DATE] at 11:44 AM revealed Staff E, CDM complete hand hygiene, open the 3 door refrigerator, remove a plastic bag with 2 foil wrapped sandwiches, retrieve one sandwich from the bag, open the foil with bare hands, grasp one sandwich from the foil with bare hand and place the sandwich on a plate that was taken out to the dining room for a resident. On [DATE] at 12:32 PM Staff G, Registered Dietitian (RD) acknowledged that she had observed Staff E handle food with bare hands. Staff G stated her expectation was that food would not be handled with bare hands. Staff G stated her expectation was that expired food would be discarded once expired. Staff G stated she expected opened items of food would be dated. Staff G explained tongs should not have been utilized for handling the handle of the metal lid and placing the bread on a plate for a resident. Staff G expressed concerns related to cross contamination when bare hands and tongs contacted the same item that bread was being served with. Review of policy revised ,d+[DATE] titled, Food Receiving and Storage documented dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by).

Based on observation, Electronic Health Record (EHR) review, resident interview, family interview, staff interviews, and policy review the facility failed to follow physician orders for a resident with an ordered breathing treatment and a resident with oral medication for 2 of 4 residents (Resident #6 and #7). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS also documented a diagnosis of pneumonia on 4/18/25. Review of Resident #6's EHR titled, Orders documented a physician's order for sodium chloride inhalation nebulization solution 3% to be administered between 7:00 AM and 9:00 AM. Review of the Medication Administration Record (MAR) documented on 4/30/25 the AM dose of sodium chloride inhalation nebulization solution was administered by Staff A, Registered Nurse (RN). The Progress Note with the created date of 4/30/25 entered by Staff H, Director of Nursing (DON), documented Resident #6 did not receive the AM dose of normal saline breathing treatment. On 5/19/25 at 11:17 AM Resident #6's daughter stated her mother was supposed to receive a breathing treatment but did not receive the treatment. The daughter stated there was a change of tubing every Sunday night at the facility for nebulizer's and masks. The daughter stated the nebulizer tubing was new in the package. The daughter stated she asked Staff A if her mother was given a nebulizer treatment that morning. The daughter explained Staff A said she would give Resident #6 another treatment. Resident #6's daughter stated she told Staff A not to give the treatment. The daughter revealed she had not found out the treatment was not given until 5:00 PM. On 5/21/25 at 3:22 PM Staff A stated it was a rough morning on 4/30/25 and the CMA left before 9 am. Staff A explained Resident #6 did not receive the breathing treatment that morning but acknowledged that she had signed off on the MAR that it was given. Staff A stated she did not take the medication down to Resident #6, it was still in her pocket that morning. Staff A stated Resident #6 had a new set up and it was not open at that time. Staff A explained Resident #6's daughter had come down and told her that the treatment was not administered. Staff A stated it was after 10 am on 4/30/25 when Resident #6's daughter notified her the treatment was not administered. Staff A stated Resident #6's daughter did not want Resident #6 to receive the breathing treatment at that point. Staff A stated Resident #6 s daughter was extremely argumentative and demanding. Staff A stated the DON was already aware because Resident #6's daughter had informed her. Staff A stated she spoke to the DON about the incident. Staff A acknowledged it was her mistake Resident #6 did not receive her breathing treatment that morning. Staff A stated she did not receive education of disciplinary actions as a result of the incident. On 5/21/25 at 3:00 PM the DON stated there was a recent event when Resident #6 did not receive a saline breathing treatment. The DON stated Staff A was asked by Resident #6's daughter if her mother had received the breathing treatment the morning of 4/30/25. The DON stated Staff A stated she had misspoke when she spoke to Resident #6's daughter. The DON stated the saline breathing treatment was a 7 am - 9 am medication. The DON stated she spoke with the physician and there were no new orders. The DON stated she did an investigation and determined that Staff A signed the medication out and the CMA was supposed to turn the nebulizer on. 2. The MDS dated [DATE] for Resident #7 documented a BIMS score of 15 indicating no cognitive impairment. The MDS also documented a diagnosis of lymphedema. Review of Resident #7's EHR titled, Orders documented a physician's order for Lasix 40 mg oral tablet one time daily mid morning. The MAR documented on 5/20/25 the mid morning dose of Lasix 40 mg was administered by Staff I, Registered Nurse (RN). On 5/21/25 at 7:27 AM Resident #7 stated she was not given these noon medications. The resident stated she was only given Tylenol so she told the nurse that she was supposed to get eye drops and Lasix and the nurse told her that she was to receive only the Tylenol. Observation on 5/21/25 at 7:40 AM of Resident #7's medication bubble pack for furosemide 40 mg 1 tablet at noon revealed medication present in the bubble with #20. On 5/21/25 at 7:40 AM Staff J, Certified Medication Aide, (CMA) acknowledged the bubble pack revealed that the furosemide 40 mg tablet was not administered yesterday for the noon dose. Staff J stated Staff I, RN administered medication for Resident #7 at noon 5/20/25. Staff J stated when a medication is noted in the bubble pack from the day before she would notify the nurse or the DON. Stated she had not notified anyone of the medication as of that time. On 5/21/25 at 8:10 AM Staff H, DON stated the date should match the number as long as the pharmacy sends a 30 day supply. The DON acknowledged that yesterday's noon dose of furosemide was still in the bubble pack. The DON reviewed other doses of furosemide to ensure it was not given from another card and acknowledged the medication doses were correct on other furosemide bubble packs. The DON acknowledged that the MAR was signed by Staff I that the noon furosemide was given. The DON acknowledged that there was no explanation on the MAR or in Resident #7 EHR that explained the extra dose. On 5/21/25 at 8:48 AM Staff I, RN stated she spoke with Resident #7 on 5/20/25. Staff I stated Resident #7 liked to self administer her eye drops. Staff I stated Resident #7 was frustrated because she was not allowed to do her eye drops. Staff I stated Resident #7 had 2-3 days worth of Lasix that were not administered. Staff I stated it was not uncommon for days to be left with no explanation. Staff I stated if you look in the center hall cart there were several other medications missed 5/20/25 as well. Staff I stated Staff J and herself had noticed the missed medication 5/20/25. Staff I stated she had never been taught the process of what to do if extra medication were found at the facility. Staff I stated she had administered the Lasix dose to Resident #7 without difficulties. Staff I stated she had also given Resident #7 her 3 eye drops, Tylenol, and furosemide. Staff I stated she did not notify anyone like the DON or anyone else about the extra doses because it is not uncommon to find extra doses at this facility. Staff I stated she had given the dose from the #18 spot on Resident #7's bubble pack. Review of the policy revised 4/07 titled, Documentation of Medication Administration documented a nurse or certified medication aide shall document all medication administered to each resident on the residents MAR. Administration of medication must be documented immediately after (never before) it is given. Documentation must include, as a minimum, the signature and title of the person administering the medication.

Based on observation, interview, clinical record review and policy review the facility failed to ensure that medications were given in a timely manner for 1 of 4 residents. On 5/11/25, the morning medication, administered via Percutaneous Endoscopic Gastrostomy (PEG) tube, for Resident #3 were not administered until afternoon. The facility reported a census of 33 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive deficits.) She was totally dependent on staff for dressing, hygiene, nutrition and transfers. She had an indwelling urinary catheter and a feeding tube, abdominal always incontinent of bowel. The Care Plan for Resident #3, last updated on 5/14/25, showed that she had a Foley catheter for neurogenic bladder. Staff were to provide catheter care every shift. The resident had a terminal prognosis related to diagnosis of progressive multifocal leukoencephalopathay (damage to the brain white matter.) Resident #3 had a tube feeding related to dysphagia disease. She was at risk for perineal infection related to peg tube site. Staff were to use Enhanced Barrier Precautions (EBP) when performing high contact area activities. On 5/21/25 at 5:22 AM, Resident #3 was in bed with her eyes open. The continuous tube feeding was hooked up to a pump and running. She made eye contact but was unable to respond to questions. A review of a Medication Administration Audit Report showed that on 5/11/25, the 10 morning medications were not administered until 12:20 PM. The 2 medications scheduled for 11:00 AM that day had been administered at 3:37 PM. The chart lacked documentation that the physician had been notified of late administration of medications. On 5/22/25 at 11:15 AM Staff B, Corporate Nurse Consultant, said that she would expect that the administration of medication times would be completed per facility policy. She thought that the nursing staff probably waited for the second administration later because of the late morning medications. According to a document titled: Medication Administration Times, the morning medications would be completed between 7 am-9 am and the later morning medications administered from 11 AM - 1 PM. The policy titled: Documentation of Medication Administration dated April of 2007 the administration of medication would be documented immediately after it was given.

Based on observations, interviews and record review the facility failed to ensure a resident does not develop pressure ulcers unless unavoidable and failed to ensure interventions in place for a resident with pressure ulcers for 1 of 3 residents reviewed. On 5/13/25, the Primary Care Provider discovered that Resident #15 had a pressure injury on his heel. Staff documented no new skin issues on the same day. In an observation on 5/22/25, staff failed to have interventions in place. The facility reported a census of 33 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #15 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He was admitted to the facility on [DATE]. Resident #15 was totally dependent on staff for toileting, dressing, transfers, and rolling over in bed. He was at risk for pressure ulcers and did not have any pressures at the time of the assessment. His diagnoses included: anemia, heart failure, renal insufficiency, malnutrition and asthma. The Care Plan for Resident #15, updated on 2/28/25, showed that he was at risk for nutritional and skin impairment. He was unable to ambulate on his own, staff used the mechanical lift for transfers and he required moderate assistance with showers. A focus area added to the Care Plan on 5/18/25, showed that he had a Stage 1 pressure ulcer on his right heel. Staff were directed to apply a pressure relieving boot when he was in bed. On 5/19/25 a 10:37 AM, Resident #15 was laying in his bed on his back and was watching television. He said his back hurts because of the mattress on his bed. The resident was wearing a protective boot on his right foot. He said that his heel was sore and was causing him some pain, but he wasn't sure about the treatment plan. According to the Skin Observation Tool dated 5/7/25 at 9:17 AM, Resident #15 did not have any new skin issues. A Wound Evaluation dated 5/13/25 at 3:46 PM, showed that on that date it was discovered that Resident #15 had a new, right heel, deep tissue injury that was in-house acquired. It measured: 3.01 centimeters (cm) total area, 2.18 cm. length and 2 cm. width. The assessment indicated that the resident didn't have any pain and no dressing was applied. The Nurse Practitioner (NP) was present and treatment orders received. On 5/21/25 at 3:21 PM, Staff C, RN, Assistant Director of Nursing (ADON), acknowledged that he had documented the information on the heel pressure discovered on 5/13/25. He said that the NP found the spot when she was doing rounds because the resident told her that he had some pain on his right heel. Staff C maintained that the resident hadn't ever told anyone else about the pain and they were not aware of the developing sore. He was not sure what the heel may have looked like before it was discovered or if staff should have found it sooner. A Wound Care (WC) note dated 5/19/25, showed that Resident #15 was admitted for WC services on 5/14/25 with suspected Deep Tissue Injury (DTI) to his right heel that was found on 5/13/25. The resident was no longer ambulatory or able to bear weight, staff were using a Hoyer (mechanical lift) for transfers. He was chronically bedbound and noticed a deep poking pain in his heel about 2 weeks prior to its discovery. The resident had been sleeping in the recliner and used the bend in the recliner foot rest to push himself up. That routine stopped when they removed the recliner from the room about 2 weeks prior. The wound was described as a smaller area of non-blanching red with a larger surrounding callous. The primary etiology of the ulcer was described as a Stage 1, intact skin with non-blanchable redness of a localized area over a bony prominence with dark pigmented skin, some blue or purple hues. The Plan of Care included cleansing the wound with soap and water, pat dry, scrub the wound bed (mechanically debrided.) and OTA (Open to Air.) At the time of the WC assessment, the resident's foot was appropriately placed in a Prevalon (ulcer protective boot) the wound measured total perimeter of area 5.3 cm. length 1.5 cm x 1.6 cm. The ulcer was consistent with pressure as the primary etiology. Staff were to keep the foot in the Prevalon boot at all times, if resident needed a break, ensure his heel was fully offloaded with use of a wedge or pillows. A review of the Nursing Notes revealed the following: a. On 4/21/25 at 3:42 PM, Resident #15 was an assist of 1 person with the EZ stand for transfers, he had poor nutritional intake, with no current skin concerns. He preferred to sleep in the recliner as he did at home. A bed had been placed in the room and the recliner would be deep cleaned. b. On 4/24/25 at 10:43 AM, the resident was incontinent of urine and soaked through recliner. Housekeeping removed the recliner for cleaning. The resident was no longer able to bear weight, using Hoyer for transfers. The following 30-day lookback report was found in the Point of Care (POC) Response History, in the electronic chart and printed on 5/20/25 at 3:13 PM: a. Does the resident have any skin injuries? From 4/21/25 through 5/20/25, the twice a day documentation showed no skin issues. On 5/21/25 at 3:09 PM, Staff A, Registered Nurse (RN) said that resident #15 had a recliner in his room that he would sleep in and they removed it out of his room because it was soiled. She said that he wouldn't come out for meals, and she didn't know if he refused showers, and didn't know about what he wore on his feet before the discovery of the pressure ulcer. On 5/22/25 at 7:08 AM, Resident #15 was in bed on his back and was wearing gripper socks. His heels were resting on the bed. The Prevalon boot was on the floor along the side of the bed. At 9:34 AM, he had a blanket over his face, breakfast food was sitting on the bedside tray table. His feet were resting on the bed, Prevalon boot was still on the floor. At 10:46 AM, the resident was still in bed on his back, the boot was on the floor and his heels rested on the bed without a pillow of wedge under his legs to float the heels. On 5/22/25 at 11:15 AM, Staff B, Corporate Nurse Consultant, said that she would expect that the boot would be in place on his right heel unless there was some explanation. She later said that staff had reported that he refused the boot earlier that morning. A facility policy titled: Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, showed that the nursing staff and practitioner would assess and document an individuals' significant risk factors for developing pressure ulcers. The physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleaning and debridement approaches, dressings and application of topical agents. The policy lacked reference to staff's responsibility to follow through with orders and/or interventions.

Based on observation, staff interviews and record review the facility failed to complete accurate resident records for 3 of 13 residents reviewed (Residents #3, #24 and #30.) Documentation on dialysis residents #30 and #24 had been completed up to 12 days after the date of the assessment. Staff entered a late nursing note for Resident #3 that indicated catheter care had been completed the previous evening when it had not been done. The facility reported a census of 33 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive deficits). She was totally dependent on staff for dressing, hygiene, nutrition and transfers. She had an indwelling urinary catheter and a feeding tube, abdominal always incontinent of bowel. The Care Plan for Resident #3, last updated on 5/14/25, showed that she had a Foley catheter for neurogenic bladder. Staff were to provide catheter care every shift. The resident had a terminal prognosis related to diagnosis of progressive multifocal leukoencephalopathay (damage to the brain white matter.) Resident #3 had a tube feeding related to dysphagia disease. She was at risk for perineal infection related to peg tube site. Staff were to use Enhanced Barrier Precautions (EBP) when performing high contact area activities. On 5/20/25 at 12:09 PM, Resident #3 was in bed on her back. There was a urinary catheter hanging on the bed frame, light color urine. The resident made eye contact but was unable to respond to questions. A Nursing Note dated 5/10/25 at 2:20 PM showed that the resident was started on an antibiotic for a urinary tract infection. An order Audit Report printed on 5/22/25 at 7:51 AM, showed an order Acetic Acid irrigation solution 0.25% use 60 ml. via irrigation every night shift for prevent blockage and Urinary Tract Infection (UTI) irrigate Foley catheter. A review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) showed that on the evening of 5/19/25 the catheter flush had not been completed and referred to the nursing notes. The following was found in the Nursing Notes: a. On 5/19/25 at 10:44 PM, solution not available. For the flush. b. On 5/19/25 at 11:07 PM (entered on 5/20/25 at 10:10 AM) the flush was completed with Normal Saline and the primary care physician was aware. On 5/21/25 at 5:15 PM, the Director of Nursing (DON) said that the overnight nurse had called and told them that there was no acetic acid available for the catheter flush, so she was told to call the doctor and get an order for Normal Saline (NS.) The DON said that she talked to the Nurse Practitioner (NP) and verified that the nurse did get an order but she did not know for sure if the nurse completed the flush. She said she assumed and that was why she documented the next day that it had been completed. 2. According to the MDS dated [DATE], Resident #24 was admitted to the facility on [DATE]. He had a BIMS score of 15 (intact cognitive ability). She was totally dependant on staff for dressing, hygiene and toilet transfers. The resident had dialysis treatments and diagnoses that included; end stage renal disease, morbid obesity, chronic pain and liver disease. The Care Plan updated on 4/29/25, showed that Resident #24 had chronic kidney disease that required dialysis three days a week. Staff were to monitor the shunt for patency, document peripheral edema, document and report symptoms of infection, or renal insufficiency such as changes in lung and heart sounds. A Dialysis Evaluation (DE) dated 5/4/25 at 12:04 PM, (entered on 5/16/25 at 12:05 PM) showed in Section 3, that the vital signs (vs) had been obtained on 5/4/25 at 8:00 AM and a reference made to see vs A review of the Weights and Vitals (W&V) tab lacked a Temperature (T) Blood Pressure (BP) or Heart Rate (HR) on 5/4/25. The DE dated 5/12/25, (entered on 5/16/25 at 12:14 PM) showed that the resident returned to the facility on [DATE] at 5:00 PM and had no edema, shortness of breath or nausea and the lung sounds were clear. The document showed that the date and time the vitals had been obtained was 5/12/25 at 4:00 PM, referenced to see vs. The W&V showed just one set of vitals taken on 5/12/25, and that was at 9:25 AM. 3. According to the MDS dated [DATE], Resident #30 was admitted to the facility on [DATE] and had a BIMS score of 15 (intact cognitive ability) He was independent with hygiene, dressing, toileting and transfers. He received dialysis treatments and had diagnoses that included: anemia, renal insufficiency, diabetes mellitus, end stage renal disease, The Care Plan for Resident #30 updated on 4/22/25, showed that he was receiving hemo-dialysis three days a week, staff were to monitor for shunt patency, edema and signs of infection. The DE form dated 5/4/25 at 3:12 PM, (entered on 5/15/25 at 9:33 PM) showed that he had no edema or shortness of breath, clear lung sounds and the fistula/graft site looked normal. The date and time of vitals obtained was 5/4/25 at 9:00 AM, referenced to see vs. The W&V lacked a BP, HR or T for that day. The DE form dated 5/12/25 at 5:18 PM (entered on 5/16/25 at 12:20 PM) indicated that the resident returned to the facility at 4:00 PM, with no fluid overload, no shortness of breath and clear lung sounds. The date and time vitals were obtained indicated it was 5/12/25 at 4:00 PM and referenced to see vs. The W&V showed that the T had been taken just one time that day at 8:30 AM, and HR was taken at 9:04 AM. On 5/22/25 at 11:15 AM, Staff B, Corporate Nurse Consultant, said that she would expect to see that documentation of assessments and vitals completed per policy Facility Policy titled: Charting and Documentation July of 2017, showed that documentation in the medical record would be objective, complete and accurate. Documentation of procedures and treatment would include care specific details including date and time procedure treatment was provided.

Based on observations, Electronic Heath Record (EHR) review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when providing care to a resident with an enteral feeding tube and stage 2 wound with one that had a care plan for Enhanced Barrier Precautions (EBP) for 2 of 3 reviewed (Resident #3 and #6). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS also indicated Resident #6 had one or more unhealed pressure ulcers. The MDS had described the pressure ulcer as a stage 2. Review of document titled, Resident Matrix revealed Resident #6 had a stage 2 pressure ulcer that was not present on admission. On 5/21/25 at 9:06 AM an observation of Resident #6's transfer onto the shower chair by Staff N, Certified Nursing Assistant (CNA) and Staff O, Observation revealed Staff N and Staff O completed hand hygiene, applied gloves, did not apply gowns, applied lift cloth to sit to stand mechanical lift, Staff N ran the mechanical lift controls, Staff O removed Resident #6's brief, Staff N lowered Resident #6 into the shower chair, Staff O removed gloves, Staff O completed hand hygiene, Staff N removed gloves and completed hand hygiene, both staff applied gloves, Staff N removed the lift sling, Staff N positioned Resident #6 in the shower, Staff N removed socks and night gown, and Staff N started the shower. On 5/21/25 at 9:16 AM Staff N stated because Resident #6 had a wound on her buttocks because of the wound she now got a shower. Staff N stated Resident #6 usually got a whirlpool. On 5/21/25 at 9:55 AM an observation of Staff C, Registered Nurse (RN) / Assistant Director of Nursing (ADON) and Staff O, CNA of dressing change to pressure area on coccyx. Observation revealed both staff completed hand hygiene, applied gloves, no gown applied, area cleansed with normal saline by Staff C, Staff C removed gloves, Staff C completed hand hygiene, Staff C mixed collagen with normal saline, Staff C mixed the collagen with cotton tip applicator, Staff C completed hand hygiene, Staff C applied gloves, Staff C applied skin prep around the wound, Staff C removed gloves, Staff C completed hand hygiene, Staff C applied gloves, Staff C applied collagen to the wound bed, Staff C applied the dressing, Staff C dated the dressing, gloves removed by both and hand hygiene completed by both staff. On 5/21/25 at 10:10 AM Staff C, RN / ADON acknowledged he was familiar with EBP. Staff C stated a gown would be worn with any resident with an MDRO, catheters, enteral feeding tube, or dialysis resident. Staff C stated when care was completed a gown and gloves should be worn. Staff C stated he believed if the wound was open and draining a gown should be worn. Staff C stated it was discussed with the nurse practitioner and it was determined that EBP was not required for Resident #6's wound. Staff C stated EBP was not required for wound care on Resident #6. Staff C acknowledged that Resident #6 had a pressure area that was covered with a border gauze. On 5/21/25 at 10:17 AM the DON stated EBP should be required with anyone with a catheter, anyone with a draining wound, and a resident with any external devices. The DON stated if the wound had drainage it would require EBP. The DON acknowledged that Resident #6 was on EBP when she had ESBL. The DON stated EBP was removed when Resident #6 no longer had ESBL. The DON stated Resident #6 did not require EBP at this time. 41785 2. According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive deficits.) She was totally dependent on staff for dressing, hygiene, nutrition and transfers. She had an indwelling urinary catheter and a feeding tube, abdominal always incontinent of bowel. The Care Plan for Resident #3, last updated on 5/14/25, showed that she had a Foley catheter for neurogenic bladder. Staff were to provide catheter care every shift. The resident had a terminal prognosis related to diagnosis of progressive multifocal leukoencephalopathay (damage to the brain white matter). Resident #3 had a tube feeding related to dysphagia disease. She was at risk for perineal infection related to peg tube site. Staff were to use Enhanced Barrier Precautions (EBP) when performing high contact area activities. On 5/21/25 at 7:10 AM, Staff A, Registered Nurse (RN) disconnected the continuous feeding from the pump for Resident #3. She clamped off the tube, then flushed the tubing with water. Staff A failed to wear gloves or a gown throughout the procedure. She talked to the resident, checked around the peg site, adjusted the gauze under the tubing, then exchanged a high five and fist bump with the resident. On 5/21/25 at 10:17 AM, the Director of Nursing (DON) stated the EBP should be required with anyone with a catheter, anyone with a draining wound, or external devices. According to an undated facility policy titled: Enhanced Barrier Precautions; the facility would implement EBP for the prevention of transmission of multidrug-resistant organisms. The facility would have an order for EBP initiated for residents with any of the following: wounds (chronic wounds such as pressure ulcers) and/or indwelling medical devices (feeding tubes) even if the resident was not known to be infected or colonized with a MDRO (Multidrug-resistant organism).

Based on observations, record review, resident, staff and family interview the facility failed to ensure 1 of 2 residents (Resident #2) had orders to change his catheter. The facility reported a census of 34 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 9/25/2024, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested he had no cognitive impairment. An admitted [DATE] was documented on the MDS. The MDS documented Resident #2 did not refuse care during the review period. The MDS documented he had an indwelling catheter. The following diagnoses were documented for Resident #2: renal failure, malnutrition, depression, and hypersomnia. According to the quarterly MDS assessment tool with a reference date of 12/25/2024, Resident #2 had a BIMS score of 15. A BIMS score of 15 suggested he had no cognitive impairment. The MDS documented Resident #2 did not refuse care during the review period. Resident #2 had an indwelling catheter. The following diagnoses were documented for Resident #2: renal failure, malnutrition, depression, and hypersomnia. The Care Plan focus area with an initiated date of 12/5/2024 documented he had an indwelling catheter. Staff were directed to: a) monitor for signs and symptoms of discomfort on urination and frequency; b) monitor, document, and report as needed any signs or symptoms or urinary tract infection UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; c) observe me for acute behavioral changes that may indicate UTI; d) complete ongoing assessment of color, clarity and character of my urine; e) refer him to a urologist for evaluation of incontinence. The following Progress Notes were noted: a) On 9/24/2024 at 12:00 AM an encounter note documented by Advanced Registered Nurse Practitioner (ARNP) noted good urine output via catheter; b) On 12/17/2024 at 2:00 AM an encounter note documented by ARNP noted resident returned from the hospital on 12/13/2024. Resident was treated for acute encephalopathy and started on intravenous (IV) antibiotics. Reviewed hospital notes with the resident. Resident #2 stated that hospital believed the sepsis was due to his catheter not being changed. Reviewed urine sample results which showed contaminant. Noted that resident's catheter change placement was delayed, but not over 6 months as stated in records. His catheter was delayed by a few days. Resident has orders for every 30 days catheter change. He stated he is feeling good today. Review of Resident #2 Medication Administration Records (MARs) and Treatment Administration Records (TARs) from 9/18/2024 through 2/12/2025 revealed the records did not contain orders to change his catheter every 30 days. Review of Resident #2's order history since admission to the facility on [DATE] revealed a standard order that was dated 12/13/2024 to change his catheter monthly. There were no other catheter orders that had been completed, discontinued or struck out in her electronic health record (EHR). On 2/7/2025 at 10:59 AM Resident #2's Power of Attorney (POA) stated his catheter was not changed since he was admitted to the facility until he went to the hospital in December. The POA was not sure what happened or why it was not changed. He added the facility never denied they did not change Resident #2's catheter. On 2/11/2025 at 10:25 AM Resident #2 sat in the dining room filling out his menu for the week. His catheter drainage bag was connected to a hook under the seat of his wheelchair. The drainage bag had a dignity bag present. On 2/11/2025 at 10:25 AM Resident #2 stated he is fairly independent when it comes to taking care of his catheter. He will clean the site, empty the drainage bag and report the output to the nursing staff. When asked if the facility changes the catheter itself, he indicated they have only changed it once since he was admitted to the facility. On 2/11/2025 at 11:59 AM the Nurse Consultant was not able to locate the orders for Resident #2's catheter to be changed. She indicated he was admitted within 24 hours of going to another facility because the admission process was horrible. There were no assessments done and his orders were not put in so when the facility admitted him they had to use the orders from his recent hospitalization or from his referral History and Physical (H&P). She did verify Resident #2 had a Foley catheter. When asked why the ARNP made a note in December 2024 about the catheter being changed a few days late in the readmission note she indicated she would go find out. At 12:28 PM the Nurse Consultant was unable to find out when it was changed prior to his December hospitalization . On 2/11/2025 at 1:05 PM the Administration indicated the facility did not have a policy about the frequency of a catheter and drainage bag needing to be changed. On 2/12/2025 at 10:13 AM Staff A Licensed Practical Nurse (LPN) stated Resident #2 does all of his own cares throughout the day and the facility changes his catheter when it's ordered to be done. Staff A added he has never had to change it but it's to be changed every 60 days. The staff will change the drainage bag when it needs to be changed. When an order is put in for a certain day to be completed, the staff member that signs in on that day, a pop up will appear that a task needs to be completed. These things never popped up on the days he worked with Resident #2. On 2/12/2025 at 10:27 AM Staff B LPN stated Resident #2 likes to do his own catheter cares because he is independent. Staff B stated she does not change his catheter because it's usually done during the day shift and she works overnights. When asked how often catheters are to be changed, she indicated every month. The orders to do so are on the MAR, when one signs in it pops up as needing to be done that day. Resident #2 will cleanse the catheter site and empty the drainage bag himself. He will then report to nursing staff how much output he has had. She will assist him with changing the drainage bag as needed then she will put a progress note in about doing that. On 2/12/2025 at 12:01 PM the Director of Nursing (DON) stated Resident #2 does his own catheter cares; he will empty the drainage bag, cleans the catheter site and the nursing staff will change it. When asked how often that catheter is to be changed she stated it used to be monthly, but the corporation went to changing the catheters every 60 days, unless the physician orders it more often. The DON was informed the ARNP documented the catheter to be changed every 30 days in a readmission note. She indicated the policy did not change until the beginning of the year and it has not been brought through their Quality Assurance and Performance Improvement (QAPI) meeting yet. She was also informed Resident #2 had no catheter orders on his MAR and/or TARs since his admission in September and there were no progress notes about the catheter being changed. She indicated it needs to be on the TAR so staff know when it needs to be completed. There was an order for it to be changed every 30 days from December but it is not on the TARs since the order was written and there were no progress notes indicating this was completed. She stated unfortunately if it was not documented then it was not done. On 2/12/2025 at 1:54 PM Staff C Registered Nurse (RN) stated Resident #2 will drain his own catheter then let the staff know how much he drained. He will also do his own site cares. Staff C stated he changed the resident's catheter on 1/9/2025 because the resident asked him to. He did a late entry in the record because there was nowhere to document it. When asked when the resident's catheter is to be changed he stated supposed to be done on the night shift because they have more time, every 30 days unless it's a silver tipped catheter then they will do different parameters. He indicated Resident #2 does not have a silver tipped catheter.

Based on interview with staff and residents, record review, and policy review the facility failed to treat all residents with dignity and respect for 4 of 18 reviewed. Staff reported that Staff G, Licensed Practical Nurse (LPN) made disrespectful remarks to Residents #12, #25, and #29. Resident #81 reported that Staff J, Registered Nurse (RN) was disrespectful to her during cares. The facility reported a census of 26 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident did not reject cares, and was totally dependent on staff for toileting hygiene and toilet transfers. Resident #12 had an indwelling urinary catheter and was frequently incontinent of bowel. His diagnoses included; renal insufficiency, diabetes mellitus, and multiple sclerosis (MS). The Care Plan updated on [DATE] showed that Resident #12 was unable to ambulate independently, required substantial assistance with the help of 2 staff for toileting. He displayed socially inappropriate behavior and comments and staff were directed to speak to him in a calm voice and not to argue with the resident. According to an incident report dated [DATE], Resident #182 reported that she overheard a Certified Nurse Aide (CNA) say to Staff G, LPN, that a resident had been incontinent of bowel and Staff G responded to the aide that she should let him sit in it, to teach him a lesson. On [DATE] at 6:53 AM, Staff H, CNA said that she needed help to change Resident #12 on [DATE], because he was a large man and incontinent of bowel and required two people to change him. She said that Staff G abruptly said well, he can just sit in it for a while. Staff H said that she was somewhat afraid of Staff G because she was loud and would often get upset. On [DATE] at 11:20 AM, Staff E said that she had many incidences where Staff G was disrespectful to residents. She heard the nurse tell Resident #12 that the staff didn't want to care for him because he was a dick. On [DATE] at 12:20 PM, Staff D said that she heard Staff G call Resident #12 a dick. [DATE] at 9:43 AM, Staff K, CNA said that she heard Staff H mention that Resident #12 had been incontinent and she needed help to clean him up. Staff G responded to her that she should just let him sit in it, and maybe he would learn a lesson. On [DATE] at 11:54 AM, Resident #182 said that she was sitting in the dining room one morning and heard a CNA say that there was a resident that had a bowel movement in his pants on purpose and needed to be cleaned. Staff G then responded let him sit in it then he will learn. She said that it took them about ,d+[DATE] minutes before they went and attended to the resident. On [DATE] at 1:20 PM, Resident #29 said that sometimes the nurses would say I have a problem and they continue to repeat it over and over. 2) According to the MDS dated [DATE], Resident #25 had a BIMS score of 12 (moderate cognitive deficit). He had diagnoses that included: hypertension, pneumonia, vial hepatitis, anxiety disorder, and respiratory failure. The Care Plan updated on [DATE], showed that Resident #25 had diabetes and staff were to monitor and report increase in heart rate. According to the nursing note dated [DATE] at 8:51 AM, the ambulance was in route to take Resident #25 to the hospital and on [DATE] at 1:03 PM, he returned from the hospital with an antibiotic order for Bronchitis. On [DATE] at 11:20 AM, Staff E said that Resident #25 was having chest pain one morning and he wanted to be sent to the hospital. She said that Staff G loudly stated that the resident was only seeking medications. On [DATE] at 7:37 AM, Staff I said that she was working the morning that Resident #25 reported that he was having chest pains, so she went and told the nurse on duty; Staff G. The nurse then responded by saying loudly; I'll send him to the hospital, but he's not really having chest pains, he's attention seeking On [DATE] at 9:43 AM, Staff K said that she was working when Resident #25 reported that he was having chest pain, and was taken to the hospital. She said that Staff G loudly stated to the Emergency Medical Technicians that the resident had Hepatitis C and was just seeking medications. 3) According to the MDS dated [DATE], Resident #29 had a BIMS score of 15 (intact cognitive ability). She required a wheel chair for mobility and substantial assistance with sit to stand and toilet transferring. Her diagnoses included coronary artery disease, renal insufficiency, renal failure, diabetes mellitus, anxiety, and depression. The Care Plan revised on [DATE], showed that Resident #25 had a pacemaker, and an impaired thought process. She was at risk for infection related to dialysis, was on antianxiety and antidepressant medications and often felt down. Staff were to allow the resident to verbalize feelings and listen in a non-judgmental manner. She had chronic pain related to end stage renal disease (ESRD) with hemodialysis every Monday, Wednesday, and Friday. Staff were to encourage her to go to her dialysis appointments. On [DATE] at 11:20 AM, Staff E said that there was an incident one day when Resident #25 had a lot of pain and she refused to go to dialysis. Staff G then loudly said that the resident was attention seeking and she asked the resident if she wanted to end up like another resident that had died . The resident was upset and depressed. On [DATE] at 9:43 AM, Staff K said she was present when Staff G told Resident #25 that she was attention seeking and the resident was upset by these comments. On [DATE] at 7:48 AM, the Director of Nursing (DON) said that she spoke with Staff G about this incident with Resident #25 and that the nurse was often very loud and demanding with residents and staff. 4) According to the MDS dated [DATE], Resident #81 had a BIMS score of 15 (intact cognitive ability) The resident required partial assistance with toileting hygiene and dressing. Her diagnoses included peripheral vascular disease, paraplegia, depression, pressure ulcers stage 2 and stage 3. She had frequent pain. The Care Plan revised on [DATE] showed that Resident #81 had pressure sores to both of her legs and required monitoring and repositioning. She was unable to ambulate on her own due to paraplegia and she was on an antibiotic medication due to infections. On [DATE] at 12:18 PM Resident #81 said that she had filed a grievance related to Registered Nurse (RN) Staff J, who had treated her very rudely. She said that he also treated her friend, Resident #29 very rudely called had her worthless. She said that the nurse would embarrass her in front of other resident and had ordered her to go to her room. He also blamed her for letting her wounds get so bad and not taking care of herself. On [DATE] at 2:53 PM, a family member for Resident #81 said that she witnessed Staff J being rude and ordering her around. She had said to him; you don't have to be rude but he just rolled his eyes. On [DATE] at 6:51 AM Staff F CNA, said that she was working when Resident #81 reported to her that Staff J was rude to her and didn't do her wound care properly. The resident told her that she filed a grievance. On [DATE] at 7:48 AM, the DON explained the grievance process and said that when a staff member or resident came to her with a concern, she would address it to the appropriate department. She acknowledged that Staff G had a rough approach and that many of the residents had mental health issues, and tended to be sensitive to a loud approach. According to the facility policy titled: Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated [DATE], Residents have the right to be free from abuse, neglect, misappropriation of resident property exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental sexual or physical abuse, and physical or chemical restraints. The facility would establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on observations, staff interviews, and facility policy review the facility failed to ensure sanitary conditions where staff prepared food, and failed to perform hand hygiene during meal service. The facility identified a census of 26 residents. Findings included: The initial kitchen walk-through on 07/01/24 10:10 AM revealed the following: a. The stove top showed a thick layer of grease with food splatter and a variety of food debris. b. A clean dish cart contained a variety of scattered food debris. c. The floor contained an accumulation of food debris and a variety of dried liquid. d. All refrigerator and freezer systems with dried liquid and debris on the bottom of the unit. e. Ice build-up in freezers and milk cooler. f. Microwave splattered with food and dried liquid inside and out. g. Toaster covered in grime. h. Dead gnats found along window sills. During the kitchen walk-through the Dietary Manager (DM) reported that she expected the refrigeration and freezer units, carts, equipment, and floor to be clean and free of food, dried liquid, and debris. The DM stated, there is a problem with someone that worked this past weekend. I'll follow up. Observation of lunch service on 7/2/24 at 12:40 PM showed the following: a. The DM entered the dining room, served a plate of food to a resident, filled the resident's cup with ice, then returned to the kitchen without performing hand hygiene. b. The DM removed a slice of bread from the bread bag, placed the slice directly on top of the bread bag, then placed a piece of cheese on the slice in preparation of making a grilled cheese sandwich. c. The DM placed a spatula directly on the counter then used the spatula to make a grilled cheese sandwich. d. Staff B, [NAME] failed to complete hand hygiene as she entered and exited the kitchen while serving lunch to the residents. During this time Staff B also accessed the refrigerator several times to retrieve drinks and food items. After Meal service the Dietician reported she observed that staff failed to use hand hygiene appropriately during meal service, and expected staff to place food and utensils on sanitized surfaces. The Dietician also reported that carts, refrigeration and freezer units, floors, and equipment should be clean and free of grime and debris. The Sanitation policy last revised October 2008 identified: a. The food service area shall be maintained in a clean and sanitary manner. b. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. c. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. d. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical.

Based on observations, record review, staff interviews, and policy reviews the facility failed to change and label oxygen tubing for 1 of 1 residents reviewed (Resident #15). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnoses of heart failure, Chronic obstructive pulmonary disease (COPD), and respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The Physician Order dated 5/21/24 for Resident #15 showed oxygen 1-4 liters per nasal cannula to keep oxygen saturation above 90%. The Physician Order dated 4/7/24 for Resident #15 showed an order to change oxygen tubing every Sunday night and as needed. The order also directed staff to ensure to date new tubing. The Care Plan on 6/12/24 showed Resident #15 received oxygen 1-4 liters per nasal cannula to keep oxygen saturation above 90%. The Care Plan failed to identify when to change oxygen tubing. Observation on 7/1/24 at 10:56 AM revealed Resident #15's oxygen concentrator tubing showed the tubing last changed and labeled on 6/12/24. In an interview on 7/1/24 at 10:57 AM, Resident #15 could not recall when the oxygen tubing change last occurred. Observation on 7/1/24 at 3:07 PM showed Resident #15's oxygen tubing changed, and newly labeled with a date of 7/2/24. In an interview on 7/1/24 at 3:08 PM, the Activity Coordinator reported she changed and labeled the oxygen tubing that day. When asked if replacing oxygen tubing was normally her responsibility, the Activity Coordinator stated, no. The Departmental (Respiratory Therapy) - Prevention of Infection policy last revised November 2011 identified oxygen tubing is changed weekly and as needed. In an interview on 7/3/23 at 9:12 AM, the Director of Nursing (DON), reported she expected oxygen tubing for all residents should be changed every Sunday.

Based on observations, record review, staff interviews and policy reviews, the facility failed to accurately document the changing of oxygen tubing for 1 of 1 residents reviewed (Resident #15). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of heart failure, Chronic obstructive pulmonary disease (COPD), and respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The Physician Order dated 5/21/24 for Resident #15 showed oxygen 1-4 liters per nasal cannula to keep oxygen saturation above 90%. The Physician Order dated 4/7/24 for Resident #15 showed an order to change oxygen tubing every Sunday night and as needed. The order also directed staff to ensure to date new tubing. The Care Plan on 6/12/24 showed Resident #15 received oxygen 1-4 liters per nasal cannula to keep oxygen saturation above 90%. The Care Plan failed to identify when to change oxygen tubing. Observation on 7/1/24 at 10:56 AM revealed Resident #15's oxygen concentrator tubing showed the tubing last changed and labeled on 6/12/24. Review of the June 2024 Medication Administration Record for Resident #15 showed staff inaccurately documented oxygen tubing as changed on the following dates: a. 6/16/24 b. 6/23/24 c. 6/30/24 The Departmental (Respiratory Therapy) - Prevention of Infection policy last revised November 2011 identified oxygen tubing is changed weekly and as needed. The policy also identified the following information should be recorded in the resident's medical record: a. The date and time the respiratory therapy was performed. b. The type of respiratory therapy performed. c. The name and title of the individual(s) who performed the respiratory therapy. In an interview on 7/3/23 at 9:12 AM, the Director of Nursing (DON), reported she expected staff to accurately document when an oxygen tubing change occurred.

Based on clinical record review, observation, staff interview, and infection control policy the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during catheter care for 1 of 1 residents reviewed for infection control (Resident #12). The facility reported a census of 26 residents. Findings include: Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of renal insufficiency, neurogenic bladder, and multiple sclerosis. The MDS further revealed Resident #12 utilized an indwelling catheter. Review of Resident #12's Physicians Orders revealed the following information: a. Enhanced barrier precautions related to suprapubic catheter and history of MRSA. Every shift. Observation 7/2/24 at 9:14 AM Staff A Certified Nursing Assistant (CNA) completed hand hygiene and donned gloves. Staff A then placed a barrier under the urinary drainage collection container. Catheter drainage port was cleansed with an alcohol swab and drained. After draining the urinary drainage bag Staff A then cleansed the port again with a new alcohol swab and returned the port. Gloves were then doffed and hand hygiene was completed. During the procedure Staff D failed to wear a gown as required per Enhanced Barrier Precautions (EBP). In an interview 7/02/24 at 9:19 AM with Staff A revealed she should have worn a gown related to enhanced barrier precautions. In an interview 7/02/24 at 9:21 AM with the Director of Nursing (DON) revealed her expectation would be for gowns and proper personal protective equipment (PPE) to be worn while draining catheter bags. Review of the facility provided policy titled: Enhanced Barrier Precautions dated 3/28/24 documented: a. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. b. High-contact resident care activities include: Device care or use: urinary catheters. Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 7/2/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of Multidrug-resistant Organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

Based on resident and staff interviews, and policy review, the facility failed to have ready and reasonable access to personal funds upon request for 1 of 18 residents reviewed (Resident #8). The facility reported a census of 26 residents. Findings Included: In an interview on 7/1/24 at 12:51 PM, Resident #8 stated, We rely on the business office person if we want money. We can only get money when she is here. In an interview on 7/2/24 at 3:10 PM, Staff C, Registered Nurse (RN) reported no personal funds are available to residents after normal business hours. In an interview on 7/2/24 at 3:13 PM, the Business Office Manager (BOM) stated, I ask residents if they need money before I leave. When asked if personal funds are available to residents after business hours, without giving her prior notice, the BOM replied, no. When asked about a policy related to personal funds, the BOM reported the facility lacked a policy related to personal funds. In an interview on 7/2/24 at 3:16 PM, the Director of Nursing (DON) reported that about $20 is kept at the nurse's station if residents should request personal funds. When informed the BOM reported funds are not available after hours, the DON reported, I was mistaken then. When asked if the DON was aware of resident's rights to have access to personal funds, the DON stated, Yes we will have to set something up.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide assessment and intervention timely for the necessary care and services after a resident fall for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15 of 15; indicating no cognitive impairment. It also listed diagnoses of Cerebrovascular accident (stroke), Non-Alzheimer's dementia, anxiety disorder, Chronic Obstructive Pulmonary Disease (COPD), and neoplasm of bronchus and lung. It also indicated the resident required moderate to maximal assistance with all care areas except bathing self, eating, and oral hygiene. The Care Plan dated 11/22/23 revealed the resident had chronic pain related to trigeminal neuralgia and directed staff to monitor, document, and report any complaints of pain or signs or symptoms of non-verbal pain to the nurse. It also indicated on 9/05/23 Resident #1 was a fall risk related to unsteady gait. It directed staff to monitor, document and report as needed signs and symptoms of pain to the physician. Review of Incident Reports for the resident revealed she had falls on 12/2/23 at 11:00 AM and 12/2/23 at 4:35 PM. The Progress Notes documented the following: On 12/02/23 at 12:00 PM Resident #1 had an unwitnessed fall and was found sitting on the floor next to her recliner at approximately 10:45 AM. Provider notified via phone and fax. No new orders at this time. On 12/2/23 at 5:15 PM resident's family made aware of resident fall at 4:15 PM. Neuro checks within normal limits and passive range of motion within normal limits. Resident denied complaints. On 12/04/23 at 10:11 AM fax received regarding fall on 12/2/23 with no new orders. The Electronic Health Record (EHR) lacked results of post-fall neurological assessments subsequent to the resident's falls on 12/02/23. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2023 revealed the resident received Gabapentin 300 mg three times per day by mouth for fibromyalgia (chronic disorder causing pain and tenderness throughout the body) and Tylenol Extra-Strength 1000 mg three times per day by mouth for trigeminal neuralgia (chronic pain disorder involving sudden, severe facial pain). It also directed staff to check the resident's pain level every shift, but no numeric pain scale rating was documented. A pain evaluation completed on 12/04/23 indicated the resident denied any pain or hurting at any time within the previous five (5) days. No other pain evaluation was completed after 12/04/24 while the resident remained in the facility. The EHR's Pain Level Summary included the following pain documentation: 1) 12/14/2023 14:00 5 Numerical 2) 12/14/2023 08:55 8 Numerical 3) 12/13/2023 08:40 3 Numerical 4) 12/12/2023 07:45 3 Numerical 5) 12/11/2023 09:29 3 Numerical 6) 12/9/2023 08:11 3 Numerical 7) 12/8/2023 06:10 0 Numerical 8) 12/2/2023 16:35 0 Numerical 9) 12/2/2023 11:46 0 Numerical The resident's EHR lacked any documented PM shift pain scale ratings. The Progress Notes lacked any documentation the medical provider was contacted regarding the resident's newly reported pain scale of 3 on 12/09/23 at 8:11 AM. The Progress Notes for the resident documented the following: On 12/05/23 at 1:34 AM the resident had increased weakness and required two (2) staff members with transfers. On 12/5/23 at 6:34 AM resident sent out to the hospital for labored respirations and a change in respiratory status. On 12/07/23 at 1:50 PM, the Director of Nursing (DON) documented a readmit evaluation that included pain but no pain rating or location included. On 1/10/24 at 9:55 AM, Staff D, Certified Nursing Assistant (CNA) stated Resident #1 historically required a gait belt for sit-to-stand but only for stability and not for substantial assistance. She also stated Resident #1 walked with a [NAME] due to Genu valgum (knock-kneed = knees touching and not ankles). Staff D stated she worked with Resident #1 on 12/03/23 and the resident's presentation (ability to perform previous functions) hadn't changed and were consistent with her ability prior to her fall. Staff D stated on 12/08/23 the resident could physically walk but didn't want to because of complaints of hip pain but couldn't remember which hip. She stated she told the nurse on duty about the resident's pain. She confirmed on 1/16/24 at 2:10 PM she notified Staff E, Licensed Practical Nurse (LPN) about the resident's pain. On 1/10/24 at 11:43 AM, Staff F, Certified Nursing Assistant (CNA) stated she didn't remember being directly assigned for Resident #1's cares but other staff asked her to assist with the resident. Staff F stated that the resident always required at least 1-person assistance but most often 2-person assistance after she transferred out of isolation. Staff F attested the resident never complained of pain to her with any care she assisted nor did she ever provide a shower/bath for the resident. On 1/10/24 at 12:15 PM, Staff F, Licensed Practical Nurse (LPN) stated the resident never complained of pain until the day the x-ray was done and was non-weight bearing (NWB) on the day of the x-ray. The Progress Notes for the resident documented the following: On 12/12/23 at 9:16 AM message left at clinic for provider regarding drastic decline in activities of daily living (ADLS) from both falls and Covid Isolation. Requesting any recommendations. Resident also complaining of left thigh discomfort and difficulty bearing weight for transfers. Assessment completed. No redness, edema, discoloration or displacement noted at time of assessment. Resident is noted to be extremely weak due to Covid. Awaiting call back. On 12/12/23 at 4:07 PM received fax back from provider regarding request for recommendations. Provider ordered X-RAY of the knee, left hip and left knee due to pain and discomfort with decreased mobility. At 9:21 PM, a linked progress note indicated - Message left back with clinic requesting number of views to complete order for mobile X-RAY. Awaiting return call. On 12/13/23 at 1:14 AM resident admitted to Hospice with primary diagnosis of COPD. On 12/13/23 at 2:12 PM call placed to clinic regarding number of views and spoke with staff. Staff will ask Primary Care Physician (PCP) and call facility back with verbal order to enter for Biotech X-RAY. Awaiting return call. On 12/13/23 at 2:42 PM received call back from clinic staff. Verbal order received by medical provider for 2-view X-RAY to Left hip and left knee. Hospice notified and stated okay to order X-RAY due to discomfort/pain. On 12/13/23 at 4:10 PM call placed to care coordinator with Biotech. Left hip and Left knee 2-view X-RAY ordered. Tech will be here tomorrow to complete. Daughter notified. On 12/14/23 at 7:31 AM resident continues to show s/s (signs & symptoms) of LLE (left lower extremity) pain-cannot pinpoint where exactly pain is located whether it is the hip, knee, etc. Called hospice on call to inform of continued pain. Biotech x-ray will be here on this date to perform x-ray of affected side. POA (Power of Attorney) aware. Hospice called back at 7:33 AM stating that once results come back, depending on findings, hospice can follow up on ordering something stronger for pain. On 12/14/23 at 8:58 AM SW initial visit to be completed. Facility charge nurse Staff F reported that patient is getting an X-ray for her left leg pain and is in a lot of pain. Facility states she has gone from a one assist to a two assist and they will look at stronger pain medication once X-ray is completed. She normally only eats about 25% and this morning didn't eat anything. No other concerns. On 12/14/23 at 1:15 PM X-ray tech arrived to facility at 1140 to complete residents LLE x-ray. Tech informed this nurse at 1210 that images obtain showed possible/likely left hip fracture. Tech requested stat read. Called POA at 1210 immediately after talking with tech. Informed POA of possible left hip fracture. POA upset about situation and venting/weighing options of having resident go through with surgery or if resident would make it through surgery with current diagnoses. Informed POA that this nurse would reach out to hospice and PCP. POA requested call back from PCP. Called hospice at 1213-operator with hospice informed this nurse that hospice nurse, would be up later on this date-no further orders/instructions from hospice at this time. Called PCP at 1217, sent to voicemail x 2. Called back to talk to staff in ER. DON made aware of situation at 1225. Hospital staff reached out to PCP who called this facility back at 1228. PCP was not aware resident was on hospice/consulted for hospice-PCP audibly agitated about this over phone. Inform PCP that x-ray stat read was not yet received at this time but imaging, per tech, showed possible left hip fracture. PCP stated she would call and talk with POA and call this nurse back with further information/orders. PCP called back at 1249 and gave verbal order to have resident sent to ER emergently/immediately for possible left hip fracture. POA aware. 911 called at 1249. Ambulance arrived to facility at 1302. Resident transported to gurney and transferred out of facility to ER at 1309. POA aware of residents transfer to ER. Report called to ER nurse at 1325. On 12/14/23 at 2:54 PM X-ray results received at this time. Faxed to ER request. On 12/14/23 at 6:24 PM received call from ER nurse at 1730. Stated resident was being sent to nearby hospital for orthopedic surgery. POA and PCP aware. On 12/15/23 at 4:48 PM late entry: (entered 12/21/23 4:49 PM) upon discovery of injury, resident's provider was immediately notified as well as POA. Resident was sent to ER and then transferred to higher level hospital for further care and repair of fracture. On 12/18/23 at 4:39 PM received call from Social work regarding Resident. At this time, working with therapy but requiring max of 2 assist. SW did not know Resident was placed on Hospice on 12/12/23. States she will look into if Resident is coming back skilled or back on Hospice. On 1/10/24 at 1:41 PM, the X-Ray dispatcher A stated X-Rays are triaged in order based on STAT, ASAP, or ROUTINE. She stated the order was placed with them on 12/13/23 after 4:00 PM as a routine status order and was scheduled for the following day based on this order. She added that it was converted to a STAT order so it would get read sooner at the request of the x-ray technician due to the presentation of the resident. On 1/10/24 at 2:23 PM, the DON stated the staff made several attempts to call the provider and office for clarification between the time of the fax noted (12/12/23 at 9:21 PM) and the documented time of (12/13/23 at 2:12 PM). On 1/10/24 at 3:00 PM, the ADON stated no attempts were made to get clarification of the order between 12/12/23 at 9:21 PM and 12/13/23 at 2:12 PM. On 1/10/24 at 3:03 PM, the ADON and DON stated the ADON called the X-Ray company multiple times before the ADON asked X-Ray dispatcher B if the X-Ray if it could be STAT. The ADON stated she was told the x-ray technician was the only technician in the area and the X-Ray order could not be ordered STAT. She stated she did not notify the physician of the x-ray delay. On 1/10/24 at 4:05 PM, the ADON stated she asked for the X-Ray to be done ASAP to get the X-Ray company to expedite the order due to historical delays with X-Rays and not because of the way the resident presented. On 1/10/24 at 4:21 PM, X-Ray dispatcher B stated the technician asked for the x-ray to be changed to STAT read. He stated he didn't remember the facility ADON requesting the x-ray to be done STAT or ASAP as he would've entered that into the order. He also stated anytime an order is requested to be done STAT, his standard response is to notify the requesting party to make sure the order states that it is to be done STAT or ASAP. He was unable to provide a turnaround time for each X-Ray triage level. He stated if an order was placed as a STAT order at 4:30 PM, it wouldn't get done only if the technician had an issue with it. The X-Ray dispatcher also stated a note was entered into the computer that read: On 12/14/23 at 12:17:33 {tech initials} completed exam asked dispatch staff to upgrade case to stat read Left hip 2 images, left knee 2 images. fell 2 weeks ago, left hip pain, marked decreased ROM. {Staff F} asked for a stat reading due to obvious deformity of left hip. On 1/10/24 at 5:00 PM, Staff F stated the resident was out of it as she used to be with other medical related issues. She stated Resident #1 usually sat in her recliner with her legs crossed and elevated but on 12/14/23, she was sitting cock-eyed with her legs slightly bent toward herself. She stated the resident was transferred to her bed skin redness at her coccyx. She stated during the transfer, she noted the resident was non-weight-bearing and didn't want to stand. She stated the resident was a 2-person, pivot transfer and was not able to tell if she favored one leg over the other. She stated she called the POA because she wasn't aware of the scheduled x-ray but the POA informed her of it. Staff F stated when the x-ray technician was taking the image, she asked him to let her know what he thinks but she knew he could not read or diagnose the image results. She stated the x-ray technician told her he was going to make a call and try to get a STAT read based on what he saw in the image. Staff F stated the resident's positioning in the recliner was the only thing different about the resident she noticed and stated the resident had no bruising. She stated Staff B, Certified Nursing Assistant (CNA) informed her the resident grabbed his arm and twitched while providing her cares. She stated Staff B described it like the resident was in pain. On 1/10/24 at 5:15 PM, the Primary Care Provider (PCP) stated when x-rays are ordered, they are typically wanted and done the same day; that has been the norm. She stated she was not notified of the x-ray delay from 12/13/23 to 12/14/23 and stated the expectation is to have been notified of the delay and added she would've sent the resident to the Emergency Department to get the x-ray done sooner. On 1/16/23 at 2:50 PM, the DON indicated staff are to immediately assess the resident for pain or injury and obtain vitals signs. Neurological checks are initiated for unwitnessed falls. The facility policy, Change in a Resident's Condition or Status, dated February 2021 documented the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy interpretation included but not limited to: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of unknown source; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital; 3. Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.

Based on observation, clinical record review, staff interview, and policy review the facility failed to implement a comprehensive care plan for 1 of 4 residents reviewed ( Resident #5). The facility reported a census of 29 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #5 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating no cognitive impairment. It included diagnoses of restlessness, agitation, and a cerebrovascular accident (stroke) and revealed the resident had two (2) previous falls that resulted in non-major injury. It also indicated the resident normally used a walker and a wheelchair and required partial/moderate assistance with toileting hygiene and toilet transfer. The Care Plan intervention dated 7/14/23 indicated Resident #5 required assistance of one for transfers to the toilet. A subsequent intervention dated 7/15/23 indicated the resident required two-person assistance with all transfers. The Kardex (informational form used by nursing as a quick, patient care reference) for the admitted [DATE] indicated the resident required two+ persons physical assistance for transfers and toilet use. During an observation of Resident #5's care on 1/08/23 at 4:30 PM, Staff C, Certified Nursing Assistant (CNA) did not provide transfer assistance for Resident #5 with his walker when he transferred from the bathroom to the middle of his room. On 1/09/24 at 1:59 PM, the Regional Nurse stated the Care Plan should be updated to match the Kardex. She also stated the CNAs use the Kardex because they don't have access to the Care Plan. A procedure document titled Bathroom, Assisting a Resident to revised 2/2018 directed staff to assist the resident back into the bed or chair.

Based on clinical record review, staff interview, and policy review the facility failed to provide timely notification to the physician for 1 of 1 residents admitted to hospice services (Resident #1). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 of 15; indicating no cognitive impairment. The MDS included diagnoses of anxiety disorder, vascular dementia with psychotic disturbances, malignant neoplasm of bronchus and lung, chronic obstructive pulmonary disease (COPD), and a cerebral infarction (stroke). It also indicated the resident required moderate to maximal assistance with all care areas except bathing self, eating, and oral hygiene. The Electronic Health Record (EHR) census report listed hospice as the primary payor source beginning 12/12/23. The Care Plan dated 12/13/23 indicated the resident chose to receive hospice services. It also directed staff to coordinate the resident's care with the hospice team. The Progress Note dated 12/13/23 revealed the resident was admitted to hospice services for COPD. It also revealed the primary care provider was not aware the resident was on hospice nor consulted for hospice and was audibly agitated about it over the phone. The Discharge Summary dated 12/19/23 indicated the resident was never admitted to hospice by the routine provider. On 1/16/24 at 12:58 PM, the Director of Nursing (DON) stated staff is to notify the physician when a resident is admitted to hospice. She also stated that the Hospice Medical Director admitted the resident to hospice but was not able to provide documentation the Physician Assistant nor the Primary Care Physician were notified. A policy titled Change in a Resident's Condition or Status revised 02/2021 indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). It directed staff to notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to update the comprehensive care plan with a change in transfer assistance needed for 2 of 3 residents reviewed (#5 and #7). The facility reported a census of 29 residents. Findings include: 1. The MDS assessment for Resident #7, dated 10/12/23, included diagnoses of Major Depressive Disorder and stroke. The MDS identified the resident required partial/moderate assistance of staff for sit to stand and transfers. The MDS identified the resident was frequently incontinent of bladder and bowel and a Brief Interview for Mental Status score of 14, indicated no cognitive impairment for decision-making. During an observation on 1/8/24 at 4:18 PM, Staff A, Certified Nurse Aide (CNA) transferred Resident #7 from the recliner to the wheelchair; Staff A held the resident's right hand with Staff A's left hand and with Staff A's right hand under the resident's left armpit lifted and transferred the resident to the wheelchair, without a gait belt on the resident. Staff A pushed resident into the bathroom and proceeded to lift and transfer the resident from the wheelchair to the toilet by holding the resident's hands with Staff A's hands, without a gait belt. Staff A completed cares for the resident and then lifted and transferred the resident back to the wheelchair with Staff A's hands on each side of the resident, without a gait belt. Interview on 1/9/24 at 12:50 PM, Staff B, CNA stated Resident #7 requires assistance of 1 staff with gait belt for transfers and Staff B uses the resident's Kardex (summary of resident care needs) to know the amount of assistance a resident need to transfer. Resident #7's Kardex, dated 1/9/24, documented to transfer with extensive assistance and 1-person physical assist. Resident #7's Care Plan, initiated date of 6/20/23, documented a focus of unable to transfer independently with intervention of requires two-person assistance with all transfers. 2. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating intact cognition. It included diagnoses of restlessness, agitation, and a cerebrovascular accident (stroke) and revealed the resident had two (2) previous falls that resulted in non-major injury. It also indicated the resident normally used a walker and a wheelchair and required partial/moderate assistance with toileting hygiene and toilet transfer. The Care Plan intervention dated 7/14/23 indicated the resident required assistance of one for transfers to the toilet. A subsequent intervention dated 7/15/23 indicated the resident required two-person assistance with all transfers. The Electronic Health Record (EHR) task list revised 9/29/23 directed staff to use one-staff assistance and a gait belt for all transfers The Kardex (informational form used by nursing as a quick, patient care reference) indicated the resident required two+ persons physical assistance for transfers and toilet use. During observation of cares on 1/08/23 at 4:30 PM, Staff C, Certified Nursing Assistant (CNA) did not provide transfer assistance for Resident #5 with his walker when he transferred from the bathroom to the middle of his room. On 1/09/24 at 1:59 PM, the Regional Nurse stated the Care Plan should be updated to match the Kardex and a gait belt should be used when assisting with transfers. A procedure document titled Bathroom, assisting a Resident to revised 2/2018 directed staff to assist the resident back into the bed or chair. A policy titled Care Plans, Comprehensive Person-Centered revised 12/2016 indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. It also directed the Interdisciplinary Team (IDT) to review and update the Care Plan when there has been a significant change in the resident's condition.

Based on clinical record review, hospital document review, staff interviews, family interviews, hospice documents, hospice agreement and facility policy review the facility failed to notify in a timely manner 1 of 3 resident's hospice provider when she had a fall with injury (Resident #1). On [DATE] at 8:30 AM the nurse was called to the resident's room by another staff member. Resident #1 was lying on the floor on her left side. The resident reported she was getting up to go to the bathroom and fell . An assessment was completed and found skin tears to her left arm and next to her left eye. Bruising was noted to start over her left eye. At 10:07 AM the hospice nurse was notified that the resident had a fall and sustained an injury. When the hospice nurse arrived to the facility at 11:38 AM she noted a large hematoma to her left eye and it was swollen shut. Various small lacerations to her bilateral upper extremities were also noted. She was later sent to the hospital and found to have a subarachnoid hemorrhage scattered throughout the brain, small amount of intraventricular hemorrhage, small intraparenchymal hemorrhage, and left sided scalp hematoma. On [DATE] at 12:28 PM Resident #1 expired at the facility. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety The facility reported a census of 32 residents with 2 residents receiving hospice services. The facility was notified of the Immediate Jeopardy on [DATE] at 4:10 PM. The IJ was removed on [DATE] at 4:41 PM when the facility submitted an acceptable removal plan and the scope and severity was lowered from a J to a D. The facility's removal plan documented the following actions: 1) Change of condition or fall, hospice notification will occur in a timely manner 2) If nurses cannot reach the on-call hospice provider they will call the primary care provider (PCP). If they cannot reach the PCP, they will contact their third-party physician services to notify the Medical Director. 3) One on one training with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and licensed nurses to notify hospice in a timely manner of a change of condition or fall. 4) Agency Orientation Checklist to be completed for all new agency staff members to review education. 5) Hospice Notification Audit created to be completed with each clinical morning meeting by DON or designee to ensure compliance. 6) Medical Director notified and reviewed through ADHOC QAPI [DATE] at 5:18 PM. 7) Information taken to QAPI monthly x 3 months. Findings include: The significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating no cognitive impairment. The MDS revealed she required extensive assistance of one staff for transfers and toilet use, and supervision of one staff for bed mobility and personal hygiene. The MDS listed the following diagnoses for Resident #1 to include chronic obstructive pulmonary disease (COPD), atrial fibrillation, CAD, heart failure, renal failure, diabetes mellitus, anxiety, depression, and morbid obesity. The care plan focus area dated [DATE] identified Resident #1 received hospice services effective [DATE] due to hypertensive disease with heart failure. The care plan indicated the facility will coordinate her care with her hospice team. The focus area dated [DATE] identified the resident at risk for falls. The care plan directed staff to ensure hourly rounding is completed on the resident to offer more frequent toileting and care needs. The care plan also directed staff to encourage and remind the resident to ask for assistance instead of getting up on her own. The care plan focus area dated [DATE] identified the resident needs staff assistance due to her right hip fracture and directed staff to provide two person assistance with routine toileting and all transfers. The care plan focus area dated [DATE] identified the resident as at risk for bleeding due to anticoagulant therapy. Review of Resident #1's Cardiopulmonary Resuscitation (CPR) Do Not Resuscitate (DNR) Declaration Form indicated she wanted CPR initiated and/or the Automated External Defibrillator (AED) used to prolong her life when biological death was imminent. Record review revealed an untitled document that indicated Hospice began serving Resident #1 on [DATE] with the primary diagnosis of congestive heart failure. Record review revealed an Interdisciplinary Group Meeting with hospice on [DATE] at 8:00 AM listed she was admitted to hospice on [DATE]. The hospice care plan documented Resident #1 required assist with transfers to her bed/chair, dressing but was able to self-propel while in her wheelchair. The meeting listed she received Clopidogrel 75mg once a day and she desired to receive CPR. Review of Resident #1's [DATE] Medication Administration Record (MAR) revealed she received clopidogrel (blood thinner) 75 milligram (mg), 1 tablet by mouth one time a day for blood clot prevention, with a start date of [DATE] and end date of [DATE]. The MAR also documented staff administered a PRN (as needed) order of Tylenol 500 milligrams (mg) every six hours as needed for pain on [DATE] and was documented as effective at 1:44 PM. The Progress Notes for Resident #1 documented the following: On [DATE] at 12:58 PM Hospice note documented the Social Worker visit completed. Facility charge nurse states the resident is a bit more confused from last week but no other concerns. On [DATE] at 2:39 PM Hospice note documented the Registered Nurse visit completed. Charge nurse, Staff A, reports resident a little more confused this morning. On [DATE] at 9:00 AM late entry documented Staff A called to the room at 8:30 AM, resident lying on the floor on her left side. Resident #1 stated she was getting up to go to the bathroom and fell . Assessment done, no noted extremity deformities, no pain in her arms or legs, active range of motion (AROM) was within normal limits. Skin tears noted on her left arm and next to her left eye. Bruising starting to develop over her left eye, attempts were made to apply ice to the area. Hospice called and nurse came and evaluated the resident. Staff A made calls to Resident #1's top two emergency contacts, no answer to either. On [DATE] at 11:38 AM Son here to see resident and very upset regarding her condition with injury to left eye from the fall. Son requested resident be sent to the emergency room (ER). Nurse contacted Hospice and spoke to the nurse. She stated she is almost to the facility to assess the resident. Currently no change to the resident, she denied pain, no change in level of consciousness and vitals stable. On [DATE] at 12:02 PM Hospice nurse here ans spoke to son and charge nurse regarding the resident. Son very upset about injury and resident having multiple falls. Charge nurse asked son to reach out to sister and brother and if they decide they want her sent out then the facility will send her out. On [DATE] at 1:44 PM Acetaminophen tablet 500mg administered as needed for pain. On [DATE] at 2:02 PM Hospice note documented the Hospice nurse received a call from Staff A at 10:07 AM that the resident had a fall with injury about an hour prior to notification and family had been notified. Upon arrival to facility at 11:38 AM observed resident sitting next to the nurse station. Large hematoma to left eye and is swollen shut. Various small lacerations to bilateral upper extremities. Vitals stable, neuro checks normal and patient denies pain at this time. Son at bedside and is upset that she was not sent out immediately to the ER. Hospice nurse advised that resident could be sent out per his request. He is awaiting his sister. At 4:29 PM Hospice nurse provided an update to son on resident with no changes. Daughter arrived to facility and she would like the resident sent out. At 4:58 PM verbal order received by physician to send resident out for evaluation. On [DATE] at 7:31 PM ER Nurse phoned and informed facility that resident had a brain scan and has several small brain bleeds for which there are no interventions and will be sent back to the facility on hospice and end of life care. On [DATE] at 7:40 PM Hospice Nurse phoned and informed facility that resident is returning to facility and she is still full code but they are going to work on changing that. On [DATE] at 8:30 PM Late entry documented resident returned to facility. Upon assessment resident lethargic. Significant swelling and bruising noted to left eye and left side of face. Dressings clean, dry and intact to skin tears on left arm. On [DATE] at 9:00 PM son and daughter arrived. Daughter at bedside and requested pain medications administered due to resident is twitching and grimacing in pain. Resident nods head when questioned about pain. As needed Morphine given. Review of the resident's clinical record revealed the resident's primary physician was not contacted by the facility staff of the incident that occured on [DATE] at 8:30 AM until notified by the Hospice Nurse at 4:58 PM. Review of the Major Injury Determination Form documented on [DATE] at 8:30 AM Resident #1 was found lying on the floor in her room. Noted a skin tear and bruising around her left eye. By the afternoon her left eye was swollen shut, was sent to the hospital and found to have several subarachnoid hemorrhages. Resident was confused, stated she was trying to go to the bathroom and fell . Resident passed away on [DATE]. At the time of the fall she was an assistance of two staff, pivot transfer to her wheelchair. The form was completed by the Director of Nursing (DON) on [DATE] at 1:30 PM. The A Registered Nurse Practitioner (ARNP) deemed injury as a major injury; signed and dated the form on [DATE] at 11:42 AM. Review of the emergency room (ER) Visit note dated [DATE] at 5:51 PM documented Resident #1 fell and had left periorbital (eye socket area) swelling. The resident was not sure how she fell and reported facial pain. She was not sure why she was in the nursing home or on hospice. Physical exam revealed left eye periorbital edema and ecchymosis (discoloration of the skin resulting from bleeding underneath). A head CT (computed tomography) scan showed: a subarachnoid hemorrhage scattered throughout the brain, small amount of intraventricular hemorrhage, small intraparenchymal hemorrhage within the medial left cerebellum, and a large left-sided scalp hematoma. Review of hospice call logs provided by the hospice company revealed Staff A called the hospice on-call number on [DATE] at 10:03 AM to report Resident #1 fell , hit her head and had a hematoma over her left eye. The message was marked as delivered to the on call hospice staff member on [DATE] at 10:06 AM. At 11:36 AM the Assistant Director of Nursing (ADON) called to report Resident #1's family was upset she did not go to the hospital after her fall. On [DATE] at 12:51 PM Resident #1's emergency contact #3 indicated when he came to visit his mom on [DATE] she was sitting up in her wheelchair behind the nurse's station. She had a softball sized raised area to her face, and that it was bad. Photo image provided of resident #1 revealed left eye swollen shut and swollen softball sized and purple with a laceration and dried blood down the left side of her face. Son feels like the facility should have sent her to the ER when it first happened. Review of Resident #1's certified death certificate with an issued date of [DATE] listed the immediate cause of death as subarachnoid hemorrhage. On [DATE] at 2:08 PM Staff B stated it was a busy morning on [DATE]. She went in to Resident #1's room about 8:05 AM to assist her roommate with getting up for breakfast. Resident #1 was still in bed sleeping which was normal because she stayed in bed during breakfast. After she was done assisting other residents she saw Resident #1 in her wheelchair about 8:,d+[DATE]:35 AM with blood coming from her face. When asked if Resident #1 was in pain, she stated her whole side of her face hurt and it was swollen, it looked absolutely horrible. Resident #1 said it hurt pretty bad and they were putting ice packs on her face to try to keep her comfortable. Her knee and head were bleeding and she had a huge knot on her head with an open spot on her eyebrow. On [DATE] at 11:12 AM Staff C Certified Medication Aide (CMA)/Certified Nursing Assistant (CNA) stated it was a crazy day on [DATE]. She indicated after breakfast, the kitchen staff were passing room trays. That staff member called down the hall indicating she needed a nurse because Resident #1 was on the floor and bleeding. Herself and the nurse on duty that day went down to the resident's room. They found her lying on the floor, in front of the bathroom. There was a lot of blood on the floor which appeared to be coming from a laceration on her eyebrow. They applied dressing to the area and got ice to place on her head. She appeared to be in pain and said her eye hurt. Staff C did give her an as needed (PRN) Tylenol but that did not help and she reported this to the nurse on duty. The nurse indicated there was not much they could do, so they continued with the ice packs. On [DATE] at 2:31 PM the hospice nurse that was on call on [DATE] stated she got a call from Staff A about 10:00 AM or so that resident had a fall out of bed. When she asked if Resident #1 had injuries he indicated she did. She told him she was about one and half hours away, heading to the facility. She was probably about five minutes from the facility when the ADON called her to report the family was upset they did not send the resident out. She had observed a large bruise to her face and her eye was swollen shut. The hospice nurse indicated the first call she got that day about the resident falling and sustaining an injury was about 10:00 AM, which she called them back right away. She gave them her personal cell phone number to contact her after that if they needed. The next call she received was when she was about five minutes from the facility and that was from the ADON. The facility calls the on call number which the triage nurse takes the call and passes the message on to the hospice nurse on-call for that day. She denied the facility calling her twice before speaking with them. She indicated once she receives the message, she calls the facility right away. On [DATE] at 10:29 AM the ADON stated she arrived to the facility about 10:,d+[DATE]:30 AM. She noted a large bruise over Resident #1's eye, a skin tear to one of her elbows. When she asked Resident #1 if she was in pain, she denied having pain. She did not believe a PRN was given since Resident #1 was denying any pain. Hospice was contacted and on their way in by the time she came to the facility herself. On [DATE] at 10:48 AM Staff A, Licensed Practical Nurse, stated about 8:,d+[DATE]:20 AM a kitchen staff member was passing trays down the hall and saw Resident #1 on the floor in her room. He went down to the resident to assess her. After he completed his assessment they brought the resident up to the nurse's station in her wheelchair so he could continue to complete his neurological assessments while he passed medication, assisted with transfers and other tasks that needed done that morning. Resident #1 had reported she was getting up to go to the bathroom and she fell , this was normal for her to get up without assistance. He noted bruising on the left side of her forehead and swelling over her eye. Staff A indicated he called hospice twice before someone called him back after the third call. He could not remember if the call was dropped or he was hung up on. When asked if he could have called the doctor, he indicated the hospice nurse notifies their hospice provider when things like this happen. When asked if Resident #1 was in pain, he stated no not really. On [DATE] at 11:29 AM Staff D Cook stated she was delivering room trays that morning and noticed Resident #1 on the floor. She called for the nurse and CMA to assess the resident. Resident #1 complained of pain in the back of her head kind of by her ear. She noticed a large amount of blood and a gash near her eye, but she was not complaining of pain above her eye. She indicated after awhile the nurse attempted to call hospice but stated he could not get through. Staff D stated her eye continued to swell and the bruising was turning a dark purple/black color, she thought maybe the resident had a fracture or brain bleed by looking at her injuries. On [DATE] at 1:05 PM the Director of Nursing (DON) stated she was not on call when Resident #1 fell on [DATE]. She came in to assist with a community event at the facility. She arrived at the facility about 10:45 AM and saw Resident #1 sitting at the nurse's station. She noticed she had some bruising to her face and her eye was swollen. She asked her if she was in pain and she said no. Staff A indicated he called hospice and she was on her way. On [DATE] at 11:37 AM during an interview with Staff F, Registered Nurse, she stated she was not working at the time of Resident #1 fall. She stated the resident's injuries to her face were pretty swollen and were from her left eye. She stated the resident should have gone to the ER sooner. She stated if she was working and with this serious of injuries and being a full code and on a blood thinner she would have sent her out. She stated when a resident is Hospice they call them first. When asked if she could not get ahold of Hospice she stated she would call the resident's physician. The facility policy titled Change in a Resident's Conidition or Status with a revised date of February 2021 documented the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been an: a. accident or incident involving the resident; d. significant change in the resident's physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing interventions; b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in an accident or incident that resulted in an injury. The facility policy titled Acute Condition Changes with a revised date of [DATE] documented the following: Policy Statement: 1. The facility shall use a defined protocol to evaluate and report changes in condition of its residents. 2. Physicians shall help identify and manage causes of acute changes of condition. Procedure: 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 6. The attending physician will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The facility provided the following hospice agreement, dated [DATE], between the facility and hospice provider. The agreement indicated the facility shall immediately notify hospice if: a significant change in the hospice resident's physical, mental, social or emotional status occurs; a need arises to transfer a hospice resident and hospice will make arrangements for any necessary continuous care, acute inpatient care or skill nursing facility care necessary related to the terminal illness and related conditions. The facility shall designate a member of facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident by facility staff and hospice staff. The facility interdisciplinary team member must have a clinical background, function within her/his Iowa scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The facility interdisciplinary team member is responsible for the following: a. Collaborating with the hospice representatives and coordinating facility staff participation in the hospice care planning process for those residents receiving these services. b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. c. Ensuring that the facility communicates with the hospice medical director, that patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. d. Obtaining the following information from the hospice provider: (iv) names and contact information for hospice personnel involved in hospice are for each patient; (v) instructions on how to access hospice provider's 24 hour on-call system; and (vii) the hospice provider physician and attending physician (if any) orders specific to each patient. For Skilled Nursing Facility Care, the facility shall provide the 24 hour services of on-site professional nurses to render direct nursing services to hospice patients. Facility shall also ensure the patients are comfortable, clean, well-groomed, and protected from negligent and intentional damage, including but not limited to accident, injury and infection.

Based on record review, observation, resident and staff interviews and facility policy review the facility failed to keep a resident (Resident #27) from physically abusing other residents while living at the facility. Review of Resident #27 record revealed documentation in the past she has open handed slapped another resident in the face, hit a resident in the back of the head, and threw water at a resident. During the survey Resident #27 threw a full pop can at a resident causing mental anguish and pain. The facility was unable to produce documentation of nursing risk management incident report investigations potentially placing all residents at risk for resident to resident abuse due to failure to review incidents. The Iowa Department of Inspections and Appeals (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 14, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. Resident # 27 was placed on one to one supervision with staff for 24 hours a day, until further assessment and safety plan can be implemented. b. Resident #27 primary care physician has been notified of the alleged behavior. c. Resident #27 care plan will be revised according to the treatment plan. d. Facility staff and agency staff (prior to their next scheduled shift) have been/will be educated to: 1. Maintain a safe environment free from resident abuse by another resident who resided at the facility by placing them one to one until evaluated by the facilities interdisciplinary team involving facility management and the primary care physician, and family, if any, to determine if the need continues after a review of behavior trends with potential medication modification or placement elsewhere is determined with no observation and/or documentation of behavior. The duration of the one to one will be based on the individual and continued exhibition of the behavior and will continue. 2. To report all allegations of abuse including physical, mental, psychosocial, sexual, verbal, and misappropriation immediately to their supervisor. The facilities management has been educated to report to DIA and/or local law enforcement within two (2) hours if applicable. 3. To fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. 4. Resident to resident altercation policy. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #27 dated 2/28/2023 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented no physical, verbal, or other behavioral symptoms directed towards others in the past 90 days. The MDS also documented she needs physical assistance of one person with transfers, dressing, walking, and locomotion. The MDS revealed diagnoses of depression, epilepsy (seizure disorder), and other neurological conditions. The MDS documented that she takes antipsychotic medication (a type of psychiatric medication used to treat psychosis) and antidepressant medication (a type of medication used for treatment of depression and anxiety disorders). Record review of a Progress Note dated 11/21/2022 at 3:40 AM for Resident #27 documented yelling throughout the shift for staff to come to her room and when they enter she yelled at them, she cursed at staff by calling them bitches or fagots. Each time she cursed at staff and used vulgar names, education was provided to her that it was rude to talk like that and ask her to please stop. The Progress Note also documented none of the interventions had been effective and she continued to yell. Record review of a Progress Note dated 12/2/22 at 5:44 AM for Resident #27 documented She was awake the majority of the shift, yelling out, cussing, and calling staff bitch redirections attempted and unsuccessful. Record review of Resident #27 Progress Note dated 12/14/22 at 5:43 PM documented another female resident was reaching across the table attempting to grab a book and Resident #27 became upset and repeatedly yelled at the other resident to stop. Resident #27 yelled, fucking bitch and the other resident yelled bitch. Resident #27 propelled her wheelchair around the table and open handed slapped the other female resident across the right side of the face hitting her glasses. The residents were separated and the Administrator was notified. Record review of Resident #27 Progress Note dated 12/23/22 at 3:39 PM documented she open handed hit another female resident in the back of the head because the other resident was singing. The Progress note documented the Administrator was notified and Resident #27 was moved to a different room for the safety of other residents at the facility and 30 minute checks on Resident #27 were started. The MDS for Resident #11 dated 3/30/23 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented she needs supervision of one person with transfers, walking, and locomotion. The MDS revealed diagnoses of anxiety, depression, and bipolar disorder. The MDS documented that she takes antipsychotic and antidepressant medications. Record review of Resident #11 Progress Note dated 12/23/22 at 3:45 PM documented she was sitting in a chair in the dining room quietly singing to herself when another female resident came up behind her and open handed hit her in the back of the head. The residents were separated and no injuries found to the back of her head. She was crying out in pain. The Administrator was notified, emergency services, and waiting for an officer to come to the facility. Record review of Resident #11 Progress Note dated 12/23/2022 at 8:26 PM documented she was upset with the lack of consequences the other female received from the police officer today. She stated she is going to call the state, she informed she feels that something needs to be done, the nurse explained that she had the right to call the state and make a complaint. Resident #11 stated she felt better, but more needed to be done because she did not feel safe living here with someone who will hit her for no reason. Record review of Resident #24 Progress Note dated 3/5/2023 at 1:36 PM documented another resident threw a glass of water on him while he was in the dining room cleaning off the tables. Resident #24 stated the cup itself didn't hit him, just the water. Resident #24 denies being fearful of the other resident and stated he doesn't know what he did. Resident #27 was visibly wet and staff assisted him to change his clothes. Record review of Resident #27 Progress Note dated 3/5/2023 at 1:38 PM documented she was in the dining room and was trying to propel herself back to her room, but another male resident was in her way and didn't move so she threw her glass of water on him. He moved and she propelled herself back to her room. Record review of Resident #27 Progress Note dated 4/16/2023 at 4:02 AM, documented Resident #27 was cursing at staff and throwing objects at staff when they assisted her to get dressed and into her wheelchair. Record review of Resident #27 Progress Note dated 4/16/23 at 7:20 PM, documented she began having aggressive threatening verbal behaviors while the facility's Doctor was in the facility seeing other residents. Resident #27 behaviors escalated to her throwing a phone and other objects at other residents. At the time the facility's Doctor decided it was safest and best to have her sent out for psychiatric evaluation and review of medications. The facility placed a call to 911 and moved her to the chapel. Resident #27 calmed but continued to be very aggressive in threats and intent on what she would do to other residents. Emergency services arrived and she left the facility. During an interview on 4/25/23 at 9:37 AM with Resident #11 revealed another resident here at the facility, Resident #27, had hit her multiple times. She revealed she was scared to live here and the facility had done nothing about it. She further informed she was at the point where she felt so unsafe living here she can't eat or sleep at night, she informed she hadn't slept for months because she was scared Resident #27 would come into her room. Record review of Resident #27 Progress Note dated 4/25/23 at 3:26 PM, documented a late entry of Incident, Accident,Unusual Occurrence Note. The Progress Note revealed Resident #27 was in the dining room going to another resident's table. The other resident stated don't sit here. This resident (Resident #27) picked up a full can of soda and threw it at the other resident. This resident was immediately removed from the situation and taken to her room for a private interview of what happened. Resident #27 stated the other resident pissed her off and told her she couldn't sit at the table, and then stated fuck you, you stupid son of a bitch, nobody tells me what to do. The facility started 15 minute checks at 3:00 PM and the police were notified. During an interview on 4/25/2023 at 2:08 PM with the facilities Administrator revealed Resident #27 and Resident #11 just had a physical resident to resident altercation where Resident #27 threw a full pop can at Resident #11 shoulder. He revealed he is working on reporting it to the State Agency and the local police department. He then informed Resident #27 and Resident #11 have not had physical altercations in the past that he was aware of. He revealed they will occasionally have arguments, he stated they have a love/hate relationship for some reason. During an interview on 4/25/23 at 2:16 PM with Resident #11 revealed she was tired of the abuse by Resident #27 and something had to be done about it. She informed Resident #27 threw a full pop can at her shoulder about 15-20 minutes ago. She stated, I'm not a target, I am a human being, something has to get done. She revealed the facility had done nothing about the continued abuse besides removing her at the time of the abuse, but then it happens again. She asked the question: how do I know if I am going to be safe? And stated the facility does nothing and so this keeps happening. She then informed this past Saturday Resident #27 hit her in the left arm in the afternoon. Throughout the interview Resident #11 was observed to have redness throughout her face, shaking in her arms, difficulty forming sentences due to excessive crying, and nasal drainage (runny nose). During an interview on 4/26/23 at 1:25 PM Staff D, Certified Nurse Aide (CNA), revealed Resident #27 has had many incidents of aggression with other residents and staff here. He recalled the following incidents: a. Resident #27 threw a pop at Resident #11 b. Resident #27 punched Resident #11 in the face less than 2 months ago in the dining room c. Resident #27 slapped Resident #22 in the face He revealed when altercations happen between residents the residents are separated and both residents are then spoken with to get both sides of the story. He informed the nurse on and the next nurse on duty is notified of the incidents. He stated he does not remember the nurses names that were working during b and c resident to resident physical altercations he mentioned because the facility used agency nurse staffing at the time. During an interview on 04/27/2023 at 8:39 AM with the Assistant Director of Nursing (ADON) and the facilities Social Services Director revealed the facility did not investigate to identify and implement root cause analysis interventions for Resident #27 Care Plan for her resident to resident physical altercations that occurred on 12/14/2022 12/23/2022, and 3/5/2023. During the interview they also confirmed they do not have incident reports for the 12/14/22 and 12/23/22 incidents. During an interview on 5/1/23 at 10:20 AM with Resident #11 she stated, thank you, thank you, thank you, Resident #27 no longer lives here, I slept this weekend, I feel safe now and love my home now. I used to feel unsafe and now everything has changed. During an interview on 5/3/23 at 11:19 AM with the facilities Housekeeping Supervisor revealed she had worked here for about five (5) years and the incident between Resident #27 and Resident #11 that occurred on 4/25/23 is the first incident she had heard of regarding Resident #27 being in a physical altercation with another resident, she then informed the day after the incident Resident #11 showed her a bruise on her collarbone. She also revealed she attends the facilities daily morning meetings. During an interview on 5/3/23 at 2:16 PM with the facilities ADON revealed the facility has had three (3) DON's in the past five (5) months. She informed multiple of Resident #27 resident to resident incidents were not put into the facilities Risk Management system on their Electronic Health Record (EHR) and so the facility did not know about them. She revealed the facility is now reading a daily document called, 24 hour progress notes, in case anything is missed that should be in Risk Management. Record review of the facilities policy titled, Resident-to-Resident Altercations, last revised on 12/2016 instructed the following: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; c. Notify each resident's representative and Attending Physician of the incident; d. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; e. Consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness; h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; i. Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator.

Based on record review, resident and staff interviews, and facility policy review the facility failed to report continued resident to resident altercations for 1 of 3 residents reviewed to the State Agency (Iowa Department of Inspections and Appeals (DIA)), (Resident #27). The facility reported Resident #27 initial resident to resident physical altercation for an incident that occurred on 12/14/2022, however the facility failed to report subsequent resident to resident physical altercations by Resident #27 that occurred on 12/23/22 and 3/5/2023. During the facilities annual survey Resident #27 had an additional resident to resident physical incident that could of potentially been avoided if the State Agency would have been aware of Resident #27 continued aggression towards other residents. The State Agency (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 23, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. Resident # 27 was placed on one to one supervision with staff for 24 hours a day, until further assessment and safety plan can be implemented. b. Resident #27 primary care physician has been notified of the alleged behavior. c. Resident #27 care plan will be revised according to the treatment plan. d. Facility staff and agency staff (prior to their next scheduled shift) have been/will be educated to: 1. Maintain a safe environment free from resident abuse by another resident who resided at the facility by placing them one to one until evaluated by the facilities interdisciplinary team involving facility management and the primary care physician, and family, if any, to determine if the need continues after a review of behavior trends with potential medication modification or placement elsewhere is determined with no observation and or documentation of behavior. The duration of the one to one will be based on the individual and continued exhibition of the behavior and will continue. 2. To report all allegations of abuse including physical, mental, psychosocial, sexual, verbal, and misappropriation immediately to their supervisor. The facilities management has been educated to report to DIA and/or local law enforcement within two (2) hours if applicable. 3. To fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. 4. Resident to resident altercation policy. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #27 dated 2/28/2023 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented no physical, verbal, or other behavioral symptoms directed towards others in the past 90 days. The MDS also documented she needed physical assistance of one person with transfers, dressing, walking, and locomotion. The MDS revealed diagnoses of depression, epilepsy (seizure disorder), and other neurological conditions. The MDS documented that she takes antipsychotic medication (a type of psychiatric medication used to treat psychosis) and antidepressant medication (a type of medication used for treatment of depression and anxiety disorders). Record review of a Progress Note dated 11/21/2022 at 3:40 AM for Resident #27 documented yelling throughout the shift for staff to come to her room and when they enter she yelled at them, she cursed at staff by calling them bitches or fagots. Each time she cursed at staff and used vulgar names, education was provided to her that it was rude to talk like that and ask her to please stop. The Progress Note also documented none of the interventions have been effective and she continued to yell. Record review of a Progress Note dated 12/2/22 at 5:44 AM for Resident #27 documented She was awake the majority of the shift, yelling out, cussing, and called staff bitch redirections attempted and unsuccessful. Record review of Resident #27 Progress Note dated 12/14/22 at 5:43 PM documented another female resident reached across the table attempting to grab a book and Resident #27 became upset and repeatedly yelled at the other resident to stop. Resident #27 yelled, fucking bitch and the other resident yelled bitch. Resident #27 propelled her wheelchair around the table and open handed slapped the other female resident across the right side of the face hitting her glasses. The residents were separated and the Administrator was notified. Record review of Resident #27 Progress Note dated 12/23/22 at 3:39 PM documented she open handed hit another female resident in the back of the head because the other resident was singing. The Progress note documented the Administrator was notified and Resident #27 was moved to a different room for the safety of other residents at the facility and 30 minute checks on Resident #27 were started. The MDS for Resident #11 dated 3/30/23 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented she needed supervision of one person with transfers, walking, and locomotion. The MDS revealed diagnoses of anxiety, depression, and bipolar disorder. The MDS documented that she took antipsychotic and antidepressant medications. Record review of Resident #11 Progress Note dated 12/23/22 at 3:45 PM documented she sat in a chair in the dining room quietly singing to herself when another female resident came up behind her and open handed hit her in the back of the head. The residents were separated and no injuries found to the back of her head. She was crying out in pain. The Administrator was notified, emergency services, and waiting for an officer to come to the facility. Record review of Resident #11 Progress Note dated 12/23/2022 at 8:26 PM documented she was upset with the lack of consequences the other female received from the police officer today. She stated she was going to call the state, she informed she felt that something needed to be done, the nurse explained that she had the right to call the state and make a complaint. Resident #11 stated she felt better, but more needed to be done because she does not feel safe living here with someone who would hit her for no reason. Record review of Resident #24 Progress Note dated 3/5/2023 at 1:36 PM documented another resident threw a glass of water on him while he was in the dining room cleaning off the tables. Resident #24 stated the cup itself didn't hit him, just the water. Resident #24 denied being fearful of the other resident and stated he doesn't know what he did. Resident #27 was visibly wet and staff assisted him to change his clothes. Record review of Resident #27 Progress Note dated 3/5/2023 at 1:38 PM documented she was in the dining room and was trying to propel herself back to her room, but another male resident was in her way and didn't move so she threw her glass of water on him. He moved and she propelled herself back to her room. Record review of Resident #27 Progress Note dated 4/16/2023 at 4:02 AM, documented Resident #27 was cursing at staff and throwing objects at staff when assisting her to get dressed and into her wheelchair. Record review of Resident #27 Progress Note dated 4/16/23 at 7:20 PM, documented she began having aggressive threatening verbal behaviors while the facility's Doctor was in the facility seeing other residents. Resident #27 behaviors escalated to her throwing a phone and other objects at other residents. At the time the facility's Doctor decided it was safest and best to have her sent out for psychiatric evaluation and review of medications. The facility placed a call to 911 and moved her to the chapel. Resident #27 calmed but continued to be very aggressive in threats and intent on what she would do to other residents. Emergency services arrived and she left the facility. During an interview on 4/25/23 at 9:37 AM with Resident #11 revealed another resident here at the facility, Resident #27, had hit her multiple times. She revealed she was scared to live here and the facility had done nothing about it. She further informed she was at the point where she felt so unsafe living here she can't eat or sleep at night, she informed she hadn't slept for months because she was scared Resident #27 would come into her room. Record review of Resident #27 Progress Note dated 4/25/23 at 3:26 PM, documented a late entry of Incident, Accident,Unusual Occurrence Note. The Progress Note revealed Resident #27 was in the dining room going to another resident's table. The other resident stated don't sit here. This resident (Resident #27) picked up a full can of soda and threw it at the other resident. This resident was immediately removed from the situation and taken to her room for a private interview of what happened. Resident #27 stated the other resident pissed her off and told her she couldn't sit at the table, and then stated fuck you, you stupid son of a bitch, nobody tells me what to do. The facility started 15 minute checks at 3:00 PM and the police were notified. During an interview on 4/25/2023 at 2:08 PM with the facilities Administrator revealed Resident #27 and Resident #11 just had a physical resident to resident altercation where Resident #27 threw a full pop can at Resident #11 shoulder. He revealed he was working on reporting it to the State Agency and the local police department. He then informed Resident #27 and Resident #11 have not had physical altercations in the past that he was aware of. He revealed they would occasionally have arguments, he stated they had a love/hate relationship for some reason. During an interview on 4/25/23 at 2:16 PM with Resident #11 revealed she was tired of the abuse by Resident #27 and something had to be done about it. She informed Resident #27 threw a full pop can at her shoulder about 15-20 minutes ago. She stated, I'm not a target, I am a human being, something has to get done. She revealed the facility had done nothing about the continued abuse besides removing her at the time of the abuse, but then it happens again. She asked the question: how do I know if I am going to be safe? And stated the facility does nothing and so this keeps happening. She then informed this past Saturday Resident #27 hit her in the left arm in the afternoon. Throughout the interview Resident #11 was observed to have redness throughout her face, shaking in her arms, difficulty forming sentences due to excessive crying, and nasal drainage (runny nose). During an interview on 4/26/23 at 1:25 PM Staff D, Certified Nurse Aide (CNA), revealed Resident #27 has had many incidents of aggression with other residents and staff here. He recalled the following incidents: a. Resident #27 threw a pop at Resident #11 b. Resident #27 punched Resident #11 in the face less than 2 months ago in the dining room c. Resident #27 slapped Resident #22 in the face He revealed when altercations happen between residents the residents are separated and both residents are then spoken with to get both sides of the story. He informed the nurse on and the next nurse on duty is notified of the incidents. He stated he does not remember the nurses names that were working during b and c resident to resident physical altercations he mentioned because the facility used agency nurse staffing at the time. During an interview on 04/27/2023 at 8:39 AM with the Assistant Director of Nursing (ADON) and the facilities Social Services Director revealed the facility did not investigate to identify and implement root cause analysis interventions for Resident #27 Care Plan for her resident to resident physical altercations that occurred on 12/14/2022 12/23/2022, and 3/5/2023. During the interview they also confirmed they do not have incident reports for the 12/14/22 and 12/23/22 incidents. During an interview on 5/1/23 at 10:20 AM with Resident #11 she stated, thank you, thank you, thank you Resident #27 no longer lives here, I slept this weekend, I feel safe now and love my home now. I used to feel unsafe and now everything has changed. During an interview on 5/3/23 at 11:19 AM with the facilities Housekeeping Supervisor revealed she had worked here for about five (5) years and the incident between Resident #27 and Resident #11 that occurred on 4/25/23 was the first incident she had heard of regarding Resident #27 being in a physical altercation with another resident, she then informed the day after the incident Resident #11 showed her a bruise on her collarbone. She also revealed she attends the facilities daily morning meetings. During an interview on 5/3/23 at 2:16 PM with the facilities ADON revealed the facility has had three (3) DON's in the past five (5) months. She informed multiple of Resident #27 resident to resident incidents were not put into the facilities Risk Management system on their Electronic Health Record (EHR) and so the facility did not know about them. She revealed the facility was now reading a daily document called, 24 hour progress notes, in case anything is missed that should be in Risk Management. Record Review of a document titled Self Reports dated 4/26/23 of the facilities self reports to DIA documented the facility only self reported the incidents that occurred on 12/14/2022 and 4/25/2023 for Resident #27. Record review of the facilities policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/2021 instructed the following: Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on record review, resident and staff interviews, and facility policy review the facility failed to implement safety measures and interventions for Resident #27 to protect residents from her physical resident to resident altercations for 2 of 3 residents reviewed (Residents #11 and #24). The facility failed to identify the root cause and implement interventions for Resident #27 aggression towards other residents potentially placing all residents at risk. The Iowa Department of Inspections and Appeals (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 14, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. Resident # 27 was placed on one to one supervision with staff for 24 hours a day, until further assessment and safety plan can be implemented. b. Resident #27 primary care physician has been notified of the alleged behavior. c. Resident #27 care plan will be revised according to the treatment plan. d. Facility staff and agency staff (prior to their next scheduled shift) have been/will be educated to: 1. Maintain a safe environment free from resident abuse by another resident who resided at the facility by placing them one to one until evaluated by the facilities interdisciplinary team involving facility management and the primary care physician, and family, if any, to determine if the need continues after a review of behavior trends with potential medication modification or placement elsewhere is determined with no observation and or documentation of behavior. The duration of the one to one will be based on the individual and continued exhibition of the behavior and will continue. 2. To report all allegations of abuse including physical, mental, psychosocial, sexual, verbal, and misappropriation immediately to their supervisor. The facilities management has been educated to report to DIA and/or local law enforcement within two (2) hours if applicable. 3. To fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. 4. Resident to resident altercation policy. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #27 dated 2/28/2023 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented no physical, verbal, or other behavioral symptoms directed towards others in the past 90 days. The MDS also documented she needed physical assistance of one person with transfers, dressing, walking, and locomotion. The MDS revealed diagnoses of depression, epilepsy (seizure disorder), and other neurological conditions. The MDS documented that she took antipsychotic medication (a type of psychiatric medication used to treat psychosis) and antidepressant medication (a type of medication used for treatment of depression and anxiety disorders). Record review of a Progress Note dated 11/21/2022 at 3:40 AM for Resident #27 documented yelling throughout the shift for staff to come to her room and when they entered she yelled at them, she cursed at staff by calling them bitches or fagots. Each time she cursed at staff and used vulgar names, education was provided to her that it was rude to talk like that and asked her to please stop. The Progress Note also documented none of the interventions had been effective and she continued to yell. Record review of a Progress Note dated 12/2/22 at 5:44 AM for Resident #27 documented She was awake the majority of the shift, yelling out, cussing, and calling staff bitch redirections attempted and unsuccessful. Record review of Resident #27 Progress Note dated 12/14/22 at 5:43 PM documented another female resident reached across the table attempting to grab a book and Resident #27 became upset and repeatedly yelled at the other resident to stop. Resident #27 yelled, fucking bitch and the other resident yelled bitch. Resident #27 propelled her wheelchair around the table and open handed slapped the other female resident across the right side of the face hitting her glasses. The residents were separated and the Administrator was notified. Record review of Resident #27 Progress Note dated 12/23/22 at 3:39 PM documented she open handed hit another female resident in the back of the head because the other resident was singing. The Progress note documented the Administrator was notified and Resident #27 was moved to a different room for the safety of other residents at the facility and 30 minute checks on Resident #27 be started. The MDS for Resident #11 dated 3/30/23 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented she needed supervision of one person with transfers, walking, and locomotion. The MDS revealed diagnoses of anxiety, depression, and bipolar disorder. The MDS documented that she took antipsychotic and antidepressant medications. Record review of Resident #11 Progress Note dated 12/23/22 at 3:45 PM documented she was sitting in a chair in the dining room quietly singing to herself when another female resident came up behind her and open handed hit her in the back of the head. The residents were separated and no injuries found to the back of her head. She was crying out in pain. The Administrator was notified, emergency services, and waiting for an officer to come to the facility. Record review of Resident #11 Progress Note dated 12/23/2022 at 8:26 PM documented she was upset with the lack of consequences the other female received from the police officer today. She stated she was going to call the state, she informed she feels that something needed to be done, the nurse explained that she had the right to call the state and make a complaint. Resident #11 stated she felt better, but more needed to be done because she does not feel safe living here with someone who would hit her for no reason. Record review of Resident #24 Progress Note dated 3/5/2023 at 1:36 PM documented another resident threw a glass of water on him while he was in the dining room cleaning off the tables. Resident #24 stated the cup itself didn't hit him, just the water. Resident #24 denied being fearful of the other resident and stated he doesn't know what he did. Resident #27 was visibly wet and staff assisted him to change his clothes. Record review of Resident #27 Progress Note dated 3/5/2023 at 1:38 PM documented she was in the dining room and was trying to propel herself back to her room, but another male resident was in her way and didn't move so she threw her glass of water on him. He moved and she propelled herself back to her room. Record review of Resident #27 Progress Note dated 4/16/2023 at 4:02 AM, documented Resident #27 was cursing at staff and throwing objects at staff when assisting her to get dressed and into her wheelchair. Record review of Resident #27 Progress Note dated 4/16/23 at 7:20 PM, documented she began having aggressive threatening verbal behaviors while the facility's Doctor was in the facility seeing other residents. Resident #27 behaviors escalated to her throwing a phone and other objects at other residents. At the time the facility's Doctor decided it was safest and best to have her sent out for psychiatric evaluation and review of medications. The facility placed a call to 911 and moved her to the chapel. Resident #27 calmed but continued to be very aggressive in threats and intent on what she would do to other residents. Emergency services arrived and she left the facility. During an interview on 4/25/23 at 9:37 AM with Resident #11 revealed another resident here at the facility, Resident #27, had hit her multiple times. She revealed she was scared to live here and the facility had done nothing about it. She further informed she was at the point where she felt so unsafe living here she can't eat or sleep at night, she informed she hadn't slept for months because she was scared Resident #27 would come into her room. Record review of Resident #27 Progress Note dated 4/25/23 at 3:26 PM, documented a late entry of Incident, Accident,Unusual Occurrence Note. The Progress Note revealed Resident #27 was in the dining room going to another resident's table. The other resident stated don't sit here. This resident (Resident #27) picked up a full can of soda and threw it at the other resident. This resident was immediately removed from the situation and taken to her room for a private interview of what happened. Resident #27 stated the other resident pissed her off and told her she couldn't sit at the table, and then stated fuck you, you stupid son of a bitch, nobody tells me what to do. The facility started 15 minute checks at 3:00 PM and the police were notified. During an interview on 4/25/2023 at 2:08 PM with the facilities Administrator revealed Resident #27 and Resident #11 just had a physical resident to resident altercation where Resident #27 threw a full pop can at Resident #11 shoulder. He revealed he was working on reporting it to the State Agency and the local police department. He then informed Resident #27 and Resident #11 have not had physical altercations in the past that he was aware of. He revealed they will occasionally have arguments, he stated they had a love/hate relationship for some reason. During an interview on 4/25/23 at 2:16 PM with Resident #11 revealed she was tired of the abuse by Resident #27 and something had to be done about it. She informed Resident #27 threw a full pop can at her shoulder about 15-20 minutes ago. She stated, I'm not a target, I am a human being, something has to get done. She revealed the facility had done nothing about the continued abuse besides removing her at the time of the abuse, but then it happens again. She asked the question: how do I know if I am going to be safe? And stated the facility does nothing and so this keeps happening. She then informed this past Saturday Resident #27 hit her in the left arm in the afternoon. Throughout the interview Resident #11 was observed to have redness throughout her face, shaking in her arms, difficulty forming sentences due to excessive crying, and nasal drainage (runny nose). During an interview on 4/26/23 at 1:25 PM Staff D, Certified Nurse Aide (CNA), revealed Resident #27 has had many incidents of aggression with other residents and staff here. He recalled the following incidents: a. Resident #27 threw a pop at Resident #11 b. Resident #27 punched Resident #11 in the face less than 2 months ago in the dining room c. Resident #27 slapped Resident #22 in the face He revealed when altercations happen between residents the residents are separated and both residents are then spoken with to get both sides of the story. He informed the nurse on and the next nurse on duty is notified of the incidents. He stated he does not remember the nurses names that were working during b and c resident to resident physical altercations he mentioned because the facility used agency nurse staffing at the time. During an interview on 04/27/2023 at 8:39 AM with the Assistant Director of Nursing (ADON) and the facilities Social Services Director revealed the facility did not investigate to identify and implement root cause analysis interventions for Resident #27 Care Plan for her resident to resident physical altercations that occurred on 12/14/2022, 12/23/2022, and 3/5/2023. During the interview they also confirmed they do not have incident reports for the 12/14/22 and 12/23/22 incidents. During an interview on 5/1/23 at 10:20 AM with Resident #11 she stated, thank you, thank you, thank you Resident #27 no longer lives here, I slept this weekend, I feel safe now and love my home now. I used to feel unsafe and now everything has changed. During an interview on 5/3/23 at 11:19 AM with the facilities Housekeeping Supervisor revealed she had worked here for about five (5) years and the incident between Resident #27 and Resident #11 that occurred on 4/25/23 was the first incident she had heard of regarding Resident #27 being in a physical altercation with another resident, she then informed the day after the incident Resident #11 showed her a bruise on her collarbone. She also revealed she attended the facilities daily morning meetings. During an interview on 5/3/23 at 2:16 PM with the facilities ADON revealed the facility has had three (3) DON's in the past five (5) months. She informed multiple of Resident #27 resident to resident incidents were not put into the facilities Risk Management system on their Electronic Health Record (EHR) and so the facility did not know about them. She revealed the facility was now reading a daily document called, 24 hour progress notes, in case anything was missed that should be in Risk Management. Record review of the facilities policy titled, Resident-to-Resident Altercations, last revised on 12/2016 instructed the following: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; c. Notify each resident's representative and Attending Physician of the incident; d. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; e. Consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness; h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; i. Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. Record Review of a document titled Self Reports dated 4/26/23 of the facilities self reports to DIA documented the facility only self reported the incidents that occurred on 12/14/2022 and 4/25/2023 for Resident #27. Record review of the facilities policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/2021 instructed the following: Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on record review and interview, the facility failed to assure that a resident with a pressure sore received necessary treatment and services, consistent with professional standards of practice, to promote healing of a Stage 4 pressure ulcer (Resident #16). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to the Minimum Data Set (MDS) assessment tool dated 11/25/21, Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 10 of 15 possible points on the Brief Interview for Mental Status Test, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS identified the resident as at risk for pressure ulcers and indicated the resident had an unhealed Stage 4 pressure ulcer during the 7 days which led up to 11/25/21. The MDS also identified the facility had placed a pressure reducing cushion in the resident's chair, added nutrition and hydration interventions, and provided pressure ulcer care and application of non-surgical dressings. Resident #16's care plan revised on 8/24/21 contained the following information: a. Resident #16 could not transfer independently due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff to use a mechanical Hoyer lift for all transfers and to apply a bariatric mattress to the resident's bed to make mobility easier for the resident. The care plan revealed the resident used an electric wheelchair for mobility and transfer bars on their hi/low electric bed to assist with bed mobility. b. Resident #16 had a potential for skin tears to the buttocks and back related to immobility. The care plan directed staff to encourage good nutrition and hydration to promote healthier skin. c. Resident #16 had impaired skin on their sacrum. The care plan directed staff to: - Educate the resident, family and caregivers of causative factors and measures to prevent skin injury. - Monitor for and document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . - Complete weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudate, and any other notable changes or observations. d. Resident #16 has potential/actual impairment to skin integrity and directed staff to keep the resident's skin clean and dry and use lotion on dry skin. The resident's care plan lacked any information related to the Stage 4 pressure on the resident's coccyx and interventions implemented which include a pressure reducing device in the resident's chair, a turning and repositioning program, nutrition and hydration supplements/extra calories or fluids, pressure ulcer/injury care, and the applications of non-surgical dressings, ointment, or medications. The Braden Scale assessments (tool used to evaluate risk of development of a pressure ulcer) documented a score of 10-12 indicating that the resident was at a high risk for pressure sore development, 13-14 meant the resident was at moderate risk, and 15-16 meant the resident was at risk for pressure ulcer development. Review of Braden Scale assessments) staff completed for Resident #16 from 5/17/21 - 11/24/21 documented the resident scored the following: on the following dates: 1. 16 on 5/17/21. 2. 12 on 8/09/21 3. 12 on 8/16/21 4. 15 on 8/24/21 5. 11 on 8/30/21 6. 15 on 8/30/21 7. 10 on 9/06/21 8. 13 on 9/13/21 9. 10 on 9/20/21 Resident #16's Wound Evaluation Forms revealed the following information: - 08/13/21: In-house acquired rash from incontinence associated [CONDITION(S)] that measured (Length x Width x Depth) 11.75 cm x 8.29 cm x no measurement. - 08/16/21: Rash improved and measured 12 cm x 8.51 cm x no measurement. No dressing applied. Photo included that revealed an open area on the coccyx with no measurements. - 8/24/21: Stage 3 pressure ulcer 8.18 cm x 6.66 cm x not measured with no exudate and 80% granulation tissue. - 9/3/21: Stage 3, coccyx pressure ulcer 2.56 cm x 0.61cm x no measurement and no other information. - 9/4/21: Rash healed. In included photo, staff documented Stage 3 pressure ulcer. - 09/4/21: Stable, Stage 3 coccyx pressure ulcer 5.06 cm x 2.79 cm x no measurement with 100% granulation tissue. - 09/10/21: Improving, Stage 3 coccyx pressure ulcer 0.23 cm x 1.72 cm x not measured with no exudate. - 09/17/21: Stage 3 coccyx pressure ulcer 4.91 cm x 1.08 cm x not measured with no other information. - On 9/24/21: Stable, Stage 3 coccyx pressure ulcer 1.61 cm x 1.24 cm x not measured. - On 10/1/21: Deteriorating, Stage 3 coccyx pressure ulcer 4.05 cm x 3.53 cm x not measured with no exudate. - On 10/10/21: Improving, Stage 3 coccyx pressure ulcer 4.46 cm x 1.98 cm x not measured without exudate. - On 10/14/21: Stalled, Stage 3 coccyx pressure ulcer on the resident's coccyx area measured 4.53 cm x 3.64 cm x not measured. - On 10/15/21: Stable, Stage 3 coccyx pressure ulcer 3.04 cm x 2.68 cm x not measured with fragile skin surrounding the wound that was at risk for breakdown. - On 10/17/21: Stable, Stage 3 coccyx pressure ulcer 4.72 cm x 3.29 cm x not measured with the fragile skin surrounding the wound at risk for breakdown. The wound drained serosanguineous fluid. - On 10/23/21: Stalled, Stage 3 coccyx pressure ulcer 4.78 cm by 6.27 cm by not measured. - On 10/29/21: Stage 3 coccyx pressure ulcer 4.3 cm x 4.68 cm x not measured with no other information documented. - On 11/6/21: Stage 3 coccyx pressure ulcer 5.55 cm x 7.01 cm x not measured with no other information documented. - On 11/13/2: Stable, Stage 3 coccyx pressure ulcer 5.26 cm x 6.55 cm x not measured. - On 11/26/21: Stage 3 coccyx pressure ulcer 4.16 cm by 2.69 cm by not measured that was being monitored. The wound bed was slough, edges appeared non-attached, skin surrounding the wound was fragile and at risk for breakdown, the skin was macerated, wet, white, and contained waterlogged tissue. - On 12/8/21: Stable, Stage 3 coccyx pressure ulcer 4.24 cm x 2.69 cm x not measured. Staff documented the wound bed as 90% slough, the skin surrounding the periwound was blanching with a moderate amount of purulent drainage and a saturated dressing. - On 12/16/2: Improving, Stage 3 coccyx pressure ulcer on the resident's coccyx area 5.51 cm x 2.99 cm x not measured and wound bed 90% slough. The skin surrounding the periwound was blanching and edges not attached. - On 12/27/21: Stage 3 coccyx pressure ulcer 3.44 cm x 4.67 cm x not measured with a bleeding and red/pink wound bed with light serosanguineous drainage. The skin surrounding the periwound was blanching with non-attached and rolling edges. - On 1/6/22: Stage 3 coccyx pressure ulcer 2.68 cm x 2.29 cm x not measured with no other information documented. - On 1/18/22: Improving, Stage 3 coccyx pressure ulcer 1.97 cm x 1.07 cm x not measured. - On 1/21/22: Improving, Stage 3 coccyx pressure ulcer 1.08 cm x 2.42 cm x not measured. - On 1/30/22: Improving, Stage 3 coccyx pressure ulcer 1.3 cm x 2.42 cm x not measured. - On 2/3/22 Improving, Stage 3 coccyx pressure ulcer 1.77 cm x 1.51 cm x not measured. ***Review of Resident #16's notes from wound care evaluations provided via telemedicine revealed the following information: An initial evaluation on 10/14/21 at 3:34 p.m. documented Resident #16 had a Stage 4 pressure ulcer measured 5 cm x 5.6 cm x 0.1 cm (Length x Width x Depth) with 70% slough and light serosanguinous drainage. Physician documented an order that directed staff to discontinue silver [MEDICATION(S)] cream and [MEDICATION(S)] sheet (thin) and start Leptospermum honey and hydrogel non-adhesive sheet. Change daily. On 10/25/21 at 3:00 p.m., Resident # 16 had a Stage 4 pressure ulcer that measured 7 cm x 7 cm x 0.8 cm with 60% slough and a moderate amount of serosanguinous drainage. The physician documented the wound had deteriorated. Dressing change orders included Santyl, alginate calcium, and gauze island border. On 11/4/21 at 1:49 p.m., Resident #16 had a Stage 4 coccyx pressure ulcer that measured 7.2 cm x 6.1 cm x 1 cm with 60% slough, a 4cm x 2.8 cm black area and a moderate amount of serosanguinous drainage. The physician documented the wound had deteriorated. Dressing change orders included alginate calcium with a gauze island border. Discontinue the Santyl. On 11/12/21 at 9:34 a.m., Resident #16 had a Stage 4 pressure ulcer on the coccyx area that measured 6.2 cm x 9 cm x not measurable. The area contained 80% slough, and a moderate amount of serosanguinous drainage. Physician documented the wound had deteriorated. Dressing change orders included Iodosorb gel with Alginate calcium covered with a foam silicone border. On 11/19/21 at 9:32 a.m., Resident #16 had a Stage 4 pressure ulcer on the coccyx area measured 4 cm by 3.8 cm by not measurable. The area contained 50% slough, a reddened wound radius, and a macerated area that measured 5.5 cm x 4.8 cm and a moderate amount of serosanguinous drainage. The physician documented the wound had improved. Dressing change orders include Iodosorb gel with Alginate calcium covered with a foam silicone border. On 11/23/21 at 5:35 p.m., Resident #16 had a Stage 4 pressure ulcer on the resident's coccyx area that measured 7 cm x 3.3 cm x not measurable. The area contained 50% slough, a reddened periwound radius, a macerated 13.1 cm x 11 cm area and heavy amount of serosanguinous drainage. Physician documented that the wound had deteriorated. Dressing change orders included [MEDICATION(S)] ointment with Alginate calcium silver covered pad with a foam silicone border. On 12/3/21 at 3:56 p.m., Resident #16 had a Stage 4 pressure ulcer on their coccyx that measured 5 cm x 2.4 cm x not measurable that contained 50% slough and a moderate amount of serosanguinous drainage. Physician documented the wound had improved. Dressing change orders included [MEDICATION(S)] ointment with Alginate calcium with silver covered with a foam silicone border. On 12/10/21 at 2:54p.m., the facility rescheduled the resident's appointment. On 12/17/21 at 11:09 p.m., Resident #16 had a Stage 4 pressure ulcer on their coccyx that measured 5.2 cm x 3.3 cm x 0.4 cm with 50% slough and a moderate amount of serosanguinous drainage. The physician documented the wound had not changed. Dressing change orders included Discontinue the [MEDICATION(S)] ointment with alginate calcium with silver and cover with foam silicone border. Start Iodosorb gel with alginate calcium with silver and a super absorbent pad to cover. On 12/21/21 at 5:26 p.m., Resident #16 had a Stage 4 pressure ulcer on their coccyx area that measured 5.3 cm x 3.3 cm x 0.2 cm that contained 40% slough and a light amount of serosanguinous drainage. The physician documented the wound had improved and noted education was given with regard to the importance of repositioning. Dressing change orders included Iodosorb gel with alginate calcium with silver and a super absorbent pad to cover. On 12/30/21 at 3:32 p.m., the resident had a Stage 4 pressure ulcer on their coccyx area that measured 4 cm x 3 cm x 0.2 cm and contained 40% slough and a moderate amount of serosanguinous drainage. The physician documented the wound had improved and noted education was given on the importance of repositioning. Dressing change orders included Iodosorb gel with alginate calcium with silver and a super absorbent pad to cover. On 1/7/22 at 11:59 a.m., the facility rescheduled the Resident #16's appointment. On 1/13/22 at 3:32 p.m., the resident had a Stage 4 pressure ulcer on their coccyx area that measured 2.7cm x 2.9 cm x 1 cm that contained 40% granulation tissue and a moderate amount of serosanguinous drainage. Physician documented the wound had improved and noted education was given regarding the importance of repositioning. Dressing change orders included Iodosorb gel with alginate calcium with silver with a super absorbent pad to cover. On 1/20/22 at 3:32 p.m., the resident had a Stage 4 pressure ulcer on their coccyx area that measured 2.7 cm x 2.9 cm x 1 cm that contained 40% granulation tissue and a moderate amount of serosanguinous drainage. The physician documented the wound had not changed and noted education was given on the importance of repositioning. Dressing change orders included Iodosorb gel with alginate calcium with silver and cover with a super absorbent pad. On 1/2/22 at 12:03 a.m., the facility rescheduled the Resident #16's appointment. On 2/3/22 at 2:00 p.m., the resident had a Stage 4 pressure ulcer on their coccyx that measured 2 cm x 2 cm x not measurable with 40% granulation tissue and a moderate amount of serosanguinous drainage. The physician documented the wound had improved and noted education was given regarding the importance of repositioning. Dressing change orders included Iodosorb gel with alginate calcium with silver and a super absorbent pad to cover. Resident #16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - 8/24/21 Apply [MEDICATION(S)] Ointment to buttock every shift for skin breakdown - 8/31/21 Give [MEDICATION(S)] in the morning - 8/31/21 Give Mighty Shake Review of Resident #16's MAR/TAR for September 2021 revealed the following: - 8/24/21 Apply [MEDICATION(S)] Ointment to buttock every shift for skin breakdown - 8/31/21 Give [MEDICATION(S)] in the morning - 8/31/21 Give Mighty shake The Documentation Survey Report for September 2021 related to mighty shake administration revealed no signature on 9/15/21 to show staff gave it that day. On 9/26/21 and 9/29/21, staff had documented not applicable. Review of Resident #16's MAR/TAR for October 2021 revealed the 8/24/21 [MEDICATION(S)] order lacked signatures for day and evening shift on 10/1/21, the 8/31/21 [MEDICATION(S)] order showed on 10/4/21 staff had documented awaiting from the pharmacy. The Documentation Survey Report for October 2021 related to mighty shake administration revealed staff had documented not applicable on 10/2/21, 10/7/21, 10/8/21, 10/20/21, 10/21/21, 10/22/21, 10/28/21, and 10/30/21. The following dates lacked signatures to show staff gave the shake on 10/4/21, 10/9/21, 10/10/21, 10/27/21, and 10/29/21. The October 2021 MAR/TAR contained an order dated 10/11/22 and discontinued on 10/22/21 that directed staff to cleanse wound with normal saline, apply silver [MEDICATION(S)] cream over the coccyx wound and then apply Duoderm to cover. Change every 3 days and as needed until healed on day shift. The MAR/TAR failed to contain a signature on 10/14/21 to show staff completed the dressing change as ordered. The MAR/TAR for November 2021 contained orders dated 8/31/21that directed give Resident #16 [MEDICATION(S)] in the morning and give the resident Mighty Shake. The Documentation Survey Report dated November 2021 revealed documentation that showed staff failed to sign the Mighty Shake documentation as given on 11/3, 11/12, 11/13, 11/18, 11/19, 11/22, and 11/26, and had documented not applicable on 11/5 and 11/13. The November 2021 MAR/TAR showed an order dated 11/6/21 at 11:00 a.m. that directed staff to apply alginate calcium to the coccyx wound and cover with gauze island with border every day for 20 days. The TAR failed to contain documentation to show staff completed the treatment on 11/9, 11/10, 11/18, and 11/23, and also failed to contain a treatment order at all from 1/26 - 11/30. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The MAR/TAR for December 2021 revealed an order that directed staff to give [MEDICATION(S)] in the morning and an order to give Mighty shake, both dated 8/31/21. Review of the Documentation Survey Report dated December 2021 revealed documentation regarding mighty shake. On 12/8/21, 12/10/21, 12/16/21, and 10/29/21, staff documented not applicable. Also, the report failed to contain a signature to show staff gave the mighty shake as ordered on 12/19/21. The TAR dated December 2021 failed to contain dressing change orders to address the open area on the resident's coccyx from 12/1/21- 12/17/21. The TAR dated December 2021 contained a 12/18/21 at 6:00 a.m. order that directed staff to cleanse the resident's wound with normal saline, place iodosorb gel into wound bed, follow with calcium alginate with silver 4 pad into wound, and cover with [MEDICATION(S)] foam dressing. The TAR failed to contain a signature to show staff provided the wound treatment/changed the dressing as ordered on 12/21/21. Review of Resident #16's MAR/TAR for January 2022 revealed an order dated 8/31/21 that directed staff to give [MEDICATION(S)] in the morning and an order dated 8/31/21 that directed staff to give a Mighty Shake. Mighty Shake administration recorded on the Documentation Survey Report for January 2021 revealed 1/13/22 and 1/18/22 lacked a signature to show staff gave Mighty Shake as ordered on those dates. On 1/28/21, staff had documented, not applicable. The January 2022 TAR contained an order dated 12/18/21 at 6:00 a.m. that directed staff to complete the following wound treatment daily on day shift: cleanse the resident's coccyx wound with normal saline, place iodosorb gel into wound bed and follow with calcium alginate silver 4, then cover with [MEDICATION(S)] foam dressing. Review of the TAR revealed no documentation to show staff changed the dressing as ordered on the following days: 1/3/22, 1/7/22, and 1/24/22. Observation on 01/26/22 at 10:09 a.m., revealed Staff A, Licensed Practical Nurse (LPN) entered the room of Resident #16 to provide wound care. Staff A entered the room and applied gloves without performing hand hygiene, removed the soiled wound dressing and put it in the garbage followed by her soiled gloved. Staff A then applied new gloves without performing hand hygiene. She then picked up a syringe, filled it with sterile water with gloved hands, pushed water out of the syringe into the wound bed with her right hand and with her left hand held a 4x4 piece of gauze to absorb the water. Once the syringe was empty, Staff A took the 4x4 that she used to absorb the water and dabbed the area around the wound, then discarded the wet 4x4 gauze and without changing gloves, picked up more 4x4 gauze and dabbed the area dry. Staff A removed her gloves toward and into the garbage and did not perform hand hygiene before reapplying gloves. With a gloved hand, she picked up a cotton tipped applicator, applied iodosorb gel to the wound bed, and tossed the cotton tipped applicator into the garbage. Without changing gloves Staff A with a gloved hand picked up calcium alginate with silver pad and cut the dressing to fit the wound size. Staff A then placed the calcium alginate with silver dressing on top of iodosorb gel in the wound and applied [MEDICATION(S)] foam dressing over the calcium alginate with silver. With the same gloved hands, she dated and initiated the [MEDICATION(S)] foam dressing with a permanent marker, assisted the resident into a comfortable position, and covered him with blankets. Staff A then removed her gloves into the garbage, did not perform hand hygiene and left the room . Staff A exited Resident #16 ' s room and did not perform hand hygiene prior to leaving the room. In an interview on 02/08/22 at 04:39 p.m., Staff Q, Certified Nursing Assistant (CNA) stated that staff are supposed to turn and reposition all residents that cannot move on their own every 2 hours, but it does not get done due to short staffing. Staff Q added that CNA staff used to have to chart, but the facility took that away because staff members were not charting correctly. Staff Q commented the residents in the facility are not always getting the care they need. On 02/09/22 at 08:37 a.m., Staff V, Nurse Practitioner (NP) reported Resident #16 just came under the care of his team. Staff V said he was aware the resident had a Stage 4 pressure ulcer, but was under the understanding it had healed and had opened up again. Staff V revealed he talked in great depth with staff and the resident about the importance of turning and repositioning Resident #16 every 2 hours. Staff V said he talked with the resident about staff turning him and if staff was not turning him, he was to call the staff and ask them to turn him. Staff V, NP revealed he had not personally seen the wound at the time of the interview. On 02/09/22 at 09:16 a.m., Staff W, NP said she did not have any current updates on Resident #16's Stage 4 pressure ulcer. In a subsequent interview on 02/09/22 at 10:31 a.m., Staff W, NP reported on 8/16/21, the facility first notified her of an open area about the size of a nickel with good granulation tissue on Resident #16's coccyx. On 8/26/21, she stated staff notified her via fax that Resident #16 had a pressure ulcer on his coccyx area and they planned to use [MEDICATION(S)] ointment and moisture barrier for the wound area. She added the fax did not include measurements or the stage of the pressure ulcer. Staff W reported she was under the impression the facility would have a wound nurse care for the resident's pressure ulcer in the facility. Staff W, NP verified after the initial notification, she signed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 02/09/22 at 09:44 a.m., Staff X, CNA revealed when Resident #16 came back from the hospital he was starting to get a pressure sore and the facility was taking pictures of it on the tablet. Staff X reported that since the resident could not move himself up in his wheelchair anymore, he had to use a manual chair and he said it made his bottom hurt. Staff X said Resident #16 did not ask to be repositioned, but they do not recall a time when he refused to be repositioned. Staff X reported Resident #16 had a lot of pain when transferring with the Hoyer lift, especially to the shower because the bath sheet the facility used rubbed on his pressure sore. On 02/09/22 at 09:52 a.m., Staff U, CNA said she remembered Resident #16 had some redness on his backside prior to his hospital admission and the facility applied aloe. She reported when he returned from the hospital he had a horrible bed sore. When asked, Staff U said she could not recall a time when Resident #16 refused to be repositioned, but he would at times refuse to allow staff to use the wedge when repositioning. On 02/09/22 at 10:25 a.m., Staff A, Licensed Practical Nurse (LPN) reported when Resident #16 returned from the hospital, he had a huge wound on his coccyx and staff started some kind of wound care. She added it took a long time to get telehealth started for his wound consults, but now Resident #16 has an appointment with telehealth wound care weekly. Staff A stated there were a couple of instances when the facility had to cancel the appointments due to staffing challenges. In an interview on 02/09/22 at 10:44 a.m., Staff Y, LPN said they cannot remember if Resident #16's pressure ulcer began at the hospital or the facility as the resident has had several skin conditions, but did remember that when he readmitted to the facility from the hospital he was unable to reposition himself anymore and his pressure ulcer continually got worse. Staff Y said Resident #16 would sometimes refuse to allow staff to reposition him, but not very often and added if another staff member asked, the resident would let them. On 02/09/22 at 11:40 a.m., Staff Z, LPN stated an RN must initiate skin sheets because LPNs are not allowed to do so. On at 08:20 a.m., Staff O, CNA said when she started working at the facility, she remembered Resident #16's pressure ulcer had been fairly deep and yucky and draining pus. She reported Resident #16 will ask to stay on one side longer than 2 hours if comfortable, but does not necessarily refuse to be repositioned. Staff O added night shift works frequently works with 1 CNA and 1 licensed nurse, which makes it hard to turn and reposition residents every 2 hours. In an interview on 02/14/22 at 08:57 a.m., Staff AA, Hospice Administrator reported she reviewed Resident #16's hospice admission documents and found the medical chart lacked documentation regarding Resident #16's pressure ulcer. The signed Order Summary Report dated 1/24/22 revealed the following orders: - Give Healthy Shot 0.65 one time a day for wound healing starting 11/23/21 - Give [MEDICATION(S)] every morning beginning on 8/31/21 - Give Mighty Shake (dated 8/31/21) - Cleanse coccyx wound with normal saline, place iodosorb gel into wound bed, apply calcium alginate silver pad (as needed), and cover with [MEDICATION(S)] foam dressing beginning 12/18/22. The Prevention of Pressure Ulcer policy dated 01/15 documented its purpose: to promote good skin integrity, relieve pressure, restore circulation and promote skin protection in the affected area. The policy directed any reddened area that remains red longer than thirty minutes after pressure is relieved is at high risk for a pressure sore to develop. The policy directed staff to use preventative measures, note any change in skin integrity, educate and notify the resident and family, and involve the physician. The policy documented establish care plan to identify the problem including diagnoses, pre-existing conditions, nutrition, and past history of ulcers , formulate goals with resident input, develop approaches with responsible disciplines identified, and make staff aware of preventative measure. The Assessments (for) Residents at Risk facility policy dated January 2015 revealed its purpose: to minimize skin problems, to identify risk factors of residents at risk and identify prevention interventions. The policy directed staff to: a. Complete Braden Scale on admission, weekly for the first 4 weeks after admission, quarterly and change of cognitive or functional condition. b. Identify at risk residents by completing and utilizing the MDS c. Complete Care Plan to minimize risks and initiate interventions d. Keep family and physician informed of findings and skin status e. Reevaluate periodically and alter plan of care as needed The policy directed that documentation should address risk factors and preventive measures upon admission to include non-compliance and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 02/14/22 at 09:19 a.m. the DON reported she expected staff to complete documentation and sign all wound treatment orders for Resident #16's pressure ulcer dressings on the MAR/TAR. With order changes, she expected staff to update the MAR/TAR with the new order and discontinue the existing order. The DON verified she expected the care plan to reflect Resident #16's actual care needs and address actual concerns for them to flow over to the Kardex for CNA charting, including: a. The presence of the Stage 4 pressure ulcer and corresponding information b. The specifics related to wound specialist care c. The pressure reducing chair device in use d. Nutritional and hydration interventions being used e. Pressure ulcer/injury care and non-surgical dressings used. The DON further verified staff should have given Resident #16 the Mighty Shake daily in accordance with physician orders. Staff A, LPN reported during the same interview that staff completed dressing changes for Resident #16 in November and December, but the facility had a hard time obtaining orders from the wound care physician.

Based on observations, record review, and staff interviews, the facility failed to follow proper infection control precautions and guidelines. The facility failed to follow current CDC guidance for staff returning to work after testing positive for Covid-19, staff did not appropriately use PPE with cares and when moving between resident rooms, and staff failed to provide adequate hand hygiene during cares for 5 of 5 residents reviewed (#4, 5, 6, 7, and #8). Due to these findings, an Immediate Jeopardy (IJ) was identified to resident health and safety. The facility reported a census of 48 residents. Findings include: The CDC website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fhcp-return-work.html) titled Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance, updated 8/10/20, gave the following guidance: Return to Work Criteria for HCP with [DIAGNOSES REDACTED]-CoV-2 Infection Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. HCP with severe to critical illness or who are severely immunocompromised: At least 10 days and up to 20 days have passed since symptoms first appeared At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved Consider consultation with infection control experts Note: HCP who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 10 days and up to 20 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. As described in the Decision Memo, an estimated 95% of severely or critically ill patients, including some with severe immunocompromise, no longer had replication-[MEDICAL CONDITION] 15 days after onset of symptoms; no patient had replication-[MEDICAL CONDITION] more than 20 days after onset of symptoms. The exact criteria that determine which HCP will shed replication-[MEDICAL CONDITION] for longer periods are not known. Disease severity factors and the presence of immunocompromising conditions should be considered in determining the appropriate duration for specific HCP. For example, HCP with characteristics of severe illness may be most appropriately managed with at least 15 days before return to work. Test-Based Strategy for Determining when HCP Can Return to Work. In some instances, a test-based strategy could be considered to allow HCP to return to work earlier than if the symptom-based strategy were used. However, as described in the Decision Memo, many individuals will have prolonged [MEDICAL CONDITION] shedding, limiting the utility of this approach. A test-based strategy could also be considered for some HCP (e.g., those who are severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the HCP being infectious for more than 20 days. The criteria for the test-based strategy are: HCP who are symptomatic: Resolution of fever without the use of fever-reducing medications and Improvement in symptoms (e.g., cough, shortness of breath), and Results are negative from at least two consecutive respiratory specimens collected =24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular [MEDICAL CONDITION] assay to detect [DIAGNOSES REDACTED]-CoV-2 RNA. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). HCP who are not symptomatic: Results are negative from at least two consecutive respiratory specimens collected =24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular [MEDICAL CONDITION] assay to detect [DIAGNOSES REDACTED]-CoV-2 RNA. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). The Infection Prevention and Control Manual for corporate policy on hand hygiene, gloves and gowns dated 2019 directed the following: - The single most effective means of reducing potential for transmission of infection is hand antisepsis before and after contact with residents, including glove removal. - Washing hands can accomplish hand antisepsis with soap and water or by using waterless alcohol based hand rub. - During providing care for residents, gloves will be changed after contact with infective material that may contain high concentrations of microorganisms. - Wearing gloves is not a substitute for hand hygiene. Gloves will be removed and discarded before leaving the resident's room, followed by hand hygiene. - Don gowns upon entry into the room or cubicle. Remove the gown and observe hand hygiene before leaving the resident care environment. During an interview with the Nurse Consultant on 10/13/20 at 11:10 AM, she stated the facility's current census was 48 and all but 2 residents were currently positive for Covid-19. She added that the right hall has all Covid-19 positive residents and that is where they are staffing Covid-19 positive staff that are asymptomatic, center hall is full isolation with Covid-19 positive residents, and left hall has two residents that are Covid-19 negative and they have them cohorted at the end of the hall. Observation on 10/13/20 at 12:45 PM, revealed Staff B in a resident's room on center hall assisting Resident #4 with her meal wearing full PPE. She exited Resident #4's room, walked across the hall to assist Resident #5 in her room with her meal, but failed to change or remove her PPE. At 12:55 PM Staff B, exited the room without removing or changing her PPE and went to Resident #6's room to assist her with using the bathroom. Staff B shut the door, provided privacy, and explained cares. She then assisted the resident into the sit to stand lift sling, fastened it, took her into the bathroom, lowered the resident's pants and brief and then adjusted the lift. While still wearing the same PPE (including the same gloves first noted at 12:45 PM), she adjusted the blankets on Resident #6's recliner and grabbed some perineal wipes off the dresser. Staff B then re-entered the bathroom, raised the lift and provided perineal care with the wipes. She used one wipe for each swipe and started by cleaning the front vaginal area before moving to the rectal area, but did not remove the soiled gloves after she finished providing perineal care. She then pulled up the resident's brief and pants and moved the resident (while she remained on the lift) back to her recliner. While still wearing the same gloves, Staff B moved the resident's table away from her recliner, used the lift controls to lower the resident into the recliner, and removed the sling from around the resident. The aide then handed her the television remote, call light, and ice water. Staff B then left the room and went half way down the hall to a trash can and removed her gloves and gown, but never washed her hands or used hand sanitizer. Observation revealed Staff B left the center isolation hall to go into the dining room to obtain the ice chest, filled it with ice from the ice machine, and then went back to center hall. Staff B proceeded to don a new gown and gloves, but never washed her hands or used hand sanitizer prior to beginning to pass ice and water to the residents. During an observation of care on 10/13/20 at 2:20 PM, Staff C closed Resident #7's door, and explained cares to the resident. Staff D washed her hands and donned gloves. Both staff leaned the Resident #7 forward and applied a gait belt. Staff D held the resident while Staff C lowered the resident's pants and brief. Staff C provided perineal care to the front groin area with one wipe in her left hand, then grabbed a wipe from the clean container with her dirty gloved left hand and wiped the rectal area. She then grabbed a wipe from the wipe container with her dirty gloved left hand and wiped the rectal area a second time. Staff C disposed of the wipes in a clear liner on the bed, pulled the brief out of the resident's pants, discarded it on the bed, grabbed a clean brief, inserted it into the pants and pulled up clean brief and pants. While wearing the same gloves, Staff C helped Staff D lower Resident #7 back into his recliner, and grabbed the walker to move it out of the way with her left hand while her right arm and hand were assisting the resident with repositioning. While wearing the same gloves, she moved his bed side table, applied his oxygen nasal cannula, adjusted his position with a wedge cushion, and gave him his call light. Staff D removed her gloves after cares, washed her hands, and then left the room. Staff C picked up the liner of trash and left the room while wearing the same PPE and proceeded up the hall. During an observation of care on 10/13/20 at 2:35 PM, Staff C and Staff D entered a resident room, washed their hands, and donned gloves. They provided privacy and then repositioned Resident #8 to the right side. Staff C used her gloves to check the brief for incontinence and stated the resident was dry. As the resident lay on her right side, the staff propped her with pillows. Staff D removed her gloves, washed her hands, and left the room. Staff C, wearing the same gloves, gathered supplies and provided oral care with toothettes, water, and mouth wash. Staff C then removed her gloves, washed her hands, and left the room. During an observation of care on 10/13/20 at 2:50 PM, Staff E entered a resident room on the center hall to assist with Resident #5's cares. Hospice Staff was in the room with the resident and wore gloves. Staff E washed her hands, donned gloves, and assisted the resident to roll to her right side toward the wall while the hospice staff provided incontinence care. The Hospice Staff used wipes from a package and wiped front to back using one wipe at a time; she discarded the wipes in the trash can next to the bed. After the Hospice Staff finished providing incontinence care, she grabbed the wipes container and tossed it into Resident #5's bedside chair, applied a clean brief, and removed a lotion bottle from the bedside table while still wearing the same gloves. She then applied lotion to both of the resident's legs and then pulled up her pants. Both staff transferred the resident to her wheelchair and the Hospice Staff lowered the wheelchair pedals and unlocked the brakes before removing her gloves and performing hand hygiene. On 10/13/20 at 3:05 PM, Staff C left the right isolation hall while wearing only her mask and glasses on and walked to the nurse's station by the dining room. The nurse consultant stopped her and reminded her she could not to leave the right isolation hall because she had tested positive for Covid-19. At that time 2 other staff sat at the nurse's station less than 6 feet away from Staff C. The facility Covid-19 Isolation Plan dated 4/7/20 documented the following: - All employees working in an isolation area to provide patient care must wear appropriate personal protective equipment (PPE) as indicated by CDC guidelines for Standard, Control and Droplet Precautions. - Staff not assigned to work in the isolation area shall not go into isolation rooms or the isolation staff work space. During an interview with the Nurse Consultant on 10/13/20 at 3:45 PM she stated she expected staff to wash their hands and utilize PPE according to facility policy. The facility's Staff Member Covid-19 Positive form indicated Staff C tested positive on 10/4/20 and was asymptomatic with a 10 day return to work date of 10/15/20. The current working Certified Nursing Assistant Schedule dated 9/24/20 - 10/21/20 revealed the facility had removed Staff C from the schedule. During an interview with Staff C on 10/14/20 at 3:30 PM, she stated that she tested positive for Covid-19 on 10/4/20 and had no symptoms except for a stuffy nose, which she had until the weekend of 10/10/20. She reported the facility told her she could work but she had to stay down right hall and couldn't leave the hall until 10/15/20 and then she could work anywhere in the building. She added that she entered the facility and screened at the end of right hall door and even took her breaks down that hall. The facility's Staff Member Covid-19 Positive form indicated Staff I tested positive on 10/5/20 with a 10 day return to work date of 10/17/20. The current working Certified Nursing Assistant Schedule dated 9/24/20 - 10/21/20 revealed the facility removed Staff I from work on 10/3/20 and she returned to work on 10/12/20. During an interview with Staff I on 10/14/20 at 3:44 PM, she stated she started having symptoms on 10/3/20 and tested positive for Covid-19 on 10/5/20. She reported she went back to work on 10/12/20 because she felt better and had worked on all of the halls of the facility. She added she had then contracted pneumonia and was off work again. The facility's Staff Member Covid-19 Positive form indicated Staff A tested positive on 10/1/20, was asymptomatic, and had a 10 day return to work date of 10/12/20. The current working Nurse Schedule dated 9/24/20 - 10/21/20 revealed the facility had not removed Staff A from the schedule, although she did not work on 10/7/20. An observation on 10/13/20 at 11:45 AM revealed Staff A at the nurse's station by the dining room, talking on the phone. During an interview with Staff A on 10/20/20 at 11:40 AM, she stated she tested positive for Covid-19 on 10/6/20 but didn't have any symptoms. She stated the facility was going to have her work just down right hall, but since all the residents on center hall had tested positive she was able to work there. She added that she completed her documentation at the nurse's station by the dining room but she never went down left hall. She stated that the first case of Covid-19 was in the Assisted Living Facility (ALF). She added that the ALF staff or residents would call them for help so they would send staff over to assist. She stated they would wear masks and goggles when they went to the ALF. The facility's Staff Member Covid-19 Positive form indicated Staff J tested positive on 10/6/20 and had a 10 day return to work date of 10/15/20. During an interview with Staff J on 10/20/20 at 6:40 PM, he stated he tested positive for Covid-19 on 10/6/20. He explained he had woken up tired with aches on 10/6/20 and had a headache on 10/10/20, but had no other symptoms. He reported he returned to work on 10/13/20 and the facility directed he could work, but he had to stay away from Covid-19 negative residents. He added that he worked on all of the halls but only went to the doorway of Covid-19 negative residents and then occasionally to the ALF to check on the residents and answer call lights. The facility's Staff Member Covid-19 Positive form indicated the Social Service Director tested positive on 10/5/20 with a 10 day return to work date of 10/15/20. During an interview with the Social Service Director on 10/28/20 at 2:55 PM, she stated she had felt off, so she scheduled a test and with was positive Covid-19 results on 10/5/20. She reported she went home and then began to experienced chest tightness, shortness of breath, and diarrhea. She added she returned to work on 10/13/20. The facility was notified of the IJ on 10/15/20. The scope and severity of the deficiencies was lowered to a D.on 10/16/20 when the facility abated the IJ by taking the following actions: 1. On 10/15/20, the facility educated staff (with any new hires and/or agency staff educated prior to the start of their shift) regarding the following information: - Proper hand hygiene; a review of the hand hygiene policy - Proper PPE usage throughout the facility - Process for asymptomatic positive staff working during their initial 10 days. 2. The DON or Designee will complete random audits x 90 days of random staff with respect to hand hygiene and proper PPE usage. The DON or designee will bring the audits to QAPI until substantial compliance has been met. 3. Effective 10/15/20 at 8:00 PM, the facility decided to no longer utilize the use of positive, asymptomatic staff until they have met the return to work criteria.

Based on observations, clinical record review, and family and staff interviews the facility failed to notify the resident's physician and family member of a change in condition and failed to transfer a resident exhibiting shortness of breath, cough, fatigue, and oxygen saturations as low as 74 percent to the emergency room according to physician orders [REDACTED].#2). The resident was later admitted to the hospital and passed away from Covid-19 complications. Due to these findings, an Immediate Jeopardy (IJ) was identified to resident health and safety. The facility reported a census of 48 residents. Findings include: According to the annual Minimum Data Set (MDS) assessment tool dated 10/2/20, Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 5/15 on the Brief Interview of Mental Status (BIMS) test which meant he demonstrated severe cognitive impairment. The MDS also documented he was independent with transfers, ambulation (walking), dressing, and eating with set up help. The MDS revealed Resident #2 did not use oxygen and did not experience shortness of breath. The resident's [DIAGNOSES REDACTED]. Review of the Progress Notes for Resident #2 revealed the following: a. On 10/6/20 at 2:49 PM, staff documented they received an order for [REDACTED]. b. On 10/7/20 at 11:47 AM, Staff found resident's brother assisting him to stand because his gait was unsteady. c. On 10/9/20 at 5:16 PM, Resident #2 complained of fatigue with a temperature (T) of 99.2 (F) and an oxygen saturation (O2 Sat) of 85% on room air (RA). d. On 10/13/20 at 8:43 AM, the resident's O2 sat was 91% on RA and T 98.2. e. On 10/13/20 at 9:34 AM staff requested an oxygen order from the physician to keep O2 sats above 94%. f. On 10/13/20 at 11:30 AM, therapy staff reported resident became short of breath with an O2 sat of 74% on RA. Oxygen (O2) started at 3 liters per nasal cannula with O2 sats of 89-90%. Staff updated the physician regarding the resident's condition. During an observation on 10/13/20 at 11:45 AM, Staff A talked on the telephone at the nurses station by the dining room and told the caller Resident #2 had oxygen saturations in the 70's (%). Review of the resident's Progress Notes revealed the following: a. On 10/13/20 at 12:42 PM, staff received an order for [REDACTED].>b. On 10/13/20 at 1:38 PM, a hospital emergency room (ER) called the facility to report the resident's daughter had called them and wanted him to be seen. c. On 10/13/20 at 1:43 PM, the resident's physician called back with an order to send the resident to the emergency room per family request. Staff notified the resident's daughter. d. On 10/13/20 at 1:50 PM, Staff notified the resident's daughter that Medivac had been unable to transport the resident at that time. Staff documented the daughter directed staff to leave the resident at the facility, then. During an interview on 10/13/20 at 12:43, PM Staff B stated Resident #2 had tested positive for Covid-19 and was requiring more assistance with all of his cares. Review of the resident's Progress Notes revealed the following: a. On 10/13/20 at 9:01 PM, Staff documented the resident's O2 sats were 87% and the resident required assist of one staff to stand and use the restroom due to fatigue. b. On 10/14/20 at 12:41 AM, Staff documented the resident's face was flushed and his lungs were clear. The resident presented with a cough but no distress and although his lungs remained clear, the resident's O2 Sats were variable on 5 liters of oxygen. c. On 10/15/20 at 7:10 AM, Therapy staff alerted the nurse consultant resident had O2 sats of 79% on 5 liters of oxygen, [MEDICAL CONDITION] on, and heart rate 104. Staff applied an oxygen mask and notified the family and physician. The physician ordered staff to send the resident to the ER. d. On 10/15/20 at 7:56 AM, Staff sent the resident to the hospital via ambulance and notified the resident's family contact. e. On 10/15/20 at 11:46 AM Daughter called and reported concern with Staff A. f. On 10/20/20 at 9:20 PM, The hospital called to report the resident passed away at 7:45 PM. During an interview on 10/15/20 at 9:20 AM, Resident #2's daughter was tearful and sounded distraught. She stated when they wanted her father seen by the physician at the ER, Staff A told her on 10/13/20 that her Dad's condition wasn't an emergent situation and therefore she would call Medivac instead of the rescue squad. She added when the Medivac didn't have any openings, Staff A called her back told her that if family wanted him to be seen, they could take him to the hospital themselves. The resident's daughter reported Staff A told her they should bring two strong men to help transfer him into the car. The daughter reported she told Staff A that they weren't going to be able to do that, so he would have to stay there then. During an interview on 10/15/20 at 9:40 AM with another daughter of Resident #2 she stated that the family was very upset because the facility did not send the resident to theER on [DATE] as the doctor had ordered. She added that on Monday 10/12/20 her dad was very weak and needed 2 staff to even dangle his legs. She reported they (the family) were very concerned with the low oxygen saturations because their dad had pneumonia recently. She added that she lived out of the state and felt like she had to fight for her dad's life from a long distance. During an interview with the nurse consultant on 10/19/20 at 12:45 PM, she reported she expected the facility nurses to transfer any resident with an O2 sat below 90% to the hospital. When asked, she verified that O2 sats in the 70's and 80's were definitely an emergency. During an interview on 10/19/20 at 3:15 PM, Staff F reported when she administered Resident #2's medications on 10/13 and 10/14, she noted he had become more unsteady, needed more cues, exhibited increased lethargy, and needed more assist to sit up and eat. During an interview on 10/19/20 at 3:35 PM, Staff G stated that on 10/14/20 Resident #2 was more sleepy than usual but when she assessed him she did not notice any signs of distress. She added she was not aware the physician had given an order to send the resident to theER on [DATE] and reported had she known, she would have followed up on it. When asked, she replied that if her assessment of the resident had been abnormal assessment (shortness of breath, distress, or oxygen saturation below 90%) she would have called the family and sent him to the hospital. During an interview on 10/19/20 at 6:20 PM, Staff H stated that on the evening and overnight shift on 10/13/20 to 10/14/20, the resident had a cough and his oxygen saturations were running in the high 80's, so she kept him on oxygen at 5 liters per nasal cannula. She stated the resident was not in any distress and was resting comfortably, so she monitored him and reported it to the day shift nurse. She commented the local hospital had denied admissions recently due to being full and that is where he would have been sent if she had transferred him to the hospital that night. During an interview on 10/20/20 at 11:40 AM Staff A stated that she didn't feel it was an emergency to send Resident #2 to the emergency room via ambulance on 10/13/20 because she was able to get his oxygen saturation back up at that time. She stated that is why she called Medivac instead of the rescue squad and when Medivac wasn't able to provide transportation she called the resident's daughter so they could make other transportation arrangements. She added that she knew they had strong young nephews so she recommended that the daughter call them to help lift and transfer the resident into a car. She stated that is when the daughter said the family would not be able to do that and would have to keep him at the facility. Staff A acknowledged she should have called the physician back at that time to let him know Medivac could not transport the resident. With regard to the nurse's documentation on 10/9/20 at 5:16 PM, Staff A said she probably should have notified the family and doctor of Resident #2's oxygen saturations dropping into the 80's, but doesn't recall doing either one. During an interview with Resident #2's physician on 10/20/20 at 12:40 PM, he stated that if he gives staff an order to send a resident to the ER he wanted them sent via ambulance. He added the local EMS is very responsive and the Medivac should have never been called for the resident on 10/13/20. He reported he was actually very upset the facility even called him because he had given the facility strict instructions if any of the residents with Covid-19 had their O2 sats drop below 90% they should call the family and if the family wants them seen, then they are to call 911 and send them to the ER immediately. He stated on 10/9/20 when the resident's oxygen saturation dropped to 85 percent he should have at the very least been notified or the family called and given the option of hospitalizing him then. During a second interview on 10/20/20 at 2:15 PM, Staff A verified another nurse had mentioned those standing orders from the physician to send residents to the ER per family request with any O2 sats below 90%, but she said she could not find that order in writing anywhere or in the resident's orders so she elected not to follow that protocol. The facility was notified of the Immediate Jeopardy determination on 10/21/20 and subsequently submitted an acceptable abatement plan. The scope and severity of the deficiencies was lowered to a D. The IJ was abated by the facility on 10/21/20 when they implemented the following actions: 1. Education was provided to all staff on 10/21/20; staff that had not acknowledged and/or received education were provided education prior to their next scheduled shift. 2. An audit of current resident conditions was completed on 10/21/20. Residents with change(s) in condition were assessed and documentation was entered in the resident's medical record. In addition, staff notified the resident's physician and family. 3. The DON or designee will complete an audit 5 times weekly x 2 weeks, then 1 audit weekly x 4 weeks of resident assessment to ensure identification of change in condition, intervention in place, family and physician notification completed. Audits will be brought to QAPI and reviewed for further recommendation.

Based on record review and staff interview the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers and ensure the resident does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 2 residents reviewed (Resident #50). On 12/17/19, Resident #50 admitted to the facility with [DIAGNOSES REDACTED]. Upon admission, the resident had three open areas on her buttock. Although the facility assessed the resident as at high risk for pressure ulcers and identified the resident had multiple risk factors, the facility failed to implement additional interventions in an attempt to address the resident's risk of developing pressure ulcers until the resident developed one on 12/28/19. The facility reported a census of 54 residents. Findings include: Review of the Braden Scale completed upon admission to the facility on [DATE] revealed Resident #50 scored 15. A score of 15 indicated the resident was at risk for pressure related skin breakdown. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #50 required extensive assist of 2 staff for bed mobility. The MDS also documented the resident did not have a pressure ulcer. The resident's Face Sheet documented medical [DIAGNOSES REDACTED]. The Progress Notes contained an Admit/Re-Admit Note documented 12/17/19 at 10:59 a.m. The noted contained an area to address skin condition that had been completed as follows: Skin/Wound (left blank) Pressure Injury: No Non-Pressure Wound: Yes Skin Temperature: Warm Dry Skin Color: Normal A Progress Note dated 12/17/19 at 11:15 a.m. documented the facility received report from a nurse at the hospital. The nurse stated the resident had moderate swelling in both lower extremities and 2 open areas on her buttocks that appeared to be from shearing ( Shearing wounds occur when forces moving in opposite directions are applied to tissues in the body. This can occur when the skin is stuck to a surface, such as a bed, while gravity forces the body downward on the bed. https://study.com/academy/lesson/shearing-friction-wounds-definitions-treatments.html ) A Progress Note dated 12/18/19 by the dietician documented the resident experienced weight loss, triggered for malnutrition, and had been receiving medpass (a nutritional supplement) 2 ounces four times per day. A Progress Note dated 12/18/19 at 3:53 p.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Pale A Progress Note dated 12/19/19 at 12:30 p.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: Yes, right hip incision healing well with no signs and symptoms of infection Skin Temperature: Warm Dry Skin Color: Normal A Progress Note dated 12/21/19 at 9:44 a.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Normal A Progress Note dated 12/22/19 at 3:24 p.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Pale A Progress Note dated 12/24/19 at 1:21 a.m. documented resident lying in bed at this time, rolled to apply Sensi to bottom, does not roll easily, and total assist of 1 staff. Incontinent of urine, briefs worn. Skin/Wound Pressure Injury: Yes Coccyx Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Pale A Progress Note dated 12/24/19 at 11:15 a.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: No Skin Temperature: Cool Dry Skin Color: Normal A Progress Note dated 12/25/19 at 12:01 p.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Normal A Progress Note dated 12/26/19 at 11:18 a.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: Yes, coccyx with 3 open areas. Sensi applied Skin Temperature: Warm Dry Skin Color: Normal A Progress Note dated 12/26/19 at 7:39 p.m. documented the resident transferred with assist of 2 staff and was incontinent of bowel and bladder. Staff applied cream to coccyx. The Progress Notes contained an Administration Note dated 12/27/19 at 10:03 p.m. documented the resident complained of coccyx pain and requested pain pill. The nurse administered 1 tablet of [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG. A Progress Note dated 12/27/19 at 12:53 a.m. documented: Skin/Wound Pressure Injury: Yes, coccyx. Unstageable due to slough. Coversite applied. Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Pale A Progress Note dated 12/28/19 at 11:48 a.m. documented slough noted in sore on coccyx when staff applied Sensi to the resident's buttock. Sores present upon admission, but coccyx deteriorated. Staff assisted the resident to lay in bed as much as possible and repositioning the resident on her sides to keep pressure off area. Coversite applied. The Pressure Injury Evaluation form dated 12/28/19 documented the resident had a pressure injury to her coccyx (tailbone) which measured 2.4 cm long by 1.9 cm wide. The ulcer was unstageable due to loose, yellow/tan slough, with surrounding tissue red and inflamed. The resident rated the resident's pain in her sacrum (a shield shaped, bony structure between the last vertebrae and the tailbone) at 5 on a scale of 0-10. A Progress Note dated 12/29/19 at 11:52 p.m. documented: Skin/Wound Pressure Injury: No Non-Pressure Wound: No Skin Temperature: Warm Dry Skin Color: Normal The Progress Notes contained a Care Plan Conference Summary dated 12/30/19 at 10:30 a.m. which documented the resident required assist of two staff with all cares and experienced both bowel and bladder incontinence. The note also documented Certified Nursing Assistant (CNA) stated they are assisting the resident to lay in bed to assist in healing the sore on her buttocks. A progress note dated 12/30/19 at 1:20 p.m. documented when the resident admitted to the facility, she had 3 superficial areas on her coccyx from shearing in the hospital that measured 2.5 x 7 cm and Sensi initiated. On 12/25/19, area measured 7 x 7 cm with areas joined with slough in center that measured 2.4 x 1.9 cm with treatment changed to Coversite. Staff attempting to encourage the resident to stay off her back although that is her most comfortable position. A progress note dated 1/3/20 at 12:23 p.m. documented staff spoke with the resident's family regarding weight loss, decline in therapy, wound worsening, and discussed hospice. Labs drawn on 12/31/19 documented a hemoglobin (a red protein responsible for transporting oxygen in the blood) of 10.2, a hematocrit (the proportion, by volume, of the blood that consists of red blood cells expressed as a percentage) of 32.3 and an [MEDICATION NAME] level of 2.2. [MEDICATION NAME], the main protein produced in the liver, has numerous functions in the body, the most important of which is maintaining intravascular [MEDICATION NAME] osmotic pressure (COP). COP helps fluid stay within the vasculature instead of leaking into tissue. https://www.vetfolio.com/learn/article/the-role-of-[MEDICATION NAME]-and-fluids-in-the-body Low [MEDICATION NAME] levels can be seen in inflammation, shock, and malnutrition. https://labtestsonline.org/tests/[MEDICATION NAME] The Pressure Injury Evaluation form dated 1/2/20 documented the coccyx pressure injury had deteriorated, had odor after irrigation, and the surrounding tissue was red and inflamed. It measured 2.5 cm length by 2.5 cm width. The MDS dated [DATE] documented the resident had one unstageable pressure ulcer. The Care Plan for Resident #50 lacked documentation of any pressure relieving devices in place to prevent skin breakdown. The Care Plan was not updated with the pressure ulcer until 12/30/19. The Pressure Injury Evaluation form dated 1/8/20 documented the coccyx pressure injury had deteriorated, had odor after irrigation, had hard black eschar present and measured 3 cm length by 2.8 cm width by 2.2 cm depth. The resident rated the sacrum pain at 5 on a scale of 0-10. The Weight Record for the resident recorded an admit weight of 129.3 pounds on 12/17/19 and 114.6 pounds on 1/10/2020. A Care Communications Sheet dated 12/25/19 contained an undated, handwritten note that directed staff to assist Resident #50 out of bed last and back to bed first: lay on sides. The facility policy Assessments - Residents at Risk dated January 2015 documented its purpose was to identify residents at risk that need prevention interventions and the specific factors placing them at risk. The policy directed staff, in part: - Address Risk Factors and preventative measures upon admission to include non-compliance and diagnoses. - Document use of protective measures according to policy - Identify problem: include diagnosis, pre-existing conditions, nutrition, and past history of ulcers. - Provide information to assure staff are aware of preventative measures. In an interview on 01/14/20 at 11:34 AM, the Director of Nursing (DON) reported the facility implemented interventions implemented to prevent the development of pressure ulcers. She reported they used a positioning wedge and also put an air mattress in place when they noticed the breakdown. She stated the chart contained documentation regarding those interventions. In a subsequent interview on 01/14/20 at 01:32 PM, the DON stated the air mattress was ordered on [DATE] and delivered on 1/7/20. She also stated the facility policy directed staff to complete a Braden Scale (a tool used to gauge pressure ulcer risk in residents) upon admission and then weekly for the first 4 weeks. She also stated reported if the resident is at risk interventions, staff are to put interventions in place to prevent (skin) breakdown. The DON reported the resident had some areas of the shearing on admission, but they didn't expect it to get so bad so quickly because the resident had a good rehab potential and was expected to go home soon. She added that she sent a fax to the physician asking if the pressure ulcer was unavoidable and the physician responded it was likely due to malnutrition.

Based on observation, clinical record review and staff interviews, the facility failed to ensure each resident received adequate supervision, assistance devices and implement interventions to reduce hazards and accidents and monitors for effectiveness of interventions for 2 of 2 residents observed (Resident #1 and Resident #2). The facility reported a census of 40. Findings include: 1. According to the MDS (Minimum Data Set) assessment with a reference date of 8/26/10, Resident #1 had [DIAGNOSES REDACTED]., anxiety, and depression. The quarterly assessment dated [DATE] documented the resident with long and short term memory problems and severely impaired for daily decision making skills. The assessment documented Resident #1 as totally dependent on staff for transfers with 1 person physical assist. A review of the RAP (Resident Assessment Protocol) dated 9/2/2010 identified a problem Area with falls. The RAP identified the resident as dependent on staff and will not wait for assistance at times. The resident had a fall risk of 18 (high risk) and unable to stand without assistance and to use an EZ-stand for transfers A review of the Care Plan dated 5/18/06 and updated 3/16/11 documented that Resident #1 had a self care deficit related to dependency on staff for all cares, including transfers and directed the nursing staff to refer to daily care guide located in the resident ' s room. To use an EZ-stand for transfers with 1-2 assist as needed. To use a mechanical lift with a 2 person assist as needed. To use 1-2 person assist for a manual transfer. A review of the document labeled Activities of Daily Living, undated, under transfers directed the nursing staff to use a 2 person manual transfer, EZ-lift with 2 person assist, and EZ-stand with 1-2 person assist. A review of the CNA Worksheet dated 5/25/11 and used by Staff S Certified Nursing Assistant (CNA) directed staff to use an EZ-lift or EZ-stand for transfers with Resident #1. A review of the Incident/Accident/Unusual Occurrences Form dated 5/25/11 documented that Resident #1 slid off the bed onto the floor and complained of leg pain. The form documented the nurse notified a physician and transferred the resident the emergency room . A review of the hospital History and Physical report dated 5/25/11 revealed Resident #1 had sustained a right femur fracture and required surgical repair. A review of the Major Injury Determination Form dated 5/26/11 documented Resident #1 had sustained a major injury in accordance with 481 Iowa Administrative Code 50.7(1)(a)(3). A review of the Fall Investigation For CNAs dated 5/25/11 documented Staff S, CNA, used a gait belt to transfer the resident to bed and the resident then scooted off the edge of the bed. An observation on 6/7/11 at 10:50 a.m. revealed Staff AA and Staff TT CNA used an EZ-lift to transfer Resident #1 from a bed to a Geri-chair. In an interview with Staff EE (Certified Nursing Assistant) on 6/7/11 at 10:35 a.m. Staff EE stated Resident #1 transferred in different ways. In the morning the aides could use a lift with 2 person assist and after breakfast the aides could use an EZ-stand with 1 person assist or use a 2 person assist pivot transfer to bed with a gait belt. Staff EE stated the care plans were up to date however conditions change and sometimes it took a while for the care plans to be updated. In an interview on 6/7/11 at 12:55 p.m., Staff AA (Certified Nursing Assistant) stated the aides are given a sheet at the beginning of the shift that tells them everything about the residents. The sheets were updated when the resident had a decline or an improvement and needed less help. Staff AA stated prior to the resident ' s fall, the resident relied on staff for all cares. Staff AA stated the staff transferred Resident #1 with a 1-2 person assist, EZ-stand or lift. In an addendum, Staff AA stated when transferring Resident #1 from a bed to a wheel chair she used a 2 person transfer or an EZ-stand. Staff AA said that when she transferred Resident #1 from a wheel chair to a bed then she transferred the resident with a gait belt. In an interview on 6/7/11 at 3:25 p.m. Staff F (Licensed Practical Nurse) stated on 5/25/11 she went to Resident #1 ' s room and found the resident laying on the floor next to the bed. Staff F stated Staff S and Staff YY were also in the room. Staff S said the resident fell off the bed. Staff F reported Staff S had stated she had transferred the resident alone and did not use an EZ-stand due to the resident not holding on to it. Staff F stated she did not have any concerns with the care or interactions Staff S provided to the residents. In an interview on 6/7/11 at 6:00 p.m. the Director of Nursing (DON) stated the daily care guides were kept in the resident ' s bathrooms and updated with the quarterly MDS by the MDS Coordinator. The daily care guides were also updated as needed by the DON. The DON stated the CNA worksheets were updated as needed and reviewed weekly and as needed. In an interview on 6/8/11 at 7:45 a.m. the DON stated the care plans were completed in the same manner the past few years and have been provided to the State surveyors. The DON stated the information available to the staff on the date of the incident was the daily care guide, posted in the bathroom, and the CNA worksheet and neither place indicated to transfer the resident by a 1 person manual assist. In an interview on 6/8/11 at 8:05 a.m. Staff S (Certified Nursing Assistant) stated she transferred the resident by herself because the other aides were busy. Staff S stated other aides transferred the resident as a 1 person assist. Staff S stated the CNA sheet indicated Resident #1 used an EZ-stand or lift. Staff S stated the Administrator said the Care Plan in the resident ' s chart indicated 1-2 manual assist or EZ-stand or lift. In an interview on 6/8/11 at 8:30 a.m. Staff LL (Registered Nurse) stated she updated the CNA sheets as needed and the MDS Coordinator updated the sheets in the bathroom. In an interview on 6/8/11 at 9:10 a.m. Staff B (MDS Coordinator) stated, " As I am looking at the 3 pieces of guides for caring for (Resident #1) they do not match. " Staff B said that the Activities of Daily Living in regard to transfer did not match the Care Plan or the CNA worksheet. The Activity of Daily Living and the Care Plan were developed by the admitting nurse, DON and MDS with input from the CNAs. The plans were changed as much as daily to keep up with the residents ' changing conditions. Staff LL developed the CNA worksheets. Staff B stated the CNAs use their knowledge and good judgment when caring for a resident. Staff B confirmed the MDS assessment tool dated 4/7/11 identified Resident #1 as a 1 person physical assist. 2. According to the MDS (Minimum Data Set) assessment with a reference date of 9/2/10, Resident #2 had [DIAGNOSES REDACTED]., anxiety, and depression. The quarterly assessment dated [DATE] documented the resident with long and short term memory problems and severely impaired for daily decision making skills. The assessment documented Resident #2 as total dependence on staff for transfers with 2 + persons physical assist. A review of the Care Plan dated 9/5/07 and updated 3/23/11 documented Resident #2 had a potential for falls, related to a history of falls, dependent on transfers, Alzheimer ' s, agitation and impaired mobility. The Care Plan directed staff to transfer Resident #2 with a mechanical lift and 2 person assist as needed. The Care Plan also documented staff may transfer with 1 - 2 assist. The directive to use a Pivot disc for transfers per physical therapy guidelines with 2 assist as needed had been highlighted with a yellow marker indicating the directive had been discontinued. The DON updated the Care Plan on 6/8/11 to again include the use of the Pivot disc as needed. A review of the CNA Worksheet directed staff to use an EZ lift and 1-2 person assist with transfers. The CNA Worksheet did not include a directive for the use of a Pivot disc. Observation on 6/7/11 at 10:50 a.m. revealed Staff AA and Staff TT, CNAs, used a Pivot disc to transfer Resident #2 from a bed to a wheel chair. The nursing staff failed to follow Resident #2 ' s Care Plan or CNA Worksheet as directed.