Every finding on record at Embassy Rehab and Care Center

Based on observations, staff interviews, and policies reviewed the facility failed to store, prepare, serve, and distribute food in accordance with professional standards. The facility failed to provide hygiene practices during food preparation, prevent cross contamination during meal service, complete temperature logs for resident snack refrigerator, and serve food at the appropriate temperatures.The facility reported a census of 42 residents. Findings include: Observed on 5/18/26 at 11:40 AM Staff A, cook, modify turkey with a roll, green bean casserole, pumpkin pie, and sweet potatoes to a pureed consistency. Staff A completed hand hygiene and donned gloves prior to the initiation of the processing. With the completion of each portion of the meal, the staff removed the components of the Robo Coup (food processor) and took them with the spatula to the dish area, placed them in the dish machine, and started it. The staff demonstrated inconsistency when removing the gloves, whether it was before placement of the dirty items in the dish machine or after placement in the dish machine. The staff donned new gloves before starting the next food modification. Staff A did not complete hand hygiene with any glove changes. Upon completion of the modification of the turkey, sweet potatoes, and green bean casserole the staff covered the divided plate and placed it on the counter near the microwave. The staff placed the covered modified pumpkin pie on the counter with the other desserts. On 5/18/26 at 12:08 PM continuous observation of the meal service revealed the following:The main meal consisted of turkey, green bean casserole, sweet potatoes, gravy, a roll, and pumpkin pie. Optional items available included grilled cheese sandwich, peanut butter sandwich, hot dogs, and hamburgers. Staff A utilized a single pair of gloves throughout the entire meal service. Staff A used the tongs from the turkey to obtain 2 pre-made sandwiches and placed them on serving plates.Staff A obtained a second set of tongs and placed them on the serving line, opposite of the turkey. Staff A utilized the second set of tongs for serving a deli meat sandwich, peanut butter sandwich, grilled cheese, hot dogs and a hamburger. The staff utilized a gloved hand to obtain a slice of cheese, placed it with the hamburger and proceeded to modify it to a ground consistency. Staff A removed the plastic wrap from the pureed meal and placed it in the microwave and warmed the food. The staff obtained temperatures of the food with the turkey at 128 degrees Fahrenheit ( ) , green bean casserole at 125 and the sweet potatoes at 135 . Staff A served the food. Staff B, Cook, wore gloves and made peanut butter sandwiches. The staff touched the bread, knife, peanut butter container, sliced the sandwich, the plate and covered the sandwich with plastic wrap.Staff B changed gloves without washing hands.Staff B, used a single pair of gloves, prepared deli meat sandwiches with the following steps: obtained the bread from a package, placed it on the preparation surface, obtained a package of deli meal, unsealed it, obtained the meat, placed it on the bread, placed sliced cheese on the bread, took deli meat to the Robo Coup and processed it, returned the meat to the bread, removed a piece of meat that did not process to the necessary size, placed the cheese/bread slice on top of the meat/bread, sliced the sandwich while holding it in place, and covered the sandwich with plastic wrap. On 5/18/26 at 12:50 PM Staff A confirmed the temperatures of the pureed meal and that it was served.Observed on 5/18/26 at 1:35 PM with the Administrator the resident snack/supplement refrigerator in the nurses medication room. The refrigerator displayed an incomplete temperature log. The May log revealed opportunities for temperatures 2 times/daily at 6:00 AM and 10:00 PM with instructions that the refrigerator needed to be checked twice a day. The document revealed missing data for 11 of 35 (31%) opportunities The Administrator stated she wanted to confirm that the correct log was present with the Director of Nursing (DON). On 5/18/26 at 1:45 PM the DON confirmed the log for the snack/supplement refrigerator was correct and not completed as required. The DON acknowledged she had not been monitoring the refrigerator log this month. The DON expected the logs to be completed daily as required. On 5/18/26 at 3:25 PM the Certified Dietary Manager (CDM) stated she expected staff to only use 1 set of tongs/serving utensil per food item, not to use 1 set of tongs for multiple food items as that would cause cross contamination. The CDM expected staff to use utensils to touch food, not to use gloved hands that had previously touched utensils, packaging and other items prior to touching the food. The CDM stated staff need to wash their hands prior to glove use and when changing gloves. The CDM stated the pureed food should be served at the serving temperature of above 135 . When clarified that the pureed plate of food had been sitting on the counter, covered and then placed in the microwave to be warmed, the CDM stated the food should be re-warmed to 160 . On 5/18/26 at 4:15 PM the Administrator concurred that staff should not utilize the same serving utensils for multiple types of food to avoid contamination. The Administrator stated staff should wash their hands when changing gloves. The Administrator stated there had been work in the kitchen for overall improvements, but was disappointed there were still concerns but stated it was much better than previously. The Administrator stated the kitchen needed to continue to work to improve and decrease the risk for food borne illness and contamination in the kitchen. The facility's Maintaining a Sanitary Tray Line Policy, undated, revealed the use of tongs/serving utensils to handle food, and to wash hands before and after wearing or changing gloves. The document disclosed that monitoring of food temperatures throughout the meal service to ensure proper hot (at or above 135 ) was maintained.The facility's Handwashing Guidelines for Dietary Employees Policy, undated, revealed dietary employees should wash their hands after touching anything unsanitary (garbage, soiled utensils/equipment), while preparing food to prevent cross contamination, and before donning gloves, The facility's Food Safety Requirements policy, undated, disclosed that refrigerated storage should have monitoring of food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. The documented included food that was cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 .

Based on observation, interviews, and policy review, the facility failed to maintain an effective infection prevention and control program and provide specific policies related to all employees' hand hygiene during meal service (Resident #5, #24 and #25). The facility reported a census of 42 residents.indings include:1. Observations on 5/19/26 at 12:24 PM showed that Staff F, Dietary Aide, wore the same pair of gloves during the entire dining room service. Staff F picked up food plates and cups from resident tables and placed the dishware into the dirty dish room. Staff F then immediately returned to the dining room and failed to remove the soiled gloves or perform hand hygiene. During the observation, Staff F touched the residents' cups before asking if they were finished. Staff F also retrieved condiments for the residents while still wearing the same gloves.2. Observation on 5/20/26 at 7:43 AM showed the following:Staff C, a Certified Nursing Assistant (CNA), played with Resident #25's hair, failed to perform hand hygiene, then obtained two coffee cups. Staff C then pulled the spout on the coffee dispenser to fill the cups and delivered the coffee to Resident #5 and Resident #24. Staff C exited the dining room without performing hand hygiene.The Dietary Manager (DM) failed to perform hand hygiene or wear gloves in the dining room during meal service. While passing out breakfast plates and refilling cups from the coffee dispenser, milk jugs, and juice jugs, she handled residents' private drinking cups. Additionally, she touched residents and wheelchair handles, picked up trash from the floor, served condiments directly from her scrub pants pockets, and drank from her personal coffee cup.The facility failed to provide a policy related to hand hygiene instructions and expectations during meal service for all employees. The submitted Handwashing Guidelines for Dietary Employees related directly to handwashing for dietary employees, which identified that dietary employees shall keep their hands and exposed portions of their arms clean. Dietary staff shall clean their hands after hands have touched anything unsanitary (e.g., garbage, soiled utensils/equipment, dirty dishes, etc.). Staff are required to clean hands after hands have touched garbage, soiled utensils/equipment, dirty dishes, bare human body parts other than clean hands (e.g., face, nose, hair, etc.). During an interview on 5/20/26 at 3:49 PM, the Administrator reported that she expects all staff to perform appropriate hand hygiene during meal service. She voiced concern regarding the DM's performance of job duties and reported a history of other concerns.During an interview on 5/21/26 at 9:17 AM, the Infection Preventionist (IP) stated that the CNA should have performed hand hygiene after touching the resident's hair or person before continuing with other duties. The IP asserted that staff must perform hand hygiene after collecting dirty dishes before continuing with their duties. The IP further emphasized that staff should not keep condiments in their pants or scrubs and acknowledged that staff must closely monitor the need for consistent hand hygiene.

Based on observations, facility policy review and staff interview the facility failed to provide dignity with speaking to residents in the dining room and provide privacy during resident treatments. The facility reported a census of 42 residents. Findings include: 1. Observation on 5/18/2026 at 1:11 p.m., of Staff D, Certified Nursing Assistant (CNA) sitting at table with a resident while she was eating. Staff D said residents name to Resident #25 sitting 2 tables away from her. Resident #25 did not acknowledge Staff D. Staff D then repeated Resident #25's name. The resident again did not acknowledge her. Staff D then whistled at Resident #25 to get her attention. Resident #25 looked at Staff D and she proceeded to ask her in the dining room loudly if she was going to need to go to the bathroom. Staff D proceeded to say if she did she should go back to her room and turn on the light for us to help you. Resident #25 just looked at Staff D and never responded or moved her wheelchair. Interview on 5/21/2026 at 9:02 a.m., with the Administrator revealed the staff should not have been saying that in the dining room or whistling at them to get their attention. 2. Observation on 5/20/26 at 1:12 PM showed Staff C (Registered Nurse) positioned a medication cart in the doorway of Resident #29's room. Staff C then prepared the necessary supplies and medications, donned personal protective equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP), and administered medications via the resident's PEG tube following facility protocol. Staff C failed to close the resident's door during the procedure to ensure privacy and dignity during care. The Resident Right Policy revised April 2019 outlined the following: Respect and Dignity: Staff must treat all residents with respect and dignity at all times. This includes using polite, clear, and supportive language, and never speaking in a demeaning, coercive, or discriminatory manner. Communication: Staff are required to communicate information about care, rights, and responsibilities both orally and in writing, in a language and format the resident understands. This ensures residents are fully informed and can participate in their care. Personal Privacy: Residents have the right to personal privacy during accommodations, medical treatment, personal care, written and telephone communications, and visits. Staff must ensure privacy during all aspects of care, such as bathing, dressing, or medical procedures. During an interview on 5/20/26 at 1:55 PM, Staff C stated that she failed to close the resident's door while administering medication. Staff C acknowledged that she typically closes the door but neglected the action in this specific instance. During an interview on 5/20/26 at 2:47 PM, the Director of Nursing (DON) reported that she expects staff to shut residents' doors or, at minimum, pull the privacy curtain during care. When asked if a medication cart in front of the door ensures privacy, the DON stated that the staff member should have closed the door.

Based on clinical record review and staff interview the facility failed to address dementia care for 1 out of 4 residents reviewed (Resident #5). The facility reported a census of 43 residents.Findings include:The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of non-Alzheimer's Dementia. The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed active diagnosis of Non-Alzheimer's Dementia.Review of Resident #5's active diagnosis list revealed alcohol dependence with alcohol- induced persisting dementia. Review of Resident #5's care plan with a revision date of 5/8/26 lacked information regarding dementia care. Interview on 5/20/26 at 1:52 p.m., with the Director of Nursing (DON) revealed dementia should be addressed on the care plan if they have a diagnosis.

Based on record review, staff interviews and facility provided policy the facility failed to maintain accurate and verified documentation of task completion. Specifically, staff signed off on assigned duties as complete without actually performing the work or communicating with assigned personnel to confirm completion. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of non- Alzheimer's Dementia, arthritis and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of facility provided documentation titled Follow Up Question Report on Toilet Transfer dated 5/1/26-5/20/26 revealed Staff G, Assistant Director of Nursing (ADON) completed documentation not assigned to her on 15 separate occasions. Staff G was not the employee assigned to these tasks. Review of facility provided documentation titled follow up question report on Toileting Hygiene dated 5/1/26-5/20/26 revealed Staff G completed documentation not assigned to her on 16 separate occasions. Staff G was not the employee assigned to these tasks. 2. The MDS assessment dated [DATE] for Resident #6 documented diagnoses of arthritis, hip fracture and legal blindness. The MDS showed the BIMS score of 6 indicating severe cognitive impairment. Review of facility provided documentation titled Follow Up Question Report on Toilet Transfer dated 5/1/26-5/20/26 revealed Staff G, Assistant Director of Nursing (ADON) completed documentation not assigned to her on 8 separate occasions. Staff G was not the employee assigned to these tasks. Review of facility provided documentation titled follow up question report on Upper Body Dressing dated 5/1/26-5/20/26 revealed Staff G completed documentation not assigned to her on 24 separate occasions. Staff G was not the employee assigned to these tasks. 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented diagnoses of non- Alzheimer's Dementia, urinary incontinence and intellectual disabilities. The MDS showed the Brief Interview for Mental Status (BIMS) score of 01 which indicated severe cognitive impairment. Review of facility provided documentation titled Follow Up Question Report on Toilet Transfer dated 5/1/26-5/20/26 revealed Staff G, Assistant Director of Nursing (ADON) completed documentation not assigned to her on 8 separate occasions. Staff G was not the employee assigned to these tasks. Review of facility provided documentation titled follow up question report on Toileting Hygiene dated 5/1/26-5/20/26 revealed Staff G completed documentation not assigned to her on 11 separate occasions. Staff G was not the employee assigned to these tasks. In an interview on 5/21/26 at 9:26 AM, when asked if the CNAs are responsible for their charting, Staff G, ADON responded, The CNAs are responsible for their charting. When asked if she has documented for the CNAs, Staff E responded, I have helped them with their charting. She clarified, If they are behind, I ask them to tell me if they are charting a change like a bowel movement or change in Activities of Daily Living (ADL). Regarding how she started charting for other staff, Staff E stated, I asked the Administrator and the DON if it was okay to chart for the CNAs. They said I could because when we do skilled charting we depend on the CNA to tell us how they transfer because we don't always go into the room to see how they are moving. When asked how often she documents for staff that completed their tasks, Staff G stated, I chart quite often for the CNAs, day and night shifts, but more for the evenings. When asked about the expectation for staff to complete their own documentation, Staff G responded, They are supposed to be doing it. I do an audit every morning, so if they don't get the charting done, the CNAs are supposed to call me or slide a note under the door with changes. When asked if a lack of documentation, calls, or notes is supposed to indicate that the CNAs finished all their tasks, Staff G responded, Yes. When asked how much time she spent charting tasks for the CNAs, Staff G replied, A lot. It's frustrating. I talked to the DON many times that staff need to be held accountable to do their own charting. When asked if she thought it was okay to chart for other staff, Staff G responded, As long as you know if there are changes. When asked if she knew for a fact that each task she documented has been completed, Staff G stated, I don't know for a fact they got done, so no. Interview on 05/20/2026 at 4:11 p.m., with Staff E, Certified Nursing Assistant (CNA) revealed they are expected to do their documentation before the end of the shift but if they do not have time the ADON has documented for Staff E. Staff E has never asked anyone to do the charting and it was finished when Staff E went in to document the next day. Review of the facility provided policy titled Documentation System with a revision date of March 2019 revealed it is the policy of the facility to document in the resident's medical record all services provided to the resident and any changes in the resident's medical or mental condition. A medical record (chart), either electronic or paper, will be maintained on each resident to provide a permanent record of the care given to the resident. The resident's medical record is a legal document. All observations, medications administered, services performed, etc., must be documented in the resident's medical record. Interview on 05/21/2026 at 9:42 a.m., with the Administrator revealed she expects Staff G would have talked to the staff providing the care about all the care they provided to ensure documentation is correct and she should not have documented it without talking to the staff.

Based on clinical records, facility policy and staff interviews the facility failed to provide a safe environment free from physical abuse for 1 of 3 (Resident #1) residents. The facility reported a census of 45 residents. Findings Include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of neurogenic bladder, anxiety disorder and dementia with other behavioral disturbances. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.The Progress Note dated 7/5/25 at 6:45 AM for Resident #1 showed Staff C, Registered Nurse (RN) documented the following: At about 3:45 AM one of the night CNA's notified me that she met another CNA yelling, restraining and hitting a resident inappropriately in his room during rounds. According to her this happened while they were trying to get a resident changed. I was notified and immediately went and assessed the resident. There were no physical injuries on the resident. No bruises also noted.The Self Report submitted on 7/5/25 at 6:54 AM identified an allegation of abuse that occurred on approximately 7/5/25 at 3:45 AM. The report identified Staff B, Certified Nursing Assistant, (CNA) witnessed Staff A, CNA restrain an aggressive resident and open-handedly hit the resident when performing cares.The Coaching Form dated 7/5/25 for Staff A, CNA documented violation of resident abuse and mistreatment of a resident. The form documented: We received a report on the morning of July 5, 2025, from CNA Staff B that she witnessed you screaming, hitting and restraining Resident #1. Events occurred as follows. You and Staff B were doing rounds. You both stopped outside of this resident's room. You stated they needed to change the resident's leg bag. You both agreed to do it together as this resident can be aggressive. Staff B told you she would run the supply cart down and be right back to meet you in the resident's room. When Staff B returned to the room you and the resident were yelling at each other. Resident #1 was hitting you and you were holding his hands down while the resident was lying in bed. You hit the resident back at least three times with an open palm to his arm. You then switched position and put his left arm down under your hand. Staff B quickly changed the leg bag to the foley bag and tried to separate you as the resident was frazzled. It was reported you were still yelling at the resident when you left the room. You were immediately suspended from work and sent home. We have attempted to contact you several times to obtain your statement regarding this matter. Due to the seriousness of your actions, you are being terminated, affected immediately.In an interview on 10/16/25 at 12:53 PM, the Assistant Director of Nursing (ADON) read from her written statement during the interview: On 7/5/25 at 5:20 AM I received a call from Staff C, RN that Staff A, CNA had slapped Resident #1. I instructed the RN to have Staff A escorted out of the building. Staff B, CNA was also working and called me to tell me what she had witnessed. I told Staff B to write her statement. Staff A called me after she left the facility and was upset because I sent her home. She stated, Whatever Staff B saw didn't happen. I was trying to change his catheter bag and he started to slap, punch, and kick me. I slapped his hand away because he had a hold of it and wouldn't let go. I've never been accused of abuse before and I have restrained myself with him until today. He has these behaviors with everyone. I stated, when a Resident is becoming upset about his behaviors, you make sure the resident is safe and leave the room. She hung up after my statement. After reading the statement aloud the ADON then stated, when Staff A, CNA first told me about it, she said she didn't do it. Later, incriminated herself by saying that she restrained herself until today. The nurse called me and said that Staff A slapped and actually held hands down, at one point she used her knee to do it. The ADON reported no inappropriate behavior occurred prior to this incident for either CNA. When asked if there seemed to be any problems between the CNA's the ADON responded, no. In an interview on 10/16/25 at 12:59 PM, Staff C, RN reported on 7/5/25 Staff B, CNA informed him that Resident #1 punched Staff A, CNA and Staff A punched the resident back in retaliation. Staff C, RN instructed Staff B, CNA to write a statement then assessed the resident and notified the ADON. Staff C reported the resident failed to recall the incident. The resident denied injury and no injury could be visualized during the assessment. Staff C stated, Resident #1 is always confused and punches, it is normal for him. We all spent time taking care of him. Staff A knew that. In an interview on 10/22/25 at 9:24 AM, Staff B CNA reported on 7/5/25 herself and Staff A, CNA planned to start rounds. Staff A, CNA entered Resident #1's room while Staff B returned the stock cart. Staff B stated, when I got back, I knocked on the door and opened it. There was already yelling going on between Staff A and the resident. Staff A was attempting to put a catheter bag on, but wasn't telling the resident what she was doing, which worked him up, because he didn't know what she was doing. They were both yelling that they were going to kill each other. Staff A had the resident's left arm pinned against the bed with her knee. As I walked up the resident was hitting her with his left hand. Staff A was hitting the resident back on the left side of his chest and arm. Staff A slapped the resident three to four times. I could hear the slaps. I walked up next to her and told her I was taking over and that she needed to leave. Staff A then moved and stood behind me as I changed the catheter bag and covered the resident. Staff A left the room when I did. I made sure. I immediately reported it to the nurse. The nurse went down to check the resident then came out and made a phone call. After that the nurse told Staff A that she had to leave. When asked if Staff A voiced anything to Staff B before she left, Staff A stated, Staff B clocked out, got her belongings and came up to me. She said, this is the first time you've seen anything like this happen. You don't know what happened. Staff B replied, raising your hand and hitting a resident is abuse. I'm a mandatory reporter, so are you. It's my job.In an Interview on 10/23/25 at 10:35 AM, Staff A, CNA report Staff C, RN instructed her and Staff B, CNA to apply a catheter bag to Resident #1's catheter. During the procedure Staff A stated, I held down the resident's hand with my knee. I had too. I had to have both of my hands free to put the catheter on but I didn't press hard or anything. Just enough he couldn't pull out. When asked how long she held the resident's hand down with her knee, Staff A stated about half a minute. When asked if she verbally threatened the resident, Staff A stated, I might have said if you hit me, I'll hit you back. But that was an idle threat. I didn't mean it and he didn't care anyway. When asked how she handled the resident's behavior in the past, Staff A stated, I just walked away, which I should've done that night. The untitled facility training record showed the facility provided abuse education to staff from 7/7/25 through 7/9/25.The Abuse Prevention Plan last reviewed February 2023 defined physical abuse as Includes but is not limited to hitting, slapping, kicking, biting, scratching, pushing, and pinching. It also includes controlling behavior through corporal punishment. Use of adverse or deprivation procedures, unreasonable confinement, or involuntary seclusion. Applying a behavior management technique that results in, or has the potential to result in, physical or psychological harm. The policy defined Mental Abuse Includes, but is not limited to humiliation, harassment, threats of punishment or deprivation.In an interview 10/22/25 at 3:18 PM, the Administrator reported after the facility investigated the allegations of abuse, the Administrator terminated Staff B. The Administrator stated, our top priority is our resident's safety. The Administrator reported the facility took extensive action and conducted comprehensive education to prevent abuse. The Administrator stated, will always be transparent with allegations of abuse.

Based on observations, staff interviews and policy review the facility failed to provide a clean homelike environment free from offensive odors. The facility reported a census of 45. Findings include: 1. Observation on 6/2/25 at 10:12 a.m., noted upon entrance into the building a strong urine odor. 2. Observation on 6/3/25 at 11:41 a.m., urine odor noted in hallways throughout the building. 3. Observation on 6/3/25 at 3:33 p.m., urine odor noted in hallways throughout the building and around the nursing station. 4. Observation on 6/4/25 at 9:36 a.m., urine odor noted in hallways throughout the building and around the nursing station. Interview on 6/4/25 at 12:09 p.m., with the Administrator revealed the hallways should not have urine smell and the facility will be working on the right away.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility. The bed hold notice also failed to notify the amount per day the resident or representative agreed to pay for 2 of 4 residents reviewed (Residents #13, # 21 and #40). The facility failed to notifiy the Long Term Care Ombudsman of discharge from facility for 1 of 4 residents reviewed (Resident #46). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented reentry to the facility on 4/11/25 for a short term hospital stay. Review of the Clinical Census report for Resident #21 revealed the following information: a. 12/15/24- hospital b. 12/20/24- active c. 4/4/25- hospital d. 4/11/25- active Review of the Progress Notes for Resident #21 revealed the following: a. On 12/15/24 at 5:58 PM, Resident admitted to the hospital for urinary tract infection. b. On 4/5/25 at 10:39 AM, Resident admitted to the hospital for a fracture. Review of the Bed Hold Notice dated 12/15/24 for Resident #21 revealed verbal authorization from Resident #21's representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. Review of the Bed Hold Notice dated 4/5/25 for Resident #21 revealed verbal authorization from Resident #21's representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. The Bed Hold Prior to Transfer policy last revised November 2022 identified it is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. DEFINITIONS Bed-hold: Holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. Reserve Bed Payment: Payments made by a State to the facility to hold a bed during a resident's temporary absence from a nursing facility. Therapeutic Leave: Absences for purposes other than required hospitalization. POLICY EXPLANATION AND COMPLIANCE GUIDELINES-Notice Before Transfer 1. The facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold and reserve bed payment policy well in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility. 2. The facility will have policies that address holding the resident's bed during periods of absence, such as during hospitalization or therapeutic leave. 3. The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences. 4. The facility will give written information concerning the bed-hold policies to the resident and/or resident representative as part of the admissions packet and a signed and dated copy of the bed-hold notice information will be kept in the resident's admission file. 5. The written information given to the resident and/or resident representative will include the following: a. The duration of the state bed-hold, if any, during which the resident is permitted to return and resume residence in the nursing facility. b. The reserve bed payment policy in the state plan, if any Nursing Policy & Procedure Manual. c. The facility policies regarding bed-hold periods to include permitting residents to return to the next available bed. d. Conditions upon which the resident would return to the facility: ·The resident requires the services which the facility provide ·The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 6. The facility will provide this written information to all facility residents, regardless of their payment source. In an interview on 6/4/25 at 3:52 PM, the Director of Nursing (DON) reported staff had available to them an example of a bed hold notice with the cost per day the facility charged and staff should fill in the cost at the time a form is completed. The DON said she would have to refer to the facility's policy about verbal consents and explained if the resident was unable to sign for cognitive reasons then staff would have to get a verbal consent. When asked if a representative should be notified for consent if the resident was cognitively impaired, the DON stated, yes. 2. The MDS assessment dated [DATE] for Resident #13 documented diagnoses of hypertension, heart failure, anemia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #13's Census tab revealed the following information: 5/4/25- Hospital no charge 5/8/25- active Review of Progress Notes revealed the following: On 5/5/25 at 2:47 a.m., Resident was admitted to hospita.l On 5/8/25 at 1:24 p.m., Resident returns to her home. Review of the bed hold dated 5/4/15 revealed verbal authorization from Resident #13 and Resident #13's representative but lacked a resident signature. The bed hold also lacked the cost per day for the bed hold. 3. The MDS assessment dated [DATE] for Resident #40 showed the Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of Resident #40's Census tab revealed the following information: 2/16/25- hospital no charge 2/24/25- active 2/27/25- hospital no charge 3/2/25- active Review of Progress Notes revealed the following: 2/16/25 at 3:52 a.m., Resident admitted to the hospital 2/24/25 at 1:19 a.m., Resident readmitted to facility 2/28/25 at 8:42 a.m., Resident admitted to the hospital Review of the bed hold dated 2/17/25 revealed verbal authorization from Resident #40's representative but lacked a resident representative signature. The bed hold lacked the cost per day for the bed hold. Review of the bed hold dated 2/28/25 revealed verbal authorization from Resident #40's representative but lacked a resident representative signature. 4. Review of Resident #46's medical chart revealed she had been admitted to the facility and left against medical advice the same day. The facility did not provide a policy on Ombudsman notification prior to exit from the facility. Interview on 6/4/25 at 2:39 p.m., with the Social Worker revealed the resident was only here for a few hours and when she ran the report for the Ombudsman, Resident #46 was not on the report. She should have been on the report to the Ombudsman.

Based on observations and staff interviews, the facility failed to post accurate nurse staffing data in a prominent location and visible to residents and visitors. The facility reported a census of 45 residents. Findings include: 1. Observation on 6/2/25 at 12:49 p.m., lacked a daily staffing sheet visible for residents and public to locate. 2. Observation on 6/3/25 at 2:19 p.m., lacked a daily staffing sheet visible for residents and public to locate. 3. Observation on 6/4/25 at 9:27 p.m., lacked a daily staffing sheet visible for residents and public to locate. Interview on 6/4/25 at 9:29 a.m., with Staff C, Licensed Practical Nurse (LPN) and Staff D, Registered Nurse (RN) revealed the staffing book on the counter is where the sheet is kept. Staff D opened the book to reveal the daily sheet. Staff C verified this is the only place where the hours are posted and all of the daily sheets are kept in the office after they are changed out. Review of facility provided policy titled Posting of Daily Nursing Hours Policy with a revision date of March 2019 revealed it is the policy to ensure the daily actual hours of RN's, LPN's, NAR's and TMA's per shift are posted in a visible area for residents and visitors. The policy further revealed the facility will post the information in a clear readable format in a prominent place in the facility, close to the main entrance. Interview on 6/4/25 at 12:03 p.m., with the Administrator revealed she did education with the staff regarding having the staff sheets out and posted and not in the book. The staffing sheet should have been posted where anyone can see the sheet.

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area. The facility identified a census of 45 residents. Findings included: The initial kitchen walk through on 6/2/25 at 10:55 AM with the Dietary Manager (DM) revealed the following: A clean dish cart contained a variety of scattered food debris. Three food preparation tables with shelving underneath showed a thick layer of grease build-up on the shelves, pans and food containers. The floor contained an accumulation of food debris and a variety of dried liquid. The freezer units with a variety of food debris in the bottom of the units. The refrigerator units with debris with a variety of food debris in the bottom of the units. The top of the dishwasher not visible due to a layer of white, crusty material. The snack cart with food debris build-up. The warming table pan covers found with dried food debris and dried liquid. Back splash of oven wall covered with multiple large food debris and dried liquid. During the initial walkthrough the DM reported the May 2025 cleaning schedules had not been started. When asked why, the DM reported three dietary staff quit at the same time. The DM reported three new staff were ready to start once their background checks were approved. When asked if she expected the kitchen area to be maintained in a clean and sanitary condition, the DM stated, yes it normally is. The Environment policy last revised September 2019 identified all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.

Based on clinical record review and staff interview, the facility failed to refer resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 2 residents (Resident #38 and #39) reviewed for PASRR requirements. The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented diagnoses of dementia with other behavioral behaviors, depression, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The Clinical Physician Orders dated 3/10/25 for Resident #39 showed hydroxyzine ordered for anxiety. The Consultation Report dated 4/3/25 for Resident #39 showed hydroxyzine continued by the physician due to anxiety. Review of the MDS for Resident #39 dated 2/20/25 revealed the following diagnosis: a. Bipolar Disorder b. Anxiety c. Dementia with other personality and behavioral disorders due to known psychological conditions. Review of the consultation behavioral health notes for Resident #39 dated 4/3/25 showed consultation took place for outpatient psychiatric services. Review of the PASRR dated 4/14/2023 showed the facility failed to resubmit an updated PASRR screening to include mental health diagnoses, dementia and psychiatric services. In an interview 5/22/24 at 8:46 AM, the DON reported that she expected the PASRR for Resident #39 to be resubmitted when diagnosed with mental health diagnoses and initiation of psychiatric services. The DON reported the facility failed to have a policy related to PASRR Screenings. The facility reported they follow standard practices for PASRR completion in lieu of a facility policy. 2. The MDS assessment dated [DATE] for Resident #38 documented diagnoses of anxiety disorder and Alzheimer's Disease. The MDS included a Brief Interview for Mental Status (BIMS) score of 12 indicating severe cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnosis: a. Anxiety Disorder b. Generalized Anxiety Disorder c. Nicotine Dependence Review of the Physicians Progress Note signed and dated 5/6/25 included: a. Nicotine Dependence b. Generalized Anxiety Disorder c. Anxiety Disorder Review of the PASRR dated 6/4/24 lacked inclusion anxiety disorder, generalized anxiety disorder and nicotine dependence. The clinical record lacked an updated PASRR to include.anxiety disorder, generalized anxiety disorder and nicotine dependence.

Based on clinical record review and staff interview the facility failed to address dementia/Alzheimer's Disease care for 1 out of 12 residents reviewed (Resident #39). The facility reported a census of 45 residents. Findings include: 1. The MDS assessment dated [DATE] for Resident #39 documented diagnoses of dementia with other behavioral behaviors, depression, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The Medical Diagnosis report for Resident #39 showed a diagnosis of dementia dated 2/27/25. The Care Plan for Resident #39 lacked information regarding the physical, mental and psychosocial needs to support the highest practical level of well being for a resident with Alzheimer's Disease or dementia. In an interview on 6/4/25 at 3:52 PM, the Director of Nursing (DON) reported she expected dementia to be included in the care plan for Resident #39.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #13 and #38). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of hypertension, heart failure, anemia.The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication during the review period. Review of the Medication Review Report dated 6/3/25 revealed the following orders: a. Aripiprazole tablet (antipsychotic medication) with an order and start date of 5/8/25 b. Buspirone tablet (antianxiety medication) with an order and start date of 5/8/25 c. Trazodone tablet (antidepressant medication) with an order and start date of 5/8/25. Review of the Care Plan with a revised date of 5/15/25 lacked non-pharmacological interventions and targeted behaviors with antipsychotic medications, antianxiety medications and antidepressant medications. 2. The MDS assessment dated [DATE] for Resident #38 documented diagnoses of anxiety disorder and Alzheimer's Disease. The MDS included a BIMS score of 12 indicating severe cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication during the review period. Review of the Medication Review Report dated 5/6/25 revealed the following orders: a. Risperdal tablet (antipsychotic medication) with an order and start date of 9/26/24 b. Sertraline tablet (antidepressant medication) with an order date of 10/22/24 and start date of 10/23/24 c. Trazodone tablet with an order date and start date of 6/26/24. Review of the Care Plan with a revised date of 3/24/25 lacked non-pharmacological interventions and targeted behaviors with antipsychotic medications, antianxiety medications and antidepressant medications. Review of the facility provided policy titled Antispsychotic Use Policy and Procedure with a revision date of November 2022 revealed all residents receiving an Antipsychotic medication will have target behaviors monitored daily, recorded, and summarized each quarter. Areas assessed will include resident specific behaviors, non-pharmacological interventions attempted and the resident ' s response to the intervention. Interview on 6/4/25 at 1:21 p.m., the Director of Nursing (DON) acknowledged the resident's care plan should have non-pharmacological interventions and targeted behaviors for the medications they are taking on them. She further explained the facility knew they had to be on there but they had not gotten to it yet.

Based on observation, record and chart review the facility failed to accurately update a physician's order in the electronic chart and failed to update the resident's chart to show a diagnosis of anxiety for 1 of 12 residents reviewed (Resident #39). The facility reported a census of 45 residents. Findings include: The MDS assessment dated [DATE] for Resident #39 documented diagnoses of dementia with other behavioral behaviors, depression, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The Clinical Orders for Resident #39 showed on 3/9/25 the physician ordered hydroxyzine 25 milligrams (MG) every eight hours as needed for anxiety. The order indicated the end date as indefinite. The Consultant Report for Resident #39 showed on 4/1/25 the pharmacy recommended either to stop the hydroxyzine or to continue for 90 days for anxiety. The physician marked that they agreed to continue for 90 days but then also wrote, okay to stop hydroxyzine. The facility clarified the order by fax dated 5/2/25 for Resident #39. The physician wrote: Since the patient is still having anxiety, continue the hydroxyzine as prescribed. The Medical Diagnosis report for Resident #39 showed the facility failed to accurately update the medical record with anxiety as a diagnosis. The Care Plan for Resident #39 showed the facility failed to accurately update the care plan to address a diagnosis of anxiety. The Clinical Orders for Resident #39 showed on 5/2/25 that the facility failed to accurately update the electronic order with the stop date for hydroxyzine from indefinite to 90 days. The Documentation System policy last updated March 2019 identified to document in the resident's medical record all services provided to the resident and any changes in the resident's medical or mental condition. PROCEDURES 1. A medical record (chart), either electronic or paper, will be maintained on each resident to provide a permanent record of the care given to the resident. Nursing Policy & Procedure 8. The resident's medical record should be up-to-date at all times reflecting the current status of the resident. 11. The plan of care is documented and reflects current standards of professional practice, including measures to facilitate the medical care prescribed that will restore, maintain or promote the resident's highest practicable level of functioning. Such measures include physiological, psychosocial and environmental factors, as well as resident and family education and discharge planning. 12. The resident's care plan is to be up-to-date at all times. In an interview on 6/4/25 at 3:52 PM, the Director of Nursing (DON) reported she acknowledged Resident #39's electronic record should be accurately updated from a stop date of indefinite to a stop date of 90 days as ordered. The DON also reported Resident #39's chart needed to be accurately updated to show a diagnosis of anxiety.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #34). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 documented diagnoses of dementia, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The facility Incident Report dated 3/25/25 at 8:45 AM for Resident #34 documented the following: At 8:45 AM this nurse was approached by CNA (Certified Nursing Assistant), and CNA attempted to block the swing and made contact with the resident causing a scratch to the bridge of nose and left cheek per CNA. When asked what happened she was unable to describe what happened. The facility investigation for Resident #34 showed the Administrator documented on 3/25/25 at approximately 8:45 AM that she became aware Resident #34 reported Staff A, Certified Nursing Assistant (CNA) hit the resident. The Self Report to DIAL dated 3/25/25 indicated the report submission time of 5:43 PM, which indicated the facility failed to submit the report within two hours. The Abuse Prevention Policy and Procedure last revised December 2022 identified: The facility requires that all suspected maltreatment will be reported to the Administrator and the State immediately. All alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator, State Survey Agency (SA) and one or more law enforcement entities for the political subdivision in which the facility is located (i.e., police, sheriffs, detectives, public safety officers; corrections personnel; prosecutors; medical examiners; investigators; and coroners). But not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. In an interview on 6/4/25 at 2:47 PM, the Administrator acknowledged the event occurred at approximately 8:45 AM and the Self Report submission time did not occur until 5:43 PM. The Administrator reported that she immediately initiated the facility investigation and failed to report the incident within the two hour requirement.

Based on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 12 residents (Resident #34) reviewed from physical abuse. The facility reported a census of 45 residents. The deficiency cited at F600 is considered past non-compliance. The Workplace Violence, HIPAA, Abuse Recap facility education and sign-in sheets dated 4/2/25 showed the facility performed education regarding abuse. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 documented diagnoses of dementia, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The facility Incident Report dated 3/25/25 at 8:45 AM for Resident #34 documented the following: At 8:45 AM this nurse was approached by CNA (Certified Nursing Assistant), and CNA attempted to block the swing and made contact with the resident causing a scratch to the bridge of nose and left cheek per CNA. When asked what happened she was unable to describe what happened. The facility investigation for Resident #34 showed the Administrator documented on 3/25/25 at approximately 8:45 AM that she became aware Resident #34 reported Staff A, Certified Nursing Assistant (CNA) hit the resident. The facility investigation dated 3/25/25 at 8:50 AM, showed the Administrator 's interview with Resident #34. The Administrator documented the following: I began by asking, How is your morning going? Resident #34 states It was going good. The Social Worker stated, It was going good? What about now? The resident explained, It was going good until that crabby nurse hit me. I asked the resident to explain more. The resident explained, It was because I wouldn't get up. I asked How did she hit you? Will you show me? The resident demonstrated opening her palm and waved it, open handed through the air. I asked the resident where she was hit. The resident pointed to the left side of her cheek. The resident said I don't know. Like here. I noted a scratch to the resident's bridge of her nose and asked What happened right there? On your nose? The resident states that she didn't know where she had gotten the scratch on her nose. I ask, Did she say anything? What was she saying? The Resident states I don't remember what she said. The facility investigation dated 3/25/25 at 8:55 AM, showed the Administrator 's interview with Staff A The Administrator documented the following: I asked Staff A, CNA, What happened this morning? Staff A states Ok at 8:30-8:45 this morning, I went into the Resident #34's room to get her up. I told her Come on we need to go to breakfast and change the pullup. Resident #34 said, I am tired . I said, ' I know but once you get up, we will change your pullup and go to breakfast. According to Staff A, Resident #34 did hesitate a little but then sat up by herself and climbed into her wheelchair. Staff A continued to explain that Resident #34 went into the bathroom independently. While Resident #34 was in the bathroom, Staff A went to assist another resident next door. After assisting the other resident for a few minutes, Staff A then walked down the hallway to retrieve the Sit to Stand (Mechanical lift) to help the other resident. While passing Resident #34's room, Staff A noticed Resident #34 had gone back to bed after she took herself to the bathroom. Staff A then entered Resident #34's room again. Staff A stated that she helped Resident #34 to sit up at the side of her bed and explained again that she had to get up for breakfast. Staff A then went back to the other resident to complete morning cares. Staff A went back to check on Resident #34 and noticed that she laid back down in bed for the third time. Staff A told Resident #34 I can't leave until your feet are on the ground. Staff A then helped her sit on the side of the bed again. Staff A stated that she sat down next Resident #34's left side and brushed Resident #34's hair. I questioned what Resident #34 was saying during this process. Staff A stated She just kept saying ' OK. OK. Staff A then stated that she got up and went to Resident #34's right side and placed the wheelchair in front of her to get out of Resident #34's way in order for her to self-transfer. Staff A states that Resident #34 just sat there. Staff A stated to Resident #34, I will help you. Staff A had then placed her left hand under Resident #34's right arm and Staff A's right hand on top of Resident #34's right arm. When attempting to guide Resident #34 into a standing position, Resident #34 grabbed Staff A's right arm with her left hand hurting Staff A with nail sticking into my arm. Staff A states I snatched my arm away and my nail cut the top of Resident #34's nose. I think it was my thumb. Staff A went on to explain that Resident #34's roommate stated just leave her alone. Staff A told Resident #34's roommate that Resident #34 needed to see the nurse. Once Staff A got Resident #34 settled in the wheelchair, Staff A noticed that her nail cut the top of Resident #34's nose. The Progress Notes for Resident #34 documented the following: a. On 3/25/2025 at 2:41 PM, Resident swinging at CNA attempted to block swing and made contact with resident ' s bridge of nose and cheek causing superficial scratches. Assessment: superficial scratches to bridge of nose and cheek no aid needed denied pain. b. On 3/25/2025 at 3:02 PM, Fax sent to primary care provider (PCP) to notify on incident this morning, awaiting fax or call back with orders related to incident causing injury to cheek and bridge of nose. c. On 3/25/2025 at 6:20 PM, Writer stops in to check on the resident periodically throughout the day. Noted the bottom lip is starting to bruise and notified the nurse. The resident appears calm and relaxed during visits. Denies negative feelings or moods.The resident requests that Writer not contact her family regarding an incident that occurred earlier in the morning as she does not want family to worry about her. d. On 3/26/2025 at 3:50 AM, Received a fax related to an incident that occurred between an CNA employee. Cleanse, apply TAO daily x3 and leave open to air until healed. Notify if any signs or symptoms of infection occur to scratch the bridge of nose and left cheek. Law enforcement report completed on 3/26/25 at approximately 1:44 PM for an altercation that occurred. The reported documented the following: Resident #34 stated that she was lying in bed when Staff A, another individual, batted her. I summarized the information I had received and asked the resident to correct any inaccuracies. According to the information, Resident #34 was in bed around breakfast time when Staff A asked her to get up. Resident #34 did not want to get up despite multiple requests from Staff A. At some point, Staff A allegedly sat next to Resident #34 to assist her in getting up, but Resident #34 denied this. Resident #34 confirmed that she usually gets into her wheelchair by herself and did not receive any assistance from Staff A. When asked if Staff A had held her arm or if Resident #34 had grabbed Staff A ' s arm, Resident #34 denied both actions. Resident #34 stated that she was sitting on the edge of her bed when Staff A hit her with an open hand. The Employee Counseling Form for Staff A indicated the following: Type of Violation: Resident Abuse/Mistreating a Resident Employer Statement: We received a report on the morning of March 25, 2025, from Resident #34 that you hit her face while getting her up that morning. When assessed, the Resident had a scratch on her nose, a red mark under her left eye and a bruise on her lower lip. It was reported that you and the Resident were arguing about getting up and going to breakfast that morning. In your statement, you report that you went to get Resident #34 up for breakfast. When attempting to guide the resident into a standing position, Resident grabbed your right arm with her left had causing her nail to stick into your arm. You snatched your arm away and your nail cut the top of Resident ' s nose. You grabbed a Kleenex and wiped her bleeding nose. Then you took her by wheelchair to Staff E, Licensed Practical Nurse (LPN). You stated it was an accident and showed a scratch on your arm. Upon further investigation, we learned the following from two other residents. Resident 1 reported that you are rough with him. Recently, you shoved the slide board under him and gave him a big bruise on his leg and hurt his muscle. Resident 2 reported that you are mouthy and rush her. You don ' t explain to the resident what you are doing, and you talk down to her as if she doesn ' t know anything. Residents should never be made to feel fearful of the services we are providing. Your actions have caused harm to two residents and made these residents feel uncomfortable, fearful of being harmed, and have created unnecessary fear and anxiety. The facility is the residents ' home, and they should not have to worry about their care or needs being properly met. Your conduct and performance towards these residents are unacceptable. Hitting a resident or causing harm is never acceptable. We are to provide care and treatment for our residents in a manner that promotes dignity and respect. Your performance and behavior are considered abusive towards the residents. Due to the seriousness of your actions, you are being terminated effective immediately. You have been reported to the Iowa State Nurse Aide registry for abuse through mistreatment. Interview on 6/2/25 at 2:42 PM, Staff E, LPN stated, Staff A, CNA approached me and said that she was attempting care when Resident #34 reached out. Staff A went to block it and somehow ended up scratching resident on the nose. Resident #34 had an abrasion under her left eye and a scratch on the bridge of her nose. In an interview on 6/3/25 at 9:16 AM, Resident #24, roommate of Resident #34, reported because the privacy curtain was closed Resident #24 could not see what happened on 3/25/25 but heard the events. Resident #24 reported Staff A told Resident #34 to get up for breakfast. Resident #24 stated, Resident #34 had on a long dress, she was tired and sleepy. Resident #34 told Staff A that she wasn ' t getting up because she wasn ' t feeling good. I heard Staff A hit Resident #34 then pick her up and throw her into bed. Resident #34 told Staff A to stop and leave her alone and that she wasn ' t going to breakfast. When asked how she knew the CNA hit and threw Resident #34, Resident #24 stated, I heard it. In an interview on 6/3/25 at 11:29 AM, Staff F, LPN stated, I saw a scratch on Resident #34 ' s nose, the resident had bruises on her right arm, bruising around the left eye. Staff E came to me right away, then I made sure Staff E got Staff A off the floor. Staff A told me that Resident #34 resisted and pinched Staff A when she pulled up Resident #34. There were no marks on Staff A ' s arm. Staff F stated, Staff A told me Resident #34 pinched her arm, then Staff A pulled away. Staff A then motioned her arm out in front and said, she tried to block Resident #34 and accidentally scratched her nose. Staff F continued, It didn t make sense. Staff A said she was beside her when Resident #34 grabbed her arm. In an interview on 6/3/25 at 12:21 PM, Staff G, LPN stated, I was in the office with Staff F when Staff A brought Resident #34 in the office. Staff A said something like, Resident #34 was resisting care. When Staff A was trying to move Resident #34 ' s arm off of her, she accidentally scratched the Resident ' s nose. Staff G reported Resident #34 had a scratch on her nose and bruising under one of her eyes. Staff G stated, Resident #34 said point blank, Staff A is mean, she hit me. In an interview on 6/3/25 at 11:41 AM, Staff H CNA stated, I was giving showers in the same hall. There are four bedrooms to the right then Resident #34's room. I heard shouting from Staff A. Staff A said, Resident #34 get up. Resident #34 get up. I started going up to see what was going on. The door was closed. I opened it and took Resident #34 to the shower. I noticed her left eye, nose and lip looked bruised. There was no bleeding. The Abuse Prevention Policy and Procedure last revised December 2022 identified: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident ' s medical symptoms. It shall be the policy of this facility to implement written procedures that includes zero tolerance for abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. POLICY INTERPRETATION AND IMPLEMENTATION All Staff and Mandatory Reporters (defined below in Appendix G) Explanation and Compliance Guidelines The facility will develop and implement written policies and procedures regarding abuse, neglect, exploitation, and misappropriation of resident property that: o Prohibit and prevent such incidents. o Outline investigative protocols. o Institute reporting procedures. o Train new and existing staff on prevention, reporting, investigation, and response. o Outline a process for dementia management o Establish program coordination and oversight as part of the QAA/QAPI program. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law (e.g., Administrator, Director of Nursing, or Social Service Director). ·The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. DEFINITIONS AND CATAGORIES OF ABUSE ·Abuse o (CMS Definition) Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Nursing Policy & Procedure o Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. o Instances of abuse of any residents, irrespective of any mental or physical condition, that causes physical harm, pain, or mental anguish. o Mental Abuse - (CMS Definition) Includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). o Physical Abuse o (CMS Definition) Includes but is not limited to hitting, slapping, kicking, biting, scratching, pushing, and pinching. It also includes controlling behavior through corporal punishment. o Use of adverse or deprivation procedures, unreasonable confinement, or involuntary seclusion. o Applying a behavior management technique that results in, or has the potential to result in physical or psychological harm. In an interview on 6/5/25 at 6:30 AM, the Administrator reported that she felt the facility did all they could to educate staff regarding abuse prior to the incident and reacted appropriately when abuse occurred.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1-March 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 38 residents. Findings include: The PBJ Staffing Data Report run date 6/13/24 triggered for Excessively Low Weekend Staffing - submitted weekend staffing data is excessively low. Review of Facility Daily Assignment Sheets revealed staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. On 6/19/24 at 3:42 PM, the Administrator stated she spoke with the home office. In the future office staff working in resident care areas will use different time clock codes to ensure the correct amount of hours are reflected in the data reported to CMS.

Based on observation, document review, policy review, and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents at the facility on regular diets. The facility reported a census of 38 residents. Findings include: A continuous observation of the lunch service on 6/19/24 from 11:50 AM - 1:10 PM revealed Staff A, [NAME] utilize a 1/3 cup green scoop #12 to serve Brussel sprouts, a 3/8 cup #10 ivory scoop used for noodles, a 2/3 cup #6 scoop white handled used for serving beef stroganoff to all the regular diets. Review of document titled, Diet Spreadsheet Week 3 Day 18 documented scoop size for beef stroganoff 6 oz or 2/3 cup, noodles 4 oz or 1/2 cup, and brussel sprouts 4 oz or 1/2 cup to be utilized when serving a regular diet. Review of color chart titled, Scoop Size Matters documented the green scoop #12 was equal to 1/3 cup and the ivory scoop #10 was equal to 3/8 cup. Review of document titled, Food Preparation Guidelines dated 4/1/24 documented the cook, or designee, shall prepare menu items following the facility ' s written menus and standardized recipes. On 6/19/24 at 1:51 PM Staff B, Certified Dietary Manager (CDM) stated the scoops were utilized for serving the noodles or the brussel sprouts. Staff B stated the facility ' s expectation was that the correct scoops would be utilized following the diet spreadsheet. On 6/19/24 at 2:08 PM the Administrator stated the facility's expectation was that appropriate scoop sizes would be utilized following the diet spreadsheet.

Based on resident interview, policy review, and staff interview the facility failed to provide snacks to residents who wanted to eat at non-traditional times or outside of scheduled meal service times. The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 6/17/24 at 12:02 PM Resident #12 stated snacks are not dropped off during the day or in the evening. Resident #12 stated snacks used to be dropped off but he was no longer given a snack. On 6/18/24 at 1:51 PM Staff C, Certified Nursing Assistant (CNA) stated she worked the AM shift but frequently stayed 2pm - 8pm. Staff C stated she had not taken the snack cart around and had not seen anyone on pm shift when she was working drop snacks off to the residents. On 6/18/24 at 2:26 PM Staff D stated she usually worked the 2pm - 10pm shift. Staff D stated the facility staff park the snack carts at the nurses desk and do not deliver the snacks to the residents in the rooms. Staff D stated the residents that want snacks turn their lights on and ask. On 6/20/24 at 8:30 AM the Administrator stated a good system was in place for water and would talk to individual residents. The Administrator stated the snacks not being delivered was talked about in the resident council. The Administrator stated the kitchen sets the snack cart up by the nursing station. The Administrator stated the CNA staff would report the residents were sleeping at the time when the snacks were delivered. The Administrator stated a couple of the residents would like to wake up. The Administrator stated she knew snacks not being delivered was a concern and have not quite got the procedure worked out yet. 44420 2. The MDS dated [DATE] documented Resident #14 had a BIMS of 14 indicating no cognitive impairment. On 6/17/24 at 10:47 AM Resident #14 stated, They sometimes bring snacks. When asked how often staff brought snacks the resident replied, less than half of the time. 3. The MDS dated [DATE] documented Resident #5 had a BIMS of 9 moderate cognitive impairment. On 6/17/24 at 11:34 AM Resident # 5 reported snacks are sometimes brought to the room. Resident #5 reported that sometimes meant about half of the time. 4. The MDS dated [DATE] documented Resident #22 had a BIMS of 15 indicating no cognitive impairment. On 6/17/24 at 1:30 PM Resident #22 reported that she is not offered snacks, reported that she used to get offered snacks but not anymore.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open items of food. The facility reported a census of 38 residents. Findings include: On 6/17/24 from 9:30 AM - 10:00 AM a continuous observation during the initial kitchen tour revealed: a. The dry storage freezer chest had cinnamon rolls in a bag open and undated. b. The dry storage room had cornbread mix and baking powder open and undated. c. The stand up refrigerator had a 3.5 pound butter spread container, a 5 pound cottage cheese container, a 5 pound sour cream container, and a 16 oz. beef base container open and undated. On 6/17/24 at 10:10 AM Staff B, Certified Dietary Manager (CDM) acknowledged the cinnamon rolls, cornbread mix, baking powder, butter spread, cottage cheese, sour cream, and beef base was open and undated. Staff B threw these items away in the garbage. Staff B stated the facility's expectation was the opened food should have been dated when the container was opened. Review of the facility policy for labeling and dating open food items revealed there was no policy. On 6/19/24 at 10:41 AM the Administrator stated the facility completed audits in the kitchen to ensure items were open and dated. The Administrator stated the facility's expectation was all open food items should be dated when opened.

Based on observations, clinical record review, resident and staff interviews and facility policy review the facility failed to assure that resident received the recommended therapeutic menu for residents at risk for choking for 5 of 5 residents reviewed (Residents #8, #6, #13, #22, and #27). This failure increased the risk of residents choking or aspirating (something entering the lungs), therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of April 24th at 3:45 P.M. The Facility Staff removed the Immediate Jeopardy on April 25, 2023 through the following actions: 1. [NAME] President of Operations, Nurse Consultant, Director of Nursing, Administrator, and Dietary Manager met at 3:20 PM on 4/24/23 to discuss Therapeutic Diets to gain understanding of problem areas. 2. The facility educated the Dietary Manager on subject of diet types, mechanically altered, additives, and consistencies on 4/24/2023 at 4:40PM. 3. The facility instructed the Dietary Manager to oversee all special instruction diets that came out of the kitchen from 4:40 PM on 4/24/23 to lunchtime on 4/25/23 to ensure the staff follow the resident's diets according to the physician's order. The facility instructed the Dietary Manager on specific instructions in the case that a resident refused the diet as ordered on 4/24/23. 4. The facility planned a meeting for on 4/25/23 at 9:30 AM between dietary cooks, Speech Therapy, management crew and a representative from their consulting company to provide education. The staff received education on following diet orders, communication to Speech Therapy and their involvement, and steps to ensure staff followed the physician's orders. 5. The facility created audits to ensure regular compliance weekly for one month and once a month for one year to follow. The Dietary Manager will complete the audits beginning the week ending 4/28/23. The scope lowered from a K to an E at the time of the survey after ensuring the facility implemented education and established procedures to ensure resident safety at meal time. Findings Include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS indicated that Resident #13 only required set up assistance for eating. The MDS included diagnoses of heart failure, renal insufficiency, diabetes mellitus and seizure disorder. The MDS listed that Resident #13 had a mechanically altered diet (thickened liquids, ground, or pureed food). The Care Plan Focus revised 6/15/22 indicated that Resident #13 ate independently but had dietary restrictions due to his diagnosis of diabetes. The Interventions directed the following a. Revised 4/1/21: Speech Therapy (ST) evaluate and treat him as needed. b. Staff to give him, his diet as ordered and monitor him for the need to change his diet and/or texture. The Order Details dated 9/22/22 listed an order for dysphagia advanced diet texture with regular fluid consistency. On 4/24/23 at 12:50 PM, observed Resident #13 receive a hamburger patty on a bun. He took one bit of the sandwich and chewed for a long period of time. He then removed the top of the bun and with his fork pulled pieces of meat apart to eat in smaller bites. 2. Resident #6's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderately impaired cognition. The MDS included a diagnosis of cerebral palsy. The MDS indicated that Resident #6 required supervision with set-up assistance with meals. The MDS listed that Resident #6 received a mechanical altered diet. The Speech Therapy Evaluation and Plan of Treatment dated 11/10/22 identified that the ST saw Resident #6 due to her having an increased dislike of her current diet of mechanical soft textures. Resident #16 warranted an analysis of her diet textures and liquid consistencies to ensure safe swallowing and her risk for aspiration. Resident #6 had a risk for aspiration, a further decline in function, and pneumonia. The documentation indicated that Resident #16 tolerated her mechanical soft diet with no signs or symptoms of aspiration. She required moderate verbal and visual cues to use safe swallow strategies. Resident #16 demonstrated the highest level of safe intake with the mechanical soft textures. The ST recommended that Resident #16 continued her diet texture. Resident #16 had inadequate mastication (rotary chew pattern) and poor attention to task decreased self-monitoring. The Order Details dated 4/6/22 listed an order for dysphagia advanced diet texture with regular fluid consistency. On 4/24/23 at 12:50 PM, observed the staff serve Resident #6 a hot dog cut into bite sized pieces. She ate the pieces without assistance with several staff members in the dining area. On 4/24/23 at 2:17 PM the Dietary Manager (DM) said that the residents get a list of food options. At the bottom of the list had options classified as always available which included a hot dog and a hamburger on a bun. She said that a resident on the dysphasia advanced diet would need to have the hamburger and/or hot dog ground before they received it. On 4/24/23 at 2:24 PM Staff R, Dietary Aide, said that none of the residents with a mechanical soft diet chose a hamburger or hot dog for lunch that day. She said that she did not grind any hamburger patties or hot dogs for lunch. On 4/27/23 at 11:52 AM the DM looked at the list of education for the kitchen staff and verified that only 1 of the 4 current dietary staff received education on texture modification. She said that the company provided the education on a rotation basis. The DM reported September 2022 as the last time the education module offered and 3 of the 4 current staff did not start until after that date. According to the Diet and Nutritional Care Manual dated 2019, the National Dysphagia Diet Levels were as follows: a. Level 1: Dysphagia Pureed b. Level 2: Mechanically Altered c. Level 3: Dysphagia Advanced d. Regular Diet. The allowed Dysphagia Advanced foods included moistened meats with sauce or gravy, must be tender, fruits without skins and moistened breads. The Dysphagia Advanced foods not allowed included dry tough meat, grapes, corn, potato skins, dry, tough, or crusty bread. On 4/24/23 at 5:08 PM the Registered Dietician (RD) for the facility said that the DM had the responsibility to educate new staff and make sure they understand the diets they serve. She agreed that the always available listed on the bottom of a resident's menu may be confusing if staff do not understand that they need to grind these meats for an Advanced Dysphasia diet. On 4/25/23 at 9:26 AM the ST reported that she gave a very specific description of diets to include meat textures, veggies, and fruits. She then sends these recommendations to the doctor for the orders. She agreed that an Advanced Dysphagia diet must have the meats ground. 44474 3. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 13, indicating intact cognition. The MDS included diagnoses of heart failure, anxiety and arthritis. The General Note dated 2/17/23 at 12:50 p.m. indicated that Resident #8 had a choking episode out of the facility. The provider indicated they would send over orders for ground meat. The General Note dated 2/17/23 at 3:33 p.m. listed the facility received the ground meat order. The Health Status Note dated 4/20/23 at 1:21 p.m. identified that the facility received an order by fax from the primary care physician for Resident #8's diet to change to a regular consistency, carbohydrate-controlled diet. Resident #8's medical chart lacked documentation of a Speech Evaluation to assess for safety to advance her diet. 26527 4. On 4/19/23 at 1:12 p.m. Resident #22 sat in the dining room. He stated he finished his lunch. Meat remained on the plate, splayed out. Resident #22 stated they didn't have any mashed potatoes. Resident #22's menu showed garlic mashed potatoes circled. His tablemate, Resident #27 said they didn't have any mashed potatoes, they got stir fry instead. There were red skinned potatoes on Resident #27's plate. Resident #22 and Resident #27's menus both showed Regular-Dysphagia Advanced diet. The menus did not have the option for red skinned potatoes. A menu indicating Regular diet had garlic roasted red skinned potatoes on the menu. The Dietary Manager (DM) checked the menus and said Resident #22 and Resident #27 received the wrong food items. She thought that they were the only ones. On 4/20/23 at 10:02 a.m. Resident # 24 stated she was on a special diet because of difficulty swallowing. She said sometimes they ground the meat and sometimes they didn't. She said she couldn't eat the ground sometimes because it was so dry. Some broth or gravy on it would help. She said she had been eating the meat when they didn't grind it. At 10:08 a.m. Resident #6 said they did not grind her meat. On 4/20/23 at 12:35 p.m. staff delivered resident noon meals. Residents on dysphagia advanced diets, and requested a sandwich received the contents ground including the bread. Two residents pushed it away and asked where their sandwich was. At 1:20 p.m. the DM stated she would have to get a therapeutic menu they didn't have one in the kitchen and they should have. At 2 p.m. the Dietician stated residents should receive their diets as ordered. She stated she knew some of the residents were on mechanical soft due to the status of their teeth. At 2:45 p.m. the DM pulled up the therapeutic menu dysphagia advanced and it showed ground meat went on the bun. Looked at other menus and they called for ground meat on bread (not a ground meat sandwich). On 4/24/23 at 12:49 p.m. Resident #24 received the casserole, carrots and cauliflower, bread and cake. Resident #24's menu called for no peas. The casserole had both peas and corn in it. Resident #24 stated she received the carrots not entirely cooked and were too hard to eat. She could not eat peas because if the skin sloughed off it could get stuck in her throat. Resident #22 received the casserole, cauliflower and carrots, bread and pineapple. Resident #27 received the same, and said she received carrots not fully cooked enough and hard to eat. On 4/24/23 at 1:17 p.m. the DM confirmed Resident #24 should not have received the casserole with peas in it, and those on advanced dysphagia diets should not have received corn. The resident should have completely cooked carrots and soft for dysphagia advanced diets. 44475 5. The MDS dated [DATE] for Resident #27 revealed a BIMS of 15 which indicated intact cognition. The same MDS revealed the resident had diagnoses of metabolic encephalopathy (a brain condition that can cause confusion and memory loss), anemia (low amount of iron in blood, iron found in meat), and mental disorder. The MDS revealed the resident was independent with eating, had speech therapy service from 12/2/22 to 12/23/22, and had a mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). The SPL (Speech Language Pathologist) Evaluation and Plan of Treatment with a start of care date of 12/6/22 revealed: 1. Reason for referral: Resident #27 referred to Speech Therapy (ST) by dietary due to their reports of difficulty with mastication (chewing) of meats/harder textures. The ST recommended Skilled ST to evaluate for analysis of diet texture and liquid consistencies to determine least restrictive diet and implement preventative strategies for decreased risk of aspiration. Without skilled ST Resident #27 has at risk for aspiration and malnutrition due to their inability to safely consume regular textures. 2. Intake recommendations mechanical soft/ground textures. The Order dated 12/6/22 signed by a physician revealed per speech therapy, may we have an order for diet change to mechanical soft, ground meat, soft veggies, soft bite sized bread, and purred fruits with the physician response as yes. On 4/17/23 at 12:37 PM observed Resident #27 receive a formed meat patty. Resident #27 left the meat patty uneaten. In an interview on 4/17/23 at 12:37, the resident reported he should have ground meat and pointed out the ground meat only wording on his menu slip that came with his noon meal. The resident reported he receives the incorrect texture for foods often. On 4/19/23 at 1:33 PM, Resident #27 reported that he received soft roast beef for lunch that he could, but the meat did not get ground. In addition, he received potatoes with the skin on them.

Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 2 of 2 residents reviewed for elopement (Residents #39 and #18). The facility's failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of January 17, 23 on April 18, 23 at 12:58 p.m. The Facility Staff removed the Immediate Jeopardy on April 19, 23 through the following actions: a. The facility engaged an additional keypad door alarm on the North Door. The door alarm sound is loud and heard throughout the facility. When the door alarm goes off, staff must enter a code at the door to turn it off. The keypad door alarm activated immediately at 1:30 p.m. on 4/18/23. The [NAME] President of Operations (VPO) and Administrator called a staff meeting to educate all present employees that effective immediately to not use the North door unless taking out trash. The Administrator notified all staff not present by a text message at 1:59pm. b. The Director of Nursing (DON) educated the resident who smoked to no longer use the North Door and if followed by another resident to immediately alert a staff member. The facility moved the designated smoking area to the front of the building at the time. c. The facility contacted the alarm company to verify the installation time of the new alarm system. The company verified the date for the alarm as 4/25/23. d. The facility will educate all staff to respond to all door alarms to ensure that it is not a resident leaving the facility by 4/19/23. f. The facility will educate all staff by 4/19/23 on the risk of elopement for residents, the facilities elopement policy and the importance of responding to door alarms. g. The facility will complete an updated elopement risk assessment on all residents by 4/19/23. h. The facility will educate the staff on the revised elopement book. The elopement book will flag residents at risk for eloping. The Maintenance Director or designee will conduct an audit twice a day to ensure that all door alarms work correctly and that the staff respond to the alarms until the installation of the new door lock system on the north double doors by 4/26/23. The facility will continue to do audits until the installation of the new locking system. The scope lowered from a K to an E at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Include: Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of diabetes mellitus, Bipolar disorder (mood disorder), and anxiety disorder. Resident #38 completed all her activities of daily living independently. The Social Services Note dated 1/17/23 at 10:51 a.m. indicated that the Social Services Director (SSD) sat and discussed the incident of when Resident #39 decided to take a walk outside without permission. Resident #16 explained that she talked with a cousin friend the day before. They mentioned donuts, so she went out for donuts. But once outside she forgot about the donuts. Resident #16 added that she became confused about her location and her plan. Resident #16 added that she wanted to go outside to get fresh air, as she had not been outside for ages. The SSD reminded her that they had colder weather then when she usually goes out for her walks. The SSD also reminded Resident #39 that when went out for a walk, she usually walked in the front lot area. This allowed the staff to keep an eye on her and know that she is out there. Resident #16 reported that she thought she told another resident. The SSD stated that she could not tell another resident. Resident #16 replied no, she told the Administrator. The SSD planned to investigate her report. The SSD reminded Resident #16 to ask a staff member to go outside with her, if she wanted to get some fresh air. If the floor staff is busy, she could ask the Activity Director (AD) or the SSD, and they would help. The Orders - Administration Note dated 1/30/23 at 12:08 AM indicated that staff completed hourly checks on Resident #16 due to exit seeking behavior that day and the day before. The Behavior Note dated 1/30/23 at 7:18 AM identified that Resident #16 attempted to exit the facility early in the shift. The Behavior Note dated 2/5/23 at 10:00 PM indicated that Resident #16 attempted to go out the front door twice with other residents' visitors as they left. She verbalized that she wanted to go outside because of it being so nice out. The staff explained to Resident #16 that she could only go out with staff for her safety. The remaining of the shift, she remained on one to one (1:1) supervision until she went to her room and got in bed. The facility then completed 15 minutes checks on her. 2. On 4/18/23 at 9:22 a.m. watched Resident #1 exit the building out of the north service entrance to smoke. Exited the building with Resident #1 and heard the door alarm sounded until the door closed. When asked if he needed to enter a code to go back into the building, Resident #1 reported the door did not have a code that worked. He added that someone could just open the door and when they close the door the alarm turns off. Resident #1 remarked that he did that every day. Witnessed Resident #1 reentered the door with the alarm sounding and turned off after entering the building and closing the door. On 4/18/23 at 9:47 a.m. the Maintenance Director reported that he checked the door alarms weekly. When asked about the north service entrance he revealed that the mag lock did not work due to shifting of the door frame. The facility applied a temporary alarm after Resident #39 left the building. The facility is working on getting alarms on the double doors before the exit but are currently waiting on alarm company. On 4/18/23 at 10:52 a.m. Staff C, Licensed Practical Nurse (LPN), reported that the facility has an elopement binder for all the residents at risk for elopement. Upon further examination Staff C, explained that the binder contained all the residents in the facility. Staff C explained that they determined the resident's elopement risk by looking in the computer under the elopement risk form. On 4/18/23 at 11:15 a.m., Staff C explained that he worked at the facility as a Certified Medication Aide (CMA) when Resident #38 left the building. Staff C reported that Resident #38 exited the facility on the north side of the building. He added that the facility did not have an alarm on the door. Staff C explained that after Resident #38 exited the facility, they installed a makeshift alarm on the north exit door. Staff C reported that the staff cannot hear the alarm unless staff members are at or close to the nurses' station. Staff C confirmed that he did not receive education or training after Resident #38 exited the building without staff knowing. The list of residents at risk for elopement dated 4/18/23 listed Resident #33. The Elopement Policy revised March 2019 instructed that the facility nursing personnel must report and investigate all reports of missing residents. On 4/19/23 at 11:23 a.m. the Administrator vocalized that the facility had a different Administrator at the time of the incident but she did review the report and understood that Resident #38 left the building through the north doors. When the police department called Resident #38 gave them a false name. After sometime the police department called back again, then the staff figured out that Resident #38 left the facility. The Administrator reported that she expected the staff to answer a door alarm if the door alarms worked. 44475 3. Resident #18's MDS dated [DATE] identified a BIMS score of 3, indicating severely impaired cognition. The MDS indicated that Resident #18 required extensive assistance from two persons with bed mobility, transfers, toilet use. Resident #18 independently used his manual wheelchair. The MDS including a diagnosis of encephalopathy (disease that affects brain function). The resident's Electronic Health Record (EHR) included a form labeled Identified Wander/Elopement Risk dated 11/19/22. The Emergency Medical Information list that Resident #18 had a diagnosis of dementia. The Elopement Risk Assessments summary question if the resident had an elopement risk, included documentation in each assessment that Resident #18 did not have a risk for elopement on the following dates: 1. 12/21/22 2. 3/27/23 3. 4/19/23 On 4/17/23 at 1:02 PM observed Resident #18 sit in his wheelchair in front of the nurses' station in between a space of the facility entrance and the North hall. During the observation the resident moved around the space using his feet to propel the wheelchair, looking around as though he needed assistance. During the observation, Resident replied when asked that he wondered where he should go, what he should do, and reported that he wanted to go home. On 4/18/23 at 10:25 AM, Staff M, Certified Nurse Aide (CNA), reported that Resident #18 knew where to find his room, they explained that he wandered the building. Resident #18 has reported to Staff M that he did not know where he's going, that he occasionally reports that he wants to go home, but he did not have exit seeking behaviors and usually congregated towards groups of people. 26527 4. On 4/18/23 at 9:10 a.m. the Marketing/Admissions Director stated if the front door opened without putting in the code the alarm sounded and got louder until somebody checked it and put in the code. The side doors that go out to the dumpsters (alarm) sounded when the door opened, and when the door closed it went off. On 4/18/23 at 9:25 a.m. the Business Office Manager (BOM) stated if the front door opened the alarm sounded and someone needed to go to the alarm and see if a resident went out. They could shut the alarm off by putting in the code. If someone put the code in, the alarm sounded if the door stayed open too long. On 4/18/23 at 9:30 a.m. Staff Q, CNA, said she would need to ask someone what she would do if a door alarm sounded. She went to the nurses' station and asked what they should do. She returned and said if an alarm sounded they went and checked the door. If they did not see a resident they reported it to the nurse so they could check the residents. The BOM reported the alarm sounded if the (alarm) door stayed open more than 19 seconds. On 4/18/23 at 9:35 a.m. Staff T, Dietary Aide, stated they take garbage out the side door and it beeps while open and stops when it shuts. On 4/18/23 at 10:38 a.m. Staff N, Licensed Practical Nurse (LPN), denied knowing if the facility had an elopement risk. She did not really know who was at risk. She said residents with mental impairment would be at risk. She added that she would check on who was at risk. At 10:42 a.m. Staff N explained that they did assessments on residents. She said they did have an elopement binder and she would get it. On 4/18/23 at 11:17 a.m. the Social Services Director stated the day of Resident #39's elopement she came in late. They asked her check Resident #39's BIMS and she scored a 15, indicating no cognitive impairment. Resident #39 said she went to meet her mom, as her mom and dad were going to pick her up in the pickup truck. She went out the side smoking door which didn't have an alarm at that time. She said they put the current alarm in place at that time. She could not even guess how long they didn't have an alarm on that door. They questioned if she followed another resident out. She said Resident #39 used to go out all the time and walk last fall. She said prior to her elopement, Resident #39 started packing up her things and pushed it out in the hall because she was leaving here. But she had never exit seek before. On 4/18/22 at 11:41 a.m. the Administrator at time of Resident #39's elopement stated she stopped working at the facility on 1/20/23. She thought Resident #39 got out and down past the fire department. She thought they went and got her, but not sure. She was tying up loose ends because she was leaving. Resident #39 did like to go out and walk. She knew the passcode to go out the front door. The Administrator thought that she went out there. She said someone called but they did not think anyone was missing. She thought Resident #39 packed her stuff up one time. She did not exit seek. The Administrator at the time said they had someone in the offices that could observe her when she went outside. On the weekend they had a nurse manager who could observe her outside. She said they had never had an elopement before. She thought Resident #39 had something mentally going on. She said that all the door alarms alarmed at that time. If they had a door without an alarm they would have someone watching that door. On 4/18/23 at 12:16 p.m. the BOM stated Resident #39 got out (eloped) before she got to work. She did know for sure what door she went out, but Resident #39 did know the code to the front door. She did not know if all the doors had the same code but she would find out. The BOM came to report all the doors had the same code to get out without alarming. On 4/19/23 at 3:20 p.m. Staff X, CNA, stated she just returned from maternity leave that day. She thought the facility maybe had 1 or 2 residents at risk for elopement. She said residents who were elopement risks would be on 15-minute checks. She said if a door alarm went off she would check where the alarm went off and check to see if anyone went out. If she didn't see anyone outside she would probably check to make sure no one was missing by looking in each resident's room. On 4/19/23 at 3:45 p.m. Staff W, CNA, said she didn't think the facility had anyone at risk for elopement at that time. If a door alarm went off she would go to the nurses' station to see which door it was, and go to the door to check if anyone went out. Then she would go and tell the nurse that no one left. On 4/20/23 1:15 p.m. Staff V, CNA, explained that the facility did tell them what they needed to know about door alarms and any new policies. She said they cannot go out the side door unless taking garbage out. Now the door had an alarm on it with the door code. She said if you hear a door alarm you have check whichever door it was and make sure that no residents went out. If you could not identify who went out, you must go check and make sure everybody's accounted for. She said reported Resident #33 as an elopement risk so they watched her more closely. She'd never actually seen Resident #33 try to go out. Staff V said that she received education about alarms and elopement yesterday. On 4/20/23 at 1:23 p.m. Staff U, CNA, explained that she knew what to do with the alarms and elopements, as they received education. She felt up to date on how to answer the alarms, how to deal with alarms, and the elopement risk. They had received new direction on using the side door, and that they could only use the door to take out the garbage. The door had a full alarm and a keypad. On 4/20/23 at 1:32 p.m. Staff B, CNA, able to tell the new policy with the side door and the alarm for that door, and who could go out that door. She knew of the elopement risk. In addition, Staff B knew how to answer the door alarms and ensure the safety of everyone.

Based on observation, clinical record, facility policy, and staff interview, the facility failed to provide care consistent with professional standards of practice, to prevent pressure ulcers and provide necessary treatment and services to promote the healing of a pressure ulcer, prevent an infection for 1 of 1 resident reviewed (Resident #16). The facility reported a census of 38 residents. The 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 (change to white); in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis (outer skin layer) 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 (fat just under the skin) may be visible but the wound did not have exposed bone, tendon or muscle. Slough may be present but does not obscure (hide) the depth of tissue loss. May include undermining (wound extends unseen under the skin) and tunneling (moves through multiple layers of skin that appear like a tunnel). 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. 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 have started as tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent (next to) 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. Findings include: Resident #16's Minimum Data Set (MDS) dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of medically complex conditions of major depression, diabetes mellitus, and cellulitis. The MDS indicated that Resident #16 had a risk for pressure ulcers. The MDS listed that Resident #16 had a pressure ulcer and infection in his foot (such as cellulitis skin infection or purulent drainage infection related drainage). On 4/17/23 at 12:25 PM Staff Z, Certified Nurse Aide (CNA) exited Resident #16's room after delivering her lunch. Staff Z completed hand hygiene but did wear any personal protective equipment (PPE). Staff Z reported that Resident #16 is on contact precautions, but she did not know why. Staff Z explained that Resident #16 did have a wound on her bottom. On 4/17/23 at 3:59 PM Resident #16 reported that she had a wound on her buttock On 4/26/23 at 2:00 PM observed Staff N, Licensed Practical Nurse (LPN), with the Director of Nursing (DON) present perform a dressing change procedure to Resident #16's pressure ulcer to her left buttock. After cleansing the wound with soap, Staff N changed her gloves without performing hand hygiene. The MDS dated [DATE] indicated that Resident #16 did not have a pressure ulcer. The MDS listed Resident #16 as a risk for pressure ulcers. The Braden Scale Assessment for Predicting Pressure Sore Risk dated 11/30/22 indicated that Resident #16 had a risk for pressure ulcers. The Comprehensive Skin Assessment and Risk Factors dated 11/30/22 revealed that Resident #16 did not have pressure ulcers present at admission. The Wound - Initial (New) Documentation Form dated 1/5/23 at 11:06 AM listed that Resident #16 had an unstageable pressure ulcer to her left buttock that measured 0.7 centimeters (cm) x 0.5 cm. The assessment indicated that the nurse notified the physician of Resident #16's wounds and requested treatment orders. The Wound - Initial (New) Documentation Form dated 1/5/23 at 11:09 AM listed that Resident #16 had an unstageable pressure ulcer to her right buttock that measured 0.3 cm x 0.3 cm. The assessment indicated that the nurse notified the physician of Resident #16's wounds and requested treatment orders. The General Note dated 1/5/23 at 11:11 AM identified the nurse found two open areas on Resident #16's buttock one on the left buttock that measured 0.7 cm x 0.5 cm and one on the right buttock that measured 0.3 cm x 0.3 cm. The nurse applied Calmoseptine to the opens areas and requested a treatment from the physician. The Wound - Weekly Form (One wound per form until healed) dated 1/26/23 at 11:59 AM listed that Resident #16 had an unstageable pressure ulcer to her left buttock that measured 0.6 cm x 0.9 cm. Resident #16's January 2023 Treatment Administration Record (TAR) included an order started on 1/15/23 to apply calmoseptine to affected areas on buttocks three times a day. The evenings of 1/23/23 or 1/27/23 lacked documentation to indicate the completion of the treatment. The Wound - Weekly Form (One wound per form until healed) dated 2/8/23 at 3:56 PM listed that Resident #16 had an unstageable pressure ulcer to her left buttock that measured 1 cm x 1.5 cm. The Dietary Note dated 2/14/23 at 10:52 PM written by the facility's Registered Dietician (RD) indicated they received notification recently of Resident #16's altered skin integrity. The noted directed to see the nursing skin assessment for details. Resident #16's had adequate intakes to meet her estimated needs. The RD had no new recommendations at the time. The Wound - Weekly Form (One wound per form until healed) dated 2/15/23 at 6:41 PM listed that Resident #16 had a pressure ulcer to her left buttock that measured 1.2 cm x 0.5 cm. The wound's edges appeared pink and intact. The Wound - Weekly Form (One wound per form until healed) dated 2/25/23 at 10:49 AM listed that Resident #16 had a pressure ulcer to her left buttock that measured 1 cm x 0.2 cm. The wound appeared stable with edges that appeared pink and intact. The Fax (facsimile) Cover Sheet dated 2/27/23 signed by a physician included an order for LiquaCel 1 packet mixed with 8 ounces of water to promote wound healing. The Clinical Record lacked a signed physician order for calmoseptine treatment for the resident's left buttock pressure ulcer. Resident #16's February 2023 TAR included the following orders: 1. Start date 1/15/23: Apply calmoseptine to affected areas on buttocks three times a day. Discontinued on 2/6/23. a. No documentation on the mornings of 2/1/23 or 2/2/23 to indicate completion of the treatment. 2. Start date 2/7/23: Apply calcium alginate dressing to the open area on Resident #16's left buttocks and change daily every day shift for wound care. Discontinued on 2/23/23. a. No documentation of administration on 2/7/23, 2/10/23, 2/13/23, or 2/23/23. The Wound - Weekly Form (One wound per form until healed) dated 3/1/23 at 3:45 PM listed that Resident #16 had a pressure ulcer staged as a suspected deep tissue injury to her left buttock that measured 1 cm x 0.5 cm. Documentation indicated the wound improved. The Wound - Weekly Form (One wound per form until healed) dated 3/8/23 at 10:54 AM listed that Resident #16 had a stage II pressure ulcer to her left buttock that measured 2 cm x 0.9 cm x 0.2 cm. The wound contained 25% epithelial tissue (basic body tissue), 50% granulation tissue (new tissue), and 25% slough tissue (dying tissue that is usually yellow/white and wet). The wound's edges appeared indurated (hard) with erythema (redness). The note listed the wound as declined due to large measurement with redness and slough. The nurse notified the physician who replied to continue the current treatment at that time. Resident #16 scheduled to see the physician that day and the nurse planned to send the skin assessments with her. The Physician Clinic Sheet dated 3/8/23 indicated that Resident #16 had a 60-day follow-up. The Advanced Registered Nurse Practitioner (ARNP) provided the following orders: a. Cephalexin 500 milligrams (mg) three times a day for ten days. b. Please reposition resident every two hours. c. Please make sure to follow the wound care orders. d. Order for Resident #16 to see the hospital's Wound Care to assess wound to buttocks and treatment e. Please follow orders as resident did not have adequate treatment to wound upon assessment in the office. f. Return in two weeks for follow-up on cellulitis on 3/27/23 at 11:15 AM. The Physician Visit note dated 3/8/23 at 4:09 PM identified that the hospital's wound care to assess and treat Resident #16's wound to her buttocks. The Wound - Weekly Form (One wound per form until healed) dated 3/15/23 at 11:25 AM listed that Resident #16 had a stage II pressure ulcer to her left buttock that measured 1 cm x 0.9 cm x 0.2 cm. The wound had a scant (small) amount of serosanguineous drainage (occurs as the wound tries to heal, it appears pale red or pink in color). The wound appeared indurated with erythema. The description detailed the buttocks wound to appear smaller with slough to the entire wound bed with indurated edges and bright red surrounding tissue. The note listed the progress as improved. The physician did not receive notification due to the improved status. The Wound - Weekly Form (One wound per form until healed) dated 3/22/23 at 9:52 AM listed that Resident #16 had a stage II pressure ulcer to her left buttock that measured 1.5 cm x 0.9 cm x 0.2 cm. The wound had no drainage or odor. The wound appeared indurated with erythema and edema (swelling). The description detailed the buttocks wound to appear smaller with slough to the entire wound bed with indurated edges and bright red surrounding tissue. The RN Analysis and Plan indicated Resident #16 at the Wound Clinic at time of documentation. The nurse provided staff education to move the ROHO cushion from the recliner to the wheelchair and encourage her to get up and out of her room. The note listed the progress as improved. The physician did not receive notification due to no change in status. The Physician Clinic Sheet dated 3/22/23 included the following orders a. Discontinue the previous wound care orders b. Left Buttock Ulcer Treatment a. Wash with soap and water. b. Apply Aquacel AG or silver alginate c. Cover with border gauze or a four by four (4x4) with Medipore tape and change daily. c. Follow-up in one week The Orders - Administration Note dated 3/22/23 at 11:32 AM indicated that Resident #16 returned from the Wound Clinic and had a new appointment for 3/29/23 at 9:45 AM. The Wound Clinic Progress Note dated 3/22/23 indicated the left buttock wound did not have tunneling or undermining, it included a medium amount of serous (fluid) drainage, a thickened wound margin, medium pink granulation tissue in the wound bed, medium necrotic (dead tissue) including adherent (sticky) slough in wound bed, stage III measured 0.9 cm length, 0.5 cm width, 0.5 cm depth. Wound culture obtained. The Microbiology Routine Culture laboratory report dated 3/25/23 identified that Resident #16's left buttock wound culture revealed an infection resistant to Vancomycin (antibiotic). Resident #16's clinical record lacked information related to her right buttock wound from 1/5/23 until 3/28/23. The Wound Clinic Progress Notes signed 3/28/23 included a new order for gentamicin (antibiotic) ointment. The order directed to apply to the left gluteal wound twice daily due to a diagnosis of VRE (Resistant infection to the vancomycin antibiotic). The Wound Clinic Progress Note dated 3/29/23 sign by an ARNP indicated that Resident #16 had a stage II pressure ulcer to her right gluteus that measured 0.4 cm length x 0.3 cm width x 0.2 cm depth. The note continued to indicate that an assessment of her wheelchair revealed a broken cushion. The wound had undermining (wound edges separate from healthy tissue create a pocket under the skin) from 7:00 to 11:00 o'clock with a maximum depth of 0.6 cm. The wound had a medium amount of serous drainage, thickened wound margin, medium pink granulation in wound bed, small necrotic including adherent slough in wound bed, stage III pressure ulcer that measured 0.8 cm length, 0.4 cm width, 0.5 cm depth. The Physician Clinic Sheet dated 3/29/23 indicated that the offloading cushion in Resident #16's chair had a broken valve that needed fixed. The order directed the resident to return in two weeks. The Wound Center's Discharge Instructions dated 3/29/23 listed a follow-up appointment of 4/12/23 at 9:45 AM. The note included handwriting that directed to see the telephone order. The Telephone Order dated 3/29/23 at 1:22 PM included an order for treatment of the Left Buttock Wound. The order directed to clean with soap and water, dry, apply Aquacel AG or Calcium Alginate, Apply to wound bed slightly moistened with saline. Cover With bordered gauze to prepped skin or cover with a 4x4 gauze and secure with Medipore tape to prepped skin. Change dally and as needed (PRN) every day shift for Wound Care and as needed for Wound Cares. The order discontinued the previous wound treatment. The Wound - Initial (New) Documentation Form dated 3/30/23 at 1:30 PM listed that Resident #16 had a pressure ulcer to her right buttock that measured 1 cm x 1 cm. The nurse notified the Physician on 3/28/23. Resident #16's March 2023 TAR included an order started on 3/23/23 and discontinued on 3/29/23 to clean with soap and water, dry, apply Aquacel Ag or Calcium Alginate dressing then cover with a border gauze. Change the dressing daily and PRN. The TAR lacked documentation of administration on 3/27/23. The Wound - Weekly Form (One wound per form until healed) dated 4/6/23 at 1:03 PM listed that Resident #16 had a pressure ulcer to her right buttock that measured 1 cm x 1 cm. Documentation indicated the wound had no change. The Wound - Weekly Form (One wound per form until healed) dated 4/12/23 at 2:08 PM listed that Resident #16 had a stage II pressure ulcer to her left buttock that measured 1 cm x 0.9 cm x 0.2 cm. The wound appeared indurated, edematous, and erythema. Documentation list the wound as stable and improved. The Wound Clinic Progress Notes signed by an ARNP dated 4/19/23 identified that the assessment of her wheelchair revealed an appropriate ROHO cushion. The left buttock wound had undermining from 7:00 to 11:00 o'clock with a maximum depth of 0.6 cm. The wound had a medium amount of serous drainage, a thickened wound margin, medium pink granulation in wound bed, small necrotic including adherent slough in wound bed, stage III pressure ulcer that measured 0.3 cm length, 0.7 cm width, 0.3 cm depth. The Care Plan Focus revised 4/5/23 indicated that Resident #16 had a potential for pressure ulcers related to decreased mobility and sleeping her in recliner instead of her bed. On 1/5/23 Resident #16 had a new pressure ulcer to her buttock and gluteal fold (the crease between the buttock and upper thigh). The Care Plan included the following Interventions: a. Initiated 12/8/22: Monitor nutritional status. Serve diet as ordered, monitor intake and record. b. Initiated 12/8/22: Follow facility policies/protocols for the prevention/treatment of skin breakdown. c. Initiated 2/9/23: ROHO cushion. d. Revised 4/5/23: Pressure relieving cushion in her wheelchair ROHO. Resident #16 likes her recliner. The staff discussed shifting her weight every 1-2hrs with her but she often declined. Resident #16 is resistant and non-compliant at times with her care and treatment. The Intervention directed the staff to work one on one (1:1) with her to keep as dry as possible, in addition to turning, repositioning, and pressure reduction interventions. The Pressure Ulcer Risk Assessment Policy revised March 2019 directed to provide guidelines for the assessment and identification of residents at risk for developing pressure ulcers. - General guidelines: a. If treatment of a pressure ulcer does not occur when discovered, they quickly get larger, become painful for the resident, and often become infected. b. Continual pressure, heat, moisture, irritating substances on the resident's skin, decline in nutrition and hydration status, acute illness and /or decline in the resident's physical and/or mental conditions make pressure ulcers worse. c. Once a pressure ulcer develops it can be extremely difficult to heal. d. Pressure ulcers are a serious skin condition for residents. e. Routinely assess and document the condition of the resident's skin per facility wound and skin programs for any signs and symptoms of irritation or breakdown. f. Complete comprehensive skin assessments on admission, readmission, annually, and with change in condition or surface. g. Skin checks: Check the skin for the presence of a developing pressure ulcer on a weekly basis or more frequently if indicated. h. Monitoring: Staff maintain a skin alert, performing routine skin inspections daily or every other day as needed. Notify the nurses to inspect the skin if skin changes identified. Nurses conduct a skin assessment at least weekly to identify changes. - Identifying Resident at Risk: a. Extrinsic factors: pressure, friction, shear, and maceration. b. Intrinsic factors: immobility, altered mental status, incontinence, and poor nutrition. c. Medications. d. Diagnosis. - Documentation: a. The type of assessment conducted. b. The date and time and type of skin care provided. c. Any change in the resident's condition. d. The condition of the skin (size and location of any red or tender areas). e. Observations of anything unusual exhibited by the resident. - Reporting: a. Notify the supervisor if the resident refused. b. Report other information in accordance with the facility policy and professional standards of practice. On 5/4/23 at 1:13 PM when asked about the lack of weekly skin assessments, lack of signed physician notification of the resident's wound, or an order for treatment of the wound, and the delay in obtaining nutritional supplements or wound clinic referral, the Director of Nursing (DON) did not respond and continued to look at the resident's clinical record to find the missing items.

Based on observations, clinical record review, facility policy review, staff interviews, and Wound Clinic Registered Nurse interview the facility failed to ensure the residents received care consistent with professional standards of practice, to prevent pressure ulcers, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 2 residents reviewed for facility acquired pressure ulcers (Residents #11 and #23). Resident #23 admitted to the facility on [DATE] following acute hospitalization for [CONDITION(S)] to the lower extremities. On 12/8/21, the facility identified Resident #23 had a Stage III pressure ulcer to the left buttock. On 12/15/21, the Wound Clinic identified three additional pressure areas in which the facility failed to identify and assess. On 12/30/21, the Wound Clinic identified two more pressure ulcers in which the facility also failed to identify and assess. The resident requested pain medications to treat the wound pain, the wounds required debridement on multiple occasions, and the resident required oral antibiotic to treat the infected wounds. The facility reported a census of 37 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE], documented Resident #23 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 required extensive assistance of two staff with bed mobility and toilet use and totally dependent on two staff for transfers. Resident #23 had a Brief Interview for Mental Status Score of 15, indicating no cognitive impairments. The MDS documented Resident #23 at risk of developing pressure ulcers and had no healed or current pressure ulcers. The MDS documented treatments of pressure reducing device for bed and chair and applications of ointment/medications other than to feet. Resident #23 had Moisture Associated Skin Damage (MASD). The MDS contained the following descriptions of pressure ulcers: Stage I 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 partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable due to coverage of the wound bed by slough &/or eschar. The Braden Scale Assessment for Predicting Pressure Sore Risk dated 12/2/21 documented Resident #23 had a score of 11, indicating high risk. The Care Plan date initiated 12/3/21, directed staff to use a total mechanical lift for transfers, provide extensive assistance of 2 staff with dressing and grooming, total assistance of staff with bathing, electric wheelchair, macerated/sheering area to bilateral buttocks, [CONDITION(S)] to bilateral lower extremities, and antibiotic for [CONDITION(S)], treatment as ordered, pressure redistributing pad on chair, pressure redistributing mattress on bed, and skin observed at least weekly by the nurse during bathing process. The Comprehensive Skin Inspection & Risk Factors (Admission Nursing Assessment) dated 12/2/21 documented Resident #23 had a sore (unknown type) to the second toe on the left foot measuring 0.5 centimeters (cm) in length by 0.5 cm in width by 0.1 cm depth. The Weekly Wound Form dated 12/8/21 documented Resident #23 had a Stage III pressure ulcer to the left buttock, multiple sheering areas noted to buttocks, bilateral buttocks raw and red in color. The area measured 2 cm by 1.3 cm by 0.2 cm. The wound edges macerated and no drainage or odor noted. The form documented a current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Clinic notes dated 12/15/21 documented the following wounds: a. Wound #17, a Stage III pressure ulcer to the right gluteus (buttock). Measured 12 cm by 5 cm by 0.5 cm, subcutaneous tissue exposed, medium amount of serosanguineous drainage (yellowish with blood), wound bed red, and small amount of necrotic (black, dead) tissue within the wound bed including slough. Debridement preformed, removed eschar, subcutaneous tissue, and slough. b. Wound #18, a Stage II pressure ulcer to the left gluteus. Measured 8 cm by 2.5 cm by 0.1 cm, medium amount serosanguineous drainage, red granulation wound bed, and small amount of necrotic tissue within the wound bed including slough. c. Wound # 19, a Stage II pressure ulcer to the left posterior upper thigh. Measured 17 cm by 17 cm by 0.2 cm, medium amount serosanguineous drainage, red granulation wound bed with small amount of necrotic tissue within the wound bed including slough. d. Wound #20, a Stage II pressure ulcer to the right posterior upper leg. Measured 6 cm by 2 cm by 0.1 cm, medium amount of serosanguineous drainage, red granulation wound bed with small amount of necrotic tissue within the wound bed including slough. Review of the facility wound assessments from 12/8/21 to 3/30/22 revealed the facility failed to identify and assess the three additional wounds identified on the posterior thighs by the Wound Clinic (Wound #17, Wound #19 and Wound #20). The facility assessments of the gluteal wounds failed to consistently assess both the left and right wounds. The Wound Clinic notes dated 12/30/21 documented 2 additional facility acquired wounds and all 6 wounds required debridement and chemical cauterization: a. Wound #17, a Stage III pressure ulcer to the right gluteus. Measured 2 cm x 1 cm x 0.3 cm, subcutaneous tissue exposed, medium amount serosanguineous drainage, red wound bed with small amount of necrotic tissue within the wound bed including slough. Debrided eschar, subcutaneous tissue, slough, and exudate. b. Wound #18, a Stage II pressure ulcer to the gluteal fold. Measured 2 cm x 1.5 cm x 0.1 cm, medium amount serosanguineous drainage, and red granulation wound bed with small amount of necrotic tissue within the wound bed including slough. Chemical cauterized the wound (reduce infection). c. Wound #19, a Stage II pressure ulcer to the left posterior upper thigh. Measured 4 cm x 2 cm x 0.1 cm, medium amount serosanguineous drainage, and red granulation wound bed with small amount of necrotic tissue within the wound bed including slough. Chemical cauterized the wound. d. Wound #20, Stage II pressure ulcer to the right posterior upper leg. Measured 4.4 cm x 1 cm x 0.1 cm, medium amount serosanguineous drainage, and red granulation wound bed with small amount necrotic tissue within the wound bed including slough. Chemical cauterized the wound. e. Wound #21, a newly acquired Stage II pressure ulcer to the right midline gluteus. Measured 0.8 cm x 0.8 cm x 0.1 cm, medium amount serosanguineous drainage, and large red/pink granulation wound bed. Chemical cauterized the wound. f. Wound #22, a newly acquired Stage II pressure ulcer to the right medial gluteus. Measured 1.6 cm x 1.1 cm x 0.1 cm, medium amount of serous (clear) drainage, large red/pink granulation wound bed. Chemical cauterized the wound. Review of the facility wound assessments from 12/30/21 to 3/30/22 revealed the facility failed to identify and assess the two additional wounds identified on 12/30/21 by the Wound Clinic (Wound #21 and Wound #22). December 2021 Treatment Administration Record (TAR) revealed the following: a. An order dated 2/2/21, to apply [MEDICATION(S)] ointment to buttock/tight two times a day for wound care. The staff omitted the treatment on 12/14/21, 12/17/21, and 12/24/21 on the day shift. b. An ordered dated 12/16/21, to cleanse the right and left gluteus with soap and water, apply zinc barrier to all affected areas. Stage III to the right buttock apply 4 by 4 soaked Dakin's 0.125%, cover with ABD & secure with tape and brief two times day, The staff omitted the treatments on 12/17/21 and 12/24/21 on the day shift. January 2022 TAR revealed the following: a. [MEDICATION(S)] ointment to buttock/thigh topically two times a day, started dated 12/2/21. The staff omitted the treatment on 1/7/21 and 1/17/22 on the evening shift and on 1/18/22 on the day shift. b. Right and left gluteus, cleanse with soap and water, apply zinc barrier to all affected areas of buttock. Stage III to the right buttock ulcer apply 4x4 soaked in Dakin's 0.125%, cover with tape and brief two times a day. The staff omitted the treatment on 1/17/22 on the evening shift and 1/18/22 on the day shift. c. Wash right and left upper leg with soap and water, apply zinc oxide two times a day for wound care. The staff omitted the treatment on 1/17/22 in the evening shift and on 1/18/22 for the day shift. March 2022 TAR revealed the following: a. Apply calcium alginate with silver to right gluteus wound bed daily, cover with ABD, and hold in place with a brief. No tape. The staff omitted the treatment on 3/1/22, 3/5/22, 3/16/22, 3/17/22, 3/21/22, 3/28/22, and on 3/29/22. b. [MEDICATION(S)] two times a day to ischium and right posterior upper leg. The staff omitted the treatment on the day shift on 3/1/22, 3/5/22, 3/8/22, 3/16/22 and on the evening shift of 3/7/22. April 2022 TAR revealed the following: a. [MEDICATION(S)] two times a day to ischium and the right posterior upper leg two times a day start date 2/24/22. The staff omitted the treatment on 4/11/22 on the day shift. b. Apply calcium alginate with silver to the wound bed right gluteus daily, cover with ABD, and hold in place with a brief, no tape. The staff omitted the treatment on 4/5/22, 4/6/22, and 4/11/22. Review of Resident #23's Progress Notes revealed: a. On 12/5/21 at 9:01 PM, Orders-Administration note revealed the resident received Acetaminophen (analgesic for pain) 325 milligrams (mg) 2 tablets for complaint of buttock pain & discomfort b. On 12/10/21 at 6:19 PM, Nutritional Evaluation revealed the resident current diet-controlled carbohydrate renal diet. Estimated protein requirements 140 grams and estimated fluid requirements 1500-2000 milliliters. Average meal intake for the resident 50-74.9% and supplement intake not applicable. Indicated the resident's skin breakdown included [CONDITION(S)] to the bilateral lower extremities, skin care in place, and on an antibiotic. c. On 12/15/21 at 10:53 AM, General Note (GN) revealed the resident hot chart due to antibiotic for [CONDITION(S)]. The resident rated pain a 3 out of 10 to bottom area. d. On 12/27/21 at 12:35 AM, Orders-Administration note revealed the resident received Acetaminophen 325 mg 2 tablets for complaints of buttock pain e. On 12/30/21 at 10:33 AM GN revealed the resident returned from an appointment at the wound clinic with new orders for [MEDICATION(S)] (antibiotic) x 2 weeks, [MEDICATION(S)] (antibiotic) x 2 weeks, zinc barrier ointment, and new treatment orders for the wounds to the left and right upper legs. f. On 1/21/22 at 1:52 PM, Dietary note (DN); Registered Dietician (RD) weight change and wound note. Weight trends show weight loss, however warranted. Per the wound assessment dated [DATE] the resident had Stage III pressure ulcer to the right buttock, however, improved and treatment in place. Recommend [MEDICATION(S)] two times daily, vitamin c, vitamin e and L-[MEDICATION(S)] for wound healing. g. On 2/10/22 at 1:54 PM, the resident returned from the wound clinic with new orders to discontinue all treatments with the exception of the right buttock ulcer. Continue current treatment to the right buttock. h. On 2/14/22 at 5:39 PM, GN revealed new order received from the wound clinic related to culture from the right buttock. Culture revealed positive [CONDITION(S)], [MEDICATION(S)] & [MEDICATION(S)] (antibiotics) ordered for 2 weeks; family notified. i. On 3/10/22 at 10:22 AM, the resident returned from the wound clinic and to continue same treatment. Culture obtained from the wound while at the wound clinic. j. On 3/17/22 at 3:20 AM, new order received from the wound clinic for [MEDICATION(S)] (antibiotic) x 14 days due to wound culture results. k. On 3/30/22 at 4:12 PM, Dietary note revealed the resident continued with pressure injury to the right buttock, larger in size. Recommended increase the [MEDICATION(S)] to aid wound healing. l. On 4/1/22 at 2:14 AM, Health status note (HSN) revealed the resident's wound larger, wound bed beefy red and sanguineous drainage noted without odor. The resident reported discomfort during treatment. m. On 4/1/22 at 12:59 PM, HSN revealed fax returned from the physician and new order to obtain culture to right buttock wound. n. On 4/4/22 at 5:18 PM, GN revealed new order received from the wound clinic related to culture results; [MEDICATION(S)] (antibiotic) x 2 weeks; resident aware. o. On 4/7/22 at 10:41 AM, GN revealed the resident returned from wound clinic appointment and new order received for the left lower leg. Facility fax dated 3/30/22, notified the Wound Clinic Resident #23's wound to right buttock larger in size, measured 3 cm x 1 cm x 0.3 cm. Order received to obtain culture dated 4/1/22. The Pressure Ulcer Risk Assessment Policy revised March 2019 stated the purpose of procedure, to provide guidelines for the assessment and identification of residents at risk for developing pressure ulcers. General guidelines: a. If pressure ulcers are not treated when discovered, quickly get larger, become painful for the resident, and often times become infected. b. Pressure ulcers made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, decline in nutrition & hydration status, acute illness, &/or decline in the resident's physical &/or mental conditions. c. Once a pressure ulcer developed can be extremely difficult to heal. d. Pressure ulcers are a serious skin condition for the resident e. Routinely assess and document the condition of the resident's skin per facility wound and skin program for any signs & symptoms of irritation or breakdown. f. Comprehensive skin assessments: on admission, readmission, annually and with change in condition or surface. g. Skin checks: skill would be checked for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated h. Monitoring: staff maintain a skin alert, performing routine skin inspections daily or every other day as needed. Nurses to be notified to inspect the skin if skin changes identified. Nurses would conduct skin assessments at least weekly to identify changes. Identifying Residents at Risk: a. Extrinsic factors: pressure, friction & shear, and maceration b. Intrinsic factors: immobility, altered mental status, incontinence, and poor nutrition c. Medications d. Diagnosis Documentation a. The type of assessment conducted b. The date & tie and type of skin care provided c. Any change in the resident's condition d. The condition of the skin (size & location of any red or tender areas) e. Observations of anything unusual exhibited by the resident Reporting a. Notify the supervisor if the resident refused b. Report other information in accordance with the facility policy and professional standards of practice. Observation on 4/12/22 at 1:48 PM, with Staff M, Registered Nurse during dressing change of calcium alginate with silver & ADB, revealed no open area to the left buttock, skin dry and scaly appearance. Right buttock dry, scaly, and calloused with an open area to the inner buttock approximately 2 cm in length with 2 smaller open areas present. The wound beds red in appearance, no slough noted. Staff M applied [MEDICATION(S)] to the left buttock and bilaterally under the posterior upper legs. No open areas noted to the bilaterally posterior upper legs. Observation on 4/13/22 at 12:40 PM, Resident #23 in bed, stated requested to stay in bed due to bottom being sore, air mattress overlay on and functioning. Along with Staff M open area to the right buttock measured 2.3 cm x 0.7 cm x 0.2 cm, bright red wound base. The skin surrounding the open area red, chaffed, dry & excoriated, measured approximately 8 cm circular area. The bilateral posterior upper leg increased redness, chaffed, dry & excoriated. Interview on 4/12/22 at 3:39 PM, the Interim Director of Nursing (DON) stated would look into the resident's pressure ulcer documentation and assessments. The Interim DON stated the Wound Clinic did not typically measure wounds at appointments. Interview on 4/13/22 at 12:26 PM, Staff M, stated skin assessments completed weekly for all residents and pressure ulcers followed up on weekly. Staff M stated had seen wounds more frequently than weekly recently. Staff M confirmed the last wound assessment for Resident #23's pressure ulcers on 3/30/22. Staff M stated pressure ulcer assessment should be done weekly. Staff M stated the wound base assessment only completed during the assessment when noticed eschar or slough. Staff M stated the wound clinic assessed the pressure ulcers during visits, however, only send the full assessment when the facility requested. Interview on 4/18/22 at 11:25 AM, the Wound Clinic Registered Nurse stated Resident #23 first started at the Wound Clinic on 12/15/21, and had Stage III pressure area to right gluteal, Stage II pressure area left gluteal, and to the back of the right and left thighs Stage II pressure areas. The Wound Clinic Registered Nurse stated the resident had [CONDITION(S)] to bilateral lower legs. The Wound Clinic Registered Nurse stated Resident #23 weighted over 300 pounds and with moisture, made for a perfect storm for pressure ulcer development. The Wound Clinic Registered Nurse stated the moisture and added pressure resulted in the pressure ulcers. The Wound Clinic Registered Nurse stated Resident #23 should have had a low air loss air mattress on admission to the facility. The Wound Clinic Registered Nurse seat mapping ordered and to be done in February 2022, however, not completed. The Wound Clinic Registered Nurse stated the resident placed on a special cushion to determine where the pressure is and based on the testing, new cushions recommended. The Wound Clinic Registered Nurse stated the seat mapping ordered on 2/10/22 and not done, and unsure why not. The Wound Clinic Registered Nurse stated would send a new order. The Wound Clinic Registered Nurses stated the resident required more of a pressure relieving cushion for wheelchair than light blue waffle one in place. The Wound Clinic Registered Nurse stated pressure ulcers preventable. The Wound Clinic Registered Nurse stated hard to say if the missed treatments caused the wound to deteriorate due to the infection in the wound. Interview on 4/18/22 at 11:53 AM, Staff Q, Certified Nurse Aide, stated he/she did not consistently work with Resident #23, however, aware the resident had a sore on bottom. Staff Q stated Resident #23 allowed the staff to reposition, one of the last resident's gotten up for meals and tried to make sure first one in bed after meals. Staff Q stated the resident would request to lay down when done eating. Staff W stated after breakfast and lunch the resident on back and afternoons tried to get on side. Staff Q stated the resident would wiggle and move self in bed, attempted to remind the resident to stay off bottom due to the open areas. Interview on 4/18/22 at 12:08 PM, Staff I, Licensed Practical Nurse, stated had been present when Resident #23 admitted to the facility on [DATE]. Staff I stated Resident #23 did not have open areas to bilateral buttocks, stated macerated 90%, no open areas. Staff I stated he resident's skin and legs red and sore. Staff I stated Resident #23's legs got worse and requested different bed immediately, however, not sure when the bed came. Staff I stated Resident #23 required a bigger bed due to the bed not being big enough. Staff I stated unable to reposition Resident #23 on side due to the resident size and the size of the bed. Staff I stated not sure when the air overlay on the bed had been initiated. Staff I stated Resident #23 repositioned as much as the resident would allow. Staff I stated as soon as the facility identified skin issues, referred to the wound clinic. Staff I stated unaware of the order for pressure mapping. Interview on 4/18/22 at 12:28 PM, Staff M, Registered Nurse, stated the first-time observed Resident #23's bottom appeared shredded, bad. Staff M stated order obtained for the wound clinic to be involved at that time. Staff M stated Resident #23 could have a shearing spot one week and the next week it would not there and show up in a different spot. Staff M stated difficult to keep track of Resident #23's open areas. Staff M stated unaware of any red or open areas on admission to the posterior legs. Staff M stated did not recall interventions put into place when the resident first admitted . Staff M stated shortly after the admission air mattress overly obtained, probably within the same week. Staff M stated the base line care plan initiated in the resident's electronic health record (HER). Interview on 4/18/22 at 1:39 PM, Staff N, Certified Nurse Aide, stated Resident #23 had been at the facility for a while before received the air mattress overlay, however, did not recall when. Staff N stated when the resident admitted , refused to reposition at times and continued to refuse at times. Staff N stated the resident would refuse to allow the staff to remove the full body mechanical lift pad at times. Staff N stated did not recall if the resident always had cushion in wheelchair, stated remembered the air mattress due to asking for it multiple times before received. Interview on 4/18/22 at 2:01 PM, Staff L, Certified Nurse Aide, stated only worked with Resident #23 one day in December and then on maternity leave. Staff L stated Resident #23 on a turn/reposition program upon return from maternity leave. Staff L stated Resident #23 complained frequently about the staff not being unable to position correctly in her wheelchair. Staff L stated when Resident #23 admitted to the facility, did not feel the facility had the equipment to care for a bariatric resident. Staff L stated utilized 4 staff initially in attempt to position correctly in the wheelchair. Staff L stated the resident preferred to lay down between meals. Staff L stated if the staff know the resident wanted to go to bingo, would offer to lay the resident down first. Staff L stated the resident would reposition at times and other times would refuse. Interview on 4/19/22 at 8:42 AM, Staff F, Certified Medication Aide, stated Resident #23's bottom looked awful, like raw hamburger when admitted to the facility. Staff F stated looked the best ever right before went to hospital and then worse when returned. Staff F stated the resident had always had treatment to bottom. Staff F stated Resident #23 had [CONDITION(S)] in wound and did not help with the healing. Staff F stated when Resident #23 admitted to the facility, encouraged repositioning & to get up in wheelchair. Staff F stated at times the resident refused, preferred to lay on back. Staff F stated unaware how long the resident had the air overlay on bed, stated possibly 2 weeks after admission to the facility. Interview on 4/19/22 at 9:19 AM, Staff B, Certified Nurse Aide, stated when Resident #23 admitted to the facility lower legs bad, however, did not recall if the resident had open areas on bottom. Staff B stated remembered legs were bad. Staff B stated the resident encouraged to reposition, however, did not like to because on the computer, and preferred to be flat to see the computer. Staff B stated the resident did not have the air mattress overlay for a while after admission, however, not sure how long at least couple of weeks after admission or longer. Staff B stated difficult to turn and reposition the resident due to size. Interview on 4/19/22 at 9:29 AM, Staff A, Certified Nurse Aide, stated when Resident #23 admitted to the facility, skin to bilateral lower legs, knee down, very dry/flaky. Staff A stated the resident's bottom very raw and red like a severe rash. Staff A stated the resident's bottom did not have a good layer of skin. Staff A stated did not recall when the resident's developed open areas. Staff A stated Resident #23 had regular standard bed, flat sheet, with a brief. Staff A stated the resident did not refuse to be repositioned. Staff A stated unaware of when the resident obtained the air mattress overlay on bed. Interview on 4/19/22 at 11:53 AM, Staff M, Registered Nurse, stated reviewed Resident #23's weekly documentation of the pressure areas for the left and right buttock and stated documented as the left buttock initially and when determined not left and actually the right, changed the documentation to the right buttock. Staff M stated would review the skin documentation for open areas to the posterior bilateral upper legs. Interview on 4/19/22 at 12:17 PM, Staff M, Registered Nurse, stated no skin documentation &/or assessments related to open areas to the bilateral posterior upper thighs for Resident #23. Staff M stated not aware the resident had any open areas to the posterior thighs. Interview on 4/19/22 at 2:05 PM, the Interim Director of Nurses, stated unaware Resident #23 had open areas to the bilateral posterior thighs. The Interim DON stated skin assessments completed weekly for all skin issues. The Interim DON stated expected all wound assessments to have a full description of the wounds, including the wound bed. The Interim DON stated the dietician should have been notified immediately and involved with identified pressure ulcers for Resident #23. The Interim DON stated the dietary department a contract service and for a while had been without a dietician. The Interim DON stated did not recall if it was at the particular time Resident #23 identified with the pressure ulcers. The Interim DON stated PACE directed the residents care. The Interim DON stated unaware of when the air mattress overly initiated for Resident #23. The Interim DON stated had not been in the facility when Resident #23 admitted and did not recall the interventions in place on admission to prevent the pressure ulcers. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 5 which indicated severely impaired cognition. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS revealed the resident was totally dependent on 2 for transfers and extensive assistance of 2 for toileting; 1 unstageable, unhealed pressure ulcer. The MDS dated [DATE] revealed that the resident did not have any pressure ulcers when she was admitted to the facility. The Order dated 12/21/21 revealed an order to irrigate the right calcaneus (heel) wound with ¼ quarter strength peroxide and 3/4 saline, rinse with saline, pat dry. Apply Santyl to wound nickel thick, cover with Dakin's soaked gauze, cover with dry gauze, wrap with kerlix. Change dressing daily. Wear prafo boot for offloading at all times. Every day shift for wound care right heel. The Order with a revision date of 03/1/22 revealed the following wound care treatment: right heel wound - irrigate with 1/4 peroxide and 3/4 saline, rinse with saline and pat dry. Apply collagen with silver Ag, cover with bordered dressing every other day. Every day shift every other day for Stage III ulcer to right heel. The Treatment Administration Record (TAR) revealed the staff omitted the treatment to the heel pressure ulcer on 2 days from 4/01/22 to 4/20/22 and omitted 6 days in March of 2022. The staff failed to complete Skin Assessments on 1/12/22 and 2/02/22. The facility failed to complete assessments after the Wound Clinic debrided the wound on 11/30/21. The Skin Program Policy dated 3/19 revealed the facility would provide care and services to promote the healing of pressure ulcers/wounds that are present and the facility would reassess the wound at least weekly to include size, stage, size, appearance of wound bed, and status of the tissue surrounding the wound.

Based on observations, clinical record reviews, policy reviews, staff, and physician interviews, the facility failed to implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to assure thorough completed weekly skin assessments for residents with an identified skin impairment for 1 of 1 resident reviewed (Resident #20). Resident #86 admitted to the facility on [DATE] from an acute care hospital following a fall at home that resulted in a fractured lower leg. Resident #86's primary care provider (PCP) ordered sequential compression devices to lower legs (method of a wrap around the legs that inflate with air to prevent blood clots & improve the blood flow in the legs), an incentive spirometer (a hand-held device used to improve lung function), and knee immobilizer on admission to the facility to prevent blood clots. The facility failed to implement the orders on admission on 2/24/21, and Resident #86 admitted to the local hospital on 3/18/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 37 residents. Findings Include: 1. Resident #86's MDS assessment dated [DATE], indicated a BIMS score of 13, indicating intact cognition. The MDS documented Resident #86 required extensive assistance of two people for bed mobility, dressing, toilet use, personal hygiene; and total dependence of two staff for transfers. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus initiated 2/26/21, identified Resident #86 admitted to the facility for displaced bicondylar fracture of the right tibia and planned on short term rehabilitation stay at the facility. The Focus included the intervention that directed staff to assist Resident #86 to gain independence as much as possible. Resident #86's Care Plan Focus initiated 2/26/21, identified she required assistance with dressing, grooming and bathing. The Care Plan interventions dated 2/26/21 included the following: a. Physical Therapy (PT) and Occupation Therapy (OT) as ordered to improve dressing, grooming, and bathing abilities b. Extensive assist of 1 staff with dressing, grooming, and bathing. c. Extensive assist for a tub bath. Resident #86's Care Plan Focus initiated 2/26/21, identified she had impaired mobility related to a history of a right tibia fracture that required surgery. Resident #86 had a potential for injury related to her fall before her admission to the facility. The Care Plan interventions included: a. Non-weight bearing (3/4/21 & resolved 6/10/21) b. Staff to utilized the full-body mechanical lift to transfer. (3/4/21 & resolved 6/8/21) c. Extensive assist of one staff with ambulation in the hall with walker (2/26/21) d. Extensive assist of two staff with bed mobility, transfers, and ambulation with the use of the stand-up lift (2/26/21) e. Utilized wheelchair (2/26/21) Resident #86's Care Plan initiated 2/26/21 and then resolved 4/13/21 indicated her medications and treatments listed in her orders were a part of her care plan. Some of them were identified throughout the plan of care with special interventions. The Care Plan intervention initiated on 2/26/21 and resolved on 4/13/21 stated the staff were to provide Resident #86 with the appropriate medications and treatments as ordered. Resident #86's February 2021 Treatment Administration Record (TAR) contained the following orders: a. An Incentive Spirometer five to six times per hour every shift, start date 2/26/21 and discontinue date 3/25/21. i. Documentation included: - medication unavailable, see nurse notes. - no entry (blank) from 2/26/21 - 2/28/21. - Night shift documented completed on 2/25/21 and 2/26/21. b. Right knee immobilizer every shift, start date 2/26/21 and discontinue date 3/25/21. i. Documentation included - medication unavailable, see nurse notes - no entry (blank) from 2/26 - 2/28/21. - Night shift documented completed on 2/25/21 and 2/26/21. c. Sequential compression device while in bed every shift, start date 2/26/21 and discontinue date 3/25/21. i. Documentation included: - medication unavailable, see nurse notes. - no entry (blank) from 2/26/21 - 2/28/21. - Night shift documented completed on 2/25/21 and 2/26/21. Resident #86's March 2021 TAR contained the following orders: a. Incentive Spirometer 5-6 times per hour every shift, start date 2/26/21 and discontinue date 3/25/21. i. Documentation varied from 3/1 - 3/18/21: - medication unavailable, see nurse notes. no entry (blank), and signed off as completed. b. Right knee immobilizer every shift, start date 2/26/21 and discontinue date 3/25/21. i. Documentation varied from 3/1 - 3/18/21: - medication unavailable, see nurse notes, no entry (blank), and signed off as completed. c. Sequential compression device while in bed every shift, start date 2/26/21 and discontinue date 3/25/21. i. Documentation varied from 3/1 - 3/18/21: - medication unavailable, see nurse notes, no entry (blank), and signed off as completed. Review of the Progress Notes for Resident #86 revealed: The Admission Note 2 dated 2/24/21 at 4:17 PM recorded that Resident #86 arrived to the facility at 12:15 PM from the hospital via the facility van, accompanied by the driver. Resident #86 noted to be alert and orientated x (by) 4 (person, place, time, and situation) with an appropriate mood. The Admission Note dated 2/24/21 at 10:48 PM recorded Resident #86 on charting for new admission. Resident #86 alert and orientated x 4, able to voice needs. The resident required assist of 2 with a full-body mechanical lift to transfer. The Skilled Status Note 2 dated 2/25/21 at 1:02 PM, recorded Resident #2 required full-body mechanical lift to transfer due to non-weight bearing right lower extremity. The General Note dated 2/25/21 at 2:16 PM, identified the nurse spoke with staff at PACE (managed care program of all-inclusive care for the elderly) to request a bariatric bed for Resident #86. The Orders-Administration Note dated 2/27/21 at 8:30 AM, recorded no immobilizer available for Resident #86. Then nurse would speak with Physical Therapy on Monday. The Orders-Administration Note dated 2/27/21 at 6:36 PM, documented the nurse faxed Resident #86's PCP (primary care provider) for bed rails to assist with mobilization while in bed. The Orders-Administration Note dated 2/28/21 at 8:27 AM, recorded Resident #86 did cough and deep breathing exercises due to no incentive spirometer. The Orders-Administration Note dated 3/1/21 at 6:04 AM, documented no available incentive spirometer, right knee immobilizer, and sequential compression device new order item, as they weren't in stock. The Orders-Administration Note dated 3/3/21 at 12:21 PM, recorded Resident #86 did deep breathing exercises due to no incentive spirometer. The Orders-Administration Note dated 3/3/21 at 12:26 PM, documented that Resident #86 had no immobilizer as she came to the facility on admission without an immobilizer. The Orders-Administration Note dated 3/4/21 at 8:17 PM, recorded no incentive spirometer, no sequential compression device, and no right knee immobilizer. The Orders-Administration Note dated 3/5/21 at 7:06 AM, recorded that the sequential compression device was unavailable as the facility didn't have the devices at that time. The Orders-Administration Note dated 3/5/21 at 8:32 PM, recorded no for the incentive spirometer. The Orders-Administration Note dated 3/5/21 at 8:32 PM, recorded Resident #86 refused to use his right knee immobilizer. The Orders-Administration Note dated 3/6/21 at 5:09 AM, 2:59 PM, & 11:47 PM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer weren't available. The Orders-Administration Note dated 3/7/21 at 8:59 PM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer weren't available. The Orders-Administration Note dated 3/8/21 at 1:20 AM & 12:50 PM, recorded that the incentive spirometer, sequential compression device, and right knee immobilizer weren't available. The Orders-Administration Note dated 3/10/21 at 1:37 AM, 9:05 PM, & 11:42 PM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer weren't available. The Orders-Administration Note dated 3/12/21 at 8:39 AM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer weren't available. The Orders-Administration Note dated 3/13/21 at 8:49 AM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer PACE to bring. The Orders-Administration Note dated 3/14/21 at 9:01 AM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer PACE to bring. The Orders-Administration Note dated 3/15/21 at 10:38 AM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer PACE to bring. The Orders-Administration Note dated 3/16/21 at 1:21 AM recorded the incentive spirometer, sequential compression device, and right knee immobilizer PACE to bring. The Orders-Administration Note dated 3/16/21 at 5:12 PM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer PACE to bring. The Orders-Administration Note dated 3/17/21 at 2:28 AM, recorded the incentive spirometer, sequential compression device, and right knee immobilizer PACE to bring. The Health Status Note (HSN) dated 3/17/21 at 10:58 AM, recorded the nurse notified PACE regarding a bariatric bed and recliner for Resident #86 while at the facility The HSN dated 3/17/21 at 9:27 PM, identified Resident #86 complained of shortness of breath after she felt hot, followed by cold sweats. Resident #86's vital signs were within normal limits except her oxygen saturation (O2 sat) fluctuated from 88-90%. Resident #86's lung sounds sounded clear. The nurse made a phone call to the physician on call who gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse updated Resident #86's family member. The HSN dated 3/17/21 at 9:54 PM, documented that Resident #86 rested in bed with her eyes open. Resident #86's O2 sat 88-90%, and encouraged to breath from nose. The General note (GN) dated 3/18/21 at 12:17 AM, documented that at approximately 10:35 PM, the nurse evaluated Resident #86 . The nurse noted earlier in the evening the previous shift's nurse notified the on-call provider due to Resident #86 complained of shortness of breath, diaphoresis (sweating), and altered mental status. The on-call provider gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . O2 sat at 92% with oxygen on at 2 liters and Resident #86's head of bed elevated. When the nursing staff provided cares, Resident #86's O2 sat dropped to 83%, and she complained of intermittent chest pain. Blood pressure (BP) 132/64, pulse (P) 71, respirations (R) 16, temperature (T) 97.0, and O2 sat ranged from 83-92%. The nurse called the provider on call and got an order to transfer Resident #86 to the emergency room for evaluation. Resident #86's family and the facility Administrator notified. The GN dated 3/18/21 at 4:05 AM, revealed Resident #86 didn't have an incentive spirometer. Resident #86 cognitively present upon her admission to the facility. Resident #86 admitted to the facility for therapy, and she planned to return home. The nurse documented that they never received information that Resident #86 didn't have incentive spirometer. The GN dated 3/18/21 at 4:55 AM, call received from the emergency room at 3:30 AM, Resident #86 admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital document titled Emergency Department (ED) to Hospital Admission identified Resident #27 arrival to the emergency roiagnom on [DATE] at 11:51 PM and discharge date from the hospital 3/24/21. The Computed tomography (CT) of the chest dated 3/18/21 at 3:03 AM, identified extensive right sided pulmonary emboli affecting all 3 lobar arteries and majority of the bronchopulmonary segments. The left lower lobe pulmonary embolism in the basal trunk and multiple segmental pulmonary arteries. The ED note revealed the resident arrived in the ED with cough, shortness of breath, and chest pain & palpitations. The resident noted to be ill appearing upon the arrival in the ED. The ED note on 3/18/21 at 4:35 AM, the resident received a [MEDICATION(S)] (blood thinner medication to treat pulmonary embolism) injection. The resident admitted to the hospital following treatment in the ED and discharged back to the facility on [DATE]. The facility failed to implement Resident #86's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #86 subsequently admitted to the hospital on 3/18/21, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an Interview on 4/19/22 at 2:05 PM, the Interim Director of Nursing (DON) stated they weren't in the facility as the Interim DON at the time Resident #86 admitted to the facility. The Interim DON reported that she inherited the issues. The Interim DON stated she could not answer why Resident #86 didn't have an incentive spirometer, sequential compression device, or the knee immobilizer. The Interim DON explained that she expected physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/19/22 at 2:48 PM Staff O, Registered Nurse (RN), confirmed Resident #86 admitted to the facility on [DATE]. Staff O stated they didn't recall the resident had orders for a knee immobilizer and incentive spirometer. Staff O explained that upon Resident #86's admission to the facility the incentive spirometer and knee immobilizer weren't available at the facility. Staff O reported that PACE was to provide the incentive spirometer and knee immobilizer, however, they weren't sure when the supplies arrived at the facility. Staff O remarked that they weren't sure when PACE received notification that an incentive spirometer and an immobilizer were needed. Staff O added that the facility either faxed or called to notify PACE, but they weren't sure which way occurred. Staff O stated they didn't recall what PACE did at that time. Staff O added that they notified the DON at the time, however, they didn't recall who the DON was at the time. Staff O remarked that they weren't sure what was supposed to happen, since the facility didn't have the supplies to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff O said they didn't recall an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff O stated they were informed later that they were supposed to notify the physician any time a resident refused physicians orders. Staff O stated at the time the facility did not have the supplies for Resident #86, they didn't know they were supposed to notify the physician. Staff O stated they knew they were to attempt three times before they charted a refusal and then notify physician. Staff O reported they were unable to recall if Resident #86 had incentive spirometer at any time before her admission to the hospitalization on [DATE]. Staff O added that later the Orthopedics discontinued the knee immobilizer. During an interview on 4/20/22 at 8:03 AM, Staff P, Physical Therapy Assistant (PTA), confirmed they provided therapy services for Resident #86 in February 2021. Staff P stated Resident #86 received therapy services for quite some time due to her goal to return home. Staff P explained that Resident #86 utilized PACE. PACE dictated the services provided, including therapy. Staff P reported that initially Resident #86 was non-weight bearing to her right leg and couldn't do anything. Staff P stated Resident #86 participated with strengthening in the beginning and then eventually she could walk. Staff P explained that Resident #86 had behaviors that affected her participation in therapy and her progression. Staff P remarked that Resident #86 did have shortened therapy services in February due to her admission to the hospital. Staff P stated that they did not recall Resident #86 with an immobilizer to her right leg during therapy services. Staff P reported that Resident #86 never had an immobilizer. Staff P added that they didn't know if Resident #86 had sequential compression devices. Staff P reported that if Resident #86 had any shortness of breath or complaints during her therapy session, the therapists would document it in the daily therapy notes. During an interview on 4/20/22 at 10:15 AM, Staff I, Licensed Practical Nurse (LPN), reported they didn't know if Resident #86 had a knee immobilizer in place at the time of her admission on 2/24/21 or before returning to the hospitalization on [DATE]. Staff I explained they did recall Resident #86 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff I stated that the facility didn't have the incentive spirometer at time of admission on 2/24/21. Staff I reported she couldn't recall an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff I stated they didn't know the specific time frame of when to notify the physician, maybe every other day or something. During an interview on 4/21/22 at 8:42 AM, Resident #86's Primary Care Provider (PCP) reported they didn't know for a while that the facility didn't have an incentive spirometer, knee immobilizer, or sequential compression devices (SCD). The PCP stated at some point, right before Resident #86 admitted to the hospital for a pulmonary embolism (PE), the facility did notify them that the equipment was unavailable. The PCP explained that the PACE nurse informed them, that the facility had difficulty getting the ordered equipment and had stated the facility needed to figure out how to get the SCD. The PCP remarked that the facility didn't informed the PCP directly at any time that the equipment was unavailable. The PCP explained that they didn't know that PACE should provide the SCD. The PCP stated the expectation was the facility would provide the equipment needed to care for the resident. The PCP explained that theoretically that it was possible Resident #86 developed the PE due to not having the SCD. The PCP stated the reason Resident #86's had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The PCP stated the SCD's weren't foolproof. The PCP stated Resident #86 had large legs, over 20 inches, and maybe there weren't SCD's to fit her. The PCP remarked that there was a lack of communication from the facility. The PCP stated the PACE nurse did good at locating durable medical equipment (DME) and if they knew the facility did not have the SCD, they could have located some for Resident #86. The PCP reported that they did not know if the needed size for Resident #86 ever existed as they never tried to obtain the SCD. The PCP stated they could have prescribed a medication like a blood thinner, however, there was high risk of side effects with that medication too. The PCP stated they chose the lesser of the two evils and ordered the SCD. The PCP explained that they didn't even want to order aspirin, but could not recall reason. The PCP stated if had been informed by the facility that they were having difficulty obtaining the SCD, maybe PACE could have got some for Resident #86. The PCP explained that in theory the SCD's were to prevent blood clots, and Resident #86 admitted to the hospital with a blood clot. 2. Resident #27's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately cognitive impairment. The MDS documented Resident #27 required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coded Resident #27 received a diuretic seven of seven days in the lookback period. Resident #27 's Care Plan initiated 6/15/21, identified he had cardiac symptoms of sick sinus syndrome, hypertension, arterial sclerotic heart disease, [CONDITION(S)], and a pacemaker. The Care Plan Identified Resident #27 took cardiac and diuretic medications. The Care Plan interventions included: a. Daily weight, update the physician with weight gain of two to three pounds overnight or 4-5 pounds in 5 days (6/30/21) b. A device to monitor Resident #27's implanted cardiac device in his room to transmit pacemaker information (7/7/21) c. Monitor for side effects related to diuretics (10/29/21) d. Monitor for signs and symptoms of cardiac complications and update the physician as needed (6/30/21) Resident #27's Treatment Administration Record (TAR) dated March 2022 included an order started on 3/24/22 for daily weights. On 3/30/22, the TAR lacked documentation of daily weight, blank. Resident #27's TAR dated April 2022 included an order started on 3/24/22 for daily weights. The entries for 4/7/22 - 4/10/22 lacked documentation of daily weights. Review of Resident #27's Progress Notes revealed: The General Note (GN) dated 3/23/22 at 2:34 PM revealed that the facility received new orders on the clinic sheet from Resident #27's appointment on 3/22/22. The new orders included the following: a. one-time dose of [MEDICATION(S)] (diuretic) 40 milligrams (mg) b. daily weights, [MEDICATION(S)] (antibiotic) 750 mg every 48 hours for five doses c. [MEDICATION(S)] (steroid) 40mg for five days. The GN dated 3/24/22 at 10:49 AM revealed Resident #27 refused to get out of bed, refused to eat, refused medications, and refused to drink water. The Orders-Administration Note on 3/25/22 at 3:05 PM revealed Resident #27 couldn't be weighed due to his decline in condition. The Orders-Administration Note on 3/26/22 at 2:03 PM documented that Resident #27 didn't get out of bed. The Orders-Administration Note on 3/29/22 at 10:00 AM revealed Resident #27 didn't want to get into the wheelchair to transfer to the scale. The Orders-Administration Note on 4/1/22 at 2:00 PM recorded that Resident #27 did not feel well enough to get her weight. The Orders-Administration Note on 4/5/22 at 1:57 PM documented that Resident #27 didn't feel well, so no weight obtained. Resident #27's Weight Summary lacked documentation of weights for 3/30/22, and 4/7/22 - 4/10/22. The facility failed to obtain daily weights per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/11/22 at 11:02 AM revealed Resident #27 in a recliner in his room. No [CONDITION(S)] observed to Resident #27's bilateral (both) lower extremities. During an observation on 4/13/22 at 9:42 AM revealed Resident #27 in recliner; well groomed, with gripper socks on, and no [CONDITION(S)]. During an interview on 4/19/22 at 2:05 PM, the Interim Director of Nursing (DON) stated they expected the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interim DON confirmed Resident #27 had missing daily weights. The Interim DON reported that the physician received notification and received an order to change from daily weights to weekly weights as to Resident #27's refusals. 3. Resident #20's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of two people with bed mobility, transfers, dressing, personal hygiene, and bathing. The MDS coded Resident #20 as non-ambulatory and required supervision only when he used his electric wheelchair. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessed Resident #20 as always incontinent of bladder and bowel, without a toileting program in place. The MDS documented Resident #20 had MASD (moisture associated skin damage). The Care Plan Focus revised 11/8/21 recorded that Resident #20 had no skins issues but did have a potential for skin breakdown due to bowel incontinence and frequent ingrown toenails. The connected Goal indicated that Resident #20 wouldn't have skin breakdown due to incontinence through the next review. The Focus included the intervention dated 4/5/21 that Resident #20 had his own schedule, and usually sit in his recliner during the day, but doesn't allow staff to check and change him every 2 hours. When Resident #20 does allow staff to change him, he has soaked through his clothes. The staff have attempted to compromise with him but he refused to change, as he was independent in his decision-making. Resident #20 knew the risks and benefits of being checked and changed. On 04/12/22 at 11:30 AM, observed Staff M say that Resident #20's wound to his right buttocks measured 3.5 centimeters (cm) x (by) 0.8 cm. Staff M reported that Resident #20 had macerated skin (exposed to moisture too long) due to his incontinence with a superficial abrasion type wound. Staff M reported being the wound nurse and responsible for the weekly skin assessments documented in the clinical record. A 90-day review of the clinical record for weekly skin assessments and wound care notes revealed no records for the week of 1/12/22, week of 2/9/22, week of 3/9/22 and the week of 3/16/22. The weekly wound care notes dated 3/23/22 had no wound measurements included. The wound care notes dated 3/2/22 documented a wound measurement to the resident's right buttocks of 2.0 cm x 1.4 cm. The next documented wound measurement on 4/13/22 to Resident #20's right buttocks measured 3.5 cm x 0.8 cm., revealing an overall increase in wound size. The Wound Care Notes document instructed to do weekly wound observations until the wound healed. The Skin Program Policy revised March 2019, identified the purpose of the policy and goal as to provide cares and services to prevent the development of pressure ulcers and wounds. The document instructed that the further comprehensive skin assessments would be completed with changes in condition or surface. The Braden Scale (measure elements of risk for pressure wounds) dated 2/23/22, identified Resident #20's score as 16, indicating a risk for injury. The elements of the assessment identified Resident #20 had no sensory impairment, chairfast, very limited in mobility, often moist skin with a potential problem for friction and shearing. On 04/13/22 at 10:46 AM, the interim DON confirmed the lack of clinical records for skin assessments and wound cares as outlined. The Interim DON explained that she expected weekly skin assessments with associated wound cares to be completed and documented weekly. 4. Resident #7's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that Resident #7 took a diuretic (used to remove excess fluid from the body) for seven out of seven days in the lookback period. The Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. (Started 1/7/21) Weigh daily and report a weight gain of more than 3 pounds per day or 5 pounds per week. b. (Started 5/13/21) [MEDICATION(S)] tablet 25 MG give daily for excess fluid. c. (Started 5/13/21) [MEDICATION(S)] tablet 2 MG to be administered daily for excess fluid. The Weights and Vitals: Weight Summary report reviewed on 4/12/22 documented the following: a. Lacked weights for the following days: 1/11/22, 1/14/22, 1/16/22, 1/18/22, 1/19/22, 1/23/22-1/25/22, 1/28/22, 1/30/22-2/1/22, 2/22/22, 3/1/22-3/3/22, 3/15/22-3/17/22, and 4/4/22. b. Weights that should've been reported to the Physician due to weight gain of three pounds or more occurred on the following dates: I. 1/26/22 316.3 pounds (Lbs.) to 1/27/22 320.0 Lbs. = 3.7 Lbs. weight gain ii. 2/5/22 313.6 Lbs. to 2/6/22 317.8 Lbs. = 4.2 Lbs. weight gain iii. 2/14/22 313.0 Lbs. to 2/16/22 316.2 Lbs. = 3.2 Lbs. weight gain iv. 2/24/22 314.8 Lbs. to 2/25/22 370.0 Lbs. = 55.2 Lbs. weight gain - no additional weight on 2/25/22, next weight on 2/26/22 at 313.8Lbs. v. 3/11/22 310.4 Lbs. to 3/12/22 315.0 Lbs. = 4.6 Lbs. weight gain The Care Plan Focus revised 4/6/21 indicated that Resident #7 had hypertension and sleep apnea that he took medications for. Resident #7 had episodes of [CONDITION(S)] and required additional medications. The Focus included the intervention initiated on 4/6/21 directed the staff to monitor Resident #7's weight daily and update his physician according to his order. The General Note dated 1/12/22 at 11:06 AM revealed the nurse notified a nurse at PACE of Resident #7's increase in weight. The nurse at PACE directed to monitor that day and call the next day with Resident #7's weight. The electronic and paper health record lacked documentation of the facility notifying the physician of Resident #7's weight increase with the exception of 1 progress note on 1/12/22 at 11:06 AM. The Orders - Administration Note dated 1/28/22 at 3:38 PM documented that Resident #7 didn't get weighed due to the facility being short staffed. In an interview on 4/21/22 at 7:32 AM, the Interim DON reported that she expected physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, clinical record review, policy review, and staff interview the facility failed to adequately supervise residents in the dining room for 1 of 1 residents reviewed (Resident #26), resulted in a second degree burn. The resident received coffee in a cup without a lid and spilled coffee on her lap. Two staff who worked at the facility at the time of the burn revealed the resident was supposed to use a cup with lid at the time. The MDS identified the resident required supervision of 1 staff with meals. The incident report identified no witnesses to the incident, indicating no supervision when the incident occurred. The facility reported a census of 42 residents. Findings include: Resident #26's Minimum Data Set (MDS) with a completion date of 8/17/20, listed [DIAGNOSES REDACTED]. The MDS identified the resident with short term and long term memory impairment. The MDS coded the resident as requiring extensive assist of 2 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS coded the resident as requiring limited assist of one staff for eating. The MDS identified the resident received a mechanically altered diet. Care Plan: Care plan focus area [DIAGNOSES REDACTED]. Interventions included: [MEDICATION NAME] (antianxiety) scheduled every day (10/9/19), went to Hope Harbor to monitor behaviors and medications (10/7/19), room moved to another hallway that was quiet as noise agitated me at times (8/8/19), encouraged to remain in the hallway of current room (11/10/19), encouraged to sit in recliner to look outside and watch television (8/8/19), encouraged to sit at nurses station, away from flow of traffic to maintain personal space (7/3/19), assess, identify, & resolve why agitated (11/29/17), remain calm and speak with low tone and slow rate (11/29/17), and allow adequate personal space (11/29/17). Care plan focus area Activities of daily living with initiation date of 11/30/17, identified the resident required extensive assist due to [DIAGNOSES REDACTED]. Care plan focus area diet/eating with initiation date of 11/30/17, identified the resident as independent with eating and on a general dysphagia advanced diet with ground meat and nectar thick liquids. Intervention included, staff to monitor for changes in ability to eat independently or safely (11/30/17). Hot Liquid Safety Review assessment dated [DATE] with lock date of 8/12/20, identified the need for care plan interventions to protect the resident while consuming hot liquids due to vision impairment, cognition, mood, contractures, mobility, and musculoskeletal. This was the only Hot Liquid Safety Review in the residents' clinical record. Incident report dated 4/17/20 at 5:52 AM, revealed the resident was in the dining room and spilled coffee on her lap. Resident Description: resident unable to give description. Immediate Action Taken: area assessed and [MEDICATION NAME] (transparent dressing) applied over fluid filled blister measuring 4.7 x 2.8. Injuries observed at time of incident: blister front of right thigh. Level of Pain, Level of Consciousness, and Mobility all left blank. Mental Status: orientated to person. Notes: No complaints of pain to the area. Injuries Report Post Incident: no injuries observed post incident. Predisposing Environmental Factors left blank. Predisposing Physiological Factors: confused, incontinent, and impaired memory. Predisposing Situation Factors left blank. Witnesses: No witnesses found. Agencies/People Notified: Fax sent to the physician 4/17/20 at 5:54 AM. Progress Notes: 4/17/20 at 5:54 AM, the resident hollered to get out of her room and staff took her to the dining room. The resident asked for a cup of coffee and staff provided her with a cup of thickened coffee. The resident took sips of coffee and missed the table, and dropped the coffee on her lap resulting in a fluid filled blister measuring 4.7 x 2.8, which was covered with [MEDICATION NAME] (transparent dressing). 4/18/20 at 3:58 AM, no dressing noted to blister area, open and dry. No drainage noted. New [MEDICATION NAME] applied. Blister area slightly red. No complaints of pain. 4/18/20 at 7:47 PM, blister to upper anterior right thigh with [MEDICATION NAME] intact. Blister had popped, area is red, non-tender and not warm to touch. 4/24/20 at 4:36 AM, dressing to right thigh off and soiled with drainage. Noted purulent drainage to burn area. Area cleansed and left open to air. Blister open area measures 6 centimeters (cm) x 3.3 cm. Red area that measures 13.5 cm x 3.8 cm in length across the thigh. Resident denies pain, temperature 96.9 degrees Fahrenheit. Faxed the resident's primary care physician related to blister infection. 4/24/20 at 9:51 AM, notified the resident's primary care provider regarding blister area right thigh has purulent drainage with skin around area red. 4/24/20 at 11:36 AM, new orders for Carnation Instant breakfast daily (to increase protein) and [MEDICATION NAME] (topical antibiotic cream used to [MEDICAL CONDITION] reduce the change of infection) to right thigh blister 2 times a day for 5 days. 4/26/20 3:38 AM, burn continues to right anterior thigh. Dressing dry and intact. Redness continues surrounding burn area. At 12:45 AM, the resident did request pain medication for back discomfort. Temperature 97.5 degrees Fahrenheit. 4/27/20 at 6:01 AM, continued with burn to right anterior thigh. Dressing dry and intact. No complaints of leg pain. Redness much improved to thigh surrounding burn. No complaints of pain. Temperature 97.0 degrees Fahrenheit. 4/28/20 4:31 PM, the resident's primary care provider to see resident and new orders received for treatment to right thigh burn. [MEDICATION NAME] 2 times a day and cover with gauze and tap for 14 days and then call with update 4/29/20 at 1:40 AM, continued to have burn right anterior thigh. Dressing dry and intact. No complaints of leg pain. No calling out at this time. Temperature 96.9 degrees Fahrenheit. Resting quietly in bed. 4/29/20 3:32 AM, another small blister to the residents' right anterior thigh, measuring 0.5 cm x 1.4 cm. Blister is slightly to the left of previous burn. Area covered with [MEDICATION NAME] for protection. No redness noted. Fax sent to the resident's primary care provider. 4/30/20 at 12:54 AM, the resident arouses easily. Respirations easy, no complaints of pain. Dressing to right thigh blister dry and intact, no redness noted. 4/30/20 at 11:13 AM, new order received related to new blister found to right thigh. Treat area the same as the other wound and will see in one week. 5/7/20 at 3:16 PM, the resident was seen by primary care provider on 5/6/20 and will fax any new orders. 5/13/20 at 11:04 AM, notified the residents' primary care provider with an update on right thigh burn. The resident's primary care provider saw resident on round and assessed area. 5/13/20 at 10:49 PM, discontinue [MEDICATION NAME] treatment and start new treatment per the resident's primary care provider. 6/3/20 at 10:07 AM, treatment to right thigh burn cleanse with normal saline, cover slough with Santyl (cream applied to [MEDICAL CONDITION] help remove dead skin tissue), cover with gauze soaked in Dakin's solution (strong antiseptic used to kill bacteria) and cover with additional gauze and tape. 6/4/20 at 10:02 AM, received new order to discontinue right thigh wound treatment and leave open to air 6/10/20 at 12:39 PM, the resident's primary care provider to see resident, no new orders. Initial Weekly Wound Documentation dated 4/17/20 at 5:57 AM, right thigh blister measuring 4.7 cm x 2.8 cm, no drainage, no odor, wound edges intact. [MEDICATION NAME] applied & notified PCP. Initial Weekly Wound Documentation dated 4/29/20 at 4:55 AM, right thigh blister measuring 0.5 cm x 1.4 cm, no drainage, no odor, pink wound edges, blister not open, fax sent to PCP Weekly Wound Forms: 4/21/20 at 11:58 PM, right thigh blister measuring 4.2 cm x 2.6 cm, no drainage, no odor, wound edges intact & pink, improved, no pain associated with wound. Cover with [MEDICATION NAME], blister had popped, skin surrounding slightly pink. Area cleansed and left open to air, notified PCP 4/28/20 at 11:17 AM, right thigh blister measuring 5.5 cm x 1.5 cm, scant amount of serosanguinous (blood and clear yellow liquid) drainage, no odor, improved, no pain associated with wound. [MEDICATION NAME] to burn, blister no longer fluid filled. Area appears to be drying up, cream applied. Resident tolerates well and no complaints of pain or discomfort. 5/5/20 at 10:27 AM, right thigh burn measuring 5.1 cm x 2.0 cm, scant amount serosanguinous drainage, no change, no pain associated with wound. Apply [MEDICATION NAME] cream to right thigh burn and cover with gauze. 5/11/20 at 10:53 AM, right thigh blister measuring 3 cm x 1 cm, yes slough, no odor, pink edges, improved, no pain associated with wound. [MEDICATION NAME] cream to right thigh burn. Blister no longer fluid filled. Area appears to be drying up, cream applied. Resident tolerates well. No complaints of pain or discomfort. ARNP to send new orders for treatment. 5/11/20 at 10:57 AM, right thigh blister measuring 0.5 cm x 1.3 cm, no drainage no odor, edges intact, no change, blister remains, and no pain associated with wound. 5/19/20 at 6:42 AM, right thigh burn measuring 4 cm x 1.5 cm, scant amount serosanguinous drainage, no change, no pain associated with wound. Apply [MEDICATION NAME] and cover with gauze. 5/26/20 at 3:36 PM, right thigh burn measuring 3 cm x 1.5 cm, scan amount serosanguinous drainage, no odor, edges intact, improved, no pain associated with wound. Cleanse with normal saline, cover slough with Santyl, cover with gauze soaked Dakin's solution and cover with gauze and tape 6/10/20 at 11:34 AM, right thigh burn measuring 0 x 0, no drainage, no odor, edges intact and dry, area healed. ARNP at facility and assessed area, healed. Leave open to air. Physician Notes: 4/17/20 fax sent notifying primary care provider (PCP) of initial burn to right thigh, no new orders 4/24/20 at 10:41 AM, new order from Advanced Registered Nurse Practitioner (ARNP) for [MEDICATION NAME] Cream, two times a day for 5 days or until healed 4/28/20 resident seen by ARNP, treatment order clarification [MEDICATION NAME] two times a day for 14 days and call with update in 14 days and labs ordered for in 2 weeks. 4/29/20 fax sent notifying the resident's PCP of new blister to right thigh, same as treatment ordered 5/13/20 at 3:39 PM, new order from ARNP to stop [MEDICATION NAME] and start twice daily cleanse with normal saline, cover slough with Santyl, cover with gauze soaked in Dakin's solution and cover with gauze and tape. 5/26/20 the resident seen by ARNP for wound follow up. Burn to right upper thigh with healed blister above larger wound. Wound with less slough today, will continue current treatment for [REDACTED]. The resident is calm and cooperative during wound care. Second degree burn on upper right thigh approximately 2.5 cm x 1.5 cm with yellow slough. A small white blister in the middle of the burn. Small blister above larger wound is healed with scab. Some serous drainage. 6/4/20 order received from ARNP to leave right thigh open to air and discontinue Santyl and Dakin's solution 6/10/20 the resident seen by ARNP for wound follow up. Right thigh wound is healed, will leave open to air. Second degree burn on upper thigh is healed with scar tissue noted. Classifications of Burns: First degree (superficial) burn - affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long term tissue damage is rare and often consists of an increase or decrease in the skin color. Second degree (partial thickness) burn - involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. Third degree (full thickness) burn - destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred. Fourth degree burn - go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed. Observations on 9/28/20/20 at: 12:45 PM, well-groomed resident was sitting in recliner, covered with blanket, feet elevated and CNA assisting with dinner. Liquids were in small Styrofoam cups with lids. 1:06 PM, staff no longer present and the resident continues to sit in recliner with feet elevated, blanket on, and call light in reach 4:21 PM, the resident was sitting in recliner, covered with blanket, feet elevated, and call light in reach. Tray table beside resident with a tall Styrofoam cup with lid and straw present Observations on 9/29/20 at: 9:16 AM, well-groomed resident sitting in wheelchair with tray table in front of her. Feet dependent on pedals with green foam boots on bilaterally. Call light in reach. 3:20 PM, the resident was sitting in wheelchair with green foam boots on bilateral lower extremities and pillow under left arm. Observed staff stand the resident in the EZ-stand lift and provide cares prior to returning to transferring the resident to the recliner. Waffle type cushion noted in wheelchair and moved to recliner with the resident. Feet elevated and green foam boots replaced to bilateral lower extremities and call light in reach. 4:18 PM, resident sitting in recliner with feet elevated, call light in reach, and green foam boots on. The resident smiles and waves. Observations on 9/30/20 at 8:42 AM, well-groomed resident sitting in wheelchair beside the bed with green foam boots on bilaterally. Styrofoam breakfast container on tray table in front of the resident, 75% eaten. The resident was wiping her hands with a napkin and requesting a wet cloth. Observations on 10/1/20 at: 8:50 AM, the well-groomed resident sitting in wheelchair beside bed. Tray table in front of resident with tall Styrofoam cup with lid and straw containing water and a small Styrofoam cup with lid containing coffee. Call light in reach. 12:29 PM, Staff L Certified Medication Aide (CMA) delivered residents lunch in Styrofoam container and sat down to assist with eating. Observation on 10/15/20 at 8:38 AM, resident lying in bed on her right side facing into the room. Head of bed slightly elevated, eyes closed, mouth open, and oxygen on. Staff H Licensed Practical Nurse (LPN) stated the resident was unresponsive at this time. Coffee temperature in the carafe on 10/14/20 at 11:58 AM, 167.4 degrees Fahrenheit. Interview on 10/14/20 at 11:25 AM, Nurse Consultant/Interim Director of Nursing (DON) stated the resident received coffee in a regular coffee mug on 4/17/20 when the spill occurred. The Nurse Consultant stated she did not know if any staff supervised the resident at the time she spilled the coffee in her lap. The Nurse Consultant stated after the incident, the facility bought coffee cups with lids and all residents then only received coffee in cups with lids. The Nurse Consultant stated she did not know would got coffee for the resident on the morning of 4/17/20, (if it would have been nursing staff or dietary staff). Questioned the Nurse Consultant about the resident requiring supervision with eating and she stated dietary staff reports to work at 6:00 AM, and they would worked in the dining room setting tables at the time of the incident. The Nurse Consultant stated if no dietary staff worked in the area then nursing staff would have been with the resident. The Nurse Consultant stated she did not know of other incidents of residents burned with spilled coffee. The Nurse Consultant identified the resident as independent with drinking and normally drank coffee. The Nurse Consultant stated intervention put into place, to prevent [MEDICAL CONDITION] occurring, all coffee served with a lid. The Nurse Consultant stated the facility should have notified the resident's responsible party of the resident burning her leg. Interview on 10/14/20 at 11:58 AM, Staff T Dietary Manager stated due to residents currently being served in their rooms, coffee is sent out in carafe and staff pours the coffee into a Styrofoam cup if the resident request coffee. The Dietary Manager stated he did not know if staff placed lids on the small Styrofoam cups of coffee when taken into residents room. The Dietary Manager stated when residents come to the dining room for meals, they are served coffee per request and no lids. The Dietary Manager stated the residents that require assist with meals are served coffee with a lid. The Dietary Manager stated Resident #26 was given a sippy cup for her coffee when she would come to the dining room. Interview on 10/14/20 at 2:02 PM, Staff U LPN (nurse when incident occurred) stated she did not remember if staff sat with the resident or if the resident sat by herself in the dining room when the coffee spill occurred on 4/17/20. The LPN stated she did not remember if dietary staff were in the dining room at the time, however, stated the dietary staff would not have assisted anyway. The LPN stated the nursing staff often have to cook breakfast for the residents because dietary staff did not show up for work at 6 AM. The LPN stated she would have initially cleansed the burn with normal saline, pat dry, and then apply the [MEDICATION NAME]. The LPN stated the resident was up frequently during the night and had her days and nights mixed around due to confusion. The LPN stated it was normal for Resident #26 to go out to the dining room and have coffee. The LPN stated due to the time of day, she believed staff would get the resident up for the day, and take her to the dining room for coffee. The LPN stated there were no concerns with the resident spilling her coffee because she drank thickened liquids and she would have gotten a handled cup with a lid. The Surveyor read the progress note entry to the LPN and she stated the Resident #26 did not have the two handled lidded cup because the lids don't come off easily. Interview on 10/15/20 at 8:53 AM, Staff V Dietary Aide stated she worked at the facility for a year and that Resident #26, received thickened liquids during the time she worked at the facility. The Dietary aide stated during Staff V's time at the facility, Resident #26 received coffee in a cup with a lid. Interview on 10/26/20 at 9:40 AM, the Nurse Consultant/Interim DON stated after Resident #26 sustained the burn to her right thigh, staff provided her coffee in a lidded cup. Questioned the Nurse Consultant that 2 staff members stated Resident #26, already used lidded cup for coffee prior to the burn to her right thigh. The Nurse consultant stated when she got to the facility the resident did not use lidded cups for her coffee and was unsure where staff had gotten that information from.

Based on record review, facility policy review, and staff interviews, the facility failed to provide cardiopulmonary resuscitation (CPR) - medical intervention used to restore circulatory and/or respiratory function that has ceased- immediately after finding a resident without pulse and respirations for 1 of 4 residents reviewed (Resident #185). The facility reported a census of 29 residents. Findings include: A Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE], documented Resident #185 with a Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS identified the resident required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. The resident had [DIAGNOSES REDACTED]. Resident #185's admission record identified the resident as a Full Code. A care plan with initiation date of [DATE] identified the resident's advanced directives as the resident with full code status. The care plan directive to staff was staff will intervene appropriately if resident should need cardiac resuscitation. Nursing Progress notes dated [DATE] at 9:14 a.m. and documented by Staff K LPN (licensed practical nurse) identified the entry type as change of condition. The entry identified on that date at 7:05 a.m. Staff K was summoned to the resident room and found the resident without pulse or respirations. Staff K then went to the nurses station to check the resident's code status and call the physician for further direction. At 7:10 a.m. Staff k notified the physician of the resident's condition and full code status. After a minute or so of hesitation, the physician responded that it was probably too late. Staff k attempted to call the on call nurse and left a message. At 7:26 a.m. Staff K phoned the DON (director of nursing) of the situation. The DON instructed Staff K to start CPR and notify 911. Following the call to the DON, staff initiated CPR and called 911 (21 minutes after assessing the resident without pulse or respirations). At 7:30 a.m. the ambulance arrived and the resident transported to the hospital emergency room (ER) with CPR in progress. On [DATE] at 9:02 a.m. the DON documented she spoke with the hospital who informed her the resident expired at 8:27 a.m. On [DATE] at 12:24 p.m. Staff H certified medication aide (CMA) on [DATE] at 12:24 PM, revealed she last saw Resident #185 on [DATE] at about 5:30 AM. The resident talked per usual, skin color appeared normal and Staff H provided check and change cares on him. She reported she did not see any concerns with him. On [DATE] at 12:02 p.m. Staff B (CMA) revealed she walked into Resident #185 room on [DATE] at 7:05 AM, and noticed the Resident's eyes drooping. Staff B yelled his name and tried rubbing his chest. She reported the resident didn't respond. She stated when she found him he felt warm. She revealed she didn't know the resident's code status when she found him and Staff K (LPN) told her not to start CPR so the certified nurse aides (CNAs) then performed post-mortem cares. She then saw Staff K and the director of nursing (DON) talking on the phone and was told staff needed to start CPR because the resident is a full code. Staff B and Staff K then proceeded to start CPR on Resident #185. Staff B did not know how much time passed between finding him and starting CPR, but stated it was awhile. During an interview with Staff L (CNA) on [DATE] at 8:49 AM, she revealed she assisted with post-mortem cares that included checking and changing the resident. she stated he was still warm to touch during cares. She revealed the CNAs provided cares prior to staff starting CPR. During an interview with Staff M (CMA) on [DATE] at 9:25 AM, revealed on [DATE] when she assisted with post-mortem cares for Resident #185 had no changes in skin color and was warm to touch when providing cares sometime after 7:00 AM. During an interview with Staff K LPN on [DATE] at 2:35 PM revealed she thought staff called her to Resident #185's room around 7:05 AM on [DATE] and found the resident not breathing and without a pulse. Staff K stated it was apparent he was gone (dead) and said she panicked. She stated she checked the resident's code status and saw he was a full code. She called the physician because she wanted further direction as how to proceed. She revealed that the physician never gave an answer either way. Staff K informed surveyor that she should initiate CPR right away on anyone that is a full code. If God forbid it ever happened again, she would handle the situation differently. Staff K denied ever seeing the facility's CPR policy prior to incident. A Basic Life Support form dated [DATE] identified that Staff K successfully completed the cognitive and skills evaluation with the curriculum of the American heart Association Basic Life support Program. The form identified that Staff K was certified and approved to perform basic life support (CPR) as of [DATE]. On [DATE] at 10:12 AM, the resident's primary care physician revealed she received a page from the facility at 7:26 AM on [DATE] and the physician returned the call shortly after. The physician informed Staff K that it had been a really long time since 7:05 AM when the resident was found without pulse and respirations, and stated she was unsure if the chances were very high for successfully restarting the resident's heart. The physician informed Staff K that she did not know the facilities policy for CPR. On [DATE] at 9:38 AM Staff J registered nurse (RN) revealed on [DATE] she checked and assessed Resident #185. She observed no heartbeat and the resident was not breathing. She stated she lost her direction and felt panicked and frozen at the same time. She revealed she told Staff K that maybe she should call the physician. ED (emergency department) notes identified the resident arrived at the ED on [DATE] at 8:12 a.m. A provider summary note from the visit revealed resuscitation attempts were initiated in the field. The resident had an unknown downtime. He was intubated in the field and was ventilating well with good air movement. However he had no heart sounds. Aggressive resuscitation was continued. He remained in asystole with no response to resuscitation attempts. Further efforts would be completely futile. resuscitation attempts were stopped and he was pronounced dead. A death certificate revealed the resident expired on [DATE] at 8:40 a.m. The immediate cause of death was listed as cardiopulmonary arrest. Review of the CPR certified staff list revealed Staff J (RN) did not have current CPR certification when the [DATE] incident occurred. On [DATE] at 12:15 PM, the DON revealed she spoke with Staff K on the phone on [DATE] at 7:26 AM, and informed Staff K that she needed to start CPR immediately and call 911. Review of the CPR certified staff list and schedule indicated that two out of 6 staff members working during the incident on [DATE] were CPR certified which included Staff K LPN. Review of the CPR/DNR (do not resuscitate) decision form revealed the resident signed the form on [DATE] indicating he wanted CPR if his heart stopped beating and/or he stopped breathing. Review of the facilities Nursing Policy and Procedure for Use of Cardiopulmonary Resuscitation (CPR) contained an effective date of (MONTH) (YEAR) and revision date of (MONTH) 2019 The policy identified staff would provide CPR to residents that experienced respiratory or [MEDICAL CONDITION] if they have chosen CPR full code status. On [DATE] at 12:15 PM, the DON revealed facility nurses did not receive training prior to the, Nursing Policy and Procedure for use of Cardiopulmonary Resuscitation (CPR), put in place (MONTH) (YEAR) or with the revision in (MONTH) 2019. She also revealed the facility did not have any documentation of reviewing the CPR policy with staff. A facility performance improvement plan summary identified revealed facility policy directs staff to initiate cardio [MEDICAL CONDITION] resuscitation on a resident who indicated they want CPR in even of [MEDICAL CONDITION]. Staff initiated CPR on Resident #185 approximately 20 minutes after they assessed with [REDACTED]. During the investigation, the facility provided a document that revealed 17 of 34 residents requested Full Code/CPR status if their heart stopped and/or breathing ceased. Abatement: The facility reviewed nursing staff's CPR certification, reviewed charts for code status and provided CPR education (MONTH) 31-[DATE]. The deficient practice detailed above resulted in an immediate jeopardy situation for the facility. This abatement resulted in past noncompliance for the facility.

Based on clinical record review, facility policy review and interviews, the facility failed to provide adequate supervision to protect one (1) of eight (8) residents reviewed for falls (Resident #1). The facility identified a census of 46 residents. Finding include: 1. The Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED].#1. The MDS documented the resident required extensive assistance of one staff for completion of transfer and toileting. Resident #1 was not steady and only able to stabilize with staff assistance when: moving on/off the toilet, when moving from a seated to standing positon, and during surface to surface transfer (transfer between chair and bed or wheelchair). Resident #1 Brief Interview of Mental Status (BIMS) revealed a score of 14 which indicated intact cognitive skills. Resident #1 utilized a wheelchair for mobility and had no falls in the previous 90 days. The Hospitalist History and Physical dated 9/15/16 documented the additional [DIAGNOSES REDACTED]. The care plan problem initiated 2/2/17 identified the resident with impaired mobility due to a fracture and required assistance of 1 for transfers. The care plan identified staff should supervise Resident #1 at all time while in the restroom. The Incident report dated 2/20/17 at 18:45 (6:45 PM) documented the resident found sitting on the floor of the bathroom facing the toilet and leaning against the wall with the resident's left leg bent and under the resident's right leg which had a brace in place. The resident's left knee and thigh looked swollen and the resident experienced pain when the leg touched or moved. Staff called 911 and the resident transferred to the hospital after ambulance personnel administered morphine (a narcotic pain medication) to the resident. The Progress Notes entry dated 2/20/17 at 21:23 (9:23 PM) documented the resident admitted to the hospital for treatment of [REDACTED]. The Hospital History and Physical dated 2/20/17 at 11:55 p.m., revealed Resident #1 had hip pain after a fall at the nursing home and had been brought to the emergency room . Previous to this fall, Resident #1 had a right femur fracture that was surgically repaired and the resident had been in the nursing home for rehab and strengthening. The resident reported he/she is wheelchair bound. The resident denied any dizziness, lightheadedness or any chest pain. Upon the physician examination, the resident's left leg was in knee immobilizer and rated his/her pain at 7 out of 10 (ten being the highest); and his/her right leg in a brace. The resident reported receiving initial pain medication which helped, however now the pain resumed. The assessment revealed the resident had a closed fracture of the distal end of the left femur and a displaced peri-prosthetic fracture (on the right). A progress notes dated 2/27/17 at 10:52 p.m. revealed Resident #1 returned to the nursing home and had a surgical incision to his/her left hip with 38 staples and a bilateral knee braces. Resident #1 is non-weight bearing an up only 1 hour at time. A Witness Statement from Staff E dated 2/20/17 at 7:45 p.m. regarding the incident revealed Resident #1 had been hanging on to the bar in the bathroom after he/she got up from the toilet. The resident had been leaving to the left side and Staff E went to his/her back side then the resident went down. The resident reported he/she was tired from therapy. During interview on 3/24/17 at 11:59 AM, Staff F, certified nursing assistant(CNA) stated she had been assigned to train Staff E, CNA, when the incident occurred. She stated she assisted the resident's roommate and Staff E assisted Resident #1 in the bathroom. Staff F stated she did not use a gait belt to transfer residents, had never been issued one and no one educated her on how and when to use it. She felt she had not been trained properly and should have not been training new staff. Staff F stated she told the Administrator, Director of Nursing (DON) and the person in charge of scheduling staff about her concern with lack of training and no one did anything for her. Staff F stated she did not instruct Staff E to use a gait belt. Review of the personnel file for Staff F revealed the DON documented Staff F completed transfer belt competency on 1/26/17. During interview on 3/24/17 at 11:53 AM, Staff E stated Staff F assisted her to transfer Resident #1 to the toilet at the time of the incident. Staff E stated normally 1 staff would assist to transfer Resident #1. Staff E stated Staff F then assisted Resident #1's roommate while she stayed in the bathroom with Resident #1. Staff E stated she assisted the resident to pull of his/her pants and pivot to the wheelchair when the resident stated he/she's was going down. Staff E stated she thinks the resident's legs straddled the toilet but the resident's left leg looked bent in an abnormal way. Staff E stated she had ahold of Resident #1's shirt and pants from the back. Staff E stated she did not use a gait belt when transferring Resident #1 and did not know she should have used one, nor did she have one available. Staff E stated she never witnessed any other staff member use a gait belt unless state surveyors or corporate staff were present in the facility. She stated she had worked for 2 month as a personal assistant to residents prior to becoming certified and witnessed other staff transfer Resident #1 in the same manner. During interview on 4/11/17 at 10:40 a.m., Staff H, CNA, stated a gait belt is issued to staff upon hire and to use it anytime you have to provide hands-on assistance to residents for transfers or ambulation. During interview on 3/23/17 at 3:50 PM, the Administrator stated Staff F never told him about her perceived lack of training. If she had, he would have provided more training time for her. The Administrator stated Staff E self-terminated after the incident and Staff F had been terminated by the facility. The facility's Transfer-Ambulation With a Transfer Belt policy revised in August, 2015 directed the following: POLICY: If is the policy of this facility that all associated utilize a transfer (gait) belts with resident during transfers ambulation and gait training. PURPOSE: The gait belt provides a firm grasping surface for the staff person and protects the resident from accidental trauma to the skin. It gives the resident a sense of security as it is tightened. The belt also allows the staff person to gradually lower a resident to the floor (if necessary) without injuring self or the resident. The procedure included step by step instructions for staff including the following : place the gait belt around the resident's waist, properly tighten the belt, bring the resident to a standing positon, grasp the belt to the resident's side while assisting him/her to stand. If ambulating, walk slightly behind and to one side of the resident while holding on to the (gait) belt. If the resident starts to fall, draw the resident close to your body using the gait belt and slowly lower the resident to the floor.

Based on record review, observation and staff interviews, the facility failed to ensure the resident environment remained as free of hazards as possible and failed to provide adequate nursing supervision to protect residents from the same for 1 of 5 residents (Resident #1) reviewed. This violation constituted immediate jeopardy to Resident #1's health and safety. The facility reported a census of 45 residents. Finding include: According to the MDS (Minimum Data Set) assessment tool dated 11/2/16, Resident #1 displayed severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS documented the resident propelled themselves in their wheelchair independently, but required extensive staff assistance with transfers from surface to surface. An Elopement Risk assessment dated [DATE] revealed the resident wandered throughout the facility, talked about leaving the facility and asked family for a ride, and wore a wanderguard due to deployment risk. Elopement is defined as when a cognitively impaired resident leaves the facility without staff knowledge or authorization. The resident's Care Plan dated 11/2/16 identified the resident experienced an alteration in mobility and was at risk for falls due to impaired mobility and a history of falls that resulted in a fracture. The Care Plan documented the resident utilized a wheelchair to propel themselves throughout the facility and wore a Wanderguard bracelet (a system that caused an alarm to activate when a resident who wore a special wrist or ankle bracelet came within a certain distance of a door armed with the same technology). In another Care Plan item dated 10/14/16, the facility identified Resident #1 as at risk for elopement due to a [DIAGNOSES REDACTED]. Progress notes dated 7/24/16 at 8:59 a.m. documented staff found the resident sitting on the floor inside the doorway to the facility and noted the resident's wanderguard bracelet failed to activate the alarm. Staff replaced the wanderguard with a new one. During an interview dated 11/30/16 at 9:35 a.m., the Director of Nursing (DON) clarified that on 7/24/16 at 8:59 a.m. staff actually found the resident inside the alcove to the front entrance between the interior and exterior doors, not an exterior doorway. Progress notes dated 9/8/16 at 11:50 p.m. documented resident had been wandering the halls in his/her wheelchair for a few hours. A Resident Fall/Incident report completed 11/21/16 documented another alert and oriented resident observed Resident #1 outside the building in his/her wheelchair on the North side of the facility (service entrance/exit door) on 11/20/16 at 6:05 p.m. Staff completed a head to toe assessment which revealed no injuries. Staff documented the resident as at risk for elopement based on behaviors of wandering and making statements of wanting to leave. A facsimile (fax) sent by the facility to the resident's physician dated 11/21/6 at 2:13 p.m. advised the physician an incident dated 11/20/16 on the 2:00 p.m.-10:00 p.m. shift of the resident had been exit seeking, making comments that he/she wanted to leave and asking people if they could take him/her somewhere. The resident did eventually make his/her way outside the building. During an inspection of the facility's 6 entrance/exit doors dated 11/28/16 at 10:11 a.m., the Administrator reported the main entrance/exit door had a working door alarm; activated in a and wanderguard alarm. The service entrance/exit door (where the resident had exited the facility on 11/20/16 at 6:05 p.m.) contained a working door alarm and also a wanderguard alarm; however the Wanderguard device located at this door did not work. The remaining 4 entrance/exit doors had an alarm system but not a wanderguard system in place. The Administrator reported that door alarms could be turned off by using a key. A key to each door alarm had been in the possession of two nurses assigned for each of three shifts in addition to certified medication aides (CMA) assigned for a shift; but that a CMA would not always be assigned to each of three shifts. The Administrator reported he conducted an investigation; asking staff who worked 11/19/16-11/20/16 if they had turned off the service door entrance/exit door alarm. The Administrator reported staff interviewed denied turning off the alarm. The Administrator reported nurses assigned on each of three shifts are to check door alarms at the beginning of their shift. During an interview dated 11/28/16 at 11:42 a.m., Staff B reported she worked 11/20/16 from 10:00 a.m.-2:00 p.m. and she had not checked door alarms because she had asked Staff A if she had checked door alarms and she had reported she had earlier that morning. During an interview dated 11/28/16 at 12:25 p.m. Staff A, a licensed practical nurse (LPN) reported she had worked 11/20/16 from 6:00 a.m.-2:00 p.m. and she had checked all door alarms and all were functioning properly. During an interview dated 11/29/16 at 8:05 a.m., Resident #8 reported he/she had gone outside through the service entrance/exit to smoke a cigarette and saw Resident #1 outside the facility sitting in his/her wheelchair without a coat on. Resident #8 stated Resident #1 said he/she was cold, so Resident #8 went inside the facility and told staff he/she had seen Resident #1 outside the facility. On 11/29/16 at 11:04 a.m. the State Climatologist reported the sun had set that day at 4:59 p.m. The air temperature at 5:52 p.m. was 37 degrees Celsius (C) with a wind chill of 32 C and an east wind at 6 miles per hour. During an interview dated 11/29/16 at 1:40 p.m. Staff H, a registered nurse (RN) reported she worked 11/20/16 from 2:00 p.m.-8:30 p.m. She had checked the service entrance/exit door in addition to all other entrance/exit door and knew the door alarm on the service had been turned off but forgot to tell someone. She reported she had seen Resident #1 wander throughout the facility except for the area around the service entrance/exit door. On weekends and holidays, the resident would go to the entrance/exit doors but he/she hadn't tried to open the doors. The facility's Elopement at Risk policy dated 2013 indicated the facility will be responsible for maintaining a system that provides protection for residents who are at risk for elopement. The facility will put measures in place to minimize the risk of elopement that are individualized to resident needs. The Facility abated the Immediate Jeopardy on 11/21/16 by implementing the following measures: 1. The facility reactivated the alarm and the door functioned as designed. 2. The facility initiated 15 minute checks (checked the resident's whereabouts every 15 minutes). 3. The facility removed the door alarm bypass key from the nurses' key rings and implemented a policy that required Administrator or DON permission to silence the alarm. 4. The facility educated all staff regarding the updated alarm policies.

Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 8 residents reviewed (Resident #8). Resident #8 had a history of [REDACTED]. The resident had a feeding tube and medications to help with comfort including medication for nausea and vomiting. On [DATE] Resident #8 had been spitting up/vomiting. Facility staff failed to assess the change of condition, provide intervention or notify Hospice until the resident experienced respiratory distress. It took Hospice staff several hours to get the resident somewhat comfortable after they arrived. The facility reported a census of 48 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated [DATE], Resident #8 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. Resident #8 required extensive assistance with bed mobility and transfers and required limited assistance with dressing, eating, toilet use and personal hygiene. Resident #8's [DIAGNOSES REDACTED]. The resident had a feeding tube and received Hospice services. The Admission Record dated [DATE] for Resident #8 showed he/she had a history of [REDACTED]. A Hospice Patient Detail report dated [DATE] documented Resident #8 had a primary [DIAGNOSES REDACTED]. The Clinical Summary documented Resident #8's mental age at 2 - 3 years old and he/she depended on staff for all cares. Resident #8's right arm and both legs were contracted in the fetal position. Resident #8 had nothing by mouth (NPO) and received nutrition per peg (feeding) tube. The resident admitted to the hospital for pneumonia related to aspiration, returned from the hospital and continued to decline. The family requested Hospice support. Resident #8 had [MEDICATION NAME] obtained for prn comfort. Resident #8 had been febrile with a moist cough, intermittent lethargy and [MEDICAL CONDITION] The resident's medications included [MEDICATION NAME] concentrate solution under the tongue every 2 hours as needed for dyspnea (shortness of breath) or pain; [MEDICATION NAME] inhalation solution 1 every 4 hours as needed; Oxygen at ,[DATE] liters as needed; [MEDICATION NAME] 4 mg every 8 hours as needed (for nausea/vomiting). A Hospice Progress Note dated [DATE] at 10:15 to 11:00 a.m. documented Resident #8 exhibited no outward sign or symptoms of pain and no facial grimacing when moved during assessment. The resident rested comfortably. Resident #8 had an oxygen saturation of 92% on room air, a pulse rate of 86, respirations at 18 and a temperature of 98.4. The Progress Notes dated [DATE] at 9:41 a.m. documented Resident #8's temperature 97.8, pulse 70, respirations 16, and oxygen saturation 94%, with rales throughout the lungs. Resident #8 had no shortness of breath and spit up brown to yellow thick phlegm. Resident #8 had no residual (undigested feeding solution) from their feeding tube and tolerated the feedings well. At 3:59 p.m. Resident #8's temperature measured 98.2. Resident #8 was very sleepy and the resident still spit yellow/brown thick phlegm. He/she had congested lung sounds throughout. At 6:04 p.m. Resident #8's condition declined with his/her lungs sounding more congested and thick green bile-phlegm coming out of his/her mouth. Staff elevated the head of the resident's bed. The resident's oxygen saturation registered 93% on room air, s/he had a temperature of 98.5 and no response to verbal and tactile stimuli. Staff G, RN (Registered Nurse) notified the resident's family and Hospice provider. The Progress Notes dated [DATE] at 10:35 p.m. documented the nurse received report at 6:20 p.m. and was informed Resident #8 had greenish brown emesis and afebrile (without fever). Hospice and the family were called. Staff stopped the tube feeding at 6:45 p.m. and provided oral cares. The Hospice nurse arrived at 7:35 p.m. and the facility nurse (Staff E, RN) assisted the Hospice nurse with cares, a suction machine and a Tylenol suppository. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The clinical record lacked documentation of administration of any of the prn medications. The Treatment Administration Record (TAR) for [DATE] showed Resident #8 to have oxygen saturations every evening shift, and registered 90 to 98 through [DATE]. The TAR showed Resident #8 had an order for [REDACTED]. An Interdisciplinary Progress Note by the Hospice nurse dated [DATE] at 7:30 p.m. documented she arrived and received report from Staff E who stopped the tube feeding and felt Resident #8 had aspirated the feeding. Resident #8 was unresponsive except to pain with movement. Resident #8 had a large amount of tan/yellow secretions coming out his/her mouth and nose. Resident #8 had congested lung sounds and a congested cough. The resident felt very warm to touch and had a temperature of 102.2 degrees temporal. The Hospice nurse requested a suction machine and Tylenol suppository. She suctioned Resident #8's oral cavity and nose with a large amount of secretions and a small amount of blood from the right side of of the mouth back cheek area. She could not see where the blood came from. Facility staff gave the Tylenol suppository. At 8:09 p.m. she called the resident's family with a condition update and a family member talked to Resident #8 on the phone. Resident #8 had an oxygen saturation of 75% (normal 90 to 100), a pulse of 135 (normal 60 to 100), and respirations of 50 (normal 16 to 20). The Hospice nurse called the physician and received orders. At 8:35 p.m. she suctioned Resident #8 then gave [MEDICATION NAME] 5 mg and [MEDICATION NAME] drops. At 9:15 p.m. Resident #8's respirations remained fast and slightly labored with abdominal breathing. Facility staff applied oxygen, and [MEDICATION NAME] 5 mg given. At 9:25 p.m. [MEDICATION NAME] 0.5 mg given. At 9:45 p.m. oxygen saturation at 87%, pulse 100 and respirations 46. Resident #8's lung sounds were congested and he/she continued to have tan secretions from his/her mouth. At 10:20 p.m. Resident #8 rested easier, but his/her respirations remained rapid and slightly labored, with an oxygen saturation at 87%. The Hospice nurse gave a condition report to an RN and the MDS Coordinator and called the family with an update. She instructed the facility staff to call with needs or concerns and Hospice staff would follow up in the morning. She suctioned Resident #8, applied cool compresses, repositioned the resident and gave [MEDICATION NAME] and Tylenol suppository at midnight. During an interview on [DATE] at 1:09 p.m. Staff F, Certified Nursing Assistant (CNA) stated on [DATE] she worked 2 to 10:30 p.m. At 2 p.m. she and Staff D CNA found Resident #8 face down in vomit, in the fetal position. Staff F stated she reported to Staff G because this was unusual. Staff G told her they had dealt with it all day. Staff F stated Resident #8 vomited enough to do a complete gown change. Staff G told her she was aware and there was nothing they could do, just to keep Resident #8 cleaned up. Staff F stated later in the shift Resident #8 struggled to breathe and seemed very uncomfortable. Staff F reported to Staff G again and she said it was fine. Staff F didn't know what Staff E RN did for Resident #8, but the Hospice nurse was very concerned about his/her condition when she arrived. Staff F stated she had not seen a resident suffer and struggle the way Resident #8 did that night. During an interview on [DATE] at 3:56 p.m. Staff H CNA stated working [DATE]. She said Resident #8 had something green/brown coming out of his/her mouth like a thick throw-up. She told the nurse (Staff G) Resident #8 had a hard time breathing and appeared to be almost choking and trying to clear his/her throat. Staff G told Staff H there was nothing they could do for Resident #8 and to make sure he/she got cleaned up if it got on his/her gown. Staff H said they (CNAs) checked on Resident #8 every 15 to 20 minutes. They put the head of the bed up and he/she continued to spit up. During an interview on [DATE] at 3:23 p.m. Staff D, CNA stated the day before Resident # 8 died , the resident threw up 2 times, a lot the first time and not as much the 2nd time. She said it was unusual and she told the nurse. The nurse said the only thing they could do was slow the tube feeding and it went as low as it could go. Staff D stated being concerned about Resident #8 and reporting to the nurse thinking she would call Hospice or something. During an interview on [DATE] at 10:39 a.m. Staff G stated it was hard to tell if (the spitting up) came from the resident's lungs or stomach, but she thought the lungs. She did not recall staff reporting that Resident #8 vomited. She thought the feeding started at about 1:45 p.m. She said if they had reported the vomiting at 2 p.m. she would have called Hospice in earlier. She said she assumed she could not stop the feeding without a doctor's order. She said if the staff had reported the vomiting at 2:00 p.m. and she called Hospice in earlier, Resident #8 may not have suffered the way he/she did. Staff G did not call Resident #8's doctor that day and did not call Hospice until the end of her shift. During an interview on [DATE] at 9:45 a.m. a representative of Hospice looked at Resident #8's record and they had received a call from Staff G on ([DATE]) around 6:00 p.m. reporting just an FYI (for your information). Resident #8 had greenish brown phlegm from his/her mouth and Staff G questioned if the resident had aspirated. During an interview on [DATE] at 3:00 p.m. Staff E RN stated on [DATE] she came to work at 6 p.m. The CNAs had concerns about Resident #8 and she went to check on the resident. Resident #8 had whitish/tanish liquid coming from his/her mouth. Staff E immediately shut the feeding off and made sure the head of the bed was elevated. Resident #8 had difficulty breathing and she could not hear air exchange in the lungs. Then Staff E talked to Staff G because she had not yet received report. Staff G told her she did not have an order to stop the feeding and Resident #8 just vomited. Staff E asked about calling Hospice and Staff G did then. Staff E stated if someone threw up, staff should shut the feeding off. When Hospice got there they found a suction machine and got oxygen going. Staff E stated she checked vital signs prior to Hospice coming, but could not be sure where she documented them. She said the (vital signs) were not good. Staff E stated she was also busy getting report and doing other tasks. When the CNAs asked her to look at Resident #8, she went right down before getting report. Staff E told Staff G that Resident #8 was not doing well and Staff G did not offer to help do anything. Staff E did not get oxygen started before Hospice got there or administer any prn medications. She did assist the Hospice nurse when she got there. Staff E stated she felt terrible for Resident #8 and felt he/she aspirated. During an interview on [DATE] at 12:43 p.m. the Hospice Nurse stated she saw Resident #8 [DATE]. She had concerns when she arrived at the facility. Resident #8 was slumped over in bed with his/her head hanging down, blowing bubbles out of his/her nose and in respiratory distress. She felt the resident aspirated and had the tube feeding coming out his/her nose and mouth. She said the nurse on at the time had stopped the feeding pump from running, but the tubing remained connected. The nurse had stopped it when she came on (duty). The resident's pulse, respirations and temperature were elevated and his/her pulse oxygen low. The Hospice nurse had oxygen started, found a facility suction machine and administered medications to make the resident comfortable. She said it took awhile to find the suction machine and equipment at the facility, but when she did, she suctioned quite a bit of secretions. She said two CNAs who were working since 2 p.m. stated there were problems since 2 p.m. She said they certainly would have seen the resident sooner if the facility had let them know about the change. It took hours to get Resident #8 somewhat comfortable. On [DATE] at 1:24 p.m. Resident #8's physician returned a call and said on [DATE] the facility should have stopped the tube feeding when Resident #8 started vomiting, it may have prevented some of Resident #8's discomfort. She checked the records and no one called about Resident #8 that day.

Based on record review, observation and staff interviews, the facility failed to provide adequate nursing supervision to ensure against hazards from self, for 3 of 10 residents reviewed (Residents #1, #3 & #8). The facility identified a census of 57 current residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 9/2/14, which identified [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility and transfers. According to the MDS, the resident had an impairment on one side of the upper extremity and not steady, only able to stabilize with staff assistance during transitions and walking. The MDS identified the resident as moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) scored as an eight. A BIMS of 13-15 determines the resident with no cognitive problems. Review of the Fall Risk Assessment, dated 8/17/14, reflected the resident had a score of 17 points. A score of 10 or above identified a resident at risk of falling. The Post Fall/Incident Analysis document identified the resident had falls on 3/31/14, 3/22/14, 5/1/14, 6/29/14 and 7/10/14. The document reflected the resident had an underlying illness/condition which was related to falls (cancer and chronic obstructive disease), had poor judgment with ambulation and safety and had slick shoes. The current intervention directed staff to keep the oxygen tubing off of the floor, shorter oxygen tubing, declutter the room/rearrange and the resident should wear gripper socks on feet. The Incident Report dated 7/15/14 reflected the staff found the resident on the floor by the extra bed in the room. The new intervention reflected the physician would be contacted to evaluate for possible discontinuous of Zyprexia (antipsychotic medication). The Incident Report dated 8/16/14 and 9/14/14 identified the resident continued to fall. The hospital record revealed the resident had a fractured right olecranon ulnar (elbow) and repair of the fracture occurred on 8/20/14. The Care Plan Report dated 9/16/14, identified the resident had a problem with being at risk for falls related to impaired mobility and a history of falls which resulted in a fracture. The multiple approaches included and directed the staff to assist the resident with non-skid socks at bedtime. Review of the Progress Notes dated 9/27/14 at 1:15 am revealed staff notified the nurse that the resident was on the floor in the bathroom. The staff observed the resident lying on the bathroom floor, positioned on the left side partially under the sink. The resident complained of right hip pain, had shortening of the right leg and had a small skin tear to the right thumb area. The facility sent the resident to the emergency room for an evaluation. Review of the Investigation Procedure Report dated 9/27/14 at 1:15 AM reflected the resident was found lying on the floor in the bathroom propped up on his/her right elbow. An x-ray report dated 9/27/14, identified the resident had a displaced right femoral intertrochanteric fracture (hip). On 10/16/14 at 9:50 PM, Staff C (Registered Nurse) was interviewed and stated a certified nursing assistant found the resident on the bathroom floor. Staff C stated she went to the resident's room and found the resident lying on her/his back and left elbow propped up. The resident laid partially under the sink in the bathroom. The resident's right leg appeared shortened and the resident complained of pain. The resident stated "I think I broke my leg " . The resident wore socks but the socks were nonskid socks. On 10/16/14 at 10:00 PM Staff B (Certified Nursing Assistant) was interviewed and stated Resident #1 required the assistance of 2 staff for toilet use. Staff B stated she heard yelling and went to the resident ' s room. Staff C stated she found the resident on the bathroom floor and (the resident) did not know what had happened. Staff B stated she had been in the room 20 minutes earlier and reminded the resident to use the call light. Staff B stated she had been passing ice water. Staff B stated the resident was independent with getting up and the personal alarm was discontinued. The resident wore white socks on his/her feet and the socks were not gripper socks. On 10/16/14 at 10:15 PM Staff A (Certified Nursing Assistant) was interviewed and stated they (other nursing assistants) had performed rounds earlier in the shift and found the resident wearing no gripper socks. Staff A looked for the gripper socks in the resident ' s room and could not find any. Staff A stated sometimes would get the gripper socks from the laundry but she got busy and didn ' t get to it (to the laundry room to get gripper socks). A family member was interviewed on 10/21/14 at 2:35 p.m. and voiced a concern with the resident ' s falls on the night shift and unsure why. The family member stated she/he had discussed alarms with the Administrator a few days prior to the fall (of 9/27/14). The pressure alarm had been removed because the resident had complaints of not sleeping very well and the personal alarm was removed. The Care Plan dated 9/16/14 reflected the pad alarm had been discontinued on 9/19/14 per the family request. Although the family requested the alarm be removed, the facility still needed to implement a means of keeping the resident safe and provide adequate supervision in order to prevent further falls from occurring. 2. Resident #3 had an MDS with a reference date of 8/11/14 which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident required extensive assistance with bed mobility and transfers. According to the MDS, the resident had impairment on both sides of the lower extremities that interfered with daily functions. The MDS identified the resident as not steady with balance during transitions and only able to stabilize with staff assistance. The fall risk assessment dated [DATE] revealed the resident with a total score of 17 points. A score of 10 or above indicated a risk of falling. The current Care Plan Report, identified the resident had a problem with being at risk for falls due to the resident requires the assistance of 2 (staff) with all transfers, has a history of falls and has the [DIAGNOSES REDACTED]. Observation on 10/17/14 at 9:30 AM revealed the resident, sitting in a wheelchair and alone in his/her room. At 9:35 AM the resident attempted to roll the wheel chair over the floor mat and reached forward to turn on the call light. 3. Resident #8 had an MDS with a reference date of 9/30/14, which identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility and transfers. According to the MDS, the staff identified the resident as not steady with balance during transitions and only able to stabilize with staff assistance. The resident had impairment on both sides of the upper and lower extremities. The Care Plan Report dated 2/19/14, identified the resident at risk for falls due to dementia and a history of falls. The approach directed staff to implement safety measures, ensure the resident ' s bed is in low position and place wedge in bed to prevent falls. Review of the Fall Risk assessment dated [DATE] revealed the resident ' s score at 17. A score of 10 or above represented the resident to be at a high risk for falls. Review of the Progress Notes dated 10/9/14 at 8:07 AM reflected the staff called the nurse to the resident ' s room due to the resident ' s fall. The nurse assessed the resident and the resident voiced complaints of severe right shoulder and right hip pain. The note reflected the bed had been in high position and the bolster hung from the side of the bed. The nurse documented she had observed bruising to the right hip and a small skin tear to the right elbow. The nurse contacted the physician and ordered to send the resident to the hospital. The Progress Notes dated 10/9/14 at 11:43 AM reflected the resident returned to the facility with bruising noted to the left and right knee, left arm and a skin tear to the right arm. Review of the Resident Fall/Incident Report dated 10/9/14 revealed that at 7:00 AM staff called to the resident ' s room. The resident found on the floor mat on the floor. The bolster hung from the side of the bed. (not attached). The bed in high position. On 10/21/14 at 5:00 PM, the ADON (Assistant Director of Nursing) was interviewed and stated the resident fell out of bed. The ADON stated the bed had been in the highest position and there were no bolsters in the bed.

Based on observation, record review, and staff interviews, the facility failed to assess and provide timely and appropriate interventions and the health facility supervisor failed to direct the implementation of the physician's order [REDACTED]. The sample consisted of 8 residents and the facility reported a census of 52 residents. Findings include: 1. Resident #8 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 1/28/13, which identified [DIAGNOSES REDACTED]. The MDS documented the resident had a supra pubic catheter (catheter placed through abdominal wall into bladder). A BIMS (Brief Interview for Mental Status) identified the resident as moderately impaired for cognition with a score of 12. (A score of 8-12 reflects moderate impairment). The Care Plan Report identified the resident had a problem with alteration in elimination do to incontinent of bowel, [DIAGNOSES REDACTED]. The hospital Discharge Instruction report dated 11/1/12 at 12:53 PM revealed a suprapubic Foley catheter in place. The facility to cleanse the site every shift per facility protocol. Attach to a gravity bag. A Physician Fax Form, dated 11/1/12 at 3:10 PM requested an order to identify size, frequency of changes and flushing of the suprapubic catheter. The Daily Skilled Nurse's Notes dated 11/3/12 identified a suprapubic catheter present and draining clear yellow urine. The Clinical Notes revealed the following: ? On 11/21/12 revealed at 4:10 AM, the staff found the resident on the floor after the roommate activated the call light system. The resident's catheter pulled out with the fall so staff reinserted a new catheter with a 16 French 10 cc (cubic centimeter) Foley/ urethral catheter. ? On 12/21/12 at 11:20 AM, the resident was due to have a change in the suprapubic catheter. Upon examination, resident noted to have a urethral catheter in place. The resident's suprapubic site closed and inaccessible. The physician on call notified and instructed to call the urologist on call. The urologist instructed the nurse to leave the urethral catheter in place and schedule an appointment for next week. ? On 12/22/2012 at 3:39 P.M. the resident ' s urinary output was monitored due to urethral and not suprapubic catheter in place. The resident did request to use the toilet, told staff she/he had the urge to void and did void but around the urethral catheter. No output in the leg bag noted. ? On 12/22/2012 at 9:25 P.M., the resident expressed the need to void and urinated around the urethral catheter. ? On 1/1/2013 at 1:59 A.M., the resident continues with Foley catheter with no output in bag. Incontinent numerous times with good amount. ? On 1/3/2013 at 3:20 P.M., the resident had an appointment with the Urologist. Resident to have cystoscopy on 1/23/2013 at 11:00 A.M. ? On 1/23/2013 at 1:23 P.M., the resident returned from the appointment for a cystoscopy. The resident to have surgery on 2/7/2013 at 11:30 a.m. for a suprapubic tube placement and removal of a bladder stent. ? On 2/7/2013 at 11:11:43 - addendum indicated the resident returned from surgery with a supra pubic catheter in place. On 3/19/2013 at 10:00 A.M., Staff N (Licensed Practical Nurse) was interviewed and stated the resident fell in his/her room. She said the resident's catheter fell out. She looked at the catheter tube and noted the tube to be a 16 French tube. She stated she inserted a urethral catheter because she thought the resident had an indwelling/ urethral catheter in place. She stated she looked at the orders and saw the tubing the same size. Staff N stated she reported the incident to the charge nurse the next morning and informed her catheter had been replaced. She did not state the type of catheter she had replaced. Staff N stated the catheter incident did not get discovered until approximately 1 month later when the resident started to have difficulty with drainage. At the time, the facility discovered the wrong type of catheter had been reinserted. Staff N stated she did not look at the treatment or admission orders [REDACTED]. The Physician Fax Form dated 11/21/12 indicated the resident was found on the floor sitting on his/her buttocks. The fax did not reference that the supra pubic catheter came out. On 3/19/2013 at 2:00 P.M., Staff B (Registered Nurse) was interviewed and stated she went to change the suprapubic catheter as scheduled and found the suprapubic catheter absent and the resident had a urethral catheter instead. Staff B stated she knew the resident had a suprapubic catheter in place because she admitted the resident into the facility. She stated no staff reported to her in the past month the resident had a urethral catheter. She stated if the catheter (Suprapubic or regular urethral catheter) fell out staff should look at the admission order or the treatment sheet to verify the type of catheter the resident had in place. If the treatment sheet did not have an order for [REDACTED]. The urologist had stated the resident would have to go through an unnecessary surgery again. On 3/20/2013 at 11:20 A.M. the resident's Urologist was interviewed. The Urologist stated the suprapubic site fills (closes) up quickly (area where inserted in abdomen) and usually within 24 hours or less. The Urologist stated the facility should not have waited until a month after the incident to notify him. The Urologist stated it appeared she would have needed the Suprapubic catheter replaced anyway because he was notified so late.