Every finding on record at Emmetsburg Care Center

Based on record review and staff interview, the facility failed to ensure residents were free of significant med errors for 3 of 4 residents reviewed (Resident #2, #6 and #7). The facility reported a census of 41 residents.Findings include:1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #2's diagnoses included diabetes and the resident received insulin daily.The current Care Plan with a goal target date of 5/31/26 identified Resident #2 at risk for complication related to Diabetes Mellitus. Interventions included encouraging compliance with diet and medication regimen, and medication as ordered. The Medication Administration Record (MAR) for April 2026 Showed Resident #2 had an order foe Lantus 20 units 2 times a day with a start date of 4/20/26. The 4/22/26 a.m. dose was blank.The MAR showed the resident had an order for Novolog per sliding scale. The resident had an a.m. blood sugar of 168. Per the sliding scale the resident would receive 17 units of the Novolog. The breakfast insulin was blank.The Progress Notes dated 4/22/26 at 11:31 a.m. documented Resident #2's blood sugar log faxed to the physician. At 12:14 p.m. Resident #2 monitored after a decrease in Lantus to 20 units 2 times a day.On 5/11/26 at 9:34 a.m. Staff I LPN Licensed Practical Nurse (LPN) stated she could not say for sure about the resident's insulin that day. He had been having low blood sugars, so not sure if she may have held the insulin. She could not remember. She said she didn't recall having given insulin and not signing it out. She said she may have written something on the fax with the blood sugars.A Blood Sugar Summary dated 4/22/26 included hand written notes about the a.m. sliding scale Novolog being held due to a blood sugar of 168 and resident only eating 1 bowl of cereal per the resident's normal, and he did receive 20 units of Lantus.On 5/11/26 at 2:34 p.m. Resident #2's Physician stated they had nothing in their record that the Novolog was held on 4/22. She said they could hold until they heard back from the physician and had a discussion. There has been an issue with receiving faxes, and if they didn't hear back timely, they needed to call. 2. According to the MDS assessment dated [DATE], Resident #6 scored 14 on the BIMS indicating no cognitive impairment. Resident #6's diagnoses included a seizure disorder. The resident received anticonvulsant (antiseizure) medication.The MAR for February showed the Resident #6 had an an order for Lacosamide 150 mg 2 times a day with a start date of 9/18/25. The MAR documented the resident received the medication 2 times a day in February.The Controlled Drug Receipt/Record/Disposition Form for Resident #6's Lacosamide 150 mg, take 1 tablet twice daily. The record showed a tab only signed out 1 time on 2/5, 6, 9, and 11/26.The Progress Notes dated 2/16/26 at 10:58 a.m. an agency nurse notified the Director of Nursing (DON) she identified a medication administration error involving omitted doses of Lacosamide 150 mg at bedtime on 2/5, 6, 9, and 11/26. The nurse acknowledged the medication was not administered on those dates but was documented as given in the medical record. Upon discovery, the nurse immediately completed a resident assessment. The resident remained at baseline with vital signs within normal limits, no adverse effects noted, and no seizure activity or seizure-like symptoms observed during the time period of the missed doses. The attending provider and responsible party were notified per facility policy. The medication was administered as ordered moving forward, and the resident will continue to be monitored. The incident will be reviewed per facility policy for follow-up and corrective action. On 5/7/26 at 8:32 a.m. the DON stated the Lacosamide was a controlled medication and an agency nurse did not pull it from the lock box several times when she worked. When the agency nurse realized she had not given it she notified the DON. She said they did education and audits after this occurred. She said the staff was from agency and she had not worked in a while.3. According to the MDS dated [DATE], Resident #7 scored 3 on the BIMS indicating severe cognitive impairment. Resident #7's diagnoses included depression. The resident received antidepressant medication.The current Care Plan with a goal target date of 5/21/26 identified Resident #6 utilized a psychotropic medication in the category of antidepressant related to depression. Interventions included administering medications as ordered.The Progress Notes documented the following regarding Resident #7's Escitalopram 5 mg daily:1/22/26 out of these meds,1/23/26 no replacement card from pharmacy,1/24/26 medication not available at this time,On 1/26/26 no medication available at this time,On 1/27/27 still no meds,On 1/28/26 needs to be ordered,On 1/29/26 med not available at this time,On 1/30/26 med not available from pharmacy,On 1/31/26 medication not available at this time,On 2/1/26 medication not available at this time,On 2/2/26 medication to be delivered from pharmacy,On 2/3/26 medication not available at this time,2/4/26 medication not available at this time,2/5/26 med not available,2/6/26 med not available,2/7/26 medication ordered from pharmacy,2/8/26 waiting for pharmacy to deliver,2/9/26 med not available,2/10/26 medication not available.2/11/26 med not available.The Progress Notes dated 3/17/26 at 8 a.m. documented it was brought to office staff attention the resident had not received her Escitalopram Oxalate 5mg and documented in progress notes 01/22/26 - 01/24/26, 01/26/26 - 01/31/26, and 02/01/26 - 02/11/26. Medication was changed from being given at a.m. to bedtime (HS) on 01/21/26 per physician orders. It was subsequently not given on the above dates. Pharmacy did not send a new card, as there should have been a card with the proper dose already. On 5/7/26 at 8:50 a.m. the DON stated they did not have the medication, and staff kept charting awaiting med. Staff should call the pharmacy to question why they didn't have the med. They did staff education, reviewed all the meds in the cart to ensure correct, and conducted audits.The Medication Administration Administration - Medication Pass policy revised 5/2023 directed the purpose to safely and accurately prepare and administer medication according to the physician order and resident needs. The procedure included opening the Electronic Medication Administration Record (EMAR) and reviewing the medication order against the medication label. Read the transcribed physician order on the EMAR, resident name, medication name, dosage, route and interval ordered. Remove medication from the cart, and compare medication to the label for accuracy. If the medication was unfamiliar or the physician order questioned, contact the physician for clarification.

Based on record review and staff interview, the facility failed to ensure a record of controlled drugs was adequately monitored allowing for the temporary inability to reconcile a controlled medication for 1 resident (Resident #1) and other residents with controlled medications. The facility reported a census of 41 residents.Findings include:According to the Minimum Data Set Assessment (MDS) dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #1's diagnoses included fractures and other multiple traumas. The resident took opioid medication.The Care Plan with a goal target date of 7/2/26 identified Resident #1 had complaints of pain described as Acute- 1 month, related to semitruck accident, with multiple fractures to bilateral lower extremities and left hand. Interventions included administering pain medication per physician orders.The Hospice Medication Orders dated 3/23/26 included Morphine Sulphate 20 mg/ml oral concentrate, quantity 30 ml. Take 0.25 ml (5 mg) by mouth or under tongue every 2 hours as needed for moderate to severe pain or shortness of breath.The Progress Notes dated 4/3/26 at 11 a.m. documented a medication event incident repot. The nurse received notification that a resident's morphine was missing from the narcotic drawer. The facility initiated an immediate investigation, including a search of both medication carts and treatment carts, with no medication located at that time. Further investigation revealed the overnight nurse was contacted and reported that she had inadvertently taken the medication home in the pocket of her scrub jacket. The nurse returned the morphine to the facility upon discovery. The returned medication was reviewed by the nurse in collaboration with hospice staff, and the narcotic count reconciled. The medication was assessed for color, amount, and consistency, with no discrepancies noted. The morphine was subsequently destroyed per facility narcotic destruction protocol with hospice present. Review of facility camera footage confirmed that the nurse exited the resident's room holding the medication and subsequently placed it in her pocket while assisting another resident. Video evidence further confirmed that the medication remained in the nurse's jacket pocket as she left the facility. Additional review indicated that proper narcotic count procedures were not followed by the nurse and medication aide at the time of shift change.The Narcotic and Controlled Substance Shift to Shift Sheet for February 2026 lacked signature for:On coming nurse 2/2/26 1st shift,Off going nurse 2/2/26 2nd shift,On coming nurse 2/10/26 1st shift,Off going nurse 2/10/26 2nd shift,Off going and on coming nurse 2/11/26 1st, 2nd, and 3rd shift,Off going and on coming nurse 2/14/26 3rd shift,Off going nurse 2/15/26 1st shift,On coming nurse 2/17/26 2nd shift,Off going nurse 2/19/26 2nd shift,Off going nurse 2/22/26 2nd shift,Off going nurse 2/23/26 2nd shift,Off going and oncoming nurse 2/23/26 3rd shift,Off going nurse 2/24/26 1st shift,On coming nurse 2/24/26 2nd shift,Off going nurse 2/24/26 3rd shift,On coming nurse 2/27/26 1st shift,Off going nurse 2/27/26 2nd shift.The Narcotic and Controlled Substance Shift to Shift Sheet for March 2026 lacked signature for:Off going and on coming nurse 3/1/26 1st shift,Off going nurse 3/1/26 2nd shift,Off going and on coming nurse 3/26/26 3rd shift,Off going nurse 3/27/26 1st shift.The Narcotic and Controlled Substance Shift to Shift Sheet for April 2026 lacked signature for:Off going nurse 4/3/26 1st shift,On coming nurse 4/4/26 2nd shift,On coming nurse 4/8/26 3rd shift,Off going nurse 4/9/26 1st shift,Off going nurse 4/9/26 2nd shift,Off going nurse and on coming nurse 4/30/26 1st shift,Off going nurse 4/30/26 2nd shift.On 5/4/26 at 3:46 p.m. Staff E CMA said Staff F Registered Nurse (RN) had already signed the narc count off (the day thet could not find the morphine). He found something he thought was off and went to tell the nurse. Staff F, Staff G Licensed Practical Nurse (LPN), and Staff H LPN all said why the patches were off and did not even offer to count with him. Staff F had already signed off the count.On 5/4/26 at 4:25 p.m. Staff H stated she did not recall Staff E saying anything about pain patches being off. She said she was not on the cart that day so she had not done the count. She said she always did count with someone, and started late if need be to get that done. On 5/4/26 at 5:18 p.m. Staff G stated Staff E did come and say they only counted boxes not patches and the count was off. They tried to explain on the 1st count they count the # of boxes/cards/etc Then they count the number in the boxes and cards. She said she always counted with the off going nurse, or on-coming nurse. She had seen spaces where the off going or on coming nurse or med aide had not signed off.On 5/5/26 at 9:09 a.m. Staff F RN stated the night she worked and inadvertently took the morphine home, she was multitasking, and put the morphine bottle in her scrub jacket, which she never wore, and she had so many pockets. She had administered the morphine in the resident's room. She drew it up in the plunger and administered it to Resident #1. After that she had a blood sugar and forgot the morphine was there. She said the CMA did the count by himself and said there was a problem with the fentanyl patches. But apparently, they count the box of patches as 1, instead of the number of patches. So, she signed the count even though she didn't do the count. She said if they had done the count together, she would have realized she still had the morphine in her pocket. She said Resident #1 had a lot of pain in his legs. She felt terrible about this, and him possibly needing it and it not being there. She felt not counting narcs together was a common practice. She said she would never do that againOn 5/7/26 at 8:32 a.m. the Director of Nursing (DON) stated Resident #1's morphine went home with a nurse. The nurse and CMA did not count the narcotics. The off going and on coming nurse/cma should count the narcs together to assure all meds were accounted for.The Controlled Medication Storage and Count Policy revised 10/2023 documented narcotic counts were completed at the beginning and end of each shift or at the time when there was an exchange of medication cart keys. The exchange required 2 nurses or 1 nurse and 1 Certified Medication Aide. The oncoming nurse validated the medication count on the med card, and the off going nurse validated medication count on the paper document. Both nurses were required to sign off on the shift to shift count record.

Based on record review and staff interview, the facility failed to ensure baths as planned for 3 of 4 residents reviewed (Resident #2, #4 and #5). The facility reported a census of 41 residents.Findings include:1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required partial/moderate assistance with bathing. Resident #2's diagnoses included anemia, inflammatory bowel disease, and diabetes.The current Care Plan with goal target dates of 5/31/26 identified Resident #2 required assistance with Activities of Daily Living (ADL's) related to generalized weakness and neuropathy to lower extremities. Interventions included assisting the resident with shower/bathing per schedule.The Tasks tab in Resident #2's Electronic Health Record (EHR) documented bathing 2 times a week and as needed.A report of bathing Tuesday and Friday showed Resident #2 had a bath documented on: a. 2/6/26 and 2/13/26, 7 days between b. 2/13/26 and 2/20/26, 7 days between c. 2/25/26 and 3/3/26, 6 days between d. 3/9/26 and 3/17/26, indicating the resident not available on 3/13/26, e. 3/17/26 and 3/27/26, 10 days between, f. 3/27/26 and 4/3/26 and 4/4/26, 7 days between. 2. According to the MDS dated [DATE], Resident #4 scored 8 on the BIMS indicating moderate cognitive impairment. The resident required supervision/touching assistance with bathing. Resident #4's diagnoses included diabetes and cardiomyopathy.The current Care Plan with a goal target date of 6/15/26 identified Resident #4 required assistance with ADL's related to difficulty in walking, generalized weakness, and obesity. Interventions included assisting the resident with shower/bathing per schedule.The Tasks tab in Resident #4's EHR documented bathing 2 times a week and as needed.A report of bathing Tuesday and Friday showed Resident #4 had a bath documented on: a. 2/8/26 and 2/20/26, 12 days between, b. 2/20/26 and 2/27/26, 7 days between, c. 3/6/26 and 3/17/26, 11 days between, d. 3/17/26 and 3/24/26, 7 days between, e. 3/27/26 and 4/3/26, 7 days between, f. 4/10/26 and 4/21/26 11 days between. 3.According to the MDS dated [DATE], Resident #5 scored 13 on the BIMS indicating no cognitive impairment. The resident required partial/moderate assistance with bathing. Resident #5's diagnoses included cancer and non-Alzheimer's dementia.The Current Care Plan with a goal target date of 6/15/26 identified Resident #4 required assistance with ADL's. Interventions included assisting the resident with shower/bathing per schedule.A report of bathing Tuesday and Friday showed Resident #4 had a bath documented on: a. 3/2/26 and 3/9/26, 7 days between. b. 3/9/26 and 3/15/26, 6 days between. c. 3/15/26 and 3/23/26 resident refused (8 days between), 3/26/26 11 days between, d. 3/26/26 and 4/6/26, 11 days between, e. 4/16/26 and 4/23/26, 7 days between, f. 4/16/26 and 4/23/26, 7 days between, g. 4/23/26 and 4/30/26, 7 days between.On 5/7/26 at 9:28 a.m. Staff B Certified Nursing Assistant (CNA) stated she did baths. She said some days she was pulled to the floor and did not get to do the baths.On 5/7/26 at 4:15 p.m. The Director of Nursing (DON) verified baths did not always get done as planned due to staffing. They were looking at changes to avoid that.

Based on record review and staff interview, the facility failed to update the care plan to reflect a resident on an antipsychotic for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 41 residents.According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 scored 7 on the Brief Interview for Mental Status indicating severe cognitive impairment. Resident #8's diagnoses included a stroke and hallucinations. The resident received 0 antipsychotic medications.The Progress Notes dated 3/24/26 at 9:25 a.m. documented a communication with the physician about Resident #8 having increased behaviors and paranoia, and requesting a review of her medication for possible update or review. At 2:27 p.m. received a signed order for Seroquel (antipsychotic) 25 mg 2 times a day.The Medication Administration Record (MAR) for March 2026 showed Resident #8 started Seroquel 25 mg two times a day with a start date of 3/24/26. The MAR showed the Seroquel dose increased to 50 mg two times a day on 3/30/26 related to dementia in other diseases classified elsewhere, unspecified severity with mood disturbance.The Care Plan with a goal target date of 6/21/26 lacked identification of Resident #8 receiving antipsychotic medication.The facility Care Plan Policy revised 3/25 documented the purpose to ensure that all care plans including base line care plans were in conjunction with the federal regulations including a comprehensive care plan developed after the comprehensive assessment of a resident. These would be reviewed and revised by the interdisciplinary team after completion of MDS assessments when applicable and with changes that warranted a care plan revision.

Based on observation, record review, and staff interview, the facility failed to implement appropriate infection control practices during wound care for 1 resident reviewed (Resident #5). The facility reported a census of 41 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #5 scored 15 on the Brief Interview for Mental Status indicating no cognitive impairment. The resident's diagnoses included paraplegia, injury of kidney, and chronic kidney disease. Resident #5 had a pressure ulcer.On 5/6/26 at 7:04 a.m. Staff J Registered Nurse (RN) and Staff A Licensed Practical Nurse (LPN) to do Resident #5's dressing change. Staff J said the resident had just had a bath. Resident #5 rolled herself to her left side. Staff J used gauze sponges saturated with Vashe cleanser. She used 1 sponge to wipe the anal area. She then used another sponge to clean the ulcer wearing the same gloves and around the ulcer, then wiped over the ulcer again with the same gauze. Staff A measured the area at 2.2 cm by 1.2 cm by 0.3 cm. Staff J washed her hands and changed gloves, then applied the collagen dressing and covered with the silicone dressing. Neither staff wore gowns during the procedure for enhanced barrier precautions.On 5/7/26 at 7:35 a.m. Staff A stated they forgot to use EBP during the wound care the previous day. On 5/7/26 at 7:45 a.m. Resident #5 stated the staff did not wear gowns when they did her dressing changes.On 5/7/26 at 8:45 a.m. the Director of Nursing (DON) stated they should be using EBP with wounds. She said a new pair of gloves would be appropriate when moving from the anal area to a wound. The facility Enhanced Barrier Precautions policy revised 3/2024 documented for residents whom EBP were indicated, gowns and gloves should be used during high contact resident care activities including wound care: any skin opening requiring a dressing.

Based on observation, record review, and staff interview, the facility failed to develop a comprehensive care plan identifying a resident's needs and describing services to be furnished for a pressure sure and catheter for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 41 residents.According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #5 scored 15 on the Brief Interview for Mental Status indicating no cognitive impairment. The resident's diagnoses included paraplegia, injury of kidney, and chronic kidney disease. Resident #5 had an indwelling urinary catheter. The Care Area Assessment (CAA) documented the resident had a suprapubic catheter in place, and it would be addressed in the care plan to avoid complications, maintain level of functioning, and minimize risks.The current Care Plan with a goal target date of 5/3/26 failed to address the indwelling catheter.A Weekly Pressure Ulcer Progress Report dated 1/13/26 documented Resident #5 had a stage 2 pressure ulcer. The report continued to present.The current Care Plan identified Resident #5 at risk for alteration in skin integrity with the goal not to develop skin alterations outside of the disease process.The Current Care Plan with goal target dates of 5/3/26 failed to address the resident had a pressure ulcer.On 5/7/26 at 7:35 a.m. Staff A MDS Coordinator/Licensed Practical Nurse (LPN) verified the catheter and the pressure ulcer should be addressed on the care plan.The facility Care Plan Policy revised 3/25 documented the purpose to ensure that all care plans including base line care plans were in conjunction with the federal regulations including a comprehensive care plan developed after the comprehensive assessment of a resident. These would be reviewed and revised by the interdisciplinary team after completion of MDS assessments when applicable and with changes that warranted a care plan revision.

Based on observation, record review and staff interview, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 41 residents.According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 8 on the BIMS indicating moderate cognitive impairment. The resident depended on staff for toileting hygiene. The resident was incontinent of urine and frequently incontinent of bowel. Resident #4's diagnoses included diabetes and benign prostatic hyperplasia (enlarged prostate).The current Care Plan with goal target dates of 6/15/26 identified Resident #4 required assistance with Activities of Daily Living (ADL's) related to difficulty in walking, generalized weakness, and obesity. Interventions included assist of 1 for toilet transfers and cares, with the front wheeled walker and belt.On 5/7/26 at 8:08 a.m. Staff C Certified Nursing Assistant (CNA) and Staff D CNA went to do a.m. cares with Resident #4. Staff assisted the resident to stand with a gait belt. After removing the incontinent pad, Staff C stood on the resident's right side and used a premoistened cloth and wiped his anal area with her left gloved hand resulting in bm on the wipe. Staff C asked Staff A LPN to help with wipes. Staff A handed wipes to Staff C and multiple wipes had bm on them. When she no longer found bm, without changing gloves she obtained a washcloth from a basin and with both hands handled the washcloth and wiped in the front genital area with the right hand, turning the cloth with her left gloved hand after each wipe. When finished she assisted in applying the new incontinent pad and shorts wearing the same gloves. When the resident sat in the w/c Staff C removed her gloves and washed her hands.On 5/7/26 at 4:15 p.m. The Director of Nursing (DON) stated when doing incontinent care they should go from front to back. If they started in the back, gloves should be changed with hand hygiene before cleaning the front.The Incontinence Care policy revised 8/2023 identified the purpose to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum to rectum. Discard soiled materials and discard gloves. Wash hands if visibly soiled and apply new gloves. Apply clean brief/incontinent pad/undergarment.

Based on record review and staff interview, the facility failed to ensure accurate medication record for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 41 residents. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #2's diagnoses included diabetes.The Medication Administration Record (MAR) for March 2026 documented Resident #2 took Pregabalin 50 mg 2 times a day. On 3/14/26 the order changed from 50 mg to 75 mg 2 times a day.The Progress Notes dated 4/10/26 at 11:54 a.m. documented during med pass the med aid alerted the nurse of a discrepancy in medication dosage. The Medication card read: Pregabalin 50 mg 2 times a day and the MAR read: 75 mg 2 times a day. Per the nurse, the morning dosage held until further clarification with the provider obtained. Called the pharmacy and the provider to clarify. Per the provider's nurse, Resident #2 to continue on Pregabalin 50 mg BID daily. Transcription error corrected on MAR.A note from the facility to the physician on 4/10/26 at 10:05 a.m. documented a need for clarification on Resident #2's Pregabalin order, citing that a nurse changed the order from 50 mg 2 times a day to 75 mg on 3/13/26. Since 3/13/26 nursing staff had been giving 50 mg 2 times a day even though the MAR stated 75 mg. The nurse sought clarification because the pharmacy never documented for 75 mg, and had the correct dose of 50 mg as ordered by the physician.The physician responded 4/10/26 at 10:18 a.m. that this had been addressed previously. The documentation in the chart on 2/19/26 in the Electronic Health Record (HER) said 50 mg 2 times a day and then clarified with the pharmacy. It had not changed. The dose sent to the pharmacy was 50 mg 2 times a day and was the dose to continue. The dose had not been adjusted since 2/19/26 and had never been 75 mg.On 5/7/26 at 8:32 a.m. the Director of Nursing was unsure how Resident #2's Pregabalin order got changed. She confirmed they continued documenting they were giving the 75 mg dose until the CMA questioned it.The facility Medication Administration-Med Pass policy revised 5/2023 documented the procedure included reading the transcribed physician order on the MAR: resident name, medication name, dosage, route, and interval ordered. If the medication was unfamiliar or physician order questioned, contact the physician for clarification if needed.

Based on clinical record review, family interview, resident interviews, staff interviews and policy review the facility failed to provide bathing assistance for 3 of 3 residents reviewed for bathing (Residents #1, #2, #3). The facility reported a census of 39 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 required partial/moderate assistance for bathing. Resident #1's MDS included diagnoses of cancer, hypertension (high blood pressure), non-alzheimer's dementia, anxiety disorder and schizophrenia. The Care Plan with a target date of 2/8/26 documented staff to assist Resident #1 with shower/bathing per schedule. The Task Form titled Bathing Monday and Thursday for the last 30 days revealed Resident #1 received a bath/shower on 12/12, 12/24, 1/1 and 1/4. The form documented Resident #1 did not receive a bath/shower on 12/11, 12/22, 12/25 and refused a bath/shower on 12/29. Review of the documentation revealed Resident #1 did not have a bath/shower from 12/13 to 12/24 (11 days) and from 12/25 to 1/1 (7 days).The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #1 to shower or bathe.On 1/5/26 at 1:39 PM, Resident #1's sister reported bathing was very infrequent and more likely to happen when she was at the facility. She said she thought a bath for Resident #1 was completed every two weeks. 2. Resident #2's MDS dated [DATE] assessment identified a BIMS score of 14, indicating intact cognition. The MDS documented Resident #2 required setup or clean up assistance for bathing. Resident #2's MDS included diagnoses of cancer, hypertension (high blood pressure), urinary tract infection past 30 days, and chronic kidney disease. The Care Plan with a target date of 3/8/26 documented staff to assist Resident #1 with shower/bathing per schedule. The Task Form titled Bathing Monday and Thursday for the last 30 days revealed Resident #2 received a bath/shower on 12/17, 12/23, 12/31 and 1/4. The form documented Resident #2 did not receive a shower on 12/11, 12/22, 12/25 and on 12/29. Review of the documentation revealed Resident #2 did not have a bath from 12/18 to 12/23 (5 days) and from 12/24 to 12/30 (7 days). The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #2 to shower or bathe.On 1/7/25 at 10:40 AM, Resident #2 reported she thought she had not had a shower/bath for about 2 1/2 weeks. When asked if she had a sponge bath or bed bath, she said staff would use the wipes to clean her bottom but that was it.3. Resident #3's MDS dated [DATE] assessment identified a BIMS score of 10, indicating moderately impaired cognition. The MDS documented Resident #3 required substantial/maximal assistance for bathing. Resident #3's MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, depression, and overactive bladder. The Care Plan with a target date of 1/15/26 documented Resident #3 preferred showers for bathing and staff to assist with shower/bathing per schedule. The Task Form titled Bathing Tuesday and Friday for the last 30 days revealed Resident #3 received a bath/shower on 12/9, 12/26, 12/30, 1/2 and 1/6. The form documented Resident #3 did not receive a shower on 12/16, 12/19, and on 12/23. Review of the documentation revealed Resident #3 did not have a bath from 12/10 to 12/25 (15 days). The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #3 to shower or bathe.On 1/8/26 at 9 AM, Resident #3 reported that he liked to take a whirlpool bath. He said the shower was gross. He said he gets a bath about once a week but would like to have a bath more often.On 1/6/26 at 2:14 PM, the Director of Nursing (DON) reported baths are scheduled two times a week and could be adjusted per resident preference. The DON reported staff documented baths in the electronic medical record. On 1/7/26 at 11:25 AM, the DON reported she was in the process of giving a written warning to all staff regarding bathing expectations. The DON reported she expected baths to be given according to the schedule and if the bath was not given to have documentation on why it was not done. She said bathing documentation had been a concern and if the bath was not documented then it did not happen. The DON reported if a resident refused to take a bath, she expected the staff to reapproach the resident, if reapproach does not work, then a different staff member was to try and if the resident still refused, the staff member was to tell the nurse and the DON. She reported she did not have any documentation or insight on why the baths were not done.On 1/7/25 at 10 AM, the Administrator reported baths are automatically offered/scheduled two times a week on admission and then adjusted according to resident preferences. A facility policy/procedure titled Hygiene- Bathing/Shower revised 3/2024 documented the purpose was to cleanse skin, promote cleanliness and prevent infection. The procedure directed staff to document the completion of the shower/bath in point of care (electronic charting).

Based on observations, clinical record review, resident interview, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 3 residents reviewed (Residents #2). The facility reported a census of 39 residents.Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #2 required partial/moderate assistance with bed mobility and was dependent on staff for all transfers. Resident #2's MDS's documented diagnoses of cancer, hypertension (high blood pressure), urinary tract infection past 30 days, and chronic kidney disease. The Care Plan with a target date of 3/8/26 revealed Resident #2 was at risk for alteration in skin integrity related to frequent urinary incontinence and the need for bed mobility assistance. The care plan directed staff to administer treatments per physician orders. A Health Status Note dated 12/29/25 documented Resident #2 had a moisture break down on the left inner buttocks measuring 0.6 centimeters (cm) x 0.9 cm. The note documented the area was cleansed and barrier cream was applied. A Physician Order dated 12/29/25 directed staff to apply barrier cream with cares every shift to promote healing. The order lacked direction on where to apply the barrier cream or what type of barrier cream to use. On 1/7/26 at 10:40 AM, Resident #2 reported the staff were in a hurry to get her up this morning. She said she ate breakfast in her room and then went to do exercise. She said her bottom was hurting. She said she did not get any cream put on her bottom this morning as the staff was in a hurry. She said she had [NAME] ointment in her bedside table drawer but that not all the staff had been using it. She said her pants would stick to the cream and then irritate her bottom. She said it is hard to get around when you have a sore butt. Review of the January 2026 Treatment Administration Record revealed the treatment for the barrier cream had been signed off as completed on 1/7/26 morning shift (6 AM to 2 PM).On 01/7/26 at 11:20 AM, Staff A, Certified Medication Aide (CMA) reported he was told the barrier cream was applied with morning cares. He said Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA got Resident #2 up this morning to go to therapy. He said it was around 7 AM. On 1/7/26 at 11:35 AM, Staff B, CNA reported she thought Staff C, CNA applied a cream to Resident #2's bottom when they got her up this morning. She said Staff C took some cream from a white tube and put it on. She said she did not know what the cream was or where Staff C got it from. On 1/7/26 at 11:49 AM, Staff C, CNA reported she did not assist with changing Resident #2's brief this morning. She said she had to step out of the room to assist another resident who was wandering. She reported she did not apply any barrier cream to Resident #2 buttocks.On 1/7/25 at 2:40 PM, the Regional Nurse Consultant reported she would expect staff to follow the physician order and administer the treatment according to the order. She reported the treatment should not be documented as completed if it had not been done.On 1/7/25 at 3:25 PM, observed Staff D, Licensed Practical Nurse (LPN) measured Resident #2's wound to the left buttocks. Staff D reported the wound was round in appearance and measured 1.4 cm x 1.4 cm with two small open areas inside the wound that measure 0.2 cm x 0.3 cm and 0.2 cm x 0.2 cm. Staff D reported she thought the wound looked like it was caused from shearing with the top layer of skin missing. Staff D applied Desitin ointment to the wound. Staff D told Resident #2 she was going to reach out to the doctor to request a patch for padding and to protect the wound from moisture. Resident #2 replied that would be nice. Resident #2 verified she did not receive any cream or treatment for the wound during the morning shift (6 AM to 2 PM).A facility policy titled Physician Orders/Transcription of Orders revised 7/2023 documented active orders should be followed and carried out as written/transcribed.

Based on diet orders, staff interviews, clinical record review, hospital record review and facility policy review the facility failed to serve the appropriate therapeutic diets to meet resident's needs according to their diet orders for 1 of 6 residents reviewed (Resident #3). The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/24/25 at 11:27 AM that began as of 7/17/25. The Facility Staff removed the IJ on 7/24/25 through the following actions:-Education to the nursing staff started on 7/24/25 to ensure they confirm the diet order and serve the appropriate diet and diet modifications. -Like residents include residents with orders for modified or altered diets. An audit was completed for residents with orders for modified or altered diets to ensure the diets are correct. The scope was lowered from a J to a G at the time of the survey after ensuring the facility implemented education.The facility reported a census of 43 residents.Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 14, indicating intact cognition. The MDS identified Resident #3 required set up or clean-up assistance with eating. The MDS included diagnoses of diabetes mellitus and noninfective gastroenteritis (inflammation of the stomach) and colitis (inflammation of the colon). The MDS documented Resident #3 was on a mechanically altered and therapeutic diet. A Diet order dated 5/13/24 directed the staff to administer a mechanical soft, ground meat texture diet related to Barrett's esophagus with dysplasia (presence of precancerous cells in the lining of the esophagus (tube that carries food from mouth to stomach), replaced by intestinal like tissue due to gastroesophageal reflux disease (GERD). In addition the diet order directed staff to provide supervision/cues for pacing, give a drink after 1-2 bites of food, give one food item at a time, soft foods only and no bread. The Care Plan with target date of 9/28/25 documented Resident #3 was at risk for altered nutritional status related to obesity, diabetes mellitus and gastrointestinal complications. The care plan directed staff to provide diet as order, feed one item at a time and encourage Resident #3 to sit up straight. The Care Plan lacked information related to Resident #3 swallowing issues and diet restrictions.Review of the Kardex (used by the facility certified nursing assistants (CNAs) as a snapshot of resident care) lacked documentation regarding Resident #3's diet order and restrictions. A Progress Note dated 7/17/25 at 9:52 PM documented Resident #3's blood sugar was 49 mg/dl (milligrams per deciliter) and the resident was given orange juice and peanut butter toast. A Progress Note dated 7/17/25 at 11:19 PM documented at 9:55 PM, Staff E, Licensed Practical Nurse (LPN) entered Resident #3's room and the resident was groggy. Resident #3's blood sugar was checked and 49 mg/dl. The note documented Resident #3 was given 8 oz (ounces) of orange juice and peanut butter and a CNA sat with the resident. At 10:10 PM, Resident #3's blood sugar was 69 mg/dl and 4 oz of a protein shake was given. Resident #3 was sitting on the side of the bed heaving and bringing up small amounts of mucus. At 10:35 PM, Resident #3's blood sugar was checked and 63 mg/dl. Resident #3 was given 8 oz of orange juice with 2 packets of sugar. Resident #3 continued to sit on the edge of the bed heaving and bringing up mucus. The note revealed Resident #3 vitals were the following: Temperature 97.5, Pulse 114 per minute, Respirations 20 per minute, Blood Pressure 99/56 and oxygen saturation (oxygen in the blood) was 63% on room air. The note indicated oxygen at 2 liters per nasal cannula was applied. A phone call to the emergency room (ER) was placed informing the ER of Resident #3's condition. At 10:42 PM, a phone call to 911 was placed and informed them of the need for transport and Resident #3's condition. At 11:00 PM Emergency Medical Technicians (EMTs) arrived at the facility.A Prehospital Care Report dated 7/17/25 documented EMTs arrived and found Resident #3 seated on the side of the bed with staff present. The note documented when the staff checked Resident #3's blood sugar they discovered the blood sugar was low, they held the insulin and gave him orange juice and toast with peanut butter. A ED (Emergency Department) Note dated 7/17/25 documented Resident #3 presented to the ER with difficulty breathing and was brought by the local EMS for altered level of consciousness, low oxygen saturation and hypoglycemia (low blood sugar). The note documented the staff reported Resident #3 had low blood sugar after supper and was given orange juice, peanut butter sandwich and a supplemental shake. A Hospital Critical Care History and Physical Note dated 7/18/25 documented Resident #3 was admitted to the hospital related to acute hypoxic respiratory failure (lungs cannot provide enough oxygen to the blood leading to dangerously low blood oxygen levels) on AIRVO (high flow nasal cannula system designed to deliver warmed and humidified air and oxygen mixtures to patients that experience respiratory distress) in setting of aspiration pneumonia (foreign material like food, liquid or vomit is inhaled into the lungs) due to impacted food bolus (piece of food gets stuck in the esophagus). A Speech/Language Pathology Note dated 7/22/25 documented speech was informed from nursing that Resident #3 was given a peanut butter sandwich prior to admission, likely leading to admission to the hospital. The note documented the need to ensure the care facility was adhering to the resident's modified diet and strategies.On 07/23/2025 4:36 PM, Staff E, Licensed Practical Nurse (LPN) reported on the evening of 7/17/25 she went to Resident #3's room to check his blood sugar and give him insulin. She said his blood sugar was low at 49 mg/dl. She said she gave him orange juice and one slice of peanut butter toast. She said Resident #3 started coughing and spitting up. She reported his blood sugar came up a little. She said Staff J told her to give Resident #3 a protein shake. She said his blood sugar had gone down a little bit. She said Staff J gave Resident #3 orange juice with sugar in it. She said Resident #3 was still coughing up a little bit and turning a little gray in color. She said Resident #3's oxygen saturations were low so she called the emergency room and 911. She said Staff J applied oxygen. She said she could not recall how many liters were applied. She said she turned over care to the EMTs. She said when the EMTs arrived, Resident #3's blood sugar had gone up to normal range but his color remained grey and his oxygen saturations were still low. She reported Staff I, CNA was in the room with Resident #3 when he ate the peanut butter toast. She said he ate all of it. When asked if Resident #3 could have bread, she said she did not have time to look at the care plan. She said after she sent him to the ER, she looked at the care plan and she did not see where he could not have toast. She said she did not see any dietary restrictions on the care plan. She said she also looked in the Physician orders and read the diet order but did not open up the order so she did not read it in its entirety.On 7/23/25 at 4:50 PM, Staff I, CNA reported she worked the evening shift on 7/17/25. She said Staff E, LPN needed a CNA to sit with Resident #3 because he had low blood sugar so she went to his room. She said Staff E gave him orange juice and two pieces of regular wheat bread with peanut butter. She said Resident #3 was not supposed to have bread because it makes him throw up and he can not digest it. She said Resident #3 did not have his teeth in when he was trying to eat the peanut butter bread. She said she did not question the nurse regarding the bread as the nurse was supposed to know what she was doing. She said Resident #3 was kind of out of it, he could talk but was really shaky. She said Staff E left the room to make phone calls as Resident #3's oxygen saturation was low at 65% and his pulse was 114. She said she sat next to Resident #3 on the bed. She said he was tearing off pieces of the peanut butter bread with his mouth. She said she was not sure how big of pieces he was getting but that he was chewing up the bread. She said he ate both pieces of the peanut butter bread. She said she was talking to him and telling him to sit up and not to lean forward too far. She reported after Resident #3 ate both pieces of the bread he was gagging, coughing, and was phlegmy. She said Staff J, RN gave Resident #3 another orange juice. She said he started coughing up chunks of the bread. She said Staff J was telling Resident #3 to cough and that it was good to cough to clear his airway. She said it looked like Resident #3 was having a hard time breathing. She said Resident #3 had oxygen on and there was brown substance coming out his nose and into the oxygen tubing. She said it looked like peanut butter was coming out his nose. She said Resident #3's face/hands were cold and his color was pale. She reported Resident #3 almost fell backwards onto the bed. She reported Staff J got behind Resident #3 and put her arms around him and did motions like the Heimlich maneuver to help him with his coughing. She reported later she did tell Staff E that Resident #3 was not supposed to have bread. She said Staff E was not aware of that. She said she felt all the nurses knew that Resident #3 could not have bread. She reported she did not feel it was her place to give direction to the nurse as she thought the nurse was doing something to help him. She said she was surprised Staff E didn't know Resident #3 could not have bread because she worked at the facility quite often. On 7/24/25 at 8:57 AM, the MDS Coordinator reported as far as she was aware Resident #3 was not to have any bread including toast. She said Resident #3 has been in and out of hospital related to esophagus issues. She said Resident #3 eats too fast. She said Resident #3 has to have his esophagus stretched every so often. She said Resident #3 has a history of getting food stuck in his esophagus. She said bread was more prone to get stuck in his esophagus. On 7/24/25 at 9:15 AM, the Dietician reported Resident #3 was not to have any bread including toast. She said the dietary department does not even give Resident #3 cake if it is dry. She said Resident #3 has had his esophagus stretched before and this is not the 1st time there have been issues. On 7/24/25 at 11:00 AM, the Administrator reported if the resident's diet order documented no bread, then bread should not be given. She reported she was not aware Resident #3 received bread/toast prior to going to the hospital. She said she did not do an investigation because he had a history of swallowing/esophageal problems and she was not aware he had received bread. She said she was going to have to do some education with the nursing staff and have a full blown meeting regarding following diet orders. She said she knew staff was aware that Resident #3 had swallowing problems because staff would give one food and drink item at a time because Resident #3 would eat too fast and then vomit. She said she would expect the nurse to open up the Physician order and read the entire order. On 7/24/25 at 11:57, the MDS Coordinator verified the swallowing issues and diet restrictions were not addressed on the current care plan. She said the issues had been addressed a year ago with the old corporation but did not transfer over to the new care plan with the new corporation. A facility policy titled Mechanically Altered Diet and Thickened Liquids revised 1/2024 documented the purpose of the policy was to prepare diets and liquids as prescribed to meet residents' needs. The policy further documented mechanically altered diets are prepared and served as prescribed by the Physician and in a form to meet individual needs. The care plan should reflect the resident's needs.

Based on clinical record review, staff and resident interviews, facility policy review, and observations. The facility failed to provide adequate nursing supervision to prevent accidents and injuries for 3 out of 7 residents reviewed for falls. Resident #2 experienced a fall outside of the facility and was not receiving an appropriate level of assistance. Resident #4 and #37 had a fall from a mechanical stand. The facility failed to use the correct harness and provide the correct level of assistance with transfers. The facility reported a census of 43. Findings include: 1. Resident #2’s Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2’s MDS included diagnoses of heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety and depression. The MDS coded Resident #2 substantial/maximal assistance, meaning the helper does more than half the effort, the helper lifts or holds the trunk or limbs and provides more than half the effort for toileting transfers. The MDS described Resident #2 continent of urine. Interview with Resident #2 on 07/23/2025 at 10:43 a.m. he stated that he had an appointment in another town approximately an hour and forty minutes away from the facility and was riding in the front seat of the transport vehicle because it was more comfortable for that long of a drive. He stated he didn’t take his wheelchair or his cane per his choice. Resident #2 stated that he had this driver before and had no issues. Resident #2 stated that they had stopped at a gas station on the way because he didn’t think he could make it to the clinic where his appointment was before using the restroom. Resident #2 stated he had been having diarrhea over the last couple of days and thought this was taken care of. Resident #2 stated he was utilizing the rock wall outside of the gas station to walk to the restroom and stated the transport driver was helping him. Resident #2 stated he got dizzy and fell to the ground. Resident #2 stated he hit his head and scraped his right knee. Resident #2 stated they called the ambulance to come get him and take him to the emergency room. Resident #2 stated he never made it into the restroom. Resident #2 stated the facility knew about the diarrhea, he stated he had been taking medication to help with that. Resident #2’s Care Plan with an initiated date of 5/23/25 revealed Resident #2 was at risk for falls related to generalized weakness, dependent on staff for mobility. Resident #2 needed assistance with transfers and ambulation. Resident #2 needed contact guard assist for long distance ambulation, and to utilize a gait belt and cane. Staff to do set up assist and check for accuracy and cleanliness for toileting. Resident #2 needed assistance from one staff member for dressing. Review of the clinical Physician Order’s revealed Resident #2 takes Apixaban (blood thinner) 5mg twice daily by mouth. Review of the Medication Administration Record (MAR) for July 2025 revealed Resident #2 requested Loperamide (antidiarrheal) 2mg to help with diarrhea on 7/8/25 and 7/9/25. Review of the fall risk evaluation through the admission assessment dated [DATE] revealed Resident #2 had a history of falls. The facility Progress Notes dated 7/10/25 at 8:45 a.m. revealed Resident #2 left the facility for an appointment with a transport car to go to a doctor’s appointment. The Facility Incident Report (IR) documented in the Progress Notes on 7/10/25 at 10:33 a.m. revealed the facility received a call from a friend of Resident #2 informing the facility Resident #2 had a fall attempting to utilize a restroom at a gas station on the way to his appointment. Resident #2 was transported to the emergency room for further evaluation. The emergency room nurse reported Resident #2 was ambulating into a bathroom and felt dizzy leading to a fall. Per the Incident Report Resident #2 was to have contact guard assist (a therapist or caregiver provides occasional physical support, like light touch, to help a patient with balance or stability while they perform a task, but the patient is mostly doing the work themselves) with long distance ambulation, a gait belt and cane. The intervention documented is to have a staff member accompany Resident #2 to appointments. Review of the emergency department’s final report dated 7/10/25 revealed Resident #2 presented to the emergency room (ER) via Emergency Medical Services (EMS) for presyncopal (the sensation of lightheadedness, dizziness, or feeling faint without actually losing consciousness) episode, while ambulating in the bathroom had a bowel movement and became lightheaded. Resident #2 noted he had several loose stool bowel movements over the course the past couple days and had been having this paroxysmal (something that occurs suddenly and intensely, often in a recurring or periodic way) on and off diarrhea for the past few weeks which he had taken medication for however patient is unable to recall the medication. Resident #2 complained of acute, focal, persistent mild pain along the right chest, hip and leg. Resident #2 confirmed hitting his head. Resident #2 received a left posterior scalp dense subcutaneous hematoma (localized collection of clotted blood beneath the skin, often appearing as a raised, firm, and painful lump. It is a more significant form of bleeding than a typical bruise, involving larger blood vessels and a more substantial amount of pooled blood) measuring 2.1 x 1.4 x 0.7 centimeters (cm). Interview with the Administrator on 07/23/2025 at 11:19 a.m. revealed the nurses made the appointment for Resident #2, he utilized the medicaid transportation and the appointment is longer than 30 miles from the facility. The Administrator stated that they take into consideration the type of appointment, how long the resident will be gone and if they are going to need to utilize the restroom to determine if they need to send a staff member along. Review of the facility’s policy named Fall Occurrence revised 2/2024 revealed it is the policy of the facility to ensure that residents are evaluated for fall risks and implement interventions to minimize risk for falls and/or risk for injury from falls. A Fall Risk Assessment is completed by the nurse upon admission, readmission, and as necessary. Based on assessment, interventions are implemented and placed on a care plan. An incident report will be completed by the nurse each time a resident has a fall. Residents will be assessed by a licensed nurse prior to being moved after a fall. The nurse will notify the physician and resident representative. Additional intervention(s) will be implemented post fall. Interdisciplinary Team (IDT) may change the intervention(s) if IDT investigation identifies a more appropriate intervention for the individual fall. The resident’s care plan will be updated with any new or revised intervention(s). Neurological assessment will be initiated for unwitnessed falls and/or falls that are witnessed and resident hits their head (neuros completed as directed on neuro flowsheet) Documentation and monitoring to be completed for 72 hours post fall. The Administrator reported the facility does not have a transportation policy. Interview with the Administrator on 07/24/2025 at 1:13 p.m. revealed the only Incident Report is in the Progress Notes and the root cause is the driver broke procedure/protocol and stopped for Resident #2. The Administrator stated the drivers are not supposed to stop. The Administrator stated they do not have a contract with this company, it is all done through the Managed Care Organization (MCO). The Administrator stated the driver is a friend of Resident #2, so they will be sending a staff person with him from now on. The Administrator stated this fell back on the facility anyway even when the driver broke protocol. 2. According to the Minimum Date Set (MDS) assessment dated [DATE], Resident #1 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident exhibited a functional limitation in Range of Motion of both lower extremities. The resident was dependent on staff for toileting, and required substantial/maximal assistance with rolling in bed, and transfers, and did not walk. The resident's diagnoses included a need for assistance with personal care, morbid obesity, and lymphedema. The resident had no falls since the previous assessment. The Care Plan with a goal target date of 8/17/25 identified the resident at risk for falls related to generalized weakness, and depending on staff for transfers. Interventions included the new sling for the sit to stand (lift)in house. The Care Plan identified the resident required assistance with activities of daily living (ADL's) related to weakness, and a history of falling. Interventions included transferring with substantial/maximal assist of 2 staff members. Sit to stand with assist of 2 per physical therapy (PT) 2-3-25. The Progress Notes dated 5/2/25 documented a CNA paged the Nurse to the resident's room where they noted the resident on the floor with the sit to stand lift in front of her, and the aide holding her back up. The CNA reported the resident slipped out of the sling by lifting her arms up. The Nurse noted the belt on the sling clasped together like it should be. The CNA reported the resident did not hit her head. The resident was incontinent of bowel at the time. They helped the resident off the floor by the Nurse and the CNA with the use of the gait belt, and placed in her recliner. Preliminary Recommendations for consideration as further preventative measures included use of the hip sling when using the sit to stand with the resident. During an observation on 7/22/25 at 9:40 a.m. Staff C, Licensed Practical Nurse (LPN) and Staff D, Certified Nursing Assistant (CNA) placed the sit to stand lift up to the resident, hooked the lift sling to the lift on the harness hooks, with no safety tabs. Staff hooked the safety strap in front of the resident and tightened. They had the resident hold onto the handles and lifted, and rolled to the recliner and sat down. During the transfer, staff used the gray sling. On 7/22/25 at 1:24 p.m. Staff E LPN stated she recalled the incident with the resident. She said when she got to the room, the resident was on the floor and the sling off. The CNA told her the resident slipped through when she raised her arms up. She said the waist belt was clasped together, but she didn't know if it had been tightened. She didn't know how she would have slipped through if it was snug. She said the new intervention was the use of a hip sling. She said no education was provided. She did not know of any other incidents with the lift, or any other incidents with the staff involved. On 07/22/25 at 3:03 p.m. Staff F CNA stated he was assisting the resident with the sit to stand lift from the commode. He cleaned her and pulled her pad up and tried to get the commode back under her because she was weak. She let go of the handles of the sling and put her arms up and slipped through the sling up to her head and neck. He said he lowered her with the sling. He thought he used the green sling. He said he received no education after the incident. They were to have 2 staff with transfers with the the lift for this resident. He did not know about a different sling to use with her after the incident. The sit to stand lift Operator's Instructions revised 3/11/09 documented: Attaching the harness to the sit to stand included with the lift arm in the lowest position, attach the harness to the hooks at the end of the sit to stand lift arm using the loops at the end of the harness. The manufacturer suggested the following components and operating points be scheduled for inspection at intervals not greater than a month. Any detected deficiency must be rectified before putting the stand back into service. Safety tabs need to be checked to make sure they were installed correctly, not missing or torn. 3. Resident #37 MDS dated [DATE] identified a BIMS score of 15, which indicated intact cognition. The MDS identified Resident #37 required substantial/maximal assistance with all transfers. The MDS documented Resident #37 was non-ambulatory. The MDS included diagnoses of cerebral palsy (abnormal development or damage to the area of the brain that controls movement, balance and posture), anxiety, depression and hypertension (high blood pressure). The Care Plan with a target date of 9/10/25 documented Resident #37 required assistance with activities of daily living (ADL’s) and was at risk for falls due to diagnosis of cerebral palsy. The Care Plan directed staff to use a sit to stand lift for all transfers. A Progress Note titled Incident Report dated 6/22/25 at 11:38 PM documented Staff C, Licensed Practical Nurse (LPN) was called into Resident #37’s room by Staff F, Certified Nursing Assistance (CNA). Upon entering the room Staff C observed Resident #37 lying on the floor on her left side with a pillow under her head next to the sit to stand lift. According to the note, the sit to stand lift sling belt was around Resident #37’s waist and the straps were disconnected. The note documented when Staff F lifted Resident #37 with the sit to stand lift, the first strap of the two straps that were connected slid causing the Resident #37’s left side to drop a few inches. Staff F then lowered Resident #37 to the ground and placed a pillow under her head. The note documented further preventive measures were to assess the sit to stand lift and use the gray sling. The green sling was placed at the nurses station to be assessed further. A Progress Note dated 7/1/25 at 8:51 AM documented Resident #37 was seen for a 60 day recertification visit by her Physician. The note documented Resident #37 reported she was lowered to the floor. Resident #37 complained of continued left thigh pain and pain when standing. The note documented new orders were received to obtain left hip/pelvis x-ray due to diagnosis of fall/pain. A Progress Note dated 7/6/25 at 2:14 PM documented the facility received signed x-ray results of Resident #37’s femur/pelvis with no acute abnormalities. On 7/21/2025 at 2:01 PM, Resident #37 reported a couple weeks ago she had a fall from the sit to stand lift. She reported she thought something had happened with the equipment and the sling had slipped off from the stopper. She said she was lowered to the floor. Resident #37 said she had x-rays done and there were no fractures. On 7/22/25 at 9:30 AM, observed a sit to stand lift in the hallway by Resident #37’s room with two different slings made by two different manufacturer’s lying on top of the machine (one sling was gray in color and the other sling was blue). Observations of the slings revealed they were not made by the same manufacturer as of the sit to stand lift. The tag on the gray sling was dated 6/13/25 and directed the sling only to be used with lifts that were made by the same manufacturer. The tag on the blue sling was not dated, worn and very hard to read. On 7/22/25 at 9:50 AM, observed Staff A, CNA and Staff B, CNA transfer Resident #37 with the sit to stand lift. They placed a gray sling behind Resident #37’s back and then fastened the safety belts around Resident #37’s waist and legs. They then hook the sling onto the harness hooks and raised the sit to stand lift up while Resident #37 held onto the handle with her left hand. The safety belts loosened around the waist and legs while Resident #37 was raised up and the CNAs did not adjust or tighten the belts. They positioned Resident #37 with the sit to stand lift in front of the commode, pulled down her pants, removed the incontinence brief and then lowered her onto the commode in a sitting position. Observation revealed the gray sling used during the transfer was not manufactured by the same company as the sit to stand lift. On 7/22/25 at 1:26 PM, Staff F, CNA reported he had put the sling under Resident #37's arms and hooked the sling to the sit to stand lift. He said the sit to stand lift had rubber boots on the handles. He said he thought the straps must have gotten stuck on the rubber boot. He said when he stood her up she started to fall as the straps on the left side of the lift became unhooked and came off the ring. He stated that he had not double checked the straps before standing the resident up. He said the belt around the waist was attached and pulled tight. He reported that he did not have the leg strap in place. He said he lowered Resident #37 to the floor using the sit to stand lift. He said he has never had any issues before using the sit to stand lift before. When asked what type of sling was being used during the incident, he said it was a gray sling with rubber grip and padding under the arms. He said it was one of the new slings that the facility had gotten in because the old slings were bad and not in good shape. On 7/22/25 at 2:30 PM, the Administrator reported after Resident #37 had a fall involving the sit to stand lift, she walked around the facility to make sure the staff knew how to use the sit to stand lift and she thought they did. The Administrator reported the facility had gotten new slings for the sit to stand lifts recently. When brought to the attention of the Administrator that the new slings were not the same manufacturer as the sit to stand lifts, she said that the slings worked with the machines. When asked what the facility expectation was with following the sit to stand operator’s manual, she said she would have to check with Corporate to see what they wanted her to do. She said she felt the sit to stand operator’s manual was a recommendation. On 7/22/25 at 2:48 PM, Staff G, Nurse Consultant reported the facility was going to order the correct slings for the sit to stand lifts. She said the staff would use the mechanical full body lifts for transfers until the new slings arrived. The sit to stand Operator’s Instructions revised 3/11/09 documented the manufacturer’s sling/harnesses are made specifically for the sit to sand lifts. The operator’s instructions documented for the safety of the resident and caregiver, only the slings/harness made by the same manufacturer as the sit to stand lift should be used. In addition, the operator’s instructions, directed when transferring a resident, for the safety of the resident, securely fasten the safety strap around the resident’s torso and pull the strap to tighten. As the resident is being raised, simultaneously tighten the safety strap buckled around their torso.

Based on observation, staff interviews, and policy review the facility failed to prepare and serve pureed food to meet the nutritional needs of 4 of 4 residents reviewed (Residents #18, #19, #21, #23). The facility reported a census of 43 residents. Findings include: A facility form titled Diet Type Report dated 7/21/25 identified four residents (Resident #18, #19, #21, #23) who received a pureed texture diet.On 7/23/25 at 11:15 AM, observed Staff H, [NAME] put 4 servings of pork tenderloins into the robo coupe (blender). She then added chicken broth and blended the contents. Staff H put the blended meat into a measuring cup and reported there were 2 1/2 cups. Staff H reviewed the Pureed Diet Portion Sizes/Scoop Chart and reported the serving/scoop size was a #12 scoop and a #16 scoop.On 7/23/25 at 11:45 AM, observed Staff H, [NAME] use a #10 scoop to serve the pureed meat to the four residents who received pureed meat. Observation at the end of the meal service revealed there was pureed meat left over in the pan (approximately 3/4 of a #10 scoop). On 7/23/25 at 1:00 PM, Staff H, [NAME] verified she used a #10 scoop for the pureed meat. She said she thought a serving size for meal was 3 ounces and used the #10 scoop instead of the #12 and #16 scoop. The cook acknowledged she had prepared 4 servings of pureed meat for 4 residents and that there should not be any pureed meat left over at the end of the meal service.On 7/23/25 at 1:10 PM, the Certified Dietary Manager (CDM) reported she would expect the cook to follow the Pureed Diet Portion Sizes/Scoop Chart for the appropriate serving and scoop sizes.On 7/24/25 at 1:30 PM, the Administrator reported she did not have a policy on the puree process. She said the facility used the Pureed Diet Portion Sizes/Scoop Chart.

Based on observations, staff interviews and policy review, the facility failed to ensure food was discarded after product expiration date, ensure freezers were clean/sanitized and prevent cross contamination during meal service. The facility identified a census of 43 residents.Findings include: An initial kitchen tour conducted on 7/21/25 at 9:30 AM, of the kitchen revealed the following items were stored in the refrigerator ready for service:a. 2 large containers of Philadelphia Cream Cheese- Expired 6/2025b. 1 large container of Philadelphia Cream Cheese with an open date 4/25- No expiration date on container. c. Plastic container labeled chicken broth- dated 7/7/25During the initial kitchen tour revealed the following observations:a. Freezer #1- food debris on the bottom of the freezer, broken plastic container with a sign that said hamburger. The plastic container had dried/frozen red substance on the bottom of the container along with food debris. The freezer door rubber seal was coming apart and there was ice build up and frost on the inside of the door. b. Freezer #2- food debris on the bottom of the freezerc. Freezer #3- 1/2 inch of ice on the bottom of the freezer and ice build up on the back of the freezer on the water drainage system.d. Freezer #4- food debris on the bottom of the freezerOn 7/23/25 at 11:45 AM, during meal service observed Staff H, [NAME] held plates of food against her dirty uniform to cut up the pork tenderloins into pieces for four different residents. Observation revealed the serving utensil for the mini baker potatoes fell into the pan multiple times, Staff H reached into the potatoes, picked up the utensil with her bare hands and then continued to use the same utensil to serve the potatoes. On 7/23/25 at 1:45 PM, the Certified Dietary Manager (CDM) reported it was not appropriate for the plate of food to touch the cook's uniform. The CDM reported if a utensil fell into the food, she would expect the staff member to put on a glove to remove the utensil and then get a new utensil to serve with.A facility policy titled Food Handling revised 10/2023 documented the purpose of the policy was to adhere to the food safety standards described in the local Food Code and as per CMS (Centers for Medicare & Medicaid Services) food safety standards for long term care. The policy directed the following:1. Ready-to-eat food must not be touched with bare hands.2. Disposable gloves, tongs, or other dispensing devices must be used properly in accordance with safe food handling practices.3. All foods prepared in operation must be covered and labeled with date of preparation prior to storage in refrigerators and freezers. A use-by date should be specified.4. Staff to follow kitchen sanitation guidelines and center specific cleaning schedules.A facility policy titled Kitchen Sanitation and Cleanliness dated 6/17/10 documented the food service preparation, storage and service area will be maintained in clean and sanitary conditions. The policy documented food service preparation, storage and service areas to be assessed on a periodic basis to develop and edit appropriate cleaning schedules for each area. A system will be maintained to monitor and evaluate effective cleaning on a regular basis as part of the Quality Assurance process.

Based on observation, record review, and staff interview, the facility failed to ensure a resident with a history of pressure sores received adequate repositioning to prevent a new pressure sore from developing for 1 resident with a pressure sore (Resident #4). The facility reported a census of 43 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister.Stage III Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound bed.Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.Findings include: According to the Minimum Date Set (MDS) assessment dated [DATE], Resident #1 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident exhibited a functional limitation in Range of Motion of both lower extremities. The resident was dependent on staff for toileting and required substantial/maximal assistance with rolling in bed, and transfers, and did not walk. The resident's diagnoses included a pressure ulcer of unspecified buttock, stage 3. The Progress Notes dated 1/31/25 at 2 p.m. documented the resident arrived at the facility. The resident had previously admitted to the hospital on [DATE] with an open area to her coccyx, treated as a pressure ulcer stage 3 with maceration (softening and breakdown of skin due to prolonged exposure to moisture) of the buttock. The Progress Notes dated 5/1/25 at 8:08 a.m. documented the pressure ulcer healed.The Braden Scale for predicting the development of pressure ulcers dated 4/28/25 scored the resident at 16, indicating low risk. The resident assessment included the resident chairfast with very limited mobility. On the Braden Scale and Clinical Evaluation, the facility answered yes to the resident having a history of, or an existing pressure sore. If answered yes, the resident should be considered high risk.According to the MDS assessment dated [DATE], Resident #1 scored 9 on the BIMS indicating moderate cognitive impairment. The resident exhibited a functional limitation in ROM of both lower extremities. The resident was dependent on staff for toileting and required substantial/maximal assistance with rolling in bed, and transfers, and did not walk. The resident's diagnoses included non-Alzheimer's dementia, need for assistance with personal care, morbid obesity, and lymphedema. The resident did not have a pressure ulcer and utilized a pressure reducing device for the bed and the chair. The MDS did not mark the resident on a turning and repositioning program.The current Care Plan with a goal target date of 8/17/25 identified the resident had a pressure ulcer of the coccyx. Interventions included encouraging the resident to reposition, following the facility policy/protocol for the prevention/treatment of skin breakdown, observing skin condition with activity of daily living care, pressure reducing devices on her chair and bed, providing preventative skin care, and using pillows/positioning devices as needed.The Progress Notes dated 6/27/25 at 4:10 p.m. documented a call to the resident's Primary Care Provider (PCP) and notified them of a new skin wound finding (pressure ulcer of the coccyx). The PCP gave orders for treatment and repositioning.On 7/21/25 at 11:07 a.m. the resident stated she had a sore on her backside. It did not hurt, and was getting better.During an observation on 7/22/25 at 9:30 a.m. Staff C, Licensed Practical Nurse (LPN) completed the dressing change to the resident's pressure ulcer. The wound appeared as a deeper crater. On 7/24/25 at 9:24 a.m. the Administrator stated the resident did not sleep in the bed, and if in bed, she laid on her side. She slept in her recliner with a pressure reduction cushion, and they repositioned her in the chair. She said they documented in the record that they repositioned her every 2 hours. She didn't know if she could get the report (that documented repositioning) back further than 30 days. The repositioning was documented on the Treatment Administration Record (TAR) (since the pressure sore identified on 6/27/25).An email from the administrator dated 7/25/25 at 10:07 a.m. documented she had tried, but can't get a report (documentation of repositioning). She stated prior to the ulcer the resident received barrier cream with cares, and they did repositioning with all of their residents for prevention, that should be on her Kardex. The current Kardex included a non-pharmacological intervention of repositioning and offloading sore areas.Neither the Care Plan or the Kardex contained specific instructions for the resident's positioning needs prior to the pressure sore developing.The facility Skin Management Guide reviewed 11/23 documented the risk factors for developing pressure sores included immobility and a previous history of a pressure ulcer. The Braden Scale was the clinically validated tool used to identify potential levels of risk for developing pressure sores. The policy identified interventions to consider for high risk included increased frequency of repositioning and advancing pressure ulcer support surfaces. The National Pressure Injury Advisory Panel (NPIAP) Pressure injury Prevention Points last updated in 2016, included developing a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stemmed from immobility, address turning, repositioning, and the support surface. Repositioning and mobilization included:a. Turning and repositioning all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. b. Choosing frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences.c. Considering lengthening the turning schedule during the night to allow for uninterrupted sleep.d. Turning the individual into a 30-degree side lying position and using your hand to determine if the sacrum was off the bed.e. Avoiding positioning the individual on body areas with pressure injury.f. Considering the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface.g. Continuing to reposition an individual when placed on any support surface.h. Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs.i. Reposition weak or immobile individuals in chairs hourly.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed (Resident #37). The facility reported a census of 43 residents.Findings include: Resident #37's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #37 required substantial/maximal assistance for transfers and toileting. Resident #37's MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, cerebral palsy, and anxiety disorder. On 7/22/25 at 9:50 AM, observed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA transfer Resident #37 onto the commode with a sit to stand lift. Staff A and Staff B entered Resident #37's room and applied gloves. Staff A applied compression socks and braces to Resident #37's lower legs with gloved hands. Staff A then removed her gloves and did not complete hand hygiene. Staff A and Staff B then hooked up Resident #37 to the sit to stand lift and stood Resident #37 up from the recliner. Staff B positioned Resident #37 with the sit to stand lift in front of the commode. Staff A pulled down Resident #37's pants, removed the incontinence brief, placed the brief in the commode and pushed the brief down inside the commode with her bare hands. Staff A did not complete hand hygiene after removing/touching the incontinence brief. Staff B then lowered Resident #37 on to the commode. Staff A unhooked the harness from the sit to stand lift and removed it. Staff A then went to the sink and put a wash cloth in the sink with soap and water. Staff A then put on a pair of gloves without completing hand hygiene prior. Staff A then proceeded to undress and change Resident #37's clothing while sitting on the commode with gloved hands. Staff A put Resident #37's dirty pants and shirt directly on the floor. After Resident #37 was redressed, Staff A hooked Resident #37 to the sit to stand lift and gave her the call light. Staff A then removed her gloves, picked up the clothes off of the floor and put the clothes in the hamper. Staff A then washed her hands at the sink. Staff A reported Resident #37's incontinent brief was wet when she had removed it. In addition, Staff A acknowledged she did not complete hand hygiene after she removed her gloves.On 7/23/25 at 9:41 AM, the Administrator reported it was an expectation for staff to complete hand hygiene after removing gloves per standard of practice. She said she had provided education to the staff and was working on ordering small bottles of hand sanitizer for the staff to carry with them. A facility policy titled Hand Hygiene revised 10/2023 documented the purpose of the policy was to prevent the spread of infection. The policy directed the staff to complete hand hygiene using alcohol- based hand rub during the following situations: Before and after direct resident contact. Before and after assisting a resident with toileting. Before moving from work on soiled body site to a clean body site on the same resident. After contact with blood, body fluids or surfaces contaminated with blood and body fluids. After removing gloves.

Based on record review and staff interview, the facility failed to perform adequate assessments following falls for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 40 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes, heart failure, anxiety disorder, and repeat falls. The resident had a fall in the last month, the last 2-6 months, and since admission. The Care Plan with a goal target date of 4/19/25 identified Resident #2 at risk for falls, generalized weakness, a history of falling, and difficulty in walking. An Incident Report dated 1/9/25 at 8:55 p.m. documented Resident #2 shouted for help. The nurse ran to the resident's room and found the resident laying on the floor. The resident stated she tried to transfer herself to the bathroom without assistance. Upon assessment the resident's vital signs were were within normal limits. Pupils were equal and reacting to light, she had a strong grip strength, and intact skin.The resident stated she hit her head. No head injuries observed, and pain rated at 4. The fall protocol initiated and they were doing neuro (neurological) assessments. On 2/19/25 at 2:03 p.m. the Regional Nurse Consultant (RNC) replied to an email with an attached Neuro Flow Sheet which indicated how the flow sheet was used. The double sided Neurological (nervous system, brain, spinal cord, and peripheral nerves) Flow Sheet directed to complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. They were to complete episodic charting for at least 72 hours including any pertinent evaluation findings related to the neurological evaluation. To review the most recent evaluation on the medical record and notify the physician of any changes from the previous evaluation. The Neurological Flow Sheet with a start date of 1/9/25 at 7:40 p.m. showed assessments were not completed at 10:10 p.m., 11:10 p.m. and 1/10/25 at 12:10 a.m. 1:10 a.m. and documented sleeping. The second page lacked any neuro assessments. An Incident Report dated 1/12/25 at 3:24 a.m. documented the writer went to administer Resident #2's bedtime (HS) meds and observed the resident laying on the floor on her left side with her legs facing her recliner and her head facing her bed. The resident could not explain how she fell . The Neurological Flow Sheet with a start date of 1/12/25 at 9:30 p.m. showed assessments were not completed 1/13/25 at 1, 2, 3, 4 a.m. and 8 p.m. and 1/14/25 at 4 a.m. documented sleeping. Assessment completed 1/13/25 at 12 p.m. The slots on 1/13/25 at 8 p.m. and 1/14/25 at 4 a.m. documented sleeping. An Incident Report dated 1/31/25 at 10:34 a.m. documented Resident #2 found sitting on floor leaned up against recliner in room when CNA rounding. Resident stated she was coming back from the bathroom and slipped. Neuros initiated per protocol. The Neurological Flow Sheet with a start date of 1/31/25 at 10:15 p.m. showed assessments not completed at 11:15 p.m., 11:45 p.m., and 2/1/25 at 12:45, 1:45, 2:45, and 3:45 a.m., documented sleeping. The second page showed the assessments completed only 2 of 9 times. On 2/20/25 at 9:38 a.m. the Regional Nurse Consultant stated they should be completing neuros per the neuro sheet.

Based on clinical record review and staff interviews the facility failed to develop a care plan to address risk factors and interventions for 2 out of 14 residents (Residents #35 and #6) reviewed for comprehensive care plans.The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #35 dated 7/5/24 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of anemia, atrial fibrillation (irregular heart rhythm), congestive heart failure (inability for the heart to pump blood), urinary tract infection (UTI) in the last 30 days, arthritis, osteoporosis, chronic pain, and low back pain. The MDS indicated Resident #35 was occasionally incontinent of urine. The MDS documented Resident #35 received diuretic and opioid medications during the assessment period (last 7 days). A Hospital Discharge Instruction form dated 6/28/24 documented Resident #35 had ongoing problems with recurrent UTIs. A Physician Order dated 6/28/24 directed staff to administer furosemide (diuretic medication) 20 mg (milligrams) one tablet one time a day every other day related to congestive heart failure. A Physician Order dated 7/21/24 directed staff to administer cefdinir (antibiotic) 300 mg twice a day for 7 days for UTI. A Physician Order dated 7/24/24 directed staff to administer oxycodone hcl 5 mg, give one tablet two times a day for pain and give one tablet by mouth as needed for pain. A Physician Order dated 8/27/24 directed staff to administer cefdinir (antibiotic) 300 mg twice a day for 7 days for UTI. Review of the current Care Plan with a target date of 10/13/24 did not address Resident #35 was at risk for urinary tract infections, what signs and symptoms to monitor for and interventions to reduce the risk for UTI. The Care Plan also did not address Resident #35 was taking high risk medication such as diuretic and opioid medications and what to monitor for including side effects while taking the medication. On 9/11/24 at 1:10 PM, The MDS Coordinator acknowledged and verified Resident #35 risks for UTIs and interventions were not addressed on the care plan. She reported she thought she had addressed it on the care plan as she had educated Resident #35 on proper toileting hygiene. She also acknowledged and verified the diuretic and opioid medications were not addressed on the care plan. She reported it was an expectation for high risk medications to be addressed on the care plan and that the medications had been missed. 2. The MDS assessment for Resident #6 dated 6/10/24 identified a BIMS score of 14, which indicated intact cognition. The MDS included diagnoses of atrial fibrillation, hypertension (high blood pressure), and renal disease. The MDS documented Resident #6 received anticoagulant medication (blood thinner) during the assessment period (last 7 days). A Physician Order dated 6/3/24 directed staff to administer apixaban (anticoagulant) 5 mg two times a day for hypertension. Review of Resident #6's Care Plan with a target date of 9/20/24 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 9/11/24 at 1:15 PM, the MDS Coordinator acknowledged and verified the anticoagulant medication was not addressed on Resident #6's Care Plan. She reported it was an expectation for high risk medications to be addressed on the care plan and that the medications had been missed. On 9/11/24 at 1:20 PM, The Administrator reported the facility does not have a policy on comprehensive care planning.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to protect resident from the use of physical restraint that the resident could not remove on their own (Resident #28). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 documented diagnoses of Alzheimer's Disease, anxiety disorder, history of falling. The MDS showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS showed Resident #28 was able to roll independently. Observation on 9/9/24 at 10:37 AM., revealed a pillow under the fitted sheet on Resident #28's right side of her back under the fitted sheet. On 9/12/24 at 10:20 AM interview with Staff J, Certified Nursing Assistant (CNA) revealed they are using the body pillow with Resident #28 so she doesn't roll out or bed. Staff J reported that she places it underneath the fitted sheet next to her. Staff J reported that she is not sure when the body pillow was implemented. On 9/12/24 at 10:40 AM, interview with Staff H, CNA, revealed they tuck the body pillow under the fitted sheet and cover it up. Staff H reported that they use the body pillow for safety hazards, because Resident #28 likes to get up and walk. On 9/12/24 at 10:49 AM, during interview the MDS Coordinator acknowledged and verified that the body pillow was not on the care plan and had no order for it. She reported they have since added it to the care plan. MDS coordinator verified how it should be placed outside of the bed or by the wall. MDS coordinator explained that she expected Resident #28 should be able to remove it, if it is under the fitted sheet it is a restriction. She revealed they are using it more for comfort. On 9/12/24 at 11:00 AM the Director of Nursing (DON) revealed the expectation of the body pillow is to be beside her in bed. The DON revealed she would never expect the body pillow to be placed under the fitted sheet because this is considered a restraint. She voiced that they have educated the staff on how to place the body pillow in bed. The facility policy named Physical Restraint Usage revised May 2005 instructed that physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts the freedom of movement or normal access to one's body. Physical restraints include tucking in or using velcro to hold a sheet, fabric or clothing tightly so that the resident's movement is restricted.

Based on clinical record review, resident and staff interview and facility record review the facility failed to provide bathing assistance per resident preference for 1 of 8 residents reviewed for bathing (Resident #2). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed the Brief Interview for Mental Status (BIMs) score of 14, which indicated cognitively intact. Resident #2 had diagnoses of diabetes, major depressive disorder, and anxiety disorder. The MDS revealed the resident required substantial/maximal assistance (helper does more than half the effort) with bathing. The Care Plan with a target date of 10/31/24 identified Resident #2 required extensive assistance of 1 person to provide baths daily. The untitled Electronic Health Record (EHR) bathing record documented completed baths from 8/12/24 to 9/10/24. The record documented baths were completed only on 8/12/24, 8/19/24, 8/23/24, 8/25/24, 8/29/24, 9/5/24, 9/6/24 and 9/10/24. The clinical record for the resident lacked documentation of any other attempts to encourage the resident to bathe or refusals to bathe. On 9/10/24 at 12:18 PM interview with Staff C, Certified Nursing Assistant (CNA) revealed typically they are not able to provide bathing to the residents due to staffing. Staff C revealed at time they choose the residents and try to give them a bed bath, Staff C stated this is better than nothing, then we will reschedule the baths, and if necessary I will try to stay after to try to get them completed. They get pretty stacked up when we reschedule them to the next day, we will try to gather enough staff to get them done. On 9/10/24 at 2:56 PM during interview with Staff G, CNA reported they couldn't give showers because there was no staff. Staff G reported residents were complaining they weren't getting bathed. During interview on 9/11/24 at 9:46 AM with Staff B, CNA revealed that it is day by day with being able to do baths, we try to work them in the next day to get them complete, if they refuse, I would try to go back and reapproach them, the 1st refusal we document in the electronic health record, but if they refuse again I would tell the nurse. During interview on 9/11/24 at 1:37 PM with Staff I, CNA revealed that bathing the residents is day by day and sometimes we don't always have enough staff. The residents get pushed to another day or the next day and there have been times where residents weren't able to have a bath because we are just too short of staff. The facility reported they do not have a policy regarding bathing. On 9/11/24 with the Director of Nursing (DON) revealed all baths are documented in the Electronic Health Record and they do not document on any other forms. The DON stated that she keeps track of the baths and goes through them each day.

Based on observation, record review, and staff interview, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 4 residents reviewed (Resident #10). The facility reported a census of 49 residents. Resident #10 showed functional range of motion limitations in both lower and 1 upper extremity since 2011. In 04/2013 Resident #10 showed a loss of motion in the right hand with Occupational Therapy (OT) initiated. The facility could not produce the therapy provided, discharge summary, or recommendations for a restorative program. The facility did not provide Resident #10 with a restorative/functional maintenance program for his/her upper extremities from July 2013 to August of 2014. On 08/12/14 the physician noted a severe contracture (loss of joint motion) of the right hand and ordered an OT evaluation (eval) and treatment. Resident #10 showed decreased range of motion of both hands and fingers and not actively using his/her hands for functional tasks. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 08/07/14, Resident #10 required extensive assistance with activities of daily living (ADL's) including bed mobility, dressing, eating, toilet use, and personal hygiene. Resident #10 depended on staff for transfers. The MDS documented Resident #10 had functional limitation in range of motion that interfered with daily functions or placed the resident at risk of injury in both lower extremities and 1 upper extremity. Resident #10's [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated 06/11/15, reflected the resident to be dependent upon staff for activities of daily living (ADL's) including eating. The resident required extensive assistance from staff for dressing. The MDS documented Resident #10 had functional limitation in range of motion that interfered with daily functions or placed the resident at risk of injury in both lower extremities and both upper extremities. The Care Plan dated 10/13/13 identified Resident #10 needed assistance with ADL's related to limited range of motion, amputation of the left leg and right foot, limited mobility and vision impairment. The interventions included that Resident #10 required use of the Hoyer (total) mechanical lift when transferring, extensive assistance for dressing, extensive assistance to turn and reposition in bed, limited assistance to eat, extensive assistance with bathing, personal hygiene and oral care. A Timeline for Resident #10's Restorative provided by the Director of Nursing on 08/06/15 included: a. In May of 2013 the Nu-step was discontinued due to increased difficulty with lower extremity transferring. The decline at the time was based on his/her difficulty with transfers, not his/her difficulty with his/her upper extremities (see PT eval 04/23/13 and OT eval 04/29/13). b. In June of 2013 a lower extremity program was initiated due to the decline only in the lower extremities, not the upper (extremities). c. In February of 2014 an annual screen was completed and no changes or declines were noted by the therapist in the upper or lower extremities (see OTA interview). d. In August of 2014 a change was noted to Resident #10's hands and an order of OT received. Since the initiation of OT, upper extremity exercises have been implemented ever since. e. In January of 2015 functional change was noted to Resident #10's right upper extremity based on MDS dated [DATE], resulting in therapy involvement at the time. f. According to an MDS dated back to 2011 Resident #10 had been coded 1-2 with his/her mobility. The decline to his her MDS did not occur until 1/2015 in which therapy initiated on 01/12/15, with a restorative program still in place. A Physical Therapy (PT) Plan of Treatment dated 04/23/13 documented Resident #10 complained of hand pain (contractures) and difficulty with toothbrush and utensils. An OT eval dated 04/29/13 documented Resident #10 had right hand loss of motion and the skilled treatment plan included 8 sessions in 8 weeks. The current [DIAGNOSES REDACTED]. They planned to discontinue Resident #10 to a restorative nursing program for ADL's. The treatment provided, the discharge summary, and the recommendations for a restorative nursing program were not available. A Request for a Therapy Screen dated 02/18/14 documented Resident #10's annual update, and questioned if the current plan of care appropriate. The Occupational Therapy Aide (OTA) commented current program appropriate and no changes noted at the time (see OTA interview). A Nursing Rehabilitation Documentation Tool for July and August 2014 revealed Resident #6 received lower extremity and neck stretches, 3-5 days a week. The Progress Notes/Physician Visit Progress Note dated 08/12/14 at 8:08 a.m. documented Resident #10 seen for a 60 day recertification. Resident #10 showed abnormal range of motion, with hands clenched with nailbed indentations. They would get an OT eval for braces. Resident #10 had severe Dupuytren's contracture on the right hand. The Physician visit resulted in new orders for OT to evaluate and treat Dupuytren's contracture of the right hand. An OT Evaluation and Plan of Treatment dated 08/14/14 page 1 of 3 documented Resident #10's [DIAGNOSES REDACTED]. Page 2 of 3 documented Resident #10 referred secondary to contracture of joint in the right hand and loss of motion in the left hand and possible orthotics or restorative nursing program to assist with joint integrity. Resident #10 had contracture of the right hand and fingers, and left fingers and hand. The eval documented Resident #10 unable to be adequately cleaned in the palm of the hand and staff concerned of nail trimming and palm issues/skin integrity. Skilled services initiated to assess orthotics, fit, schedule, instruct caregivers on orthotic use, and transition to restorative nursing program for range of motion for hands. An OT Therapy Progress Report dated 08/14/14 to 09/16/14 documented on 08/14/14 Resident #10 not actively using his/her bilateral hands for functional tasks and loss of motion in the digits. A Therapy Alert dated 10/01/14 directed staff in the use of splints for Resident #10, including passive range of motion required prior to splint application. The goal to tolerate upper extremity/hand program without precautionary symptoms met. The OT Discharge Summary dated 10/8/14 documented Resident #10's prognosis to maintain current level of function good with consistent staff follow through. An OT Evaluation and Plan of Treatment dated 01/12/15 documented Resident #10 referred due to increased signs and symptoms of pain and decreased tolerance for wearing hand splints. An OT Treatment Encounter dated 01/12/15 documented education of nursing caregivers in purpose and use of palm protectors to protect skin without causing pain. A Therapy Alert dated 02/02/15 documented as tolerated Resident #10 to wear left palm protector during the day and right palm protector at night. During an observation on 08/05/15 at 11:07 a.m. Resident #10 had a splint (palm protector) to his/her left hand. Staff B Certified Nursing Assistant (CNA) and Staff C CNA provided personal care with Staff D Registered Nurse (RN) observing. When staff removed the palm protector, Resident #10 complained of pain. During an observation on 08/06/15 at 7:54 a.m. Resident #10 had a palm protector to his/her left hand. During an interview on 08/06/15 at 9:35 a.m. the Director of Nursing (DON) stated when they noted Resident #10 had issues they obtained the OT evaluation and treatment for [REDACTED]. The DON stated Resident #10 used to do the Nu-Step and that worked the arms and upper extremities as well as the lower extremities. After they discontinued (the Nu-Step) they did not do ROM on Resident #10's upper extremities, as shown on the July and August 2014 restorative records. The DON stated prior to August 2014 Resident #10 continued to feed him/herself. When they noted a problem they started therapy. She could not speak to Resident #10's ROM limitations. During an interview on 08/06/15 at 10:35 a.m. the Administrator stated Resident #10 continued to feed him/her so they did not do ROM. She said Resident #10 discontinued use of the Nu-Step in July 2013. During an interview on 08/06/15 at 11:21 a.m. the Occupational Therapy Aide (OTA) stated Resident #10 had been seen for a long time. The OT stated ROM to his/her hands would not prevent contractures, but may slow the progression. The OTA stated she was sure they did ROM prior to August of 2014, because that was what they worked on. The OTA stated when she did the screen in February 2014 she looked at Resident #10's hands. The OT stated (for screens) she talked to the restorative person, and the resident, and looked at the resident. She did not touch the resident, because that would be an assessment, and she only did a screen. OT stated she dealt with the upper extremities and PT with the lower extremities and neck. At 12:46 p.m. the OTA stated regarding the screen in February of 2014, she looked at Resident #10's hands because that's what they worked with, but she also looked at his/her legs and neck, but again, she did not touch the resident or assess ROM. The OT stated she was sure Resident #10 was on a restorative program before August 2014 for his/her upper extremities. During an interview on 08/06/15 at 1:15 p.m. the Administrator presented 1 page of OT from 2013. The therapy provided, discharge summary, and recommendations for a restorative program were not included. The Administrator stated they would look for them. During an interview on 08/06/15 at 1:50 p.m. the Physical therapist stated she did the PT eval 04/23/13. Resident #10 complained of hand pain, which prompted the OT eval that same month. The PT stated the resident complained of hand pain with contractures. During an interview on 08/06/15 at 11:40 a.m. the Occupational Therapist could not recall Resident #10's treatment prior to August 2014, and would need the record (to comment). During an interview on 08/13/15 at 1:05 p.m. the Administrator stated they were unable to find the OT information previously requested