Every finding on record at Garden View Care Center

Based on observations, resident and staff interviews, Electronic Health Record (EHR) review and policy review the facility failed to provide food at a palatable/appetizing temperature to 2 of 4 residents reviewed (Resident #22 and and #32) .The facility reported a census of 32 residents.1. Review of Resident #22's Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 12 indicating no cognitive impairment.On 7/22/26 at 12:40 PM observation revealed Staff A, [NAME] used a temperature probe to obtain temperatures on Resident #22's room tray. The room tray temperatures obtained at the residents room included: [NAME] sandwich at 138 degrees Fahrenheit, green beans at 136 degrees Fahrenheit and sweet potato tots at 124 degrees Fahrenheit. Staff A returned Resident #22's plate to the kitchen and reheated the sweet potato tots with a post temperature of 143 degrees Fahrenheit.On 7/22/26 at 12:45 PM Staff A stated in her opinion food temperatures should be 145 degrees Fahrenheit though she knew the book stated 135 degrees Fahrenheit. Staff A stated the room tray temperature was below 135 degrees Fahrenheit on the sweet potato tots. 2. Review of Resident #32's MDS documented a BIMS score of 12 indicating no cognitive impairment. On 7/21/26 at 11:07 AM Resident #32 stated the food is frequently served cold and eats her meals in her room. On 7/23/26 at 10:47 AM Staff B, Certified Dietary Manager (CDM) acknowledged her concerns with food temperatures. On 7/23/26 at 11:45 AM the Director of Nursing (DON) acknowledged her concerns with the room tray temperature and stated it was below the required temperature of 135 degrees Fahrenheit and would expect room tray temperatures to follow the safe food handling practices.Review of a facility provided policy dated 11/22 titled, Food Preparation and Service documented food and nutrition service employees to prepare, distribute and serve food in a manner that complies with safe food handling practices. The policy documented that the danger zone included temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit would allow rapid growth of pathogenic microorganisms that can cause foodborne illness. The policy further documented proper hot and cold temperatures are maintained during food distribution and service with the temperatures of the food held in steam tables to be monitored throughout the meal service by food and nutrition services staff.

Based on clinical record review, family interviews, staff interviews, and policy review the facility failed to hold Care Conferences for 4 of 4 residents reviewed (Residents #6, #11, #12, #16). The facility failed to hold and document Care Plan Conferences that included the resident and/or the resident representative. The facility reported a census of 32 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2/15 indicating severe cognitive impairment. The document included diagnoses of Non-Alzheimer's Dementia and anxiety. The Care Plan revised 5/15/26 included focus area and staff interventions for risk for falls, diversional activity deficit, communication deficit, psychotropic medications, hospice, behaviors, impaired cognitive function and self care. Review of the clinical record documentation revealed a Care Conference had not been held that included the resident's family and/or representative. The clinical record census revealed the resident was admitted on [DATE]. In an interview on 5/28/26 at 11:00 AM Resident #6's family stated they were contacted by the facility for the need of a Care Conference within the first 3 days of admission due to the resident's behaviors and were going to kick him out. The family stated they agreed to the need for a Care Conference and stated they had been asking for a conference since that time and one had not been held. 2. Resident #11's MDS assessment dated [DATE] revealed the resident had a BIMS score of 2/15 indicating severe cognitive impairment. The document included diagnoses of diabetes mellitus (DM), cerebrovascular accident (stroke), Non-Alzheimer's Dementia, anxiety, depression and bipolar. The Care Plan revised 5/26/26 included focus areas and staff interventions for risk bleeding, self care deficits, activities, nutritional problems, skin integrity, restorative nursing, and medications. Review of the clinical record Progress Notes revealed a Care Conference had been held on 1/14/26 with dietary, social services, activities, charge nurse and the resident in attendance. The entry revealed the resident's representative was not present or involved in the Care Conference. Review of the Progress Notes revealed no notification to the resident's representative prior to the Care Conference. The Progress Notes revealed no additional Care Conferences were held since 1/14/26. On 5/21/26 at 1:01 PM Resident #11's family member indicated he was also the resident's Power of Attorney (POA). The POA stated he had not been involved in a Care Conference and did not know what that was. On 5/20/26 at 10:40 AM Staff P, prior Administrator, stated the Care Plans were managed by the offsite MDS Coordinator for the initial Care Plan and the Director of Nursing (DON) for updates. Staff P stated Social Services set up the Care Conferences, but that staff had resigned over a week ago. Staff P stated a formal plan for scheduling Care Conferences was not set but it would likely be up to himself and the DON. 3. Review of Resident #12's MDS dated [DATE] revealed Resident #12 was admitted to the facility from the community on 10/9/17. The MDS further revealed a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident #12's Electronic Healthcare Record (EHR) page titled, Progress Notes revealed an entry dated 1/14/26 at 10:58 AM indicated that Resident #12 last had a care conference on 1/13/26 attended by dietary, social services, activities, a charge nurse, and Resident #12. The record lacked any documentation of a care conference held since then. 4. Review of Resident #16's MDS dated [DATE] revealed Resident #16 was admitted to the facility 4/18/23. The MDS further revealed a BIMS score of 15 indicating intact cognitive functioning. Review of Resident #16's EHR page titled, Progress Notes revealed an entry dated 12/22/25 at 2:57 PM indicated that Resident #16 last had a care conference on 12/22/25 at 11:30 AM with dietary, social services, activities, and Resident #16. Interview 6/1/26 at 12:25 PM with Staff K the current Director of Nursing (DON) revealed the facility did just hire a new social services employee. The DON further revealed she was unaware as to when the old social services worker left their position, and was unaware if care conferences were being completed. Follow up interview 6/1/26 with Staff K revealed she would expect care conferences to be completed appropriately and quarterly. Interview 6/1/26 at 2:01 PM with Staff L revealed the facility did just hire a new social services employee, but this new employee was still in the paperwork process. Staff L then revealed that care conferences had not been conducted. Review of a facility provided policy titled, Care Planning- Interdisciplinary Team with a revised date of September 2013 indicated that the resident, the resident's family and/or legal representative/guardian are encouraged to participate in the development of and revision of the resident's care plan. The policy further indicated that the facility will make every effort to schedule care plan meetings at the best time of the day for the resident and family.

Based on clinical record review, facility audit review, observations, resident interviews, staff interviews, and policy review the facility failed to provide professional standards of care by not providing treatments per physician orders, documenting treatments before completion, documenting provision of medications when not available, and providing medications outside of parameters for 4 of 5 residents reviewed (Residents #2, #3, #8, #20). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #2, dated 3/25/26, included diagnoses of acquired absence of right leg below the knee and diabetes. The MDS indicated the resident had a surgical wound and a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment for decision-making. Resident #2's Treatment Administration Record (TAR) for 5/1/26 – 5/31/26 revealed a physician's order for left anterior knee distal, left medical knee, left below the knee amputation(BKA) (surgical wound): Cleanse area with wound cleaner soaked gauze, apply skin prep to peri wound (area around edges of wound), apply hydrofera blue ready (antibacterial foam dressing used to promote healing in various wounds) to wound bed, cover with silicone bordered foam, change 3 times weekly on Monday, Wednesday, Friday on day shift and as needed for soiling. Interview and observation on 5/12/26 at 5PM, Resident #2 stated he recently had a left BKA amputation and was receiving treatments to his surgical site. The resident had three dressings, dated 5/11/26, on his left BKA surgical site area. Observation on 5/13/26 at 11:00 AM, Resident #2 outside for scheduled activity. Resident with two dressings on his left BKA surgical site area and one uncovered wound approximately 4 centimeters (cm) X 3 cm. with a yellow-colored surface and yellowish/red drainage on the pillowcase in his wheelchair where the uncovered wound is touching. Observation on 5/13/26 at 4:52 PM, Resident #2 in wheelchair and two dressings dated 5/11/26 remain on left BKA surgical area and one wound remains open. On 5/13/26 at 4:49 PM, Resident #2's TAR for 5/1/26 – 5/31/26, revealed the treatment for the resident's left anterior knee distal, left medial knee, and left BKA (surgical wound) was documented as completed by Staff H, Licensed Practical Nurse (LPN). A facility's Medication Admin Audit Report for Resident #2, dated 5/21/26, revealed on 5/13/26 at 1:47 PM the treatment for the resident's left anterior knee distal, left medial knee, and left BKA (surgical wound) was documented as completed by Staff H, LPN. Interview on 5/14/26 at 8:00 AM, Staff A, Certified Nurse Aide (CNA) stated yesterday morning when she got Resident #2 up, his dressing was off the open wound. Staff A stated after getting the resident up, she reported to Staff H that the wound was open without a dressing. Staff A further stated that she knows the wound remained without a dressing until at least 2:00 PM when she laid the resident down. Observation on 5/19/25 at 3:10 PM, Resident #2 in the dining room participating in group activity. The resident had no dressing on his left BKA wound area. Resident #2's TAR for 5/1/26 – 5/31/26 documented left anterior knee, left lateral knee treatment of cleanse with saline and swab with betadine completed by Staff F, Registered Nurse (RN). Interview on 5/19/26 at 3:15 PM, Staff F stated she completed Resident #2's treatment for the lateral and anterior knee this morning and the wound was covered at that time. Staff F further stated Staff G, CNA assisted her to complete the treatment. Interview on 5/19/26 at 3:30 PM, Staff G denied she assisted Staff F with completing Resident #2's treatments today as Staff G is not even working down that hall. Interview on 5/19/26 at 3:35 PM, queried Staff F that Staff G denied assisting Staff F with Resident #2's leg/knee treatment this morning. Staff F stated that is why she asked if the resident had gone to activities as Staff F was insinuating that the dressing could have fallen off when the resident went to activities. Staff F further stated the left BKA wound area was wrapped and Staff F will just have to do it again. 2. The MDS for Resident #3, dated 4/7/26, included diagnoses of acquired absence of left leg below knee, encounter for orthopedic aftercare following surgical amputation, and diabetes. The MDS the resident had a BIMS score of 12, indicating mild cognitive impairment for decision-making. Resident #3's TAR for 5/1/26 – 5/31/26 revealed a physician's order, start date of 4/10/26, for surgical incision to left lower extremity- cleanse area with wound cleanser, idoform packing (medicated gauze to pack open wounds to combat infection) to open area, cover with gauze, wrap with kerlix (gauze wrapping), and wrap with ace bandage, change daily and as needed for soiling, every day shift for wound care. The TAR revealed the treatment was signed as completed every day from 5/1/26 – 5/19/26 except for 5/16/26. Resident's hospital after visit summary dated 5/11/26 revealed diagnosis of wound of left leg, wound dehiscence (a surgical wound that has reopened) with instructions to leave the dressing on, keep it dry and intact until the next visit on 5/29/26. Observation and interview on 5/14/26 at 9:00 AM, Resident #3 sitting on the side of the bed, with stocking over her left BKA. The resident stated she has a new amputation of her left leg below the knee and recently had to return to the hospital for surgical treatment of her amputation. The resident further stated she is supposed to have a treatment every day to her BKA but depends on which staff is on, sometimes the treatment only gets done every other day. Observation on 5/18/26 at 1:33 PM, Resident #3 with a dressing partially attached to her left BKA dated 5/17. The resident stated a nurse had changed the dressing and threw away the stocking cover due to blood on the stocking. Observation on 5/19/26 at 2:40 PM Staff F assisted Resident #3 to activities and Staff F told the resident she will do her BKA treatment after the activity. The resident's left BKA site with stitches visible and no dressing. Interview on 5/19/26 at 2:45 PM, Staff F stated she had not completed Resident #3's left BKA treatment for the day. Queried Staff F about treatment already signed off as completed. Staff F reviewed the resident's electronic health record and confirmed the left BKA treatment was documented as completed by herself at 11:26 AM. Staff F stated she thinks she may have accidentally signed off the treatment when she administered and signed off the resident's insulin. Observation 5/20/26 at 1:50 PM, Resident #3 sitting in a wheelchair, left BKA site with stitches not covered, yellowish-red fluid dripping from stitched area. Observation and interview on 5/20/26 at 2:15 PM, Staff J, RN entered Resident #3's room and cleansed suture site with wound cleanser, placed Iodoform on top of the sutures, wrapped the BKA with kerlix and then ace wrap. Staff J stated that was the current ordered treatment for the resident's BKA suture site. Interview on 5/21/26 at 11:40AM, Staff K, Director of Nursing (DON) stated her expectation for treatments to be completed per physician orders and not document treatments as done before they are completed. 3. Resident #8's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS documented diagnoses of anemia, hypertension -high blood pressure (HTN), and diabetes mellitus (DM). The document included the resident during 6 of the last 7 days of the reporting period the resident received an injection and hypoglycemic medication. The Care Plan revised 4/29/26 revealed a problem area related to DM and risk for frequent infections, visual impairment, hyper/hypoglycemia revised on 3/17/25 with staff interventions including all concerns with DM to be addressed with the primary care physician (PCP), diabetes medications as ordered by PCP with monitoring and documented side effects and effectiveness, and monitor/checks blood glucose levels as ordered. The document included a problem area related to altered cardiovascular status and risk for shortness of breath, chest discomfort, pain/numbness/weakness in extremities with diagnoses of peripheral vascular disease (PVD), HTN, and hyperlipidemia revised 4/29/26 with staff interventions of notification to PCP of signs/symptoms of complications of diagnoses, altered vascular status and side effects of medications. The clinical record's Medication Administration Record (MAR) for 4/26 revealed the following orders: Amlodipine Besylate Oral Tablet 10 milligram (mg); give 1 tablet in the morning related to HTN, hold if systolic blood pressure - top/first number (SBP) is less than 100 with a start date of 5/20/25. On 4/1 blood pressure 86/42 medication administered. On 4/7 blood pressure 96/48 medication administered. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 hour 100 mg; give 100 mg in the morning related to HTN, hold if SBP is less than 100 with a start date of 5/20/25. On 4/1 blood pressure 86/42 medication administered. On 4/7 blood pressure 96/48 medication administered. Hydralazine HCI Oral Tablet 50 mg; give 1 tablet three times a day (TID) related to HTN, hold if SBP is less than 100 with a start date of 3/4/25. On 4/1 morning blood pressure 86/42 medication administered. On 4/7 morning blood pressure 96/48 medication administered. On 4/10 morning blood pressure 98/54 medication administered. The clinical record's MAR for 5/26 revealed the following orders: Amlodipine Besylate Oral Tablet 10 milligram (mg); give 1 tablet in the morning related to HTN, hold if SBP is less than 100 with a start date of 5/20/25. On 5/4 blood pressure 90/50 medication administered. On 5/9 blood pressure 96/66 medication administered. On 5/14 blood pressure 98/36 medication administered. On 5/15 blood pressure 90/40 medication administered. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 hour 100 mg; give 100 mg in the morning related to HTN, hold if SBP is less than 100 with a start date of 5/20/25. On 5/4 blood pressure 90/50 medication administered. On 5/9 blood pressure 96/66 medication administered. On 5/14 blood pressure 98/36 medication administered. On 5/15 blood pressure 90/40 medication administered. Hydralazine HCI Oral Tablet 50 mg; give 1 tablet TID related to HTN, hold if SBP is less than 100 with a start date of 3/4/25. On 5/4 morning blood pressure 90/50 medication administered. On 5/9 morning blood pressure 96/66 medication administered. On 5/15 morning blood pressure 90/40 medication administered. On 5/19 mid day blood pressure 94/46 medication administered. On 5/20 evening blood pressure 94/65 medication administered. On 5/28 evening blood pressure 92/74 medication administered. On 5/29 mid day blood pressure 94/48 medication administered. Mounjaro Subcutaneous Solution Auto-injector 10 mg/0.5milliliters (ml); inject 1 syringe subcutaneously every Monday related to Type 2 DM without complications with a start date 4/27/26. On 5/4 medication not available. On 5/11 medication administered. On 5/18 medication administered. On 5/25 medication not available. The clinical record's Progress Notes revealed the following entries: 4/21/26 the resident returned from appointment with new orders: lower Mounjaro to 10mg weekly with the resident and pharmacy notified and the MAR updated. 5/4/26 Mounjaro 10 mg/0.5 ml waiting on prior authorization. 5/25/26 notification to PCP that Mounjaro not available; medication has been reordered. Requested a one-time order to give when medication arrives. 6/1/26 call placed to PCP regarding need for prior authorization for Mounjaro. Per pharmacy the medication has needed a prior authorization since March and has not been filled. On 6/2/26 at 10:50 AM Staff R, pharmacy representative, stated the pharmacy last attempted to fill Resident #8's Mounjaro prescription on 5/25 and was denied for insurance reasons. The staff stated the last time the medication was delivered to the facility was on 3/30 and 3/31, they had to send partial dosages for a total of 4 doses of 15 mg Mounjaro. Staff R stated the 4 dosages equaled a 4 week supply. Staff R stated the pharmacy received a new order for decreasing Mounjaro to 10 mg on 4/21/26 and has not been able to fill the new dose secondary to insurance and preauthorization. The facility failed to hold hypertensive medications when Resident #8's blood pressure was below the physician ordered parameter. The facility failed with documentation of the resident's Mounjaro, documenting the medication had been provided when the medication had not been filled by the pharmacy. 4. Resident #20's MDS dated [DATE] revealed a BIMS score of 14/15 indicating normal cognition. The MDS documented diagnoses of HTN and DM. The document included during 7 of the last 7 days of the reporting period the resident received an insulin injection, took diuretic and hypoglycemic medications. The Care Plan revised 4/28/26 revealed a focus area risk for altercations in cardiovascular status revised on 4/28/26 with interventions to administer medications as ordered and monitor blood pressure as ordered revised 5/8/25. The document contained a problem area for nutrition revised on 4/28/26 with interventions for staff including: notification to PCP signs of altered mental status, HTN, chest pain and signs of malnutrition. A problem area of diuretic therapy revised on 8/5/25 provided staff interventions of administering medication as ordered with medications interacting with hypertensive medications, obtaining and reporting any orders to PCP, and reporting any adverse effects to PCP. The Care Plan provided a problem area related to DM revised on 7/9/25 with interventions to provide medications as ordered, dietitian to follow nutritional regimen, observe for side effects and signs of hypo/hyperglycemia, and provide with meal times, dietary restrictions and snacks revised 7/2/25. The clinical record's Clinical Physician Orders revealed an order for daily weight every day shift for use of Torsemide with a start date of 3/31/26. The clinical record's MAR for 4/26 revealed the following orders: Accuchecks TID related to Type 2 DM without complications with a start date of 1/2/25 had no documentation on the evening of 4/23/26. Humalog KwikPen Subcutaneous Solution Pen Injector 100 unit/ml per parameters related to Type 2 DM with a start date of 1/2/25 had no documentation on the evening of 4/23/26. The clinical record's MAR for 5/26 revealed the following orders: Lantus SoloStar Subcutaneous Solution Pen Injector 100 unit/ml; inject 18 units at bedtime related to Type 2 DM with a start date of 3/12/26 had no documentation on 5/10/26. Accuchecks TID related to Type 2 DM without complications with a start date of 1/2/25 had no documentation on the evening of 5/19/26. Humalog KwikPen Subcutaneous Solution Pen Injector 100 unit/ml per parameters related to Type 2 DM with a start date of 1/2/25 had no documentation on the evening of 5/19/26. The clinical record's Weight Log revealed lack of documentation on 4/1, 5/7, 5/8, 5/11, 5/18, 5/28, and 5/29. The facility failed to document and/or provide care, treatment and medication per physician orders. On 6/1/26 at 4:45 PM Staff K, Director of Nursing (DON), stated if a physician ordered parameters with a medication then the medication should not be administered outside of those parameters. The staff stated if a Certified Medication Aide (CMA) was providing medications then that staff needed to make contact with the nurse regarding the medication. Staff K stated if there was a blank on a MAR it would indicate that the medication/treatment had not been provided. The facility's undated Charting and Documentation Policy revealed all services a resident receives shall be documented in the resident's medical record which included medications, treatments and services. The policy included entries will document the date and time of the procedure/treatment was provided, refusal, notification of the family/physician if indicated, and must be accurate. The facility's undated Provision of Physician Ordered Services Policy revealed care and all services are provided according to accepted standards of clinical practice. The facility's Wound Care Policy, revised 10/10, provided guidelines for the care of wounds to promote healing. The document disclosed the steps necessary when completing the treatment and for documentation. The policy revealed documentation included: documenting the dressing with initials/ time/date, documenting in the medical record the type of wound care, date/time when the wound care was provided, assessment data, and documentation/notifications of refusal of treatment.

Based on clinical record review, observations, resident interviews, staff interviews, and facility policy review the facility failed to provide oral care for 4 of 4 residents (Residents #1, #6, #2, #12) reviewed. The facility reported a census of 32 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS documented diagnoses of atrial fibrillation, heart failure, and diabetes mellitus (DM). The document coded the resident required setup for grooming/hygiene tasks. The Care Plan revised 4/30/26 identified a problem area of self care deficit as evidenced by requiring assistance with activities of daily living (ADLs) revised on 4/30/26 with a staff intervention of need for 1 person assistance for oral care including encouraging care in the morning, afternoon and hour of sleep. The document included the resident had own teeth with some broken and for staff to assist with oral care revised on 9/15/25. Observed on 5/27/26 at 7:40 AM Staff C, Certified Nursing Assistant (CNA) and Staff G, CNA, assist Resident #1 with personal care. Observed the resident's emesis basin, dated 5/2, contained a toothbrush sealed in plastic, sealed mouthwash and unused toothpaste. Following a dependent transfer to her recliner, Staff G asked Resident #1 if she would like to brush her teeth and provided set up for the resident to complete the task. On 5/27/26 at 8:40 AM Resident #1 stated she never brushed her teeth as she was over here indicating seated in her recliner, and the water and all of the stuff was over there gesturing to the sink/counter area across the room. 2. Resident #6's MDS Assessment Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 2/15 indicating severe cognitive impairment. The document coded the resident was dependent upon staff for oral care. The document included diagnoses of Non-Alzheimer's Dementia and anxiety. The Care Plan revised 5/15/26 identified a problem area with self care deficit by requiring assistance with ADLs revised on 5/7/26 with a staff intervention of 1 person assistance encouraging care in the morning, afternoon and at hour of sleep, and the resident had his own teeth revised on 5/7/25. Observed on 5/27/26 at 7:08 AM Staff C and Staff G assist Resident #6 with peri care, dressing, transfer to a wheelchair and combing hair. Staff G pushed the resident to the nurse's station. Observed the resident's spit basin dated 5/2 contained an unopened sealed in plastic toothbrush, sealed mouthwash, and unused toothpaste. On 5/27/26 at 7:35 AM Staff C stated staff should be completing oral care with residents. On 5/27/26 at 7:45 AM Staff G acknowledged Resident #6 should have had oral care and face washed prior to leaving his room. 3. Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. The MDS further indicated that Resident #2 was dependent on staff assistance for oral hygiene, toileting hygiene, upper body dressing, and lower body dressing. Further review of the MDS indicated that Resident #2 had diagnoses of coronary artery disease, heart failure, renal insufficiency, diabetes mellitus, and blindness in the left eye. Review of Resident #2's Care Plan with a revision date of 4/28/26 indicated that Resident #2 required the assistance of 1 staff to encourage oral care in the morning, afternoon, and at bedtime. The care plan further indicated that Resident #2 has his own teeth with some that are broken. Observation 5/26/26 at 1:45 PM revealed Resident #2's toothbrush was still wrapped in plastic and unopened in a spit basin labeled 5/2/26. Interview 5/26/26 at 3:00 PM with Resident #2 revealed that staff do not help brush his teeth as he has no teeth to brush. Resident #2 further revealed that staff do not offer to help brush his gums either, and confirmed that his toothbrush is still in the plastic by his sink. 4. Review of Resident #12's MDS dated [DATE] revealed a BIMS score of 8 indicating moderate cognitive impairment. The MDS further indicated that Resident #2 required substantial assistance with oral hygiene, upper and lower body dressing, and personal hygiene. Further review of the MDS indicated Resident #2 had diagnoses of coronary artery disease, renal insufficiency, and non-Alzheimer's dementia. Observation 5/26/26 at 1:50 PM of Resident #12's toothbrush still wrapped in plastic and unopened in a spit basin labeled 5/2/26. Interview 5/26/26 at 3:58 PM with Staff N Certified Nursing Assistant (CNA) revealed night shift changes out the toothbrushes for the residents monthly at the beginning of the month. Staff N then revealed she knows toothbrushing is not getting completed twice a day as staff seem to be running all the time due to call ins. Interview 5/26/26 at 4:06 PM with Staff K the current Director of Nursing (DON) revealed that she would expect oral care and toothbrushing to be completed twice a day or more depending on orders. Review of a facility provided policy titled, Oral Care with an implementation date of 5/27/26 indicated the facility is to provide oral care to residents in order to prevent and control plaque-associated oral diseases.

Based on observations, resident and staff interviews, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents (Residents #10, #19, #21, #1) reviewed. The facility reported a census of 32. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document coded the resident was dependent upon staff for all self care activities including dressing, toileting hygiene, transfers, eating and grooming/hygiene. The document revealed the resident had an indwelling catheter and was always incontinent of bowel. The MDS Assessment documented a diagnosis of quadriplegia (paralysis of 4 limbs). The Care Plan revised on 4/29/26 identified a problem area of self care deficit revised on 4/29/26 with staff interventions of ensuring the call light was within reach and bed mobility/transfers/dressing required the assistance of 2 staff. On 5/21/26 at 2:15 PM Resident #10 stated he has waited for over an hour for his call light to be answered, especially later evenings and overnight. The resident stated in the past couple of days there had been only 1 Certified Nursing Assistant and 1 Certified Medication Aide (CMA) getting people ready for bed. The resident stated when this happens the CMA has to help with transfers and then medications may be late. 2. Resident #19's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The assessment coded the resident as requiring partial/moderate assistance for toilet hygiene. The MDS Assessment documented diagnoses of spinal stenosis of lumbar region (narrowing of space of the spine in the lower back causing pain and pressure), and diabetes mellitus (DM). The Care Plan revised on 4/30/26 identified a problem area related to DM revised 3/17/25 with staff interventions of snacks and monitoring of blood glucose levels. The document disclosed a problem area of chronic pain and decreased function related to spinal stenosis, and DM with polyneuropathy revised 8/5/25 with staff interventions of provision of scheduled and as needed (PRN) medications. The Care Plan's problem area of self care deficit revised 4/30/26 instructed staff to ensure call light was within reach. On 5/21/26 at 1:20 PM Resident #19 stated he turned his call light on at approximately 3:00 AM and it was not answered until after 6:00 AM when the next shift came on duty. The resident stated he didn't think there was enough staff on the overnight shift. 3. Resident #21's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The assessment coded the resident as requiring total assistance from staff for toileting hygiene, transfers, dressing, and bed mobility. The document included the resident had an indwelling catheter and was always incontinent of bowel. The MDS Assessment documented diagnoses of stroke, paraplegia, and anxiety. The Care Plan revised on 4/29/26 contained a problem area for risk for falls revised on 8/6/25 with a directive for staff to ensure the call light was within reach and encourage the resident to use it for assistance. The document revealed a self care deficit revised on 8/6/25 with staff interventions of 2 person assist for bed mobility, toileting and transfers using a Hoyer lift. Continuous observation on 5/20/26 beginning at 1:44 PM Resident #21 turned his call light on, at 2:00 PM Staff E, CNA, asked the resident what he wanted and left the area. At 2:02 PM Staff E, donned PPE and entered the room with a Hoyer lift and turned the call light off. 4. Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document coded the resident was dependent on staff for toilet hygiene, transfers, and lower body dressing. The document revealed the resident was incontinent of bowel and bladder. The MDS Assessment documented diagnoses of atrial fibrillation, heart failure, and diabetes mellitus (DM). The Care Plan revised on 4/30/26 identified a problem area of self care deficit revised on 4/30/26 with staff interventions of 2 person assist with bed mobility, 2 person assist for dressing, resident's call light is within reach, 2 person assist for toileting, and 2 person assist with transfers using a Hoyer (dependent mechanical non weight bearing lift). On 5/20/26 at 3:57 PM Resident #1 stated she has had to wait up to an hour for her call light to be answered. The resident stated she knows how long as she watches the time on her phone. Resident #1 stated she thought it was due to lack of staff rather than staff themselves. During continuous observation 5/26/26 from 3:33 PM until 3:57 PM (24 Minutes) Resident #1's call light was observed to be on with Resident #1 waiting by the door of the room watching her phone. Interview 5/26/26 at 4:06 PM with Staff K the current Director of Nursing (DON) revealed she would like to see call lights answered within 15 minutes or less. Review of a facility provided policy titled, Call Lights: Accessibility and Timely Response with an implementation date of 5/27/26 indicated call lights will directly relay to a staff member to ensure appropriate response.

Based on observations, clinical record review, resident interview, staff interviews, and policy review the facility failed to properly secure and store medications to minimize loss or access by storing medication in a resident's room for 1 of 5 residents (Resident #13) reviewed. The facility further failed to properly secure medications for 1 of 4 medication carts. The facility reported a census of 32 residents. Findings include:1. Review of Resident #13's MDS dated [DATE] revealed a BIMS score of 12 indicating moderated cognitive impairment. Review of Resident #13's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order dated 3/10/26 for Lidocaine-Prilocaine external cream 2.5-2.5% to be applied topically to the right foot/ankle twice daily related to pain. Observation 5/26/26 at 10:45 AM revealed Resident #13's lidocaine cream sitting on top of the bedside nightstand. No staff or residents were observed around the medication at this time. Interview 5/26/26 at 11:15 AM with Resident #13 revealed that he keeps his cream next to his bed just in case he needs it. Observation 5/27/26 at 9:28 AM revealed Resident #13's lidocaine cream was sitting in the top drawer of the bedside nightstand. Review of a facility provided document titled, Self Administration Medication assessment dated [DATE] for Resident #13 indicated that Resident #13 did not want to self administer medications. Interview 6/1/26 at 12:25 PM with Staff K the current Director of Nursing (DON) revealed she would like to see lidocaine stored in the medication cart unless there was an assessment, an order from the physician for the resident to self administer the medication. 2. Continuous observation 6/1/26 from 1:05 PM until 1:10 PM revealed the treatment medication cart on the west hallway was unlocked. This cart was observed to have insulin pens and needles in the cart. During this observation period multiple nursing assistants, laundry staff, and residents passed the medication cart. At 1:10 PM Staff M Licensed Practical Nurse (LPN) came out of a resident's room and took the treatment cart. Interview 6/1/26 at 1:10 PM with Staff M revealed that she normally locks the cart when it is unattended and must have forgotten this time. Follow up interview 6/1/26 at 2:01 PM with Staff K revealed she would expect medication carts to be locked when not being accompanied. Review of a facility provided policy titled, Medication Storage with a copyright date of 2025 indicated all drugs and biologicals will be stored in locked compartments. The policy further indicates all medications housed at the facility will be stored appropriately to ensure proper security.

Based on facility record review, staff interview, and facility policy review the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program in place to provide quality care for residents. The facility failed to make good faith attempts to correct quality deficiencies, and maintain and implement a comprehensive QAPI program and plan, The facility identified a census of 32 residents.Findings include: The Department of Health and Human Services/Centers for Medicare and Medicaid Services (CMS) 2567 documents revealed the facility had repeated deficient practices in the years 2025 and 2026 as exhibited by the following:F550 Resident Rights/Exercise of Rights (4/8/26, 6/2/26 ) F609 Reporting of Alleged Violations (4/8/26, 6/2/26)F610 Investigate/Prevent/Correct Alleged Violations (12/8/25, 6/2/26)F656 Develop/Implement Comprehensive Care Plan (4/10/25, 12/8/25)F657 Care Plan Timing and Revision (2/27/25, 12/8/25, 6/2/26)F658 Services Provided Meet Professional Standards (2/27/25, 12/8/25, 6/2/26)F677 Activities of Daily Living (ADL) Care Provided for Dependent Residents (10/21/25, 4/8/26, 6/2/26)F684 Quality of Care (2/27/25, 12/8/25) F686 Treatment for Healing/Prevention of Pressure Ulcers (2/27/25, 12/8/25, F688 Increase/Prevent Decrease Range of Motion/Mobility (4/10/25, 12/8/25)F689 Free of Accident Hazards/Supervision/Devices (2/27/25, 6/2/26) F695 Respiratory/Tracheostomy Care and Suctioning (12/8/25, 6/2/26)F725 Sufficient Nursing Staff (2/27/25, 12/8/25, 6/2/26)F726 Competent Nursing Staff (2/27/25, 12/8/25) F755 Pharmacy Services/Procedures/Pharmacist Records (4/10/25, 12/8/25, 6/2/26)F757 Drug Regimen is Free from Unnecessary Drugs (2/27/25, 6/2/26)F804 Nutritive Value/Appearance/Palatable/Preferred Temperature (12/8/25, 4/10/25F842 Resident Records - Identifiable Information (4/8/26, 12/8/25, 2/27/25, F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (2/27/25, 4/10/25, 12/8/25, 4/8/26, 6/2/26)F880 Infection Prevention and Control (2/27/25, 4/10/25, 4/8/26, 6/2/26)On 6/2/26 at 2:50 PM Staff U, current Administrator, stated the facility had held QAPI meetings in April and May that he had not been a part of. The staff stated moving forward the facility will be holding standup and standdown meetings daily for everyone in the building, and the interdisciplinary team (IDT) will be meeting daily, and the Clinical Leadership Team will be meeting daily once the new Assistant Director of Nursing (ADON) begins. Staff U stated the facility had Performance Improvement Plans (PIPs) in place and would be developing additional plans related to the current survey as there were repeat deficiencies. The facility's QAPI Quality Assessment Assurance (QAA) Plan updated on 1/2/2025 revealed the purpose of QAPI is to develop a culture of proactive leadership and includes ongoing development of plans for improvement leading to systemic changes that support exceptional health care to seniors.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to provide infection prevention measures to ensure the use of Enhanced Barrier Precautions (EBP) when required, hand hygiene during wound care, and hand hygiene during dependent activities of daily living (ADLs) for 4 of 4 residents (Residents #15, #2, #6, #1) reviewed. The facility reported a census of 32 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #15, dated 5/12/26, included diagnoses of encounter for other orthopedic aftercare following surgical amputation, Multidrug-Resistant Organism (MDRO) (bacteria that resist treatment with more than one antibiotic) and diabetes. The MDS identified the resident was dependent on staff for toileting hygiene and transfers and a Brief Interview for Mental Status (BIMS) Score of 15, indicating no cognitive impairment for decision-making. Resident #15's Care Plan with revision date 4/28/26, revealed the resident required EBP related to the presence of a wound and EBP will be instituted during completion of high contact activities. Observation on 5/13/26 at 12:31 PM, Staff B, Certified Nurse Aide (CNA) was in Resident #15's room and Staff A, CNA entered the room with a full body mechanical lift. Staff A and Staff B, with only gloves on and no gowns on, proceeded to transfer the resident from her bed to a wheelchair with the lift. Interview on 5/13/26 at 12:40 PM, Staff B stated she had just finished with getting Resident #15 off the bed pan before she and Staff A transferred the resident. Staff B further stated that she did not wear a gown when she assisted the resident with the bedpan and she should have and that both staff should have worn a gown also when transferring the resident as the resident is on EBP due to the resident has a wound and EBP requires a gown and gloves with any care of the resident. 2. The MDS for Resident #2, dated 3/25/26, included diagnoses of acquired absence of right leg below the knee and diabetes. The MDS identified the resident had a surgical wound and a BIMS score of 15, indicating no cognitive impairment for decision-making. Resident #2's Treatment Administration Record for 5/1/26 – 5/31/26 revealed a physician's order for left anterior knee distal, left medical knee, left below the knee amputation(surgical wound): Cleanse area with wound cleaner soaked gauze, apply skin prep to periwound (area around edges of wound), apply hydrofera blue ready ( antibacterial foam dressing used to promote healing in various wounds) to wound bed, cover with silicone bordered foam, change 3 times weekly on Monday, Wednesday, Friday and as needed for soiling. Observation on 5/14/26 at 10:40 AM, Staff D, Registered Nurse (RN) applied a gown and gloves and removed 3 old dressings from Resident #2's left below the knee amputation wound areas. Staff D proceeded to cleanse the open wounds with wound cleanser, changed gloves without completing hand hygiene and then applied the new wound treatment and dressing as ordered. Facility Enhanced Barrier Precautions Policy dated 3/25/24 revealed EBPs are utilized to prevent the spread of MDROs to residents and are indicated for residents with chronic wounds. EBPs employ targeted gown and glove use during high-contact resident care activities with examples of high-contact resident care activities requiring the use of a gown and gloves include transferring and changing briefs or assisting with toileting. Interview on 5/21/26 at 11:40 AM, Staff K, Director of Nursing (DON) stated expectation for staff to wear gowns and gloves for residents on EBP when providing care. Staff K further stated when staff complete wound treatments and after removing the old wound dressings and cleansing wounds her expectation to change gloves and complete hand hygiene before applying the new treatment and dressing. 3. Resident #6's MDS assessment dated [DATE] revealed the resident had a BIMS score of 2/15 indicating severe cognitive impairment. The document coded the resident was dependent upon staff for all dressing, toileting hygiene, oral care, and transfers. The document revealed the resident was frequently incontinent of bladder and bowel continence was not rated. The document included diagnoses of Non-Alzheimer's Dementia and anxiety. The Care Plan revised 5/15/26 identified a problem area with self care deficit by requiring assistance with ADLs revised on 5/7/26 with a staff intervention of 1 person assistance for dressing, bed mobility, oral care, grooming/hygiene, and 1-2 person assistance for transfers. Continuous observation on 5/27/26 at 7:08 AM of Staff C, Certified Nursing Assistant (CNA)/bath aide, and Staff G, CNA, providing morning ADL care to Resident #6 revealed the following: Both staff entered the room, completed hand hygiene, and donned gloves. Staff observed the floor/fall mats were covered in urine. Staff C utilized wipes to remove urine from the mats and stated she would take them to the shower room to clean when they were finished with the resident. Staff removed gloves, completed hand hygiene, and donned new gloves. Staff G removed gloves, left the room without completing hand hygiene. Staff G returned to the room with a mop bucket due to urine on the floor, completed hand hygiene, donned gloves and worked with Staff C to assist the resident with putting on a shirt. Staff G removed gloves, left the room without completing hand hygiene. Staff G returned to the room with socks, completed hand hygiene, donned gloves and assisted the resident with putting on socks. Staff C noted the resident's sheets were wet. Staff C and G set the resident up for standing with a front wheeled walker (FWW), gait belt, and initiating an adult dependent brief and pants. Both staff assisted the resident with moving to a standing position. Staff C maintained physical contact with verbal cues for standing, while Staff G utilized wipes for peri care using her left gloved hand. Staff G then used both gloved hands to fasten the dependent brief and pull the resident's pants up. Staff C and G worked together to assist the resident using the FWW to his w/c. The resident required total assistance for positioning in the w/c. Staff C gathered dirty items and placed them in plastic bags for removal from the room. Gloves removed and hand hygiene completed. Staff G removed gloves, completed hand hygiene, and combed the resident's hair. 4. Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document coded the resident required setup for grooming/hygiene tasks and dependent upon staff for toilet hygiene, transfers, and dressing. The document revealed the resident was incontinent of bowel and bladder. The MDS included diagnoses of atrial fibrillation, heart failure, and diabetes mellitus (DM). The Care Plan revised 4/30/26 identified a problem area of self care deficit as evidenced by requiring assistance with ADLs revised on 4/30/26 with a staff intervention for 1 person assistance for oral care, 2 person assistance for dressing, bed mobility, and dependent for transfers. Continuous observation on 5/27/26 at 7:40 AM of Staff C and Staff G complete ADL care with Resident #1 revealed the following: Staff entered the room with Staff C bringing a shower chair and Staff G bringing a dependent mechanical lift. Note the dependent mechanical lift did not have disinfectant wipes on it. Both staff completed hand hygiene and donned gloves. Both staff working together assisted the resident with rolling to remove the wet brief, place a sling, and transferred the resident to the shower chair using the dependent mechanical lift. Staff C left the room with Resident #1. Staff G removed her gloves, and prepared the bed for the resident's return. Staff G donned gloves and assisted Staff C transfer Resident 1 from the shower chair to the bed. Staff C and G completed lower body dressing, bed mobility, placement of the lift sling and transferred the resident to the recliner. Staff C removed gloves, completed hand hygiene, and removed the shower chair from the room. Staff G removed gloves, completed hand hygiene, and provided the resident with setup for oral care. Staff G moved the dependent mechanical lift to the hallway and left it. Neither Staff C nor Staff G returned to disinfect the mechanical lift. Observed on 5/27/26 at 6:55 AM Staff C disinfecting the shower chair. On 6/2/26 at 12:10 PM Staff K, current Director of Nursing (DON) stated the expectation was for hand hygiene to be completed with glove changes either with hand sanitizer or washing hands. Staff K stated the dependent mechanical lift should be disinfected between use with residents and acknowledged she had observed the bracket on the lift for holding disinfecting wipes was empty. The facility's Handwashing/Hand Hygiene Policy, revised 8/19, revealed the primary means to prevent the spread of infections with hand hygiene. The document included single-use gloves that should be utilized when anticipating contact with bodily fluids and when in contact with a resident who is on contact precautions. The document disclosed hand hygiene should be completed before donning gloves, after glove removal, and is the final step after removing and disposing of personal protective equipment.

Based on clinical record review, resident interviews, staff interview, and policy review, the facility failed to provide dignity and respect to residents during interactions and care (Residents #8, #18, #20). The facility reported a census of 32 residents.Findings Include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS provided the resident did not have hallucinations, delusions, verbal/physical behaviors towards others or have rejection of care. The MDS documented diagnoses of anemia, hypertension-high blood pressure (HTN), and diabetes mellitus (DM). The MDS revealed the resident required no assistance with self care skills and ambulation. The resident's Care Plan revised 4/29/26 identified a problem area of potential for psycho-social well-being deficit initiated on 5/27/25 with staff interventions of encouraging the resident to express feelings and concerns and report additional needs to nursing. The document did not contain a problem area indicating the resident made false allegations or statements about or to staff. In an interview on 5/21/26 at 10:20 AM Resident #8 stated she felt 2 staff on the overnight shift did not treat her with dignity and she felt that if she spoke out about concerns she had with her care there would be retaliation. The resident stated she had brought up concerns during Resident Council and felt her concerns had been shared by the Administrator (previous) to the staff with her name being given to the staff as the complainant. Resident #8 stated since that time the staff had not treated her the same demonstrated by their mannerisms and care. 2. Resident #18's MDS dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The MDS provided the resident did not have hallucinations, delusions, verbal/physical behaviors towards others or have rejection of care. The MDS documented diagnoses of renal insufficiency and DM. The MDS coded the resident was dependent on staff for toilet hygiene, transfers and required substantial/maximal assistance for rolling left and right. The document disclosed the resident was frequently incontinent of bladder and always continent of bowel. The Care Plan revised 4/29/26 identified self care deficits with a staff intervention for 1 person assist with bed mobility (revised 4/29/26), ensuring the call light was within reach (8/6/25) and provision of a grab bar x1 to assist with bed mobility (revised 1/19/26). The document did not contain a problem area indicating the resident made false allegations or statements about or to staff. In an interview on 5/21/26 at 3:00 PM Resident #18 stated that some staff on the overnight shift did not always assist her with her care and speak to her in a respectful manner. The resident stated the staff's tone when talking to her felt disrespectful. 3. Resident #20's MDS dated [DATE] revealed a BIMS score of 14/15 indicating normal cognition. The MDS provided the resident did not have hallucinations, delusions, verbal/physical behaviors towards others or have rejection of care. The MDS documented diagnoses of HTN and DM. The MDS revealed the resident required no assistance with self care skills and ambulation. The resident's Care Plan, revised 4/28/26, did not contain a problem area or staff intervention regarding the resident making false statements or accusations against staff. In an interview on 5/21/26 at 1:35 PM Resident's #20 stated there had been some problems with 2 CNAs on the overnight shift. The resident stated the CNAs had been notified of a concern raised during Resident Council and things had been better, but more recently the staff had not been speaking to him and he felt as though he was being ignored. The resident stated he was hesitant to bring it to the attention of administration due to fear of unnecessary retaliation. In an interview on 6/2/26 at 12:10 PM Staff K, Director of Nursing (DON), stated that residents should be treated with respect and not have fear of asking for assistance. The staff stated education needed to be provided to staff regarding interactions with and/or in front of residents. The facility's Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, undated, revealed all residents had the right to be free from abuse and neglect.

Based on clinical record review, staff interviews, and policy review the facility failed to protect a resident from misappropriation of property when a resident's medication became missing from the facility for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 32 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] indicated that Resident #2 was taking opioid medications during the seven day look back period. The MDS further indicated that Resident #2 had diagnoses of heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Hydrocodone-Acetaminophen 10-325 MG (Milligrams) to give one tablet by mouth every 4 hours as needed for increased pain with a start date of 2/15/26 and a discontinued date of 4/24/26. Further review revealed another order for Hydrocodone-Acetaminophen 5-325 MG to give one tablet by mouth every 6 hours as needed for pain with a start date of 4/24/26 and a discontinuation date of 5/7/26. Review of a facility provided document titled, Controlled Drug Record with a date of 4/23/26 revealed a narcotic count sheet for Resident #2's Hydrocodone-Acetaminophen 10-325 MG. Further review of the document revealed a count of 54 tablets left on 4/28/26 at 6:33 AM. The document further revealed an entry that was yellow highlighted on 4/28/26 at 2:00 PM the medication was discontinued. Interview 5/19/26 at 2:45 PM with Staff Q Certified Medication Aide (CMA) revealed that she was passing medications from the cart for Resident #2 on 4/28/26. Staff Q continued that Resident #2's Hydrocodone-Acetaminophen 10-325 MG tablets were discontinued, but were still on the medication cart. Staff Q revealed that she would not give the medication as it did not match the current order for Hydrocodone-Acetaminophen 5-325 MG. Staff Q then revealed that she took the medication along with the narcotic count sheet for the medication and placed them at the nurses station on the desk to be destroyed. Staff Q further indicated that she did not hear anything for 3 days, until Staff D Registered Nurse (RN) informed her that the medications were missing. Staff Q then revealed no one found the missing medications. Staff Q continued that she had never been part of destroying medications as the facility requires 2 staff. Staff Q further revealed that she believed Staff D had destroyed the medication. Interview 5/27/26 at 1:24 PM with Staff H Licensed Practical Nurse (LPN) revealed that the nurse practitioner had come through the facility to complete rounds and had written an order for a frequency change on Resident #2's Hydrocodone-Acetaminophen 10-325 MG, but the order did not have the milligrams specified. Staff then revealed that she assumed it was for a dosage decrease to 5-325 MG. Staff H then confirmed she should have clarified the order instead of just changing the dosage from 10-325 MG to 5-325 MG. Staff H continued that she was not working on 4/28/26 when the medication went missing. Interview 5/27/26 at 1:49 PM with Staff D confirmed she was working on 4/28/26 when the medication for Resident #2 went missing. Staff D revealed that she did not see the Hydrocodone at the nurses station, and that she was the nurse on the floor that day. Staff D further revealed that she did find the count sheet in a pile of paperwork several days later. Staff D continued that she did notify Staff S the previous Regional Clinical Director of the missing medication, as well as Staff P the previous Administrator at the same time. Interview 5/27/26 at 2:06 PM with Staff S revealed that she was notified several days after the medication for Resident #2 had gone missing. Staff S then revealed that the staff did look all over for the medications when she was notified on 5/7/26, but could not locate the 54 missing tablets. Interview 6/1/26 at 12:25 PM with Staff K the current Director of Nursing (DON) revealed that she would have liked to have seen that when medications are discontinued that the medications stay on the cart. Staff K further revealed that she would like to have these medications continue to be counted until 2 staff, with one being a nurse, can destroy the narcotics in the drug buster solution. Review of a facility provided policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting with an updated date of 3/18/26 indicated that the facility will identify, through ongoing assessment, high-risk situations where abuse, neglect, or misappropriation of resident property may occur and provide appropriate intervention in such occasions.

Based on clinical record review, law enforcement interview, staff interviews, and policy review the facility failed to report possible abuse in a timely manner related to the misappropriation of residents medications for 1 of 1 resident's (Resident #2) reviewed. The facility reported a census of 32 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] indicated that Resident #2 was taking opioid medications during the seven day look back period. The MDS further indicated that Resident #2 had diagnoses of heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Hydrocodone-Acetaminophen 10-325 MG (Milligrams) to give one tablet by mouth every 4 hours as needed for increased pain with a start date of 2/15/26 and a discontinued date of 4/24/26. Further review revealed another order for Hydrocodone-Acetaminophen 5-325 MG to give one tablet by mouth every 6 hours as needed for pain with a start date of 4/24/26 and a discontinuation date of 5/7/26. Review of a facility provided document titled, Controlled Drug Record with a date of 4/23/26 revealed a narcotic count sheet for Resident #2's Hydrocodone-Acetaminophen 10-325 MG. Further review of the document revealed a count of 54 tablets left on 4/28/26 at 6:33 AM. The document further revealed an entry that was yellow highlighted on 4/28/26 at 2:00 PM the medication was discontinued. Interview 5/19/26 at 2:45 PM with Staff Q Certified Medication Aide (CMA) revealed that she was passing medications from the cart for Resident #2 on 4/28/26. Staff Q continued that Resident #2's Hydrocodone-Acetaminophen 10-325 MG tablets were discontinued, but were still on the medication cart. Staff Q revealed that she would not give the medication as it did not match the current order for Hydrocodone-Acetaminophen 5-325 MG. Staff Q then revealed that she took the medication along with the narcotic count sheet for the medication and placed them at the nurses station on the desk to be destroyed. Staff Q further indicated that she did not hear anything for 3 days, until Staff D Registered Nurse (RN) informed her that the medications were missing. Staff Q then revealed no one found the missing medications. Staff Q continued that she had never been part of destroying medications as the facility requires 2 staff. Staff Q further revealed that she believed Staff D had destroyed the medication. Interview 5/26/26 at 11:58 AM with the local Chief of Police revealed that the facility did call to inform them of the missing Hydrocodone for Resident #2 on 5/8/26. Interview 5/26/26 at 12:25 PM with Staff P the previous Administrator revealed he had an incident number from the police department. Staff P then revealed that he did not have a police report at this time. Staff P further revealed that he still needed to send some information to the local police department. Staff P continued that he would follow up with the police department and wait for their investigation. Follow up interview 5/26/26 at 12:47 PM with the police department officer conducting the investigation into the missing narcotics revealed that Staff P had sent him the requested information to conduct their investigation. Interview 5/26/26 at 1:05 PM with Staff P confirmed that the investigation was turned into the State Agency on 5/8/26 when the medications went missing on 4/28/26. Staff P then revealed that Staff S had completed the investigation and no longer works with the facility. Staff P continued that he believed the missing narcotics was a criminal thing, and was unsure if this would be an abuse issue. Staff P then confirmed the missing narcotics would be a reportable concern. Staff P continued this situation should have been turned in quicker than the 11 days that it was turned in. Staff P further indicated that it was 54 tablets of Hydrocodone-Acetaminophen 10-325 MG that had gone missing. Follow up interview 5/26/26 at 2:05 PM with Staff P confirmed that Staff D was the Director of Nursing (DON) at the time of the medications going missing. Staff P further revealed that he was not notified of the missing narcotics by Staff D until 5/7/26, and he then turned it into the police department, and the State Agency on 5/8/26. Interview 5/27/26 at 1:24 PM with Staff H Licensed Practical Nurse (LPN) revealed that the nurse practitioner had come through the facility to complete rounds and had written an order for a frequency change on Resident #2's Hydrocodone-Acetaminophen 10-325 MG, but the order did not have the milligrams specified. Staff then revealed that she assumed it was for a dosage decrease to 5-325 MG. Staff H then confirmed she should have clarified the order instead of just changing the dosage from 10-325 MG to 5-325 MG. Staff H continued that she was not working on 4/28/26 when the medication went missing. Interview 5/27/26 at 1:49 PM with Staff D confirmed she was working on 4/28/26 when the medication for Resident #2 went missing. Staff D revealed that she did not see the Hydrocodone at the nurses station, and that she was the nurse on the floor that day. Staff D further revealed that she did find the count sheet in a pile of paperwork several days later. Staff D continued that she did notify Staff S the previous Regional Clinical Director of the missing medication, as well as Staff P the previous Administrator at the same time. Staff D further revealed that she was the interim Director of Nursing (DON) at the time, and confirmed that she did not report the missing narcotics to Staff S, Staff P, the local police department, or the State Agency until 5/7/26. Staff D continued that she was not trained on what to do in this situation with the missing narcotics. Staff D then revealed that she should have reported to the appropriate people within 24 hours. Interview 5/27/26 at 2:06 PM with Staff S revealed that she was notified several days after the medication for Resident #2 had gone missing. Staff S then revealed that the staff did look all over for the medications when she was notified on 5/7/26, but could not locate the 54 missing tablets. Staff S continued that the missing narcotics were not reported to the State Agency, or the police department until 5/8/26. Staff S then revealed that she would have liked to have seen the police department investigate this prior to 5/26/26 when the State Agency notified the police department to inquire about their investigation. Staff S further revealed the DON at the time did not notify the appropriate persons in a timely manner. Interview 6/1/26 at 12:25 PM with Staff K the current Director of Nursing (DON) revealed she would expect missing narcotics to be reported to the police department, and the State Agency as soon as medications are discovered missing. Review of a facility provided policy titled, Nursing Facility Abuse Prevention, Investigation and Reporting with an updated date of 3/18/26 indicated all allegations of misappropriation should be reported immediately to the Administrator. The policy further indicated all allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the appropriate state entity not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury.

Based on clinical record review, law enforcement interview, staff interviews, and policy review the facility failed to investigate the misappropriation of resident medications that went missing for 1 of 1 residents (Resident #2) reviewed. The facility reported a census of 32 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] indicated that Resident #2 was taking opioid medications during the seven day look back period. The MDS further indicated that Resident #2 had diagnoses of heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Hydrocodone-Acetaminophen 10-325 MG (Milligrams) to give one tablet by mouth every 4 hours as needed for increased pain with a start date of 2/15/26 and a discontinued date of 4/24/26. Further review revealed another order for Hydrocodone-Acetaminophen 5-325 MG to give one tablet by mouth every 6 hours as needed for pain with a start date of 4/24/26 and a discontinuation date of 5/7/26. Review of a facility provided document titled, Controlled Drug Record with a date of 4/23/26 revealed a narcotic count sheet for Resident #2's Hydrocodone-Acetaminophen 10-325 MG. Further review of the document revealed a count of 54 tablets left on 4/28/26 at 6:33 AM. The document further revealed an entry that was yellow highlighted on 4/28/26 at 2:00 PM the medication was discontinued. Interview 5/19/26 at 2:45 PM with Staff Q Certified Medication Aide (CMA) revealed that she was passing medications from the cart for Resident #2 on 4/28/26. Staff Q continued that Resident #2's Hydrocodone-Acetaminophen 10-325 MG tablets were discontinued, but were still on the medication cart. Staff Q revealed that she would not give the medication as it did not match the current order for Hydrocodone-Acetaminophen 5-325 MG. Staff Q then revealed that she took the medication along with the narcotic count sheet for the medication and placed them at the nurses station on the desk to be destroyed. Staff Q further indicated that she did not hear anything for 3 days, until Staff D Registered Nurse (RN) informed her that the medications were missing. Staff Q then revealed no one found the missing medications. Staff Q continued that she had never been part of destroying medications as the facility requires 2 staff. Staff Q further revealed that she believed Staff D had destroyed the medication. Interview 5/26/26 at 11:58 AM with the local Chief of Police revealed that the facility did call to inform them of the missing Hydrocodone for Resident #2 on 5/8/26. The Chief of Police then revealed that the facility was hesitant to have the police department come to investigate, but he informed the facility that if they were reporting to the State Agency then they would want the police to complete an investigation. He continued that they have been unable to complete their investigation as they were not supplied the staff's names and phone numbers that were working on the day the medications had gone missing. Interview 5/26/26 at 12:25 PM with Staff P the previous Administrator revealed he had an incident number from the police department. Staff P then revealed that he did not have a police report at this time. Staff P further revealed that he still needed to send some information to the local police department. Staff P continued that he would follow up with the police department and wait for their investigation. Follow up interview 5/26/26 at 12:47 PM with the police department officer conducting the investigation into the missing narcotics revealed that Staff P had sent him the requested information to conduct their investigation. Interview 5/26/26 at 1:05 PM with Staff P confirmed that the investigation was turned into the State Agency on 5/8/26 when the medications went missing on 4/28/26. Staff P then revealed that Staff S had completed the investigation and no longer works with the facility. Staff P continued that he believed the missing narcotics was a criminal thing, and was unsure if this would be an abuse issue. Staff P then confirmed the missing narcotics would be a reportable concern. Staff P continued this situation should have been turned in quicker than the 11 days that it was turned in. Staff P further indicated that it was 54 tablets of Hydrocodone-Acetaminophen 10-325 MG that had gone missing. Follow up interview 5/26/26 at 2:05 PM with Staff P confirmed that Staff D was the Director of Nursing (DON) at the time of the medications going missing. Staff P further revealed that he was not notified of the missing narcotics by Staff D until 5/7/26, and he then turned it into the police department, and the State Agency on 5/8/26. Interview 5/27/26 at 1:24 PM with Staff H Licensed Practical Nurse (LPN) revealed that the nurse practitioner had come through the facility to complete rounds and had written an order for a frequency change on Resident #2's Hydrocodone-Acetaminophen 10-325 MG, but the order did not have the milligrams specified. Staff then revealed that she assumed it was for a dosage decrease to 5-325 MG. Staff H then confirmed she should have clarified the order instead of just changing the dosage from 10-325 MG to 5-325 MG. Staff H continued that she was not working on 4/28/26 when the medication went missing. Interview 5/27/26 at 1:49 PM with Staff D confirmed she was working on 4/28/26 when the medication for Resident #2 went missing. Staff D revealed that she did not see the Hydrocodone at the nurses station, and that she was the nurse on the floor that day. Staff D further revealed that she did find the count sheet in a pile of paperwork several days later. Staff D continued that she did notify Staff S the previous Regional Clinical Director of the missing medication, as well as Staff P the previous Administrator at the same time. Staff D further revealed that she was the interim Director of Nursing (DON) at the time, and confirmed that she did not report the missing narcotics to Staff S, Staff P, the local police department, or the State Agency until 5/7/26. Staff D continued that she was not trained on what to do in this situation with the missing narcotics. Staff D then revealed that she should have reported to the appropriate people within 24 hours. Interview 5/27/26 at 2:06 PM with Staff S revealed that she was notified several days after the medication for Resident #2 had gone missing. Staff S then revealed that the staff did look all over for the medications when she was notified on 5/7/26, but could not locate the 54 missing tablets. Staff S continued that the missing narcotics were not reported to the State Agency, or the police department until 5/8/26. Staff S then revealed that she would have liked to have seen the police department investigate this prior to 5/26/26 when the State Agency notified the police department to inquire about their investigation. Staff S further revealed the DON at the time did not notify the appropriate persons in a timely manner. Interview 6/1/26 at 12:25 PM with Staff K the current Director of Nursing (DON) revealed she would expect the facility to properly investigate when narcotics go missing. Review of a facility provided policy titled, Nursing Facility Abuse Prevention, Investigation and Reporting with an updated date of 3/18/26 indicated that should an incident or suspected incident of resident abuse be reported or observed, the Administrator must be notified immediately. The policy further indicates the Administrator will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals. This written report shall be forwarded to the Department within five days of the initial report.

Based on observation, resident electronic health record review, staff interview, and policy review the facility failed to provide safe ambulation/transfer techniques by not using a gait belt to ambulate a resident that required assistance for 1 of 3 (Resident #14) residents reviewed. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14, dated 5/12/26, included diagnoses of cancer and anxiety disorder. The MDS identified the resident required substantial/maximal assistance of staff for sit to stand, transfers, and walking. The MDS identified the resident was occasionally incontinent of bladder and bowel and a Brief Interview for Mental Status score of 9, indicated moderate cognitive impairment for decision-making.Resident #14's Care Plan, with revision date 5/23/25, documented the following problems and interventions:a. Self-care deficit as evidenced by requiring assistance with activities of daily living, impaired balance during transitions requiring assistance and /or walking with an intervention for mobility of assist of 1 staff with front-wheeled walker and wheelchair with revision date 2/18/26.b. At risk for falls related to impaired balance, poor safety awareness, neuromuscular functional impairment and the use of medications that may increase falls risks, revised 5/1/26, with interventions of educated resident to utilize call light for assistance and encourage resident to ask for assistance when wanting to transfer/ambulate.Observation on 5/14/26 at 7:30 AM, Resident #14 walked down the hall and to the dining room with a wheeled walker and Staff C, Certified Nurse Aide (CNA), with Staff C's hand on resident's lower back, no gait belt on resident.Interview on 5/14/26 at 11:40 AM, Staff E, CNA stated Resident #14's care plan revealed the resident is an assist of 1 staff with a walker which would require a gait belt to be used when transferring or walking with the resident. The facility Use of Gait Belt Policy, undated, revealed it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.Interview on 5/21/26 at 11:40 AM, Staff K, Director of Nursing stated expectation for staff to use a gait belt for transfers and ambulating residents that need assistance and as documented in the resident's care plan.

Based on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to meet professional standards for ostomy care by not releasing the build up of gas in the ostomy bag, which caused the appliance to spill the contents for 1 of 1 (Resident #13) reviewed. The facility reported a census 32.Findings include:Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS further indicated Resident #12 had diagnoses of functional quadriplegia, ileostomy status, noninfective gastroenteritis (inflammation of the stomach and intestines) and colitis (inflammation of the inner lining of the large intestine), and Ogilvie syndrome (sudden paralysis and massive dilation of the colon). Review of Resident #13's Care Plan with a revision date of 4/28/26 indicated that Resident #13 requires an assist of 1 staff with colostomy care and emptying. Observation 5/26/26 at 3:20 PM revealed Resident #13's ostomy bag completely filled with air, after bingo.Interview 5/26/26 at 3:30 PM with Resident #13 revealed that staff are not always the best about burping or draining his ostomy bag. Resident #13 further revealed that if staff don't burp his ostomy bag it will make a mess as the sides of the appliance will blow out and everything that is inside will spill out. Resident #13 continued that this has happened several times. Observation 5/27/26 at 9:28 AM revealed Resident #13 sitting by the nurses station on the west hall with his ostomy appliance full of air at this time. Interview 6/1/26 at 9:40 AM with Staff A Certified Nursing Assistant (CNA) revealed that she completes the task of burping Resident #13's ostomy appliance, but she believes that not all staff are completing this. Staff further revealed that when charting the task of burping the appliance that the system will not always record correctly that it is being done. Staff A further continued that Resident #13's ostomy appliance fills with air pretty quickly, and that it really does need to be burped or it will pop and come apart. Interview 6/1/26 at 10:15 AM with Staff G CNA revealed that ostomy outputs are to be charted twice a day, and that Resident #13 does have a task for Resident #13 to have his ostomy appliance burped every 2 hours. Staff G further revealed that if the ostomy is not emptied of the air then the ostomy will pop and will be a mess. Staff G continued that if Resident #13's ostomy is getting burped when she is working, but does not think that all the staff are completing this task. Interview 6/1/26 at 1:13 PM with Staff K the current Director of Nursing (DON) revealed that she would expect staff to empty and burp ostomy appliances at the appropriate times. Review of a facility provided policy titled, Ostomy Care-Colostomy, Urostomy, and Ileostomy with and implementation date of 5/27/26 indicated residents who required colostomy, urostomy, or ileostomy services will receive care consistent with professional standards of practice.

Based on observation, resident interview, electronic health record review, policy review, and staff interview the facility failed to provide a respiratory treatment timely for 1 (Resident #17) of 1 residents reviewed. The facility reported a census of 32 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #17, dated 2/24/26, included diagnoses of Panlobular Emphysema (a severe form of chronic obstructive pulmonary disease (COPD) with widespread lung damage) and COPD. The MDS identified a Brief Interview for Mental Status score of 9, indicated no cognitive impairment for decision-making.Resident #17's Care Plan documented a problem of resident has COPD and is at risk for shortness of breath, impaired breathing, and respiratory infections with the intervention to administer medications/inhalers as ordered.Observation on 5/14/26 starting at 10:00 AM, Resident #17 walked down the hall, leaning on the wall and holding the hand rail, was able to hear the resident wheezing and the resident appeared short of breath, and resident stated he needed a vial of medication for his nebulizer (breathing treatment) now. Staff I, Certified Medication Aide replied to the resident that she had notified the nurse as she was no longer able to do his breathing treatments. Staff D, Registered Nurse came and walked to the resident's room with the resident, listened to the resident's lungs, and started a breathing treatment. Interview on 5/14/26 at 10:25 AM, after Resident #17's breathing treatment completed, Resident #17 stated he had been waiting for at least 40 minutes for his breathing treatment and had been having a hard time breathing prior to the treatment. The resident stated he turned on his call light at 9:10 AM, according to the clock on his wall, and approximately 10 minutes later an unknown staff member came in, which he reported to her that he needed a breathing treatment and she said she would tell the nurse, and nobody has ever come back. The resident stated this happens frequently that he has to wait way over 15 minutes when he asks for a breathing treatment and has had to wait up to 2 hours before. Resident #17 stated the staff can be late with his other medications but he can't wait that long for his breathing treatments as he needs to be able to breathe.Resident #17's Medication Administration Record, 5/1/26 - 5/31/26, revealed a physician's order for Ipratropium-Albuterol Inhalation Solution, (medication administered in a breathing treatment) inhale orally every 6 hours as needed for shortness of breath related to COPD.Resident #17's electronic health record Progress Note, dated 5/14/26 at 10:08 AM, created by Staff D, documented: Resident complaining of shortness of breath, audible wheezing noted. Upon auscultation (listening to lungs with a stethoscope) wheezing noted throughout.The facility Nebulizer Therapy policy, not dated, documented it is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed.Interview on 5/21/26 at 11:40AM, Staff K, Director of Nursing stated expectation for staff to evaluate a resident's breathing status and administer ordered breathing treatments timely when needed by a resident.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to provide appropriate treatment and services to meet a resident's highest practicable physical, mental, and psychosocial well-being for residents diagnosed with dementia for 2 of 2 residents reviewed (Resident #6, #11). The facility had a census of 32.Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 2/15 indicating severe cognitive impairment. The document revealed the resident displayed fluctuating inattention, physical behaviors directed towards other 4-6 days of the last 7 days of the reporting period, verbal behavioral symptoms towards other 1-3 days of the last 7 days of the reporting period and those behaviors significantly interfered with the resident's care, social interaction and significantly impacted the privacy, care, and living environment of others. The document disclosed the resident required significant assistance or was dependent upon staff for self care and transfers. The document included diagnoses of Non-Alzheimer's Dementia and anxiety. The document revealed the resident took antipsychotic, antianxiety, and opioid medications. The clinical record's Medical Diagnoses identified the resident had a diagnosis of vascular dementia, severe, with agitation (5/1/26). The Care Plan revised 5/15/26 identified a problem area related to fall risk revised on 5/7/26 with staff interventions of low bed and safe environment with even floors and personal items within reach. A problem area identified the potential or diversional activity deficit due to cognitive impairment with staff interventions of encouragement of resident's family/friends to attend special activities, invite to attend activities, 1:1 bedside/in-room activities, and provide social interaction activities. A problem area of impaired cognitive function revised on 5/7/26 identified staff interventions of cue/orient/supervise as needed, report changes in cognitive function, and use of task segmentation. The Care Plan failed to identify Resident #6's specific diagnosis of vascular dementia and specific interventions related to that diagnosis. The Care Plan failed to provide individualized interventions to provide the resident related to activities, behaviors and non-pharmalogical interventions for behaviors. The document failed to provide revisions to the Care Plan with individualized behaviors. The Care Plan did not identify Resident #6 required 1:1.The clinical record's Physician Orders identified to monitor behaviors every shift with 0 = no behaviors, 1 = physical aggression, 2 = hallucinations, 3 = verbal aggression, 4 = resisting care, 5 = attention seeking, 6 = paranoia, 7 = wandering, 8 = agitation, and 9 = see nurse notes. The Physician Orders neither contained an order for 1:1 nor individualized behaviors. Observed on 5/20/26 at 1:00 PM Resident #6 seated in a w/c at the nurses' station with no activity present; staff present without interaction with the resident. Observed on 5/20/26 at 2:15 PM Resident #6 seated in a w/c at the nurses' station without activity and without interaction with staff.Observed on 5/20/26 at 2:55 PM Resident #6 seated in a w/c at the nurses' station with no activity; staff present at the nurse's station but not engaging with the resident. Observed on 5/20/26 at 4:15 PM Resident #6 seated in a w/c at the nurses' station in a wheelchair (w/c) with no activity and no interaction from staff. Observed on 5/20/26 at 4:45 PM Resident #6 seated in a w/c at the nurses' station, appearing restless demonstrated by moving leg rests and shifting in the w/c - no staff present. Oberved on 5/20/26 at 5:15 PM a visitor stating Resident #6, seated at the nurses' station, had urinated on himself and urine was running onto the floor. Observed no staff present. As the visitor stated urine all over the floor, Staff P, Previous Administrator, walked up, observed the urine on the floor, the resident's wet pants, and attempted to find staff to assist the resident. Oberved on 5/21/26 at 9:59 AM Resident #6 seated in his w/c sleeping at the nurses' station. Oberved on 5/27/26 at 9:35 AM Resident #6 seated at the nurses' station in his w/c with a blanket across his lap with no activity for engagement.Observed on 5/27/26 at 10:10 AM Resident #6 seated at the nurses' station seated in a recliner with the leg rest extended. Observed the resident moving around in the recliner with no activity and no staff in the area. Observed on 6/1/26 at 1:45 PM Resident #6 seated at the nurses' station seated in a w/c without any activity.On 5/27/26 at 12:50 PM Staff O, Certified Nursing Assistant (CNA), stated Resident #6 was a 1:1.On 5/27/26 at at 3:14 PM Staff T, CNA, stated Resident #6 was 1:1. 2. Resident #11's MDS assessment dated [DATE] revealed the resident had a BIMS score of 2/15 indicating severe cognitive impairment. The document disclosed the resident was dependent upon staff for all self care activities, transfers and wheelchair (w/c) mobility. The document included diagnoses of diabetes mellitus (DM), cerebrovascular accident (stroke), Non-Alzheimer's Dementia, anxiety, depression and bipolar.The clinical record's Medical Diagnoses identified Resident #11 had a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (10/9/15).The Care Plan revised 5/26/26 revealed a problem area that the resident chose not to participate in many activities, revised 4/29/26, with staff interventions to encourage the resident to attend activities, the resident enjoyed cornhole and animal visits, enjoys listening to music and provide 1:1 as needed, all revised 4/28/26. The Care Plan failed to identify Resident #11's specific diagnosis of unspecified dementia and specific interventions related to that diagnosis. On 5/21/26 at 11:15 AM Resident #11 seated in w/c at the nurses' station without any activity. On 5/27/26 at 9:35 AM Resident #11 seated at the nurses' station seated in her w/c without any activity or staff engagement. On 5/27/26 at 10:10 AM Resident #11 seated at the nurses' station without activity or staff present.In an interview on 5/20/26 at 10:47 AM Staff P stated the facility did not have a full time Activity Director, but did have a shared Activity Director with another facility who was present 3 days a week. In an interview on 6/2/26 at 12:10 PM Staff K, current Director of Nursing (DON), concurred there needed to be more education to staff on interactions with residents with diagnosis of dementia and activities available to them. The staff stated that Resident #6 was not identified as a 1:1 needing to be at the nurses' station, but did exhibit numerous behaviors and was a fall risk. Staff K stated if residents were at the nurses' station, activities/stimuli should be available. The facility did not have a policy related to dementia care and activities.

Based on clinical record reviews, resident interviews, staff interview, and policy review the facility failed to order and dispense medications per physician orders for 3 of 7 residents reviewed (Residents #1, #16, #19). The facility reported a census of 32 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS Assessment documented diagnoses of atrial fibrillation, heart failure, hyperlipidemia (high cholesterol), and diabetes mellitus (DM). The document revealed the resident received 1 injection, antibiotics, diuretics, and hypoglycemic medications during the past 7 days of the reporting period. The clinical record's Medical Diagnoses included: Type 2 diabetes mellitus without complications, hyperlipidemia, and hypokalemia (lower than normal potassium in blood that helps regulate heart rhythms, muscle contractions, and nerve signals). Resident #1's Care Plan, revised 4/30/26, revealed a problem area of DM revised 8/12/25 with staff interventions of diabetic medication as ordered by physician (revised 5/8/25), and to monitor/document/report episodes of hyper/hypoglycemia (high/low blood sugars). A problem area related to altered cardiovascular status and risk for shortness of breath, chest discomfort and diagnosis of hypokalemia (revised 4/30/26) with staff interventions for monitoring signs/symptoms of congestive heart failure/altered vascular status and lunch sounds, and observe for side effects of beta blockers (revised 4/30/26). Resident #1's Medication Administration Record (MAR) 4/26 revealed the following: Potassium Chloride Extended Release (ER) Oral Tablet Extended Release 20 MEQ. Give 1 tablet by mouth in the afternoon for electrolyte replacement related to Hypokalemia to be given after lunch start date 3/27/26 - medication not available 4/29/26.Potassium Chloride ER Oral Tablet Extended Release 20 MEQ. Give 1 tablet every day (QD) for electrolyte replacement start date 2/26/25 - medication not available 4/29/26. Resident #1's [DATE]/26 revealed the following:Potassium Chloride ER Oral Tablet Extended Release 20 MEQ.Give 1 tablet by mouth in the afternoon for electrolyte replacement related to Hypokalemia to be given after lunch start date 3/27/26 - medication not available 5/20/26.Potassium Chloride ER Oral Tablet Extended Release 20 MEQ. Give 1 tablet every day (QD) for electrolyte replacement start date 2/26/25 - medication not available 5/20/26.The clinical record's Progress Notes revealed the following:4/29/26 12:27 PM Potassium Chloride ER Oral Tablet Extended Release 20 MEQ. Give 1 tablet by mouth in the afternoon for electrolyte replacement related to Hypokalemia to be given after lunch medication on order.5/20/26 1:34 PM Potassium Chloride ER Oral Tablet Extended Release 20 MEQ. Give 1 tablet by mouth in the afternoon for electrolyte replacement related to Hypokalemia to be given after lunch - medication unavailable pharmacy notified.Potassium Chloride ER Oral Tablet Extended Release 20 MEQ. Give 1 tablet every day - medication not available, nurse and Director of Nursing (DON) notified. The clinical record lacked documentation of physician notification of medication unavailability. On 5/20/26 at 1:51 PM Staff Q stated there had been a lack of medication again for residents. The staff stated Resident #1's order for potassium had been faxed and the facility still did not have the medication. On 5/20/26 at 3:57 PM Resident #1 stated there had been a couple of instances where she did not receive all of her medications as they were not available. The resident stated some staff had spoken to her about it and told her the medication had not been ordered. The resident stated she could not remember the exact name of her medication as she took several of them. 2. Resident #16's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating intact cognition. The MDS included the diagnoses of hypertension, traumatic brain injury (TBI), and depression. The MDS revealed the resident received antidepressant, diuretic, opioid, hypoglycemic, and anticonvulsant medications during the last 7 days of the reporting period. The clinical record's Medical Diagnoses included diagnoses of personal history of TBI, essential hypertension, and depression.Resident #16's Care Plan, revised 4/29/26, revealed a problem area related to pain/discomfort and increased risk for injury from decreased function from TBI and history of skull/facial bone fractures and shingles revised on 8/5/25 with staff interventions of administer scheduled/PRN pain medications as ordered, attempt and document any non-pharmalogical interventions, and observe for side effects of narcotic medications (all initiated 8/5/25). Resident #16's [DATE]/26 revealed documentation had been completed that all medications were dispensed as ordered. Resident #16's [DATE]/26 revealed an order for Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG. Give 150 mg QD with documentation indicating the medication had been provided every day until the last date reviewed 5/26/26. On 5/19/26 at 2:45 PM Staff Q, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA), stated there had been multiple times when medications had not been available for residents. The staff stated she had notified Staff S, Previous Regional Clinical Director, of medications not being available. Staff Q stated a new process had been developed with the use of the medication stickers, placing in the ordering book, and marking when the pharmacy was faxed. On 5/20/26 at 1:51 PM Staff Q stated there had been a lack of medication again for residents. The staff stated she had borrow from the day shift to provide Resident #16's Wellbutrin as the night shift was out. 3. Resident #19's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The MDS Assessment documented diagnoses of hypertension, DM, hyperlipidemia, and depression. The document included the resident received 7 insulin injections, antidepressant, diuretic, antiplatelet, hypoglycemic, and anticonvulsant medications in the last 7 days of the reporting period. The clinical record's Medical Diagnoses included: other specified diabetes mellitus with diabetic neuropathy, unspecified (3/8/24), Type 2 DM with mild non- proliferative diabetic retinopathy without macular edema, unspecified eye (4/23/18), diverticulitis of intestine, part unspecified without perforation or abscess without bleeding (3/4/21), hyperlipidemia (4/23/18), and hypothyroidism (4/23/18).Resident #19's Care Plan, revised 4/30/26, revealed a DM problem area (revised 3/17/25) with staff interventions to provide with meal times, portion sizes, snacks, monitor/document signs/symptoms of high/low blood sugars, sliding scale as ordered, and observe for anti-diabetic medications. A problem area related to altered cardiovascular status and risk for shortness of breath, chest discomfort and diagnosis of hypokalemia (revised 4/28/26) with staff interventions for monitor/document/report PRN with signs/symptoms of altered vascular status, monitor PRN changes in lung sounds, and monitor sign/symptoms of changes of skin conditions (revised 4/28/26). A problem area related to hypothyroidism (revised 9/15/25) provided staff interventions to give thyroid replacement therapy as ordered and monitor for signs/symptoms of hypothyroidism (initiated 9/15/25). Resident #19's [DATE]/26 revealed the following:Levothyroxin Sodium Oral Tablet 175 MCG. Give 1 tablet QD related to hypothyroidism, unspecified start date 2/5/26 - medication not available on 4/22.Resident #19's [DATE]/26 revealed the following:Atorvastatin Calcium Oral Tablet 40 MG. Give 1 tablet QD related to hyperlipidemia, unspecified start date 6/10/25 - medication not available 5/11/26.Lactobacillus Oral Tablet. Give 1 tablet in the morning related to diverticulitis of intestine, part unspecified without perforation or abscess without bleeding, start date 1/29/26 - medication not available 5/13/26. The facility failed to document the medications not available, pharmacy, DON/charge nurse, and physician notification. On 5/19/26 at 2:45 PM Staff Q, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA), stated there had been multiple times when medications had not been available for residents. The staff stated she had notified Staff S, Previous Regional Clinical Director, of medications not being available. Staff Q stated a new process had been developed with the use of the medication stickers, placing in the ordering book, and marking when the pharmacy was faxed. On 5/21/26 at 1:20 PM Resident #19 stated he has had episodes in the past 2 months of medications not being available. The resident stated he was notified by nursing staff during medication administration of unavailability.On 6/1/26 at 4:45 PM Staff K, Current DON, acknowledged there had been a problem with the availability of medications. The staff stated if a medication was not available and was a prescribed medication the primary provider should be notified and documented. The staff stated if the medication was an over-the-counter medication, then she (current DON) should be notified so the medication could be purchased and provided to the resident. The facility's Medication Orders Policy, revised 12/12, revealed a current list of orders must be maintained in the clinical record of each resident, and orders must be written and maintained in chronological orders. The facility did not provide a policy specific to ordering/refilling medications.

Based on clinical record review, staff interviews, resident interview and policy review the facility failed to regulate a resident's medication to treat the resident's medical condition for 1 of 3 residents (Resident #16) reviewed. The facility failed to provide a current diagnosis for a narcotic medication. The facility reported a census of 32 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS included the diagnoses of traumatic brain injury (TBI), and other psychoactive substance abuse, uncomplicated. The MDS provided the resident did not receive scheduled pain medication or non-pharmalogical pain medication, but did receive as needed (PRN) pain medication during the last 5 days of the reporting period. The MDS revealed the resident received opioid medication during the last 7 days of the reporting period. The clinical record's Medical Diagnoses included a diagnosis of other psychoactive substance abuse, uncomplicated created 9/22/25. The Medical Diagnoses did not include a current diagnosis of shingles. Resident #16's Care Plan, revised 4/29/26, revealed a problem area related to pain/discomfort and increased risk for injury from decreased function from TBI and history of skull/facial bone fractures and shingles revised on 8/5/25 with staff interventions of administer scheduled/PRN pain medications as ordered, attempt and document any non-pharmalogical interventions, and observe for side effects of narcotic medications (all initiated 8/5/25). The facility's Physician Order document revealed an order for Tramadol HCI Tablet 50 mg by mouth every (Q) 6 hours as needed for pain PRN related to shingles with a date and time of 11/27/23 1:47 AM. Resident #16's Medication Administration Review (MAR) 4/26 revealed an order for Tramadol HCI 50 mg Q 6 hours PRN related to shingles - start date 11/27/23 with 33 doses provided during the month with no medication provided on 4/5, 4/17, and 4/30. Resident #16's [DATE]/26 revealed an order for Tramadol HCI 50 mg Q 6 hours PRN related to shingles - start date 11/27/23 with 21 doses provided until 5/25 at 9:07 PM with no medication provided on 5/1, 5/2, 5/4, 5/9, 5/11, 5/12, and 5/14. Review of Resident #16's Narcotic Count Sheet for Tramadol HCL 50 mg tablet revealed the following: 4/4/26 Amount Given 1, Amount Remaining 124/5/26 Amount Given 1, Amount Remaining 11 - MAR not documented 4/6/26 Amount Given 1, Amount Remaining 10 No discrepancies from 4/6 to 4/16/26 between the MAR and Narcotic Count Sheet.4/17/26 Amount Given 1, Amount Remaining 22 4/17/26 Amount Given 1, Amount Remaining 21 - MAR not documentedNo discrepancies from 4/17 to 4/30 between the MAR and Narcotic Count Sheet. 4/30/26 Amount Given 1, Amount Remaining 8 - MAR not documented5/1/26 Amount Given 1, Amount Remaining 7 - MAR not documented5/3/26 Amount Given 1, Amount Remaining 6 5/4/26 Amount Given 1, Amount Remaining 5 - MAR not documentedNo discrepancies from 5/5 to 5/8 between the MAR and Narcotic Count Sheet.5/9/26 No documentation on the Narcotic Count Sheet.5/10/26 Amount Given 1, Amount Remaining 0 5/11/26 Amount Given 1, Amount Remaining 29 - MAR not documented5/12/26 Amount Given 1, Amount Remaining 28 - MAR not documented5/13/26 Amount Given 1, Amount Remaining 27 5/14/26 Amount Given 1, Amount Remaining 26 - MAR not documentedThe clinical record's Progress Notes revealed the following entries:On 1/9/26 at 6:13 AM the order noted a drug interaction between Wellbutrin XL Oral Tablet Extended Release 24 hour 150 mg related to major depressive disorder, single episode, unspecified and Tramadol HCI Oral Tablet 50 mg related to shingles with moderate severity.On 1/28/26 at 10:06 PM resident requested Tramadol 50 mg and 2 Tylenol 500 mg for right leg discomfort. The resident provided a dose of Augmentin 500/125. The noted included observation of right anterior food was bright red, no pitting edema, right ankle and above to mid leg is dusky gray in color.On 3/8/26 at 10:57 PM the resident's BLEs were purple, red in color, turgor is good, tops of both feet were bright red, right foot has 2+ edema. The resident indicated pain 3/10 and requested PRN Tramadol 50 mg PRN and 2 Tylenol 500 mg PRN.On 3/31/26 at 11:10 AM resident required 2 Tylenol 500 mg and 1 Tramadol 50 mg for pain in BLE, rating pain a 3/10.On 4/19/26 at 10:50 PM resident requested 1Tramadol mg PRN and 2 Tylenol mg PRN for pain in bilateral lower extremities (BLE). The Progress Notes failed to provide documentation related to the treatment of shingles since 11/30/23 with the exception of entries related to the dispensing of Tramadol.The facility's Physician Nursing Home Visit document dated 11/5/23 at 11:20 AM revealed the resident expressed some boredom at the facility and wished he could have some more pain medications. The document included diagnoses of TBI and history of polysubstance abuse. The document disclosed the resident was not a good candidate for pain medications and would attempt non-pharmaceutical management of his pain. The facility's Consultant Pharmacist Recommendation to Physician dated 9/28/24 revealed the pharmacy request for discontinuation or lowering the order of PRN Tramadol with no justification provided by the physician other than no change to current medication. On 5/20/26 at 1:35 PM Resident #16 stated he took Tramadol for pain in his legs. On 6/1/26 at 4:45 PM Staff K, current Director of Nursing (DON, stated she was unable to find any signed pharmacy driven Gradual Drug Reduction (GDR) recommendations from the physician for the past year for Resident #16 regarding the use of Tramadol. The staff acknowledged she had read the documentation from the physician regarding the recommendation of not using pain medications dated 11/5/23 due to the diagnosis of polysubstance abuse. Staff K stated the use of a narcotic was not uncommon for the treatment of pain associated with shingles, but she was not aware of Resident #16's Tramadol order had a related diagnosis of shingles dated 11/27/23. Staff K stated the diagnosis needed to be current for the use of any medication. Staff K acknowledged she had become aware of discrepancies in documentation for individualized narcotic count sheets and the residents MARs. The facility's Controlled Substances Policy, revised 12/12, revealed the individual resident controlled count sheet must contain the date and time of medication administered and by whom. The document must also contain the number on hand of each controlled medication. The facility's Medication Orders Policy, revised 12/12, revealed Physician Orders/Progress Notes must be signed and dated every 30 days (may be changed to every 60 days after the first 90 days of the resident's admission). The document included PRN orders must include the type, route, dosage, frequency, strength, and reason for administration.

Based on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to provide snacks to 3 of 4 residents (Residents #8, #19, #20) who wanted to eat at non-traditional times or outside of scheduled meal service times. The facility reported a census of 32 residents.Findings include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS documented diagnoses of anemia, hypertension -high blood pressure (HTN), and diabetes mellitus (DM). The document included the resident during 6 of the last 7 days of the reporting period the resident received an injection and hypoglycemic medication. The Care Plan revised 4/29/26 revealed a problem area related to DM and risk for frequent infections, visual impairment, hyper/hypoglycemia revised on 3/17/25 with staff interventions including all concerns with DM to be addressed with the primary care physician (PCP), diabetes medications as ordered by PCP with monitoring and documented side effects and effectiveness, monitor/checks blood glucose levels as ordered, and snacks allowed. The clinical records titled Physician Orders contained an order for the resident to have a mid afternoon snack dated 10/4/23 at 3:30 PM. The clinical records Task Documentation for Snacks for the past 30 days (5/4 - 6/1/26) revealed the following:19 total entries for 13 days. 13 entries completed for times between 7:02 AM and 10:17 AM indicated snacks provided.6 entries for snacks provided between noon and evening meals. 0 entries for evening (after supper) snacks provided.The facility failed to offer and document that Resident #8 was offered snacks as per physician orders. On 5/21/26 at 10:20 AM Resident #8 stated she did not consistently get snacks as she needed due to her blood sugars and diabetes. The resident stated not receiving evening snacks was worse than not receiving afternoon snacks. The resident stated her concerns had been voiced to the Administrator and at Resident Council. 2. Resident #19's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The MDS Assessment documented diagnoses of HTN, DM, hyperlipidemia, and depression. The document included the resident received 7 insulin injections and hypoglycemic medications in the last 7 days of the reporting period. The clinical records titled Medical Diagnoses contained other specified diabetes mellitus with diabetic neuropathy and diverticulitis (inflammation or infection in the colon) of the intestine, part unspecified, without perforation or abscess without bleeding. Resident #19's Care Plan, revised 4/30/26, revealed a DM problem area (revised 3/17/25) with staff interventions to provide with meal times, portion sizes, snacks, monitor/document signs/symptoms of high/low blood sugars, sliding scale as ordered, and observe for anti-diabetic medications.The clinical records Task Documentation for Snacks for the past 30 days (4/29 - 5/24/26) revealed the following:21 total entries for 13 days.11 entries completed for times between 6:30 AM and 8:30 AM indicated snacks provided.1 entry for mid morning snack provided.8 entries for snacks provided between noon and evening meals.0 entries for evening snacks provided. On 5/21/26 at 1:20 PM Resident #19 stated he was supposed to get food 6 times/daily due to his diabetes and diverticulitis. The resident stated he never gets snacks in the morning between breakfast and lunch. The resident stated snacks were available in the afternoon. Resident #19 stated evening snacks and snacks on the weekend were not provided.3. Resident #20's MDS dated [DATE] revealed a BIMS score of 14/15 indicating normal cognition. The MDS documented diagnoses of HTN and DM. The document included during 7 of the last 7 days of the reporting period the resident received an insulin injection, took diuretic and hypoglycemic medications. The Care Plan revised 4/28/26 revealed a problem area for nutrition revised on 4/28/26 with interventions for staff including: notification to PCP signs of altered mental status, HTN, chest pain and signs of malnutrition. The Care Plan provided a problem area related to DM revised on 7/9/25 with interventions to provide medications as ordered, dietitian to follow nutritional regimen, observe for side effects and signs of hypo/hyperglycemia, and provide with meal times, dietary restrictions and snacks revised 7/2/25.The clinical records Task Documentation for Snacks for the past 30 days (5/4 - 6/2/26) revealed the following:78 total entries with documentation every day.25 entries documented as not applicable for snacks provided with times between 12:00 AM and 6:00 AM.3 entries documented as not applicable for snacks provided in the morning between breakfast and lunch.1 entry documented as not applicable for snacks provided in the afternoon between noon and evening meals.1 entry documented as not applicable for snacks provided in the evening.10 entries documented snacks provided between 6:00 AM and 10:30 AM.18 entries documented snacks provided between noon and evening meals. 19 entries documented snacks provided in the evening. 1 entry documented snacks not taken in the evening. On 5/21/26 at 1:35 PM Resident #20 stated concerns regarding inconsistent snacks in the evening and they had been discussed at Resident Council. The resident stated that the snack cart may be available in the hallway and he has to obtain his own snacks rather than staff delivering the snacks in the evening. Resident #20 stated snacks were not always available. On 5/27/26 at 11:28 AM Staff P, Previous Administrator, stated he was aware of the concerns regarding lack of evening snacks and had worked with staff to correct the problem. Staff P stated the facility provided the residents snacks around 2:30 PM and 7:30 PM. Staff P stated the facility did not provide morning snacks. On 5/27/26 at 12:50 PM Staff O, Certified Nursing Assistant (CNA), stated there had been times when it was difficult to get the snacks passed in the evenings due to the needs of the residents regarding toileting, fall risk and 2 staff required for transfers. The staff stated the evening staff try to deliver snacks while completing care and attending residents' needs. On 5/27/26 at 3:14 PM Staff T, CNA, stated there had been problems with snacks in the evening, but staff were trying their best to provide them in a timely manner. On 6/2/26 at 12:10 PM Staff K, current Director of Nursing (DON), stated staff should be providing snacks to residents. The staff expected snacks to be provided in the afternoons and evenings. When asked about documentation of snacks offered between the times of 6:00 AM and 8:00 AM, the staff stated she suspected staff were documenting what they planned to do rather than what had been completed. The facility provided document for meal times indicated the following:Breakfast served at 7:30 AM Lunch served at 12:00 PMDinner served at 5:30 PM The facility's Snacks (Between Meal and Bedtime) Serving Policy, undated, revealed the purpose was to provide the resident with adequate nutrition. The document contained steps for providing the resident snacks which included bringing the snacks into the resident's room and ensuring the resident was able to manage without further assistance. The document disclosed documentation should include date, time, amount of snack consumed, and refusals.

Based on review of previous Centers of Medicare and Medicaid Services (CMS) form 2567, staff interviews, and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 31 residents. Findings include:A review of the Department of Inspections, Appeals, and Licensing website revealed the facility had repeated deficient practices identified during complaint investigations and recertification surveys from 2/2/2024 to 12/8/2025. The repeated deficiencies cited include:-4/5/2024 during a complaint and incident investigation: 609 failure to report and 842 resident records-identifiable information,-7/24/2024 recertification survey and complaint investigation: 880 infection prevention and control,-9/11/2024 complaint and incident investigation: 584 safe/clean/comfortable/homelike environment, 609 failure to report, 842 resident records-identifiable information, 865 QAPI program/plan, disclosure/good faith attempt, and 880 infection prevention and control,-2/27/2025 complaint and incident investigation: 842 resident records-identifiable information, 865 QAPI program/plan, disclosure/good faith attempt, and 880 infection prevention and control,-4/10/2025 recertification survey and complaint survey: 865 QAPI program/plan, disclosure/good faith attempt, and 880 infection prevention and control,-10/21/2025 compliant and incident investigation: 677 ADL care provided for dependent residents,-12/8/2025 recertification survey, compliant and incident survey: 842 resident records-identifiable information, 865 QAPI program/plan, disclosure/good faith attempt.On 4/8/2026 at 11:20 AM the Administrator stated he started in the facility as their Interim Administrator in February this year. Stated he could only speak on what they have started working on as a Quality Assurance (QA) team since he started here. He plans to revamp QAPI. When asked what is completed after the facility receives their 2567 form from the State Agency (SA) he stated he would first review it, go through it with their QAPI team and individual departments to develop their plan of correction, review this information in their QAPI meetings initiate audits. The audits are important when working towards ensuring deficiencies are not repeated in further surveys. The audits have to put in place to see if they are effective. If they are not they will do an analysis and look at what can be done differently and look at it again.The facility provided a document titled Quality Assurance Performance Improvement (QAPI) updated 1/2/2025. The purpose of QAPI in our organization is to develop a culture of proactive leadership that solicits the input from employees in various departments, including contracted professionals, if indicated, as well as those we serve residents, resident representatives, and family members. Further, our purpose includes ongoing development of plans for improvement leading to systematic changes that support exceptional health care to seniors and operating excellence in every aspect of our business. The facility will use a broad range of sources when monitoring and gathering data. Sources of this data may include but will not be limited to: input from employees, residents, resident representatives, families and other (satisfaction surveys, grievances, etc ), adverse events-IDT review of risk management/quality conference: performance audit findings, survey findings (annual and complaint) and compliance findings and/or complaints. Findings will be reviewed by QAPI committee and compared with historical data, facility and company benchmarks and/or established targets to identify areas for improvement. Findings and action for the QAPI committee will be communicated following QAPI meetings and as often as deemed necessary to assure positive outcomes, through postings to relevant employees/departments, submission of QAPI plans to regional management team and all other methods as deemed necessary by QAPI committee.

Based on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to prevent neglect when Staff A refused to provide or delayed providing suctioning for Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck). Resident #34 stated Staff A, Licensed Practical Nurse (LPN) refused to suction him nearly nightly when he worked at the facility. The resident experienced psychosocial harm as evident by severe anxiety, fear of being unable to breath and dying. Staff A worked at the facility 9/17/25 - 11/12/25 on the overnight shift with the last day of training with a second nurse on 10/4/25. Schedule documented Staff A was the only nurse when working the overnight shift when scheduled. Resident #34 stated he would have to turn the call light on 3 or 4 times before Staff A would complete the suctioning. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 6, 2025 on December 3, 2025 at 11:15 a.m. The facility staff removed the immediacy of the IJ on December 4, 2025, and decreased the scope to G, through the following actions:a. All residents residing at the facility were interviewed to ensure they feel safe in their environment and free from abuse or exploitation on 12/3/25.b. All Department heads to include Administrator and DON were educated by the Director of Clinical Services to complete thorough investigations into all concerns brought to them including conducting root cause analysis to identify adequate and quantifiable interventions to prevent further abuse or exploitation 12/4/25.c. The DON and all staff nurses were immediately trained at the direction of the DCS on Tracheal Care and Suctioning to ensure competency in this skill. d. Administrator and DON were educated by the Director of Clinical Services on abuse policies to include timely reporting of all allegations of abuse and exploitation to the state agency as required on 12/4/25.The facility identified a census of 37 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #34 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. MDS also indicated Resident #34 had diagnoses of acute and chronic respiratory failure with hypoxia, functional quadriplegia and presence of tracheostomy.Review of Resident #34's EHR titled, Orders documented a physician's order with a start date of 8/7/25 for deep suctioning if needed with 4-5 passes if resident needs every 20 minutes as needed.Review of Resident #34's EHR titled, Medication Administration Records/Treatment Administration Records documented a physician's order with a start date of 8/7/25 for deep suctioning if needed with 4-5 passes if resident needs every 20 minutes as needed. Further review of MAR/TAR for the months of October and November of 2025 revealed no documentation of the order being utilized by Staff A. On 12/2/25 at 1:36 PM Resident #34 stated Staff A would refuse to suction his tracheostomy frequently. Resident #34 explained he had to call the Certified Nursing Assistants (CNA) 3 or 4 times before Staff A completed the suctioning. Resident #34 said it would cause severe anxiety when Staff A worked because Staff A would not suction when he felt he needed it. Resident #34 stated when his tracheostomy was not suctioned it felt like he could not breathe and was dying. Resident #34 stated he felt he was being neglected when Staff A did not suction when he requested it. Resident #34 acknowledged all of the overnight CNA staff knew Staff A would refuse to suction his tracheostomy. Resident #34 stated basically every night Staff A worked he would refuse to suction his tracheostomy. Resident #34 said Staff C, CNA and Staff B, CNA could speak about Staff A and that he did not come in and suction his tracheostomy when requested and would frequently refuse to suction his tracheostomy. Resident #34 stated it did not seem like Staff A knew what he was doing. On 12/2/25 at 9:34 AM Staff C stated Staff A refused to suction Resident #34 even when Resident #34 requested. Staff C explained Staff A would say he had just been in Resident #34's room. Staff C stated she looked at Resident #34's orders and Resident #34 had as needed orders for suctioning his tracheostomy. Review of text message sent to the DON by Staff C documented on 11/9/25 another nurse checked on Resident #34 because Staff A would not. Text message sent to the DON on 11/10/25 at 1:47 AM Resident #34 was asking to be suctioned again but Resident #34 said he wanted the DON and did not want to say it out loud and upset Staff A. DON replied via text. Tell Staff A he was the nurse on the floor.On 12/2/25 at 6:15 AM Staff F, CNA said Resident #34 would request medication or to be suctioned. Staff F stated it doesn't happen too often through the night. Staff F explained she worked with Staff A a couple of times. Staff F expressed one night, Resident #34 had requested to have his tracheostomy suctioned and Staff F told Staff A. Staff F stated Staff A's response was that he had just done it one hour prior and Staff A refused to go in and Staff A refused suction Resident #34's tracheostomy. Staff A said she called the DON and then the other nurse that was on duty (it was earlier in the evening) went in and suctioned Resident #34's tracheostomy.On 12/4/25 at 4:18 PM Staff B stated she was never in the room when Staff A completed tracheostomy cares for Resident #34. Staff B explained she would answer Resident #34's call light 2 or 3 times over a length of time and continue to tell Staff A before he completed the tracheostomy suctioning. Staff B stated Resident #34 would get angry sometimes when he wanted his tracheostomy suctioned because Staff A would not come to his room to suction him. Staff B said Resident #34 appeared more scared than mad most of the time when he requested his tracheostomy to be suctioned. Staff B explained refusal by Staff A to complete the tracheostomy suctioning occurred every time Staff A worked. Staff B restated Staff A refusing to complete suction when requested by Resident #34 and Resident #34 had to turn his light on 2-3 times with the CNA's telling Staff A that Resident #34's requests for his tracheostomy to be suctioned occurred every night Staff A worked.On 12/2/25 at 2:08 PM the DON stated she received a call on her cell phone asking how many times Resident #34 could be suctioned. The DON stated she forgot about the call but she had documented the call from the CNA (Staff F) somewhere. The DON explained sometimes Resident #34 obsessed over his tracheostomy suctioning and it is the one thing Resident #34 had control of in his life. The DON explained Resident #34 had been suctioned but the aide wanted to know how often Resident #34 could be suctioned. The DON said the call occurred in the evening between 6:00 pm and 10:00 pm and there also was a 2nd nurse (Staff O) at the facility. The nurse that was working with Staff A that evening that completed the suctioning was Staff O, LPN. The DON stated Staff O left at 10 PM and she contacted Staff O to see if there were any issues. The DON elaborated that Staff O explained Resident #34 was fine. The DON explained Staff O checked on Resident #34 because Staff A was doing something with another resident. The DON stated she came in according to the master schedule on 11/9/25 at 11:00 PM or 11:30 PM. The DON explained she frequently came into work on the overnight shift. The DON said any time the staff reaches out to her with questions or concerns she would come to the building and that she did not go to the facility because Resident #34 had requested to be suctioned at that time. The DON said she was at the building so she might as well make an observation of Staff A while he completed tracheostomy suctioning on Resident #34. The DON stated Staff A spoke to Resident #34 that night and explained to Resident #34 why Staff A was there. The DON stated Staff A did an excellent job with the task. The DON stated Resident #34 would request to be suctioned a couple times during the night. The DON explained Staff F did not have any concerns with Resident #34 not being suctioned enough. The DON stated she thought that Staff F just wanted to know for her own information about suctioning. The DON stated no staff had brought to her any concerns about Staff A's treatment of Resident #34. The DON stated she asked Resident #34 pretty routinely about concerns and Resident #34 was not one that was shy about saying anything. The DON stated Resident #34's grandmother would also let them know about concerns. The DON stated if staff reported any concerns with residents she would investigate. Review of document provided by the DON dated 11/9/25 documented the DON received a call from Staff F asking how many times Resident #34 could be suctioned. The DON explained Resident #34's orders to her and questioned if there was a concern. Staff F voiced she was asking because Resident #34 had requested to be suctioned frequently and had requested Staff A. The DON attempted to contact Staff A but was told he was busy at the moment. Staff O in the facility at the time. DON contacted her to see if there was an issue. Staff O stated she had just come from Resident #34's room and there were no issues. The DON arrived at the building and shadowed Staff A the rest of the shift. The DON stated Staff A was observed suctioning Resident #34 without issues. No concerns with Staff A's ability to perform his job duties at that time. On 12/8/25 at 12:00 PM the DON explained Staff A was in training until 10/4/25. The DON acknowledged Staff A's first day on the overnight shift by himself from 10:00 PM - 6:00 AM was on 10/5/25. Review of document titled, Staff A's payroll provided by the Administrator documented Staff A worked the overnight shift on 10/5, 10/6, 10/7, 10/9, 10/13, 10/15, 10/19, 10/22, 10/24, 10/26, 10/27, 10/29, 10/30, 11/4, 11/8, 11/9 and 11/11.Review of Resident #34's EHR titled, Census documented Resident #34 was out of the facility 9/29 - 10/6 and 10/15 - 10/20.On 12/4/25 at 7:59 AM Staff A, LPN stated he started working at the facility a couple months ago. Staff A stated he was terminated 11/12/25. Staff A acknowledged that he worked the overnight shift from 6:00 PM - 6:00 AM. Staff A explained he had to suction a tracheostomy while at the facility as part of his job duties. Staff A said Resident #34 had a tracheostomy. Stated he worked from 6pm - 6AM. Staff A stated he did not usually have a second nurse on his shift. Staff A stated he had to suction Resident #34 a lot during his shift. Staff A said he would suction Resident #34 multiple times a night, sometimes every hour. Staff A explained he would suction Resident #34's tracheostomy at least 2 or 3 times before he went to sleep. Staff A revealed Resident #34's suction order was as needed. Staff A said he did not recall having to sign out the suctioning on the MAR. Staff A said Resident #34 did not have an order for suctioning. Staff A explained he would stop in and ask Resident #34 if he needed to be suctioned. Staff A stated the CNA's would come and tell him that Resident #34 needed suctioned on the overnight shift all the time. Staff A stated he would go and suction Resident #34 immediately unless he was in the middle of something and then would go suction right afterwards. Staff A stated the CNA never had to come and remind him multiple times to suction Resident #34. Staff A revealed he never refused to suction Resident #34. Staff A stated Resident #34 had never died on him and Resident #34 could breathe. Staff A elaborated he never had to be told twice to suction Resident #34. Staff A stated Resident #34 would panic and whip himself up into a frenzy. Staff A stated at times when Resident #34 had to be suctioned; he did appear to have anxiety. Staff A acknowledged the DON came in on her own late at night one time to make an observation. Staff A said the DON stated she was worried about what was going on at the facility. Staff A revealed he thought one of Resident #34's family members, possibly the grandmother had called the DON and told her that he was not suctioning Resident #34 when it was requested. Staff A stated Resident #34 never went more than a few minutes after requesting to be suctioned. Staff A said he worked 3 nights a week but not a set schedule. Review of policy updated 7/8/24 titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy documented all Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in personal degradation* including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances: Neglect of a dependent adult. Neglect of a dependent adult means deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult's life or physical or mental health.

Based on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to investigate the allegation of neglect, failed to separate Staff A, Licensed Practical Nurse (LPN) from Resident #34 and failed to take corrective actions to prevent further abuse/neglect of Resident #34. Resident #34 stated Staff A would refuse to provide or delayed providing suctioning to Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck) frequently. Resident #34 explained he would have to call the Certified Nursing Assistants (CNA's) with the call light 3 or 4 times before his tracheostomy would be suctioned by Staff A. Staff A worked at the facility from 9/17/25 - 11/12/25 on the overnight shift with the last day of training with a second nurse on 10/4/25. Schedule documented Staff A was frequently the only nurse who worked the overnight shift when scheduled. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 6, 2025 on December 3, 2025 at 11:15 a.m. The facility staff removed the immediacy of the IJ on December 4, 2025, and decreased the scope to D, through the following actions:a. Remove any staff implicated in abuse or failure to report from resident care immediately. Increase supervision and monitoring in all care areas.b. Ensure residents identified at risk are protected and monitored. Resident #34 was interviewed on 12/3/2025 to ensure the resident felt safe and cared for. c. All staff were educated on reporting allegations of abuse and exploitation to the Administrator (Abuse coordinator) or DON if abuse coordinator is absent immediately as well as immediate separation of alleged victim and perpetrator on 12/3/25 or before their next shift.d. All staff including the Administrator, DON and ADON were educated on Residents Rights.The facility identified a census of 37 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #34 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. MDS also indicated Resident #34 had diagnoses of acute and chronic respiratory failure with hypoxia, functional quadriplegia and presence of tracheostomy.Review of Resident #34's EHR titled, Orders documented a physician's order with a start date of 8/7/25 for deep suctioning if needed with 4-5 passes if resident needs every 20 minutes as needed.Review of Resident #34's EHR titled, Medication Administration Records/Treatment Administration Records documented a physician's order with a start date of 8/7/25 for deep suctioning if needed with 4-5 passes if resident needs every 20 minutes as needed. Further review of MAR/TAR for the months of October and November of 2025 revealed no documentation of the order being utilized by Staff A. On 12/2/25 at 1:36 PM Resident #34 stated Staff A would refuse to suction his tracheostomy frequently. Resident #34 explained he had to call the Certified Nursing Assistants (CNA) 3 or 4 times before Staff A completed the suctioning. Resident #34 said it would cause severe anxiety when Staff A worked because Staff A would not suction when he felt he needed it. Resident #34 stated when his tracheostomy was not suctioned it felt like he could not breathe and was dying. Resident #34 stated he felt he was being neglected when Staff A did not suction when he requested it. Resident #34 acknowledged all of the overnight CNA staff knew Staff A would refuse to suction his tracheostomy. Resident #34 stated basically every night Staff A worked he would refuse to suction his tracheostomy. Resident #34 said Staff C, CNA and Staff B, CNA could speak about Staff A and that he did not come in and suction his tracheostomy when requested and would frequently refuse to suction his tracheostomy. Resident #34 stated it did not seem like Staff A knew what he was doing. On 12/2/25 at 9:34 AM Staff C stated Staff A refused to suction Resident #34 even when Resident #34 requested. Staff C explained Staff A would say he had just been in Resident #34's room. Staff C stated she looked at Resident #34's orders and Resident #34 had as needed orders for suctioning his tracheostomy. Staff C explained she reported to the Director of Nursing (DON) verbally, face to face and by text. Staff C repeated she notified the DON.Review of text message sent to the DON by Staff C documented on 11/9/25 another nurse checked on Resident #34 because Staff A would not. Text message sent to the DON on 11/10/25 at 1:47 AM Resident #34 was asking to be suctioned again but Resident #34 said he wanted the DON and did not want to say it out loud and upset Staff A. DON replied via text. Tell Staff A he was the nurse on the floor.On 12/2/25 at 6:15 AM Staff F, CNA said Resident #34 would request medication or to be suctioned. Staff F stated it doesn't happen too often through the night. Staff F explained she worked with Staff A a couple of times. Staff F expressed one night, Resident #34 had requested to have his tracheostomy suctioned and Staff F told Staff A. Staff F stated Staff A's response was that he had just done it one hour prior and Staff A refused to go in and Staff A refused suction Resident #34's tracheostomy. Staff A said she called the DON and then the other nurse that was on duty (it was earlier in the evening) went in and suctioned Resident #34's tracheostomy.On 12/4/25 at 4:18 PM Staff B stated she was never in the room when Staff A completed tracheostomy cares for Resident #34. Staff B explained she would answer Resident #34's call light 2 or 3 times over a length of time and continue to tell Staff A before he completed the tracheostomy suctioning. Staff B stated Resident #34 would get angry sometimes when he wanted his tracheostomy suctioned because Staff A would not come to his room to suction him. Staff B said Resident #34 appeared more scared than mad most of the time when he requested his tracheostomy to be suctioned. Staff B explained refusal by Staff A to complete the tracheostomy suctioning occurred every time Staff A worked. Staff B stated the concern was brought up to the DON. Staff B restated Staff A refusing to complete suction when requested by Resident #34 and Resident #34 had to turn his light on 2-3 times with the CNA's telling Staff A that Resident #34's requests for his tracheostomy to be suctioned occurred every night Staff A worked.On 12/2/25 at 2:08 PM the DON stated she received a call on her cell phone asking how many times Resident #34 could be suctioned. The DON stated she forgot about the call and she documented the call from the CNA somewhere. The DON explained sometimes Resident #34 obsessed over his tracheostomy suctioning. The DON stated it is the one thing Resident #34 had control of his life. The DON explained the CNA's was Staff F. The DON explained Resident #34 had been suctioned but wanted to know how often Resident #34 could be suctioned. The DON said the call occurred in the evening between 6:00 pm and 10:00 pm and there was a 2nd nurse at the facility on a medication cart. The nurse that was working with Staff A that evening that completed the suctioning was Staff O, LPN. The DON stated Staff O left at 10 PM and she contacted Staff O to see if there were any issues. The DON elaborated that Staff O explained Resident #34 was fine. The DON explained Staff O checked on Resident #34 because Staff A was doing something with another resident. The DON stated she came in according to the master schedule on 11/9/25 at 11:00 PM or 11:30 PM. The DON explained she frequently came into work on the overnight shift. The DON said any time the staff reaches out to her with questions or concerns she would come to the building. The DON stated she did not go to the facility because Resident #34 had requested to be suctioned at that time. The DON said she was at the building so she might as well make an observation of Staff A while he completed tracheostomy suctioning on Resident #34. The DON stated Staff A spoke to Resident #34 that night and explained to Resident #34 why Staff A was there. The DON stated Staff A did an excellent job with the task. The DON stated Resident #34 would request to be suctioned a couple times during the night. The DON explained Staff F did not have any concerns with Resident #34 not being suctioned enough. The DON stated she thought that Staff F just wanted to know for her own information about suctioning. The DON stated no staff had brought to her any concerns about Staff A's treatment of Resident #34. The DON stated she asked Resident #34 pretty routinely about concerns and Resident #34 was not one that was shy about saying anything. The DON stated Resident #34's grandmother would also let them know about concerns. The DON stated if staff reported any concerns with residents she would investigate. Review of document provided by the DON dated 11/9/25 documented the DON received a call from Staff F asking how many times Resident #34 could be suctioned. The DON explained Resident #34's orders to her and questioned if there was a concern. Staff F voiced she was asking because Resident #34 had requested to be suctioned frequently and had requested Staff A. The DON attempted to contact Staff A but was told he was busy at the moment. Staff O in the facility at the time. DON contacted her to see if there was an issue. Staff O stated she had just come from Resident #34's room and there were no issues. The DON arrived at the building and shadowed Staff A the rest of the shift. The DON stated Staff A was observed suctioning Resident #34 without issues. No concerns with Staff A's ability to perform his job duties at that time. Review of the clinical record revealed the record lacked a thorough investigation of the allegations of neglect to Resident #34 by Staff A. On 12/8/25 at 12:00 PM the DON explained Staff A was in training until 10/4/25. The DON acknowledged Staff A's first day on the overnight shift by himself from 10:00 PM - 6:00 AM was on 10/5/25. Review of document titled, Staff A's payroll provided by the Administrator documented Staff A worked the overnight shift on 10/5, 10/6, 10/7, 10/9, 10/13, 10/15, 10/19, 10/22, 10/24, 10/26, 10/27, 10/29, 10/30, 11/4, 11/8, 11/9 and 11/11/25.Review of Resident #34's EHR titled, Census documented Resident #34 was out of the facility 9/29 - 10/6 and 10/15 - 10/20/25.On 12/4/25 at 7:59 AM Staff A, LPN stated he started working at the facility a couple months ago. Staff A stated he was terminated 11/12/25. Staff A acknowledged that he worked the overnight shift from 6:00 PM - 6:00 AM. Staff A explained he had to suction a tracheostomy while at the facility as part of his job duties. Staff A said Resident #34 had a tracheostomy. Stated he worked from 6pm - 6AM. Staff A stated he did not usually have a second nurse on his shift. Staff A stated he had to suction Resident #34 a lot during his shift. Staff A said he would suction Resident #34 multiple times a night, sometimes every hour. Staff A explained he would suction Resident #34's tracheostomy at least 2 or 3 times before he went to sleep. Staff A revealed Resident #34's suction order was as needed. Staff A said he did not recall having to sign out the suctioning on the MAR. Staff A said Resident #34 did not have an order for suctioning. Staff A explained he would stop in and ask Resident #34 if he needed to be suctioned. Staff A stated the CNA's would come and tell him that Resident #34 needed suctioned on the overnight shift all the time. Staff A stated he would go and suction Resident #34 immediately unless he was in the middle of something and then would go suction right afterwards. Staff A stated the CNA never had to come and remind him multiple times to suction Resident #34. Staff A revealed he never refused to suction Resident #34. Staff A stated Resident #34 had never died on him and Resident #34 could breathe. Staff A elaborated he never had to be told twice to suction Resident #34. Staff A stated Resident #34 would panic and whip himself up into a frenzy. Staff A stated at times when Resident #34 had to be suctioned; he did appear to have anxiety. Staff A acknowledged the DON came in on her own late at night one time to make an observation. Staff A said the DON stated she was worried about what was going on at the facility. Staff A revealed he thought one of Resident #34's family members, possibly the grandmother had called the DON and told her that he was not suctioning Resident #34 when it was requested. Staff A stated Resident #34 never went more than a few minutes after requesting to be suctioned. Staff A said he worked 3 nights a week but not a set schedule. Review of policy updated 7/8/24 titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy documented all Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in personal degradation* including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances: Neglect of a dependent adult. Neglect of a dependent adult means deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult's life or physical or mental health. Should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the Administrator must be notified immediately. (If the Administrator is on vacation, then a designee must be named as the temporary Abuse Coordinator until the Administrator returns) The Administrator will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. The Administrator will review documentation in the resident record (including review of assessment if resident injury). Assess the resident for injury if the allegation involves physical or sexual abuse. Provide proper notifications to the primary care provider, responsible party, etc. Attempt to obtain witness statements (oral and/or written) from all known witnesses. If there is physical evidence that can be preserved, attempt to do so, and maintain it in a safe location to minimize risk of evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation.

Based on staff interviews, provider interview, hospital reports and clinical record review the facility failed to ensure that residents received accurate and timely assessment and intervention for 1 of 2 residents reviewed (Resident #1). Early in November 2025, Resident #1 was found to have a Urinary Tract Infection (UTI) and was put on an antibiotic. He continued to be febrile (elevated temperature) off and on throughout the month. Staff failed to provide timely and consistent assessments to include vital signs, and failed to contact the doctor with continued fever. On December 1, 2025, Resident #1 was admitted to the hospital with urosepsis (severe life threatening infection in the blood that originated from a UTI). The facility reported a census of 37 residents. Findings include:The Minimum Data Set (MDS) dated [DATE], showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) He was totally dependent on staff for dressing, eating, hygiene, transfers and toileting. The resident had an indwelling catheter and tube feedings. His diagnoses included urinary tract infection in last 30 days, diabetes mellitus, aphasia (difficulty speaking), cerebrovascular accident (CVA/stroke), and hemiplegia (paralysis one side of the body). The Care Plan for Resident #1, updated on 11/14/25, showed that he had the potential for infection related to history of UTI. Staff were to monitor daily for dehydration, pain/discomfort and report to the physician. Staff were directed to monitor temperature, pulse during active administration of antibiotics report signs of sepsis, rapid breathing, heart rate, shortness of breath, extreme pain, fever/shivering. According to the Medication/Treatment Administration Record (MAR/TAR), Resident #1 was put on an antibiotic; Cefpodoxime Proxetil, 100 milligrams (mg) two times a day for UTI started on 11/6/25 at 8:00 PM and the treatment was completed on 11/17/25 at 9:53 AM. The following documentation was found in the Nursing Progress Notes (NPN) and the Vitals Tab (VT) of the electronic chart: a. NPN: on 11/6/25 at 1:30 PM readmitted to the facility from the hospital b. On 11/7/25, 11/10 and 11/11 the chart lacked vitals in the VT or NPN c. NPN: on 11/12/25 at 3:24 AM, T 99.7 and Tylenol was given. d. VT: on 11/12 at 8:51 PM, T 99.2 (the chart lacked follow up temperature check) e. On 11/13/25, the chart lacked any vitals in the VT or NPN.f. NPN: On 11/14 at 9:55 AM, T 100.2 and Tylenol was giveng. VT: on 11/14 at 8:03 PM, T 99.4 the chart lacked documentation of follow up assessment. h. NPN: on 11/15 at 11:55 PM 100.2 i. VT: 11/16 at 8:23 PM, T 96.0j. 11/17/25 chart lacked vitalsk. NPN: 11/18 at 8:24 PM, T 100.1l. 11/19/25 chart lacked vitalsm. VT: 11/20 at 8:04 PM. T 98 tempn. NPN: 11/21 at 6:52 PM, T 100.7 Tylenol giveno. NPN: 11/21 at 10:00 PM, T 99.2p. 11/22 the chart lacked vitals. q. NPN: 11/22 at 9:33 PM left arm swollen, elevated on pillowr. VT: 11/23 at 4:53 PM, T 98.2s. 11/25, chart lacked vitals t. 11/27, chart lacked vitals u. VT: on 11/28 at 7:21 PM, T 98 v. NPN: on 11/29 at 4:30 AM, T 102 w. VT: on 11/30 at 6:28 PM, T 99.0 x. NPN: on 12/1 at 2:30 AM, T 102, edema, called the doctory. VT: on 12/1/25 at 3:06 AM, T 102 From 11/6/25 through 11/30/25, the chart lacked documentation that the doctor had been contacted regarding the on-going fever. A hospital report progress note for Resident #1, dated 12/1/25, showed that the chief complaint upon admission was; infection and fever. The Assessment and Plan included: 1. Multifocal bilateral pulmonary infiltrates, questionable pneumonia. 2. Urinary tract infection. On 12/2/25 at 6:15 AM, Staff F, Certified Nurse Aide (CNA) said that Resident #1 was running a Temperature (T) for several nights and she told Staff A, Licensed Practical Nurse (LPN) that the resident could use a medication for the fever, but Staff A refused to give the resident a Tylenol because babies run that temp. Staff F said that this was shortly before the resident had been sent to the hospital. The Discharge Summary from the hospital, dated 12/4/25 at 3:43 PM, showed that the Emergency department findings included urine analysis with three plus bacteria and epithelial cells present. Xray showed multifocal bilateral pulmonary infiltrates. He was admitted for management of UTI and pneumonia. Hospital Course: admitted with sepsis due to UTI. He was treated with multiple antibiotics, however, he did not improve, likely due to multiple comorbidities. The family made the decision to for-go further lifesaving treatment and make him comfortable. Transferred back to nursing home on hospice care. On 12/8/25 at 9:09 AM, Staff G, Licensed Practical Nurse (LPN) said she came in on a Sunday and had taken the blood sugar for Resident #1 and noticed increased edema. She said she took his temp and he was a-febrile with a lower blood pressure and his lungs sounded like he had phlegm stuck. He didn't seem in distress and she passed it onto the next shift. She did not get anything reported to her at shift change that he'd been having high temps. On 12/8/25 at 7:51 AM, Staff E, Registered Nurse (RN) said that she was told that Resident #1 had a stroke that caused brain stem damage, so he wasn't having normal temp control. She didn't see this information on any of his paperwork, but that was what the other nurses were saying. She remembered that Resident #1 was having temps around 99 and his skin looked okay. She had given him some Tylenol several times. Staff E said that she had him sent to the hospital, when his temperature got up to 102. She said that the prior nurse had reported that he had edema, and she became concerned that he could have been septic. Staff E said that the expectation was to provide full assessments at least twice a day because Resident #1 he was on skilled care. On 12/8/25 at 9:15 AM, the Primary Care Physician (PCP) said that he thought that Resident #1 had gone to the hospital with the diagnoses of UTI and pneumonia. The PCP remembered that the resident had been on an antibiotic early in November for a UTI but he was not aware that the resident continued to have high temperatures on and off before the hospitalization. The PCP looked through the notes for Resident #1, and saw that he had been contacted on [DATE]th with a concern of high blood pressures. That was right around the time they started him on an antibiotic for a UTI. The PCP said that he was contacted about some blood sugars and for authorization for skilled services, but did not see any communication about high temperatures until [DATE]/[DATE]st. He said that he would have liked to know about continued high temps so they could have done repeat labs or urine cultures. The PCP said that it could possibly have made the difference in the outcome of the resident having to go to the hospital. The doctor was not aware of any brain injury that Resident #1 had that would cause him to have continued higher temperatures. On 12/08/2025 at 2:29 PM, the Director of Nursing (DON) said that when a resident had an infection, the staff should have been taking at least a temp per shift, and they should have notified the doctor of elevated temps. Facility policy titled: Notification of Change The purpose of the policy was to ensure the facility promptly informed resident, consults with resident's physician when there was a change requiring notification. Clinical complication defined examples include recurrent UTIs. The facility must inform the resident, consults with the resident's physician when there was a change requiring notification. Circumstances requiring notification include significant change in the resident physical condition including clinical complications. The facility's Notification of Changes Policy, revised 2025, to ensure the facility promptly consults with the resident's physician and notify the resident's representative when there is a change requiring notification.

Based on observations, electronic medical record (EMR) reviews, staff interviews, and facility policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents (Resident #22) reviewed, requiring the use of oxygen and nebulizer treatments. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #22 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating normal cognition. The document revealed diagnoses of dependence on supplemental oxygen, diabetes mellitus, anxiety disorder, depression, chronic obstructive pulmonary disease (COPD) and respiratory failure. The document disclosed the resident received oxygen therapy, and was prescribed antidepressant, diuretic, antiplatelet and hypoglycemic medications. Resident #22's Care Plan dated 11/3/25 contained a problem area with continuous use of oxygen and was at risk for alterations in oxygen levels due to COPD, asthma and obstructive sleep apnea revised 4/23/25. The identified goal was to remain free from signs/symptoms of respiratory infections through the next review revised 11/3/25 with a target date of 1/19/26. Interventions for staff to follow included: give medications as ordered by physician with monitoring for side effects and effectiveness, history of noncompliance with using oxygen while ambulating, oxygen settings via nasal cannula as ordered and monitoring for signs/symptoms of respiratory distress and report to physician with initiation date of 4/23/25. A problem of altered respiratory status with a history of respiratory failure and risk for respiratory rate increases/decreased, nose flaring, grunting, sweating, wheezing, color changes, continuous oxygen and diagnoses of COPD, asthma and obstructive sleep apnea. The goal area showed no signs of respiratory failure/distress revised on 11/3/25 with a target date of 1/19/26. Interventions for staff to follow included administration of medications as ordered with monitoring of effectiveness and side effects, administration of medications/puffers as ordered with monitoring of effectiveness and side effects, oxygen via nasal cannula as ordered, monitor/document an signs/symptoms of respiratory distress to physician and monitor/document any abnormal breathing patterns to physician all dated 4/23/25. A problem area identified a diagnosis of COPD and risk for shortness of breath, impaired breathing and respiratory infections revised on 4/23/25. The goal related to the problem was to maintain adequate air exchange daily with no signs/symptoms of distress with a revision date of 11/3/25 and target date of 1/19/26. The interventions identified included administration of medications/puffers as ordered with monitoring for effectiveness and side effects, administration of supplemental oxygen as ordered by physician, monitor for signs/symptoms of acute respiratory insufficiency and monitor for signs of respiratory infections/distress, adventitious lung sounds, shortness of breath, coughing and elevated temperature with notification to the physician - all initiated 4/23/25.Resident #22's Clinical Physician Orders included the following orders:-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml 1 vial inhale 3 times/day. -Oxygen 3 L continuous every shift related to COPD. Observed on 12/1/25 at 1:13 PM Resident #22 walking down the hallway pulling an E-tank using a nasal cannula for supplemental oxygen. The resident walked into her room, took the cannula off and continued to her bed. The resident stated she was having increased difficulties with her breathing this week. Observed the resident reach over to the bedside table, obtain a nebulizer mask, place it on her face and turn the machine on. The resident then stopped and stated did that wrong, removed the mask, obtained Albuterol solution from the bedside table, opened the vial, put it in the medicine cup, and placed the mask back on her face. The Electronic Medical Record (EMR) Progress Notes revealed a Nurse's Note on 12/3/25 at 12:01 PM that at 11:00 AM Resident #22 was complaining of an increase in shortness of breath with oxygen saturations of 85% with 3 L oxygen via nasal cannula. The note further contained lung sounds revealed rubs in the upper lobes and the resident was very lethargic. An order was received for transport to the hospital via ambulance. A Nurse's Note on 12/3/25 at 2:41 PM disclosed Resident #22 was admitted for COPD exacerbation. A General Progress Note on 12/4/25 at 11:06 AM revealed the resident was returning to the facility with continuation of oxygen per previous orders, the resident was provided Levofloxacin (antibiotic) via IV, and will have a new diabetic medication, Zituvimet. The Hospital Discharge Summary revealed Resident #22 was brought to the Emergency Department on 12/3/25. The resident presented with a one-week history of worsening dyspnea and productive cough with thick mucus shortness of breath with subjective fevers associated with hot and cold sensations. The document indicated the resident was given DuoNeb treatment and Solu-Medrol (Methylprednisolone Sodium Succinate) in the Emergency Department. The resident was admitted with a diagnosis of COPD with acute exacerbation. The resident was also treated with Levofloxacin 750 mg during her hospitalization. The EMR did not contain an assessment for self administration of medications. The Clinical Physician Orders did not contain an order for the resident to self administer her medications or manage her own oxygen. On 12/3/25 at 4:15 PM Staff H, Certified Medication Aide, stated Resident #22 did have a nebulizer treatment. The staff stated she would provide the resident with her Albuterol vial and let the resident set it up herself when she was ready. Staff H stated she recognizes she is not supposed to do that but the resident is very independent. On 12/3/25 at 4:25 PM Staff Z, Licensed Practical Nurse (LPN) stated Resident #22 did have a nebulizer treatment. The staff stated she would put the Albuterol in the medication cup of the nebulizer and let the resident turn it on when she was ready. On 12/3/25 at 4:30 PM Staff AA, CMA, stated she would set the nebulizer up for the resident by putting the Albuterol in the medication cup and if the resident wasn't ready for the medication she would leave it for the resident to complete when she was ready. On 12/8/25 at 10:15 AM the Director of Nursing (DON) stated she expected the nurses and/or CMAs to provide medications as ordered. The DON stated Resident #22's Albuterol should not be left for the resident to administer herself. The DON stated Resident #22's nebulizer should not be set up and left for the resident to turn on herself. The DON stated the facility did have an assessment for self administration of medication but Resident #22 did not have this. The DON acknowledged Resident #22 was admitted to the hospital for COPD exacerbation and self administration of a medication that was not prescribed as self administration could be a contributing factor.On 12/8/25 at 5:17 PM the physician stated he could not envision Resident #22 self administering her nebulizer treatments. The physician stated the resident could be extremely difficult. The physician stated there should be better documentation on medication administration. The physician stated if an assessment were given for self administration of medication, the assessment would say she could. However the physician stated he was unsure if she actually would give herself the medication as prescribed. The physician stated it would be much better if the nursing staff set up the nebulizer treatment and started it when the resident was ready for it rather than leaving it for the resident to self administer.The facility's Medication Therapy Policy, revised 4/07, revealed medication orders will be supported by appropriate care processes and practices. It further stated medication use shall be consistent with an individual's condition, prognosis and responses to treatments. The facility's Medication Orders Policy, dated 2025, disclosed medications should be administered only under the order of a person lawfully authorized to prescribe.

Based on observation, record review, policy, and staff interviews, the facility failed to prevent physical and verbal abuse of Resident #2 and Resident #5. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The investigation revealed the same CNA had a history of verbally and physically abusing Resident #2 and Resident #5 without being separated. This failure resulted in residents living at the facility exposed to the actual abuse and the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 26, 2024 on September 8, 2024 at 11:30 a.m The facility staff removed the IJ on September 8, 2024 through the following actions: -Resident and staff interviews to determine any unreported incidence of abuse conducted on 8/28-29/24. -All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation on 8/28-29/24 and continuing 9/8/24 with all employees being educated on the abuse policy prior to working with residents. -The Administrator has been identified as the Abuse Coordinator and signage for phone number/contact for 24/7 reporting has been placed conspicuously in the facility. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS assessment also indicated Resident #2 required substantial / maximal assistance with dressing and undressing the upper and lower body. Review of Resident #2's electronic health record (EHR) titled, Weekly Skin Assessment-V5 dated 8/27/24 at 3:55 PM documented by Staff D, Licensed Practical Nurse (LPN) 3 bruises to the chest. Bruising measured 2 cm x 2 cm, 4 cm x 3 cm, and 1 cm x 1.5 cm. Review of the facility provided incident report dated 8/25/24, completed by the Administrator revealed as the Administrator was interviewing staff regarding another incident with Resident #2, it was reported that Staff U had stated to Resident #2 don't f-ing hit me. I'll never take care of you again. when Resident #2 had hit Staff U on the side kinda in her back. The Administrator was not able to interview Resident #2 due to her mental status. Resident #2's BIMS is 3/15. The Administrator focused on interviewing Certified Nurses Assistants (CNA) that would have worked with Resident #2 and employees, as well as other staff. Random resident interviews reflected no issues regarding being verbally threatened by a staff member or another resident. Random staff interviews reflected some had no concerns with employees being verbally abusive to residents. Others mentioned Staff U and how she talks to residents, threatening to hit the residents when they hit her during care. The Administrator could substantiate that verbal abuse had occurred, but not the specific dates due to interview comments. Review of the facility provided incident report with incident date of 8/27/24, completed by the Administrator revealed it was noted that Resident #2 had 3 fingertip bruises to her chest when staff were getting her up on 8/27/24. The Administrator focused on interviewing staff that worked from Sunday, (8/25) to Tuesday, (8/27) to address if they worked with Resident #2 and, if so, what date, in what capacity, did they provide care to Resident #2 or assist with cares, if assisting who did they assist, did they notice any bruises, and if they noticed any bruises who and when did they report it. Staff D, Licensed Practical Nurse (LPN) was given a report of bruising and thought she would address the bruising with Resident #2's skin assessment that was due on 8/27/24. When Staff D went to do a skin assessment, she stopped the minute she saw the fingerprint type bruising and asked the DON to come with her to complete the skin assessment. Employees interviewed had not seen the bruising until the morning of 8/27/24 when getting resident up for the day. Staff M left a statement under the Administrators door on 8/27/24 because she worked after the Administrator left, stating that Staff U had pushed Resident #2 down in her chair after changing her. Staff M stated that Staff U had aggressively pulled Resident #2 down into her chair from the shoulder area. Based on staff members' interviews the facility could substantiate that physical abuse occurred as Resident #2 had fingerprint bruises and Staff M witnessed Staff U pull Resident #2 down into her chair. This is most likely caused due to resident diagnosis/disposition and the alleged perpetrator's poor disposition, lack of empathy, and understanding of the resident population. On 9/6/24 at 9:45 AM the Administrator stated facility staff acknowledged that they were probably wrong for not reporting the abuse. The Administrator stated she did not look at Resident #2 or Resident #5 because the nurse addressed the concern right then about Resident #2. The Administrator stated the facility's expectation was that all possible abuse would be reported to the management but the nurse did not see this as abuse. The Administrator stated she thought that the possible verbal and physical aggression to Resident #2 and #5 probably should have been reported to the state agency as an allegation. The Administrator stated the allegations to both Resident #2 and #5 were unreported. The Administrator stated she wrapped everything in on the 2 facility reported incidents because it was related to Staff U. On 9/6/24 at 4:20 PM Staff D stated staff had told her that Staff U had pushed Resident #2 back in the wheelchair. Staff D stated Resident #2 was a weekly skin assessment that day. Staff D stated she asked Staff J and Staff J told her the bruising was on Resident #2's chest. Staff D stated there were 3 bruises that resembled fingers on Resident #2's left upper chest. On 9/7/24 at 10:26 AM Staff V stated Staff J brought the bruise on Resident #2 to her attention at 6:10 AM. Staff V stated Staff D came in at 6:20 AM. Staff V stated she was fired related to not assessing the bruise. 2. The MDS assessment dated [DATE] documented Resident #5 had a BIMS score of 6 indicating severe cognitive impairment. The MDS assessment also indicated Resident #5 was dependent on staff for dressing and undressing the upper body, lower body and for toileting. On 9/6/24 at 1:43 pm Staff B, Certified Nursing Assistant (CNA) stated she used to work on evenings shift. Staff B stated she worked with Staff U and had seen her be aggressive to residents. Staff B stated Resident #5 was one of the residents. Staff B stated Resident #5 did not want to get up for supper. Staff B stated Staff F, Certified Medication Assistant (CMA) was present and Staff U grabbed Resident #5 by his feet and swung them over the bed and pulled him up by his arms unnecessarily rough. Staff B stated Resident #5 was cussing and asked what she was doing. Staff B stated Staff F was asking Resident #5 why he was being so mean. Staff B stated she wrote a statement about it and it was in the statement. Staff B stated this incident happened recently. Staff B stated Staff U was suspended the next day. Staff B stated the day after Staff U was suspended she found a bruise on Resident #5's arm Staff B stated talk to Staff L she had been around a lot of things Staff U did that was not acceptable. On 9/7/24 at 11:30 AM Staff G, CNA stated she had heard a staff member speak very verbally abusive. Staff G stated the CNA was Staff U. Staff G stated Resident #5 told Staff U to leave him alone and called her a f***ing bitch. Staff G stated Staff U said to Resident #5 you are not going to talk to me like that you f***ing a**hole. Staff G stated one time Staff U was getting Resident #5 up and Staff U took Resident #5's legs and flung his legs in an aggressive manner out of bed. Staff G stated it was done in a manner that if it was done to her it would have hurt her back. Staff G stated Resident #5 would say he would punch Staff U and Staff U would say she would punch him before he could get to her. Staff G stated she had seen the 3 finger bruises and it looked like finger print marks on Resident #2. Staff G stated she found it right when she was got Resident #2 up the morning of 8/27/24. Staff G stated that Staff L came in the evening of 8/27/24 and she said she knew where those bruises came from. Staff G stated Staff L stated Staff U had pushed Resident #2 back and down in her wheelchair. On 9/7/24 at 1:51 PM Staff K CNA stated she had seen Staff U be unnecessarily rough with Resident #2. Staff K stated when Staff U completed personal cares for Resident #2 she would talk down to Resident #2 and tell her that she shouldn't piss her pants. Staff K stated she should have reported the incident. Staff K stated these verbal and physical incidents towards residents had been happening since May. Staff K stated Resident #5 cussed at staff and residents. Staff K stated Staff U was very mean to Resident #5. Staff K stated Staff U would say to Resident #5 you f***ing bitch i will hit you before you hit me. Staff K stated Resident #5 does not like taking his shirt off and Staff U would force his shirt off over his head. Staff L stated Staff U was very forceful. Staff U stated Staff U would pull Resident #2 up by the arms and swing the legs very forcefully out of bed. Staff K stated she had seen Staff U push Resident #2 back in the chair and pulling her back by the shoulders but did not remember if she did the evening of 8/26/24. Staff stated she worked with Staff U the night before the bruise was found on Resident #2. On 9/7/24 at 2:27 PM Staff L, CNA stated Staff U, her and Staff E went into Resident #5's room to put him to bed and Staff L was very new at that time. Staff L stated they had sat Resident #5 in bed and Staff U told Resident #5 don't f***ing kick me or I will hit you. Staff L stated Staff U was not very gentle when assisting Resident #2 with care. Staff L stated had heard Staff U tell Resident #2 to stop f***ing hitting her or she will never take care of her again. Staff L stated she saw the bruises on Resident #5 on the 27th 2-10 PM shift and they looked like finger bruises. On 9/7/24 at 3:07 PM Staff M, CNA stated had seen physical and verbal abuse by Staff U. Staff M stated Staff U was physical with Resident #2 before getting her ready for dinner on 8/26/24. Staff M stated she worked 8/26/24 2:00 AM - 6:00 AM and then returned at 4:30 PM. Staff M stated they were getting Resident #2 changed before supper and Staff U went to stand Resident #2 up next to the sink, changed her, and Resident #2 would not sit down. Staff M stated Staff U put her hand over Resident #2's shoulder and pushed her down in the wheelchair. Staff M stated when Resident #2 wouldn't sit Staff U put her whole hand over Resident #2's shoulder and forcefully sat Resident #2 down. Staff M stated she told Staff U not to do that and then she went and told Staff V. Staff M stated the bruise on Resident #2 looked like 3 perfect fingerprints and appeared in the same spot that Staff U had put her hands on Resident #2. Staff M stated she was in the room when Staff U said don't f***ing hit me because I will hit you back to Resident #5. On 9/7/24 at 4:00 PM the Administrator stated most of the complaints from the staff were about Staff U's negative attitude. The Administrator stated Staff U was given a final written warning regarding harassment to other staff. The Administrator stated Staff U was suspended because of verbal abuse. The Administrator stated when the bruises showed up on Resident #2, she tried to figure out where the bruise came from and that is when the verbal abuse came out. The Administrator stated as the facility was going through the investigation it was discovered how rough Staff U was with Resident #2 and #5. The Administrator acknowledged Staff U should have been separated immediately from resident care and that did not occur. On 9/7/24 at 4:28 PM Staff U stated when she was terminated she worked the PM shift and worked AM shift for almost [AGE] years at the facility prior. Staff U stated the staff that worked at the facility treated the residents with dignity and respect. Staff U stated she never witnessed any staff being physically and verbally aggressive. Staff U stated she never heard any staff cuss at the residents. Staff U stated she never cussed at any residents. Staff U stated she never forced a resident to move if they did not want to. Staff U stated she had worked with Resident #2 and #5. Staff U stated she had never seen Resident #2 have any bruising of unknown origins. Staff U stated she was accused of verbally abusing residents. Staff U stated she did not abuse any residents at the facility. Review of documents titled, Employee Questionnaire for Abuse Allegations dated 8/29/24, Staff G documented she had witnessed Staff U telling Resident #2 and #5 if you hit me I will hit you back and had witnessed her being rough with both of them like harshly pulling their legs out of bed. Staff G also documented Staff U had called them a**holes. Staff L documented Staff U yelled at Resident #5 don't f***ing kick me or I will hit you. Review of policy titled, Abuse Prevention Program and Reporting Policy revised 4/23 documented abuse was defined as willful infliction of injury, unreasonable confinement, intimidation with resulting physical harm or pain or mental anguish, and punishment with resulting physical harm or pain or mental anguish. Verbal abuse was defined as oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or within their hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse was defined including hitting, slapping, pinching, scratching, spitting, holding roughly. It also includes controlling behavior through corporal punishment.

Based on observation, record review, policy, and staff interviews, the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of physical and verbal abuse of Resident #2 and Resident #5. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The CNA stated she reported the physical abuse of Resident #2 to a nurse on 8/26/24 between 5:00 pm - 5:30 pm. Neither the CNA nor the nurse reported the physical abuse to the state agency or the administration. The investigation revealed the same CNA had history of verbally and physically abusing Resident #2 and Resident #5 and those allegations were also not reported. This failure resulted in residents living at the facility to be exposed to actual abuse and the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 26, 2024 on September 8, 2024 at 11:30 AM. The facility staff removed the IJ on September 8, 2024 through the following actions: -Resident and staff interviews to determine any unreported incidence of abuse conducted on 8/28-29/24. -All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation on 8/28-29/24 and continuing 9/8/24 with all employees being educated on the abuse policy prior to working with residents. -The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for 24/7 reporting has been placed conspicuously in the facility. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS also indicated Resident #2 required substantial / maximal assistance with dressing and undressing the upper and lower body. Review of Resident #2's electronic health record (EHR) titled, Weekly Skin Assessment-V5 dated 8/27/24 at 3:55 PM documented by Staff D, Licensed Practical Nurse (LPN) 3 bruises to the chest of Resident #2. Bruising measured 2 cm x 2 cm, 4 cm x 3 cm, and 1 cm x 1.5 cm. 2. The MDS assessment dated [DATE] documented Resident #5 had a BIMS score of 6 indicating severe cognitive impairment. The MDS also indicated Resident #5 was dependent on staff for dressing and undressing the upper body, lower body and for toileting. Review of the facility provided incident report dated 8/25/24, completed by the Administrator revealed as the Administrator was interviewing staff regarding another incident with Resident #2, it was reported that Staff U had stated to Resident #2 don't f-ing hit me. I'll never take care of you again when Resident #2 had hit Staff U on the side kinda in her back. The Administrator was not able to interview Resident #2 due to her mental status. Resident #2's BIMS is 3/15. The Administrator focused on interviewing Certified Nurses Assistants (CNA) that would have worked with Resident #2 and employees, as well as other staff. Random resident interviews reflected no issues regarding being verbally threatened by a staff member or another resident. Random staff interviews reflected some had no concerns with employees being verbally abusive to residents. Others mentioned Staff U and how she talks to residents, threatening to hit the residents when they hit her during care. The Administrator could substantiate that verbal abuse had occurred, but not the specific dates due to interview comments. Review of the facility provided incident report with incident date of 8/27/24, completed by the Administrator revealed it was noted that Resident #2 had 3 fingertip bruises to her chest when staff were getting her up on 8/27/24. The Administrator focused on interviewing staff that worked from Sunday, (8/25) to Tuesday, (8/27) to address if they worked with Resident #2 and, if so, what date, in what capacity, did they provide care to Resident #2 or assist with cares, if assisting who did they assist, did they notice any bruises, and if they noticed any bruises who and when did they report it. Staff D, Licensed Practical Nurse (LPN) was given a report of bruising and thought she would address the bruising with Resident #2's skin assessment that was due on 8/27/24. When Staff D went to do a skin assessment, she stopped the minute she saw the fingerprint type bruising and asked the DON to come with her to complete the skin assessment. Employees interviewed had not seen the bruising until the morning of 8/27/24 when getting the resident up for the day. Staff M left a statement under the Administrators door on 8/27/24 because she worked after the Administrator left, stating that Staff U had pushed Resident #2 down in her chair after changing her. Staff M stated that Staff U had aggressively pulled Resident #2 down into her chair from the shoulder area. Based on staff members' interviews the facility could substantiate that physical abuse occurred as Resident #2 had fingerprint bruises and Staff M witnessed Staff U pull Resident #2 down into her chair. This is most likely caused due to resident diagnosis/disposition and the alleged perpetrator's poor disposition, lack of empathy, and understanding of the resident population. On 9/6/24 at 9:45 AM the Administrator stated facility staff acknowledged that they were probably wrong for not reporting the abuse. The Administrator stated she did not look at Resident #2 or Resident #5 because the nurse addressed the concern right then about Resident #2. The Administrator stated the facility's expectation was that all possible abuse would be reported to the management but the nurse did not see this as abuse. The Administrator stated she thought that the possible verbal and physical aggression to Resident #2 and #5 probably should have been reported to the state agency as an allegation. The Administrator stated the allegations to both Resident #2 and #5 were unreported. The Administrator stated she wrapped everything in on the 2 facility reported incidents because it was related to Staff U. On 9/6/24 at 1:43 PM Staff B, Certified Nursing Assistant (CNA) stated she used to work on evenings shift. Staff B stated she worked with Staff U and had seen her be aggressive, physically and verbally abusive to residents. Staff B stated on that day she did not speak to the nurse or the management because she felt when you tell certain people here that nothing really happened. Staff B stated the day after Staff U was suspended she found a bruise on Resident #5's arm and she reported this to the Administrator because Staff U had pulled him up out of bed by his arms. Staff B stated talk to Staff L she had been around a lot of things Staff U did that was not acceptable. On 9/6/24 at 4:20 PM Staff D stated staff had told her that Staff U had pushed Resident #2 back in the wheelchair. Staff D stated Staff V was the overnight nurse and told her to look at the bruising on Resident #2 as the overnight nurse had not looked at it. Staff D stated Resident #2 was a weekly skin assessment that day. Staff D stated she asked Staff J and Staff J told her the bruising was on Resident #2's chest. Staff D stated there were 3 bruises that resembled fingers on Resident #2's left upper chest. Staff D stated she immediately reported this to the DON of the suspicious marks. On 9/7/24 at 10:26 AM Staff V stated Staff J brought the bruise on Resident #2 to her attention at 6:10 AM. Staff V stated Staff D came in at 6:20 AM. Staff V stated she was fired related to not assessing the bruise. Staff V stated she did not look at the bruise but Staff D was at the facility about 5 minutes after notified. On 9/7/24 at 11:30 AM Staff G, CNA stated she had heard a staff member speak very verbally abusive to residents. Staff G stated the CNA was Staff U. Staff G stated she felt like Staff U would have retaliated if she told the nurses or administration. Staff G stated she had seen the 3 finger bruises and it looked like finger print marks on Resident #2. Staff G stated she reported this to Staff V. Staff G stated Staff V did not come down and look at the bruises. Staff G stated she found it right when she was got Resident #2 up the morning of 8/27/24. Staff G stated Staff L stated Staff U had pushed Resident #2 back and down in her wheelchair. Staff G stated she felt that she should have reported Staff U's behavior towards the residents and she did not. On 9/7/24 at 1:51 PM Staff K CNA stated she had seen Staff U be unnecessarily rough with Resident #2. Staff K stated these verbal and physical incidents towards residents had been happening since May. Staff K stated she did not know if what Staff U was doing was counted as abuse but was told yesterday that all of it was counted as abuse. Staff K stated she had worked in the last 2 weeks. Staff K stated she works 5 hours at least 2 days a week. Staff K stated has worked at least 20 hours since the incident. Staff K stated she noticed the bruises on Resident #2. Staff K stated she had seen Staff U push Resident #2 back in the chair and pulling her back by the shoulders but did not remember if she did the evening of 8/26/24. On 9/7/24 at 2:27 PM Staff L, CNA stated she reported multiple times to the Administrator about the way Staff U spoke to the residents. Staff L first spoke to the Administrator about Staff U's behavior back in May the first time. Staff L stated she had worried about retaliation at work. On 9/7/24 at 3:07 PM Staff M, CNA stated she had seen physical and verbal abuse by Staff U. Staff M stated Staff U was physical with Resident #2 before getting her ready for dinner on 8/26/24. Staff M stated she told Staff U not to do that and then she then told Staff V. Staff M stated she told Staff V and Staff V said she would talk to Staff U and report it to the Administrator. Staff M stated she probably should have told the Administrator herself but she thought Staff V would tell the Administrator. Staff M stated the bruise on Resident #2 looked like 3 perfect fingerprints and appeared in the same spot that Staff U had put her hands on Resident #2. Staff M stated Staff V never looked at the bruise. On 9/7/24 at 4:00 PM the Administrator stated most of the complaints from the staff were about Staff U's negative attitude. The Administrator stated Staff U was given a final written warning regarding harassment to other staff. The Administrator stated Staff U was suspended because of verbal abuse. The Administrator stated when the bruises showed up on Resident #2 they tried to figure out where the bruise came from and that is when the verbal abuse came out. The Administrator stated as the facility was going through the investigation it was discovered how rough Staff U was with Resident #2 and #5. The Administrator acknowledged Staff U should have been separated immediately from resident care and that did not occur. On 9/7/24 at 4:28 PM Staff U stated when she was terminated she worked the PM shift and worked the AM shift for almost [AGE] years at the facility prior. Staff U stated the staff that worked at the facility treated the residents with dignity and respect at the facility. Staff U stated she never witnessed any staff being physically and verbally aggressive. Staff U stated she never heard any staff cuss at the residents. Staff U stated she never cussed at any residents. Staff U stated she never forced a resident to move if they did not want to. Staff U stated she had worked with Resident #2 and #5. Staff U stated she had never seen Resident #2 have any bruising of unknown origins. Staff U stated she was accused of verbally abusing residents. Staff U stated she did not abuse any residents at the facility. Review of documents titled, Employee Questionnaire for Abuse Allegations dated 8/29/24 documented Staff G had witnessed Staff U telling Resident #2 and #5 if you hit me I will hit you back and have been rough with both of them like harshly pulling their legs out of bed. Staff G also documented Staff U had called them a**holes. Staff L documented Staff U yelled at Resident #5 don't f***ing kick me or I will hit you. Review of policy titled, Abuse Prevention Program and Reporting Policy revised 4/23 documented when witnessed abuse or suspected abuse occurs staff should notify the shift supervisor immediately. Report the incident immediately to the Administrator, and Director of Nursing. Any staff member with knowledge of the event is responsible for notifying the Administrator and/or DON. Report the appropriate state agency immediately by fax or telephone or on-line reporting after identification of alleged/suspected incident. Initiate process according to State-specific regulations. Notify the legal guardian, spouse, or responsible family member/significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property immediately. The Facility Administrator is responsible to initiate contact with local law enforcement, immediately, when warranted, as required by state law. Consult with management consulting companies as needed for additional support.

Based on clinical record review, facility document review, staff interviews and policy review, the facility failed to separate an alleged CNA abuser to prevent further verbal and physical abuse of Resident #2 and Resident #5 and failed to complete a comprehensive investigation immediately. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The CNA stated she reported the physical abuse of Resident #2 to a nurse on 8/26/24 between 5:00 pm - 5:30 pm. The CNA stated the nurse never assessed the area. The CNA continued to work with Resident #2 and Resident #5 after the CNA witnessed the abuse. On 8/27/24 the staff identified a bruise to the upper left side of Resident #2's chest in the shape of fingers. Upon investigation of the bruises on Resident #2, it was identified the same CNA had history of verbally and physically abusing Resident #2 and Resident #5. This failure resulted in residents living at the facility to be exposed to actual abuse and the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 26, 2024 on September 8, 2024 at 11:30 AM. The facility staff removed the IJ on September 8, 2024 through the following actions: - Resident and staff interviews to determine any unreported incidence of abuse conducted on 8/28-29/24. -All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation on 8/28-29/24 and continuing 9/8/24 with all employees being educated on the abuse policy prior to working with residents. -The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for 24/7 reporting has been placed conspicuously in the facility. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS assessment also indicated Resident #2 required substantial/maximal assistance with dressing and undressing the upper and lower body. Review of Resident #2's electronic health record (EHR) titled, Weekly Skin Assessment-V5 dated 8/27/24 at 3:55 PM documented by Staff D, Licensed Practical Nurse (LPN) 3 bruises to the chest of Resident #2. Bruising measured 2 cm x 2 cm, 4 cm x 3 cm, and 1 cm x 1.5 cm. Review of the facility provided incident report dated 8/25/24, completed by the Administrator revealed as the Administrator was interviewing staff regarding another incident with Resident #2, it was reported that Staff U had stated to Resident #2 don't f-ing hit me. I'll never take care of you again. when Resident #2 had hit Staff U on the side kinda in her back. The Administrator was not able to interview Resident #2 due to her mental status. Resident #2's BIMS is 3/15. The Administrator focused on interviewing Certified Nurses Assistants (CNA) that would have worked with Resident #2 and employees, as well as other staff. Random resident interviews reflected no issues regarding being verbally threatened by a staff member or another resident. Random staff interviews reflected some had no concerns with employees being verbally abusive to residents. Others mentioned Staff U and how she talks to residents, threatening to hit the residents when they hit her during care. The Administrator could substantiate that verbal abuse had occurred, but not the specific dates due to interview comments. Review of the facility provided incident report with incident date of 8/27/24, completed by the Administrator revealed it was noted that Resident #2 had 3 fingertip bruises to her chest when staff were getting her up on 8/27/24. The Administrator focused on interviewing staff that worked from Sunday, (8/25) to Tuesday, (8/27) to address if they worked with Resident #2 and, if so, what date, in what capacity, did they provide care to Resident #2 or assist with cares, if assisting who did they assist, did they notice any bruises, and if they noticed any bruises who and when did they report it. Staff D, Licensed Practical Nurse (LPN) was given a report of bruising and thought she would address the bruising with Resident #2 ' s skin assessment that was due on 8/27/24. When Staff D went to do a skin assessment, she stopped the minute she saw the fingerprint type bruising and asked the DON to come with her to complete the skin assessment. Employees interviewed had not seen the bruising until the morning of 8/27/24 when getting resident up for the day. Staff M left a statement under the Administrators door on 8/27/24 because she worked after the Administrator left, stating that Staff U had pushed Resident #2 down in her chair after changing her. Staff M stated that Staff U had aggressively pulled Resident #2 down into her chair from the shoulder area. Based on staff members' interviews the facility could substantiate that physical abuse occurred as Resident #2 had fingerprint bruises and Staff M witnessed Staff U pull Resident #2 down into her chair. This is most likely caused due to resident diagnosis/disposition and the alleged perpetrator ' s poor disposition, lack of empathy, and understanding of the resident population. 2. The MDS assessment dated [DATE] documented Resident #5 had a BIMS score of 6 indicating severe cognitive impairment. The MDS assessment also indicated Resident #5 was dependent on staff for dressing and undressing the upper body, lower body and for toileting. On 9/6/24 at 9:45 AM The Administrator stated facility staff acknowledged that they were probably wrong for not reporting the abuse. The Administrator stated she did not look at Resident #2 or Resident #5 because the nurse addressed the concern right then about Resident #2. The Administrator stated the facility's expectation was that all possible abuse would be reported to the management but the nurse did not see this as abuse. The Administrator stated she thought that the possible verbal and physical aggression to Resident #3 and #5 probably should have been reported to the state agency as an allegation. The Administrator stated the allegations to both Resident #3 and #5 were unreported. The Administrator stated she wrapped everything in on the 2 facility reported incidents because it was related to Staff U. On 9/6/24 at 1:43 pm Staff B, Certified Nursing Assistant (CNA) stated she used to work on evenings shift. Staff B stated she worked with Staff U and had seen her be aggressive to residents. Staff B stated Resident #5 was one of the residents. Staff B stated Resident #5 did not want to get up for supper. Staff B stated Staff F, Certified Medication Assistant (CMA) was present and Staff U grabbed Resident #5 by his feet and swung them over the bed and pulled him up by his arms unnecessarily rough. Staff B stated Resident #5 was cussing and asked what she was doing. Staff B stated Staff F was asking Resident #5 why he was being so mean. Staff B stated she wrote a statement about it and it was in the statement. Staff B stated this incident happened recently. Staff B stated Staff B was suspended the next day. Staff B stated on that day she did not speak to the nurse or the management because she felt when you tell certain people here that nothing really happened. Staff B stated the day after Staff U was suspended she found a bruise on Resident #5's arm and she reported this to the Administrator because Staff U had pulled him up out of bed by his arms. Staff B stated talk to Staff L she had been around a lot of things Staff U did that was not acceptable. On 9/6/24 at 4:20 PM Staff D stated staff had told her that Staff U had pushed Resident #2 back in the wheelchair. Staff D stated Staff V was the overnight nurse and told her to look at the bruising on Resident #2 as the overnight nurse had not looked at it. Staff D stated Resident #2 was a weekly skin assessment that day. Staff D stated she asked Staff J and Staff J told her the bruising was on Resident #2's chest. Staff D stated there were 3 bruises that resembled fingers on Resident #2's left upper chest. Staff D stated she immediately reported this to the DON of the suspicious marks. On 9/7/24 at 10:26 AM Staff V stated Staff J brought the bruise on Resident #2 to her attention at 6:10 AM. Staff V stated Staff D came in at 6:20 AM. Staff V stated she was fired related to not assessing the bruise. Staff V stated she did not look at the bruise but Staff D was at the facility about 5 minutes after notified. On 9/7/24 at 11:30 AM Staff G, CNA stated she had heard a staff member speak very verbally abusive. Staff G stated the CNA was Staff U. Staff G stated Resident #5 told Staff U to leave him alone and called her a f***ing bitch. Staff G stated Staff U said to Resident #5 you are not going to talk to me like that you f***ing a**hole. Staff G stated one time Staff U was getting Resident #5 up and Staff U took Resident #5's legs and flung his legs in an aggressive manner out of bed. Staff G stated it was done in a manner that if it was done to her it would have hurt her back. Staff G stated with Resident #5 would say he would punch Staff U and Staff U would say she would punch him before he could get to her. Staff G stated she felt like Staff U would have retaliated if she told the nurses or administration. Staff G stated she had seen the 3 finger bruises and it looked like finger print marks on Resident #2. Staff G stated she reported this to Staff V. Staff G stated Staff V did not come down and look at the bruises. Staff G stated she found it right when she got Resident #2 up the morning of 8/27/24. Staff G stated Staff D might have arrived 5 minutes after she told Staff V. Staff G stated that Staff L came in the evening of 8/27/24 and she said she knew where those bruises came from. Staff G stated Staff L stated Staff U had pushed Resident #2 back and down in her wheelchair. Staff G stated she felt that she should have reported Staff U's behavior towards the residents and she did not. On 9/7/24 at 1:51 PM Staff K CNA stated she had seen Staff U be unnecessarily rough with Resident #2. Staff K stated when Staff U completed personal cares for Resident #2 she would talk down to Resident #2 and tell her that she shouldn't piss her pants. Staff K stated she should have reported the incident. Staff K stated these verbal and physical incidents towards residents had been happening since May. Staff K stated Resident cussed at staff and residents Staff K stated Staff U was very mean to Resident #5. Staff K stated Staff U would say to Resident #5 you f***ing bitch i will hit you before you hit me. Staff K stated Resident #5 does not like taking his shirt off and Staff U would force his shirt off over his head. Staff L stated Staff U was very forceful. Staff K stated she did not know if what Staff U was doing was counted as abuse but was told yesterday that all of it was counted as abuse. Staff U stated Staff U would pull Resident #2 up by the arms and swing the legs very forcefully out of bed. Staff K stated she had worked in the last 2 weeks. Staff K stated she works 5 hours at least 2 days a week. Staff K stated she has worked at least 20 hours since the incident. Staff K stated she noticed the bruises on Resident #2. Staff K stated she had seen Staff U push Resident #2 back in the chair and pulling her back by the shoulders but did not remember if she did the evening of 8/26/24. Staff stated she worked with Staff U the night before the bruise was found on Resident #2. On 9/7/24 at 2:27 PM Staff L, CNA stated she reported multiple times to the Administrator about the way Staff U spoke to the residents. Staff L first spoke to the Administrator about Staff U's behavior back in May the first time. Staff L stated Staff U, her and Staff E went into Resident #5's room to put him to bed and Staff L was very new at that time. Staff L stated they had sat Resident #5 in bed and Staff U told Resident #5 don't f***ing kick me or I will hit you. Staff L stated Staff U was not very gentle when assisting Resident #2 with care. Staff L stated had heard Staff U tell Resident #2 to stop f***ing hitting her or she will never take care of her again. Staff L stated she saw the bruises on Resident #5 on the 27th 2-10 shift and they looked like finger bruises. Staff L stated she had worried about retaliation at work. On 9/7/24 at 3:07 PM Staff M, CNA stated she had seen physical and verbal abuse by Staff U. Staff M stated Staff U was physical with Resident #2 before getting her ready for dinner on 8/26/24. Staff M stated she worked 8/26/24 2:00 AM - 6:00 AM and then returned at 4:30 PM. Staff M stated they were getting Resident #2 changed before supper and Staff U stood Resident #2 up next to the sink, changed her, and Resident #2 would not sit down. Staff M stated Staff U put her hand over Resident #2's shoulder and pushed her down in the wheelchair. Staff M stated when Resident #2 wouldn't sit Staff U put her whole hand over Resident #2's shoulder and forcefully sat Resident #2 down. Staff M stated she told Staff U not to do that and then she went and told Staff V. Staff M stated she told Staff V and Staff V said she would talk to Staff U and report it to the Administrator. Staff M stated she probably should have told the Administrator herself but she thought Staff V would tell the Administrator. Staff M stated the bruise on Resident #2 looked like 3 perfect fingerprints and appeared in the same spot that Staff U had put her hands on Resident #2. Staff M stated Staff V never looked at the bruise. Staff M stated she was in the room when Staff U said don't f***ing hit me because I will hit you back to Resident #5. On 9/7/24 at 4:00 PM the Administrator stated most of the complaints from the staff were about Staff U's negative attitude. The Administrator stated Staff U was given a final written warning regarding harassment to other staff. The Administrator stated Staff U was suspended because of verbal abuse. The Administrator stated when the bruises showed up on Resident #2 they tried to figure out where the bruise came from and that is when the verbal abuse came out. The Administrator stated as the facility was going through the investigation it was discovered how rough Staff U was with Resident #2 and #5. The Administrator acknowledged Staff U should have been separated immediately from resident care and that did not occur. On 9/7/24 at 4:28 PM Staff U stated when she was terminated she worked the PM shift and worked the AM shift for almost [AGE] years at the facility prior. Staff U stated the staff that worked at the facility treated the residents with dignity and respect at the facility. Staff U stated she never witnessed any staff being physically and verbally aggressive. Staff U stated she never heard any staff cuss at the residents. Staff U stated she never cussed at any residents. Staff U stated she never forced a resident to move if they did not want to. Staff U stated she had worked with Resident #2 and #5. Staff U stated she had never seen Resident #2 have any bruising of unknown origins. Staff U stated she was accused of verbally abusing residents. Staff U stated she did not abuse any residents at the facility. Review of documents titled, Employee Questionnaire for Abuse Allegations dated 8/29/24 revealed Staff G documented she had witnessed Staff U telling Resident #2 and #5 if you hit me I will hit you back and have been rough with both of them like harshly pulling their legs out of bed. Staff G also documented Staff U had called them a**holes. Staff L documented Staff U yelled at Resident #5 don't f***ing kick me or I will hit you. Review of policy titled, Abuse Prevention Program and Reporting Policy revised 4/23 documented identified events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, neglect, and/or mistreatment and investigate. Injuries of unknown source classified as injuries of unknown source when both the following conditions are met. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Instruct staff, resident, family and visitor, to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Initiate an internal Incident/Accident Report immediately upon identification of actual or suspected abuse, neglect, mistreatment, and/or misappropriation of property. Provide for the immediate safety of the resident/patient upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Means of providing protection include, but are not limited to: Immediately separating resident from alleged perpetrator. Moving residents to another room or unit. Provide 1:1 monitoring as appropriate. Implement discharge process immediately if the resident is a danger to self or to others. In the case of a direct caregiver being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator must immediately relieve the individual of their duties without pay until the investigation is completed.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (Resident #1, Resident #9) reviewed for wandering and elopement. The facility failed to change the door code after knowledge of a resident who presented as an elopement risk knew the code and failed to ensure that door alarms worked properly. On 8/25/24 at 9:00 PM. facility staff realized Resident #1 was not in the building. The resident was last seen at 8:30 PM, and the police found the resident in Walmart around 10:00 PM. Resident #1 had a history of exit seeking behaviors, could enter the code to the front door to exit without setting off the alarm, and had presented with exit seeking behaviors the day of the elopement. When Resident #1 returned to the facility through the front door the Wanderguard System (WGS) alarm did not go off. The facility reported 3 residents wore WGS bracelets and the WGS for the main entry was last checked for functioning on 8/23/24. Resident #1 wore a WBS bracelet but it had not been checked to ensure it functioned properly. The State Agency informed the facility on 9/8/24 at 11:30 AM of the Immediate Jeopardy (IJ) that began on 8/25/24. The immediacy was removed on 9/8/24 when the facility implemented the following: -The code to the door was changed on 8/26/24. -All Residents had Elopement Risk Assessments reviewed and/or completed by 8/26/24. Elopement Binders were updated with current at risk residents and care plans were added to the binders regarding the resident's individual supervision needs. -Residents with WGS had Sensor Checks added to the Electronic Medication Administration Record (EMAR) for placement and function daily (QD). -The WGS door alarm checks were to be completed QD and audited by the Administrator starting 8/26/24. -The facility provided education to the staff on Elopement Procedures/Protocols which was completed 8/26/24. -Additional education was provided starting on 9/8/24 regarding supervision levels of residents per care plan and the removal plan. Employees will be educated over next week prior to the start of their next shift. Observation on 9/10/24 at 10:50 AM revealed a group of residents gathered in the large living room at the front of the building including Resident #9, identified by the facility as high risk for elopement and Resident #2, identified as moderate risk for elopement. Resident #14, identified by the facility as moderate risk for elopement, entered the code for opening the main door and proceeded to exit the building. The door alarm began going off as Resident #14, Resident #13, and Resident #12 exited the building. As Resident #9 came near the door, the WGS alarm began sounding. No staff responded to either alarm. The door closed due to the difficulty of a resident exiting the building. The alarms sounded for approximately 1.5 minutes before staff responded. Resident #9 indicated he did have an intention of exiting the building. The State Agency informed the facility on 9/10/24 at 11:40 AM the removal of the immediacy for the IJ was retracted and continued to be a concern. The immediacy was removed on 9/10/24 when the facility implemented the following: -Code to the front door was changed on 9/10/24 and staff educated that only staff members were to have the code. -No family members, residents, or visitors were to know the code for exiting the building. -The resident smoking area moved to the back of the facility. -Staff were re-educated on the elopement policy and not sharing the front door code on 9/10/24. The scope was lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 dated 7/24/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented diagnoses that included: hypertension, renal insufficiency, non-Alzheimer's dementia, depression, chronic obstructive pulmonary disease (COPD), difficulty in walking, and unsteadiness on feet. The document revealed that since the previous quarterly assessment was completed on 5/1/24 the resident had 1 fall without injury and two or more falls with injury, except major. Resident #1 was independent with toileting, dressing, transfers, and ambulation. The resident utilized a walker and had a wander/elopement alarm that was used daily. A Neuropsychological Evaluation completed on 1/18/24 revealed a diagnostic impression of Alzheimer's dementia with behavioral disturbance. The document provided a recommendation that due to the resident's diagnosis and evidence of cognitive impairment, she should be considered a vulnerable adult and supervision was recommended. An Elopement Risk assessment dated [DATE] revealed the resident had a score of 15 which indicated a high risk for wandering. The document revealed the resident was a known wanderer/history of wandering, but did not indicate the resident was known to have exit seeking/history of exit seeking. A Fall Risk assessment dated [DATE] revealed a score of 8 which indicated a moderate risk for falls. The Care Plan printed on 9/6/24 revealed the document did not contain a focus area or interventions for wandering until 8/26/24. A Facility Investigation revealed Resident #1 was observed by Staff N seated in the lobby at 8:30 PM on 8/25/24. At 9:00 PM Staff N noted the resident was neither in the lobby nor in her bedroom. A search for the resident was initiated and the administrator was notified at 9:18 PM of the resident's unknown location. Staff were dispersed to look within the building, outside of the building, and local stores. The Administrator notified the police at 9:29 PM. The resident was located by the police in Walmart at 9:45 PM with the Administrator notified at 9:54 PM. The resident presented without injury upon return to the facility. The Administrator identified the WGS was not working on the front door. The resident had been demonstrating exit seeking behaviors previously that day, as had been asking staff to take her shopping. Further investigation revealed on 5/18/24 Resident #1 had demonstrated exit seeking behavior. On 9/7/24 at 10:41 AM Staff E stated on 5/18/24 the resident had been asking staff to take her to the bar and had stated she was going to leave the building. Despite redirection the resident entered the code to the front door and exited the building. The staff maintained visual eyesight on the resident until the Administrator had eyesight on the resident. The resident returned to the facility escorted by the Administrator. The facility did not complete an Elopement Risk Assessment after this event. Additionally, the Progress Notes within the electronic health record revealed an entry on 6/1/24 of Resident #1 attempting to leave the facility and signing herself out. Observation on 9/7/24 revealed the facility was located on a main east/west 2 lane road with a speed limit of 25 MPH without a shoulder or sidewalk. The Walmart was located .6 miles away on a 5 lane highway with posted speed limit of 35 MPH without a shoulder or sidewalk. The highway crossed over an active railroad. Review of the weather on 8/25/24 revealed the temperature was 86 degrees with 79% humidity and a low of 72 degrees. The sunset occurred at 8:30 PM. On 9/6/24 at 2:30 PM Staff T, Maintenance Director, stated he had to rewire the WGS because it was broken and not working appropriately after Resident #1's elopement on 8/25/24. On 9/7/24 at 1:00 PM Staff H stated when working on 8/25/24 she had provided Resident #1 her medications around 6:30 PM but did not see her after that time. The staff stated the door alarm did not go off when the resident returned to the building after 10:00 PM. Resident H stated she did not announce overhead the resident was missing due to concerns of a Health Insurance Portability and Accountability Act (HIPAA) concerns. The staff stated she could barely hear the WGS alarm at the nurse's station in the back of the building, but if there was additional noise or she was not near the nurse's station she could not hear it at all. The staff further revealed that the front doorbell could also not be heard at the rear of the building. Staff H stated she was aware that Resident #1 knew the door code to exit the building, as did other residents. The staff stated independent smokers were allowed to go out of the building alone. Staff H further revealed Resident #1 would assist other residents out of the building (independent smokers who did not know the door code), and visitors. The staff stated checking a resident's WGS bracelet involved visually seeing the bracelet, not checking the functioning of the device. On 9/7/24 at 3:20 PM Staff M stated on the night of 8/25/24 she did not have a lot of interaction with Resident #1. The staff stated she drove around the area to different stores looking for the resident when she was discovered to be missing. Staff M stated she did not recall the door alarm going off when the resident returned that night. The staff stated she could not hear the alarm in the back of the building when working. On 9/7/24 at 5:40 PM Staff N stated she had been told Resident #1 had been exhibiting exit seeking behaviors earlier in the day on 8/25/24. The staff did not recall the front door alarm going off on 8/25/24 at 9:00 PM when she went to prepare to take residents outside for a smoke break and discovered Resident #1 was not in the vicinity. The staff stated the alarm did not go off upon the resident's return that night. Staff N stated she was unable to hear the WGS alarm when working in the back of the building. The staff further revealed that prior to Resident #1's elopement, checking a resident's WGS bracelet consisted of visually seeing the bracelet, not checking for functioning. The Administrator stated on 9/7/24 at 4:01 PM Resident #1 had a history of wandering and exit seeking behaviors. The Administrator acknowledged Resident #1 as well as some other residents knew the door code to exit the building. The Administrator further acknowledged the facility should have completed an updated Elopement Risk Assessment for Resident #1 following her exit from the building. The administrator stated the WGS had repairs completed on 8/28/24 to ensure functioning appropriately. The facility provided document, Elopement Policy, dated 6/18/19, revealed specific plans would be developed for each resident identified at risk for elopement/wandering including causes and patterns. The document further revealed the facility would maintain a notebook with demographics and pictures of residents at risk for elopement, and keep its location in a known place for all staff to reference. The facility provided document, Missing Resident Protocol, dated 6/18/19, revealed staff would make an announcement overhead to alert all staff of the missing resident, and the missing resident would be considered a facility-wide emergency.

Based on observations, clinical record review, hospital document review, resident and staff interviews, and facility policy review, the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (Resident #13, and #39). The facility reported a census of 40 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) 5 Day Medicare assessment for Resident #13, dated 5/7/24 documented a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident cognitively intact. The document revealed the resident required dependence for toileting, bathing, lower body dressing, shoes, and partial moderate assistance for upper body dressing. The resident was dependent for rolling, lying to and from seated positions and transfers. Resident #13 had occasional bowel and bladder incontinence. Diagnoses included: orthostatic hypotension, renal insufficiency, hip fracture (fracture unspecified part of neck of left femur, subsequent for closed fracture with routine healing, seizure disorder/epilepsy (conversion disorder with seizures or convulsions), left artificial hip joint; pain medication as needed, pain reported occasionally. Resident #13's Baseline Care Plan dated 5/2/24 indicated in Section E the resident required total dependence for transfers. Section D of the document revealed safety concerns of history of falls, history of fall related injuries. Resident #13's Care Plan printed on 7/23/24 revealed the resident was a moderate risk for falls with initiation on 7/21/22 and revised 9/20/22. The interventions for staff to utilize included: anticipating and meeting the resident's needs (9/20/22), resident required a safe environment (6/5/23), and evaluation for use of a walker (9/20/22). A focus area of renal insufficiency (revised 3/27/24) indicated an intervention for staff to assist with activities of daily living (ADLs) and ambulation as needed. Watch for shortness of breath (SOB) and match the level of assistance to residents current energy level (initiated 7/19/23). The ADL focus revision was on 3/27/24 with the intervention of 2 staff participation to use the toilet, 2 staff to participate with transfers, and 2 staff to reposition and turn in bed. The electronic health record (EHR) revealed on 7/21/24 at 4:30 PM Resident #13 had increased pain, swelling and bruising to the left lower extremity (LLE). The document revealed a staff had attempted to transfer the resident to the wheelchair for toileting and the resident had fallen on 7/19/24. The resident was taken to the emergency department where the resident was diagnosed with a left ankle fracture and was non weight bearing (NWB). Resident #13's hospital medical record dated 7/21 and 7/22/24 revealed diagnosis of 1. acute comminuted impacted fracture of the distal tibia extending to the tibia plafond. 2. Acute comminuted fracture of the distal fibula above the level tibiofibular syndesmosis. 3. acute longitudinal mid calcaneal fracture extending to the mid subtalar joint. 4. Surround ankle swelling with ankle effusion. Swelling in the dorsum of the foot. On 7/23/24 at 2:14 PM Staff G, Certified Nursing Assistant (CNA) stated Resident #13's call light was on and she went into the room. The staff asked Resident #13 what she needed and the resident stated she was going to the bathroom. The staff stated she asked the resident if she needed the bedpan and the resident indicated no she was using the bathroom. Staff G stated Resident #13 was normally lying down in bed upon entry into the room, but at this time the resident was seated on the edge of the bed. The staff stated the resident stated she had been cleared by therapy for stand pivot transfers. Staff G stated she placed the wheelchair in front of the resident as the resident directed, the resident locked the brakes, and placed her arms on the armrests. The staff stated she went to help her, the resident stood for a couple of seconds and her leg gave out. Staff G stated she called Staff E for assistance. Staff E, Licensed Practical Nurse (LPN), and Staff H, LPN, came into the room. Staff G stated Resident #13 did not hit her head, was on her knees with her upper body on the wheelchair. Staff G stated Staff H and herself put a gait belt on the resident and attempted to get the resident up. Staff G acknowledged she had not put a gait belt on prior to this as she didn't know where one was. Staff G stated as Resident #13 was unable to get up from this position, the resident was lowered to the floor. The sling was obtained and placed under the resident. Resident #13 stated she thought she had twisted her ankle. Staff G stated she moved Resident's LLE and Staff H moved the right lower extremity (RLE) into position for use of the NWB dependent mechanical lift. Staff G stated she told Staff E that Resident 13's ankle looked like Jell-o. The staff stated she restated the RLE did not look right to Staff E once the resident was in bed. Staff G stated when Resident #13 was back in bed, it was noticed the resident did not have gripper socks on her feet (feet were bare) and they were donned at that time. Staff G stated Staff E directed her to get vitals. Staff G stated she took her blood pressure 4 times as it was low and she wanted to make sure it was right. Staff G stated the resident required a NWB dependent mechanical lift. The staff stated the resident had recently had the LLE brace removed and was more independent in self care. Staff G stated the resident was able to put on her brief, pants, and rolled in bed. The staff stated there were not big changes in Resident 13's abilities on dialysis and non-dialysis days as the resident was compliant with attending dialysis. Staff G stated she would know about a resident's assistance needs by reading the communication book, however unsure if this still exists, the CNA's report, and nurses would notify staff. The CNA did not recall anything specific to this resident during the report that night. On 7/23/24 at 2:56 PM Staff I, Physical Therapist Assistant (PTA), and Staff J, Occupational Therapist Registered (OTR), stated Resident 13 sustained a fall 2 years prior when preparing to go on a home safety assessment and sustained a left hip fracture. Staff I and Staff J stated the resident was not recommended for surgery and had been NWB until March 2024. The staff stated the resident had a hip replacement in 3/24 and while receiving therapy in the hospital the resident stood up and sustained a multisite left femur fracture. Resident #13 had surgery with screws and wires to put the bone back together. The resident returned to the facility with NWB to LLE. Staff stated the resident could not utilize a NWB dependent mechanical lift due to hip precautions and the resident was unable to stand. Staff stated the resident needed to stand pivot independently or use a NWB dependent mechanical lift to attend dialysis. Staff I and J stated after missing 5 days of dialysis the resident returned to the acute hospital and remained there for 6 weeks. The staff stated upon return from the hospital (5/1/24) the resident had a LLE immobilizer and was NWB. Resident #13 could use the NWB dependent mechanical lift as hip precautions had been discontinued. Staff I stated the immobilizer was to be in place at all times except for bathing. Staff I and Staff J stated trials had been to complete sit to stand at the parallel bars with the resident unsuccessful. The staff stated on 7/11/24 Resident #13 returned from the orthopedic physician with LLE immobilizer discontinued, range of motion (ROM) as tolerated, weight bearing as tolerated (WBAT) to the LLE, and follow up if needed. Staff I and Staff J stated therapies worked together on sit to stand at the parallel bars and were not successful. Staff J stated that Resident #13 on 7/16/24 stated she was worn out and couldn't complete the sit to stand as she had tried herself in her room. Staff I and Staff J stated education had been provided to the resident regarding safety and progression of therapy, and due to the extensive time of NWB the resident had significant weakness in the lower extremities. The staff stated the resident was cognizant and knew she had been unable to complete trials in therapy; however the resident had decreased safety, cognition and insight into abilities. Staff I and Staff J stated Resident #13 was still in therapy, and would work on strengthening. The staff stated if a resident had a change in status/transfer/self care, the therapy department utilized a Therapy Communication Form to notify the facility. The document would go to the nurses station and would be placed up in the resident's room. Staff I and Staff J reiterated at the time of the fall the resident required a NWB dependent mechanical lift. On 07/23/24 at 3:35 PM Resident #13 stated she wanted to get up and go to the bathroom on 7/19/24. The resident stated there was 1 CNA present and no gait belt, as she did not have a brief on just her top. Resident #13 stated she started to pivot and her right foot slid under the bed, and her arms and chest were on the wheelchair. Resident #13 stated the staff got a sling to get her off of the floor. The resident stated she didn't think any more about it as there was no pain, she thought she had sprained her ankle. Resident #13 stated she stayed in bed on Saturday, per normal, and when she tried to move around to get up on Sunday (7/21/24) she had increased pain. The resident requested nursing to wrap her ankle, as she thought she had sprained it. Resident #13 stated she went to the hospital and had 3 fractures. The resident stated she had been transferring with a NWB dependent mechanical lift prior to fall and now transferring that way again. The resident stated it was her own decision to transfer to the wheelchair and had set it up to do what she had done in therapy. On 7/24/24 at 11:40 AM Staff E, Licensed Practical Nurse (LPN), provided the following information regarding the sequence of events on 7/19/24. Staff E stated she was getting a report from Staff H, LPN, when she received a call from Staff G, CNA, stating a nurse was needed to come to the resident's room. Staff E and Staff H went to the Resident #13's room and observed the resident on her knees with the top part of her body on a wheelchair in front and legs under the bed but not touching the bed. Staff G, E, and Staff H moved the wheelchair, placed the sling under the bed, and slid the resident out away from the bed to connect to the NWB dependent mechanical lift. The staff stated she could visualize the leg/ankle. Staff H moved the resident leg/ankle with the resident having no c/o pain. Resident #13 was transferred into bed. The staff stated Staff G stated the resident told her that she was released from therapy and refused to use the NWB dependent mechanical lift as she could transfer. Staff E stated the resident is very aware of things and could have stated that. Staff E stated she faxed the physician notifying of the fall. Staff E stated she would call the physician if the resident had hit head, or had an obvious injury, change in vitals. The staff stated she did not notify the Director of Nursing (DON), as there had been several DON's in the past few months and one DON has specified not to contact at night. The staff couldn't remember which DON it was. The staff stated the resident had no c/o pain on Friday night or Saturday night. Staff E stated an assessment was completed and placed in the Risk Management Document. Blood pressure was taken 3 different times as was low. Staff E stated she forgot to put the fall on the 24 hour sheet and in the Progress Notes. The staff stated as the fall was witnessed it did not trigger the Fall Assessment. On 7/24/24 at 12:50 PM the Administrator stated the DON and/or the Administrator should have been contacted on the night of the fall. The Administrator stated assessments were to be completed at the time of the fall and before moving the resident to ensure there was not an injury. The Administrator stated Staff E did not complete a Fall Assessment as the staff when completing the Risk Assessment did not select the correct category and therefore Fall Assessment did not trigger for completion. The Administrator indicated that Resident #13 has a history of lower blood pressures thus it may have required multiple assessments. The Administrator indicated the facility was a no lift facility and would not have required 2 staff for transfers. The Administrator did acknowledge the Care Plan may have indicated 2 staff when Resident #13 returned from the hospital briefly and was unable to use a NWB dependent mechanical lift due to precautions. The Administrator concurred the Care Plan was not up to date. On 7/24/24 at 1:40 PM the DON indicated the process for CNA finding a resident on the floor was to look for bodily fluids, call the nurse and teammates to get assistance. The nurse would complete a head to toe assessment, including vitals, prior to moving the resident with questions asked including what happened, pain, hitting of limb/head. Based on the assessment document pain and would seek physician orders for x-ray. If the resident complained of head pain/increased confusion or if the fall was unwitnessed neuro checks would be initiated. If there was no obvious injury the use of NWB dependent mechanical lift would be used to get the resident off of the floor. The DON stated a physician should be called, not faxed, to notify of a fall. Depending upon whether the resident was their own responsible part an emergency contact or Power of Attorney would be contacted, as well as the Facility Administrator and/or the DON. The DON stated a Fall Assessment should be fully completed. The DON indicated the Fall Assessment would be triggered from the Risk Assessment by selecting fall as the category. The DON stated an immediate intervention should also be put into place at the time of the fall. The DON expected a Progress Note would be entered into the EHR with the head to toe assessment, what happened, contacts made. On 7/24/24 at 2:05 PM Staff J, OTR, stated the Therapy Communication Form was utilized to communicate all changes in therapy to the facility. The document required the signature of the therapist and a representative from the facility acknowledging the change. Staff I, PTA, stated the facility was a no lift facility and 2 person transfers were not typically done. Staff I stated when a Therapy Communication Form was completed it was taken to the nurse in charge of that resident for education and signature, the CNA working with that resident was trained in the change, a copy was placed in the folder for scanning to EHR and Care Plan updating, and was posted in the resident's room. Staff I stated she would post in the resident's room during a treatment session to ensure completed and would document the posting. On 7/24/24 at 2:15 PM the Administrator stated the facility was moving to a no lift facility to ensure the safety of the residents and staff. The Administrator stated if there were special circumstances requiring a 2 person transfer there would be specific training for that resident. The Administrator acknowledged a person transitioning from a NWB dependent mechanical lift to stand pivot of one assist would be hard. The Administrator stated transitioning from a NWB dependent mechanical lift to weight bearing mechanical lift to stand pivot transfer would be a more natural progression. On 7/24/24 at 2:20 PM Staff K stated she would ask the nurse or DON about a resident's abilities, and ask to see a Care Plan. The staff stated if a resident had a change in function would ask the nurse or DON, but couldn't tell how she would know if someone had a change in function prior to her shift. On 7/25/24 at 11:26 AM the DON stated she felt every resident that requires assistance to transfer should be issued a gait belt or every CNA should be issued a gait belt for use with individuals needing assistance to prevent having to look for gait belts at times of transfers. The DON expected staff assisting residents with transfers utilize gait belts. Review of the facility's Fall Risk Reduction and Management Policy revised 12/15 revealed components of the falls risk reduction program contains, but not limited to identification of risks for falls, implementation of individualized interventions, interdisciplinary review of each fall, post fall care and management, and analysis of fall data for quality improvement opportunities. Procedures identified in the document include identified interventions with the fall risk, individualized goals and interventions in the care plan, and completion of the admission/re-admission documents and review of the initial Care Plan. Higher fall risk was defined as an individual with 2 or more falls in the previous 6 months, history of falls and determination by the Interdisciplinary Team. The documentation revealed the care plan would need to be revised with new interventions and as indicated, and changes would be communicated to the caregiving team. Review of the facility's Clinical Change in Condition Management Policy revised 6/15 revealed the resident would be assessed if there was a change in condition, review of the medical record, review of the condition with a Registered Nurse (RN), notification to the physician, complete documentation requirements, review the Care Plan interventions and modify, and update the staff of changes. 41785 2. According to the MDS assessment dated [DATE], Resident #39 had a BIMS score of 9 (moderate cognitive deficit). He required partial assistance with eating, dressing, toileting and transfers. The Care Plan updated on 1/29/24, showed that Resident #39 had chronic pain related to lung cancer and urothelial carcinoma of the bladder. He had an Activities of Daily Living (ADL) self-care performance deficit and he was a fall risk related to dementia. Staff were to provide frequent checks due to falls and to review information on past falls and attempt to determine cause of falls and remove any potential causes if possible. Observations revealed the following: On 7/22/24 at 11:50 AM, Resident #39 was in his recliner, sitting on edge of seat. The wheel chair was behind the recliner, and the call light was on the floor near the bed. On 7/22/24 at 2:32 PM, the resident was in his room, in the wheel chair, bent over and reaching for his shoes on the floor. On 7/22/24 at 3:02 PM, the resident was in his room, in the wheel chair. His glasses were on the floor and he is reaching for them. A review of the clinical record revealed that Resident #39 had the following falls since June 1,2024: a. 6/5/24 at 12:51 PM, he was found on floor in room said he was trying to reach the bed. b. 6/14/24 at 1:30 AM, he was lying on right side on floor. trying to get my shoes c. 6/15/24 10:20 PM, he was found on the floor, unable to say what happened, no injuries d. 6/16/24 at 6:00 AM, he was found lying on the floor next to the recliner. foot rest still extended. no clothes on trying to get rid of the smell. e. 6/18/24 at 5:35 AM he was standing, holding up brief and went backwards. f. 6/21/24 at 3:00 PM he was in his room alone, tried to transfer self on bed and was found sitting in front of the bed on his knees. g. 6/23/24 at 3:12 PM, he was found on the floor in room, on his hands and knees in front of his wheel chair. h. 6/23/24 at 9:37 PM he was found on the floor in the dining room. He stated that he slid to the floor. i. 6/24/24 at 10:57 AM, found on the floor in his room with the wheel chair behind him. The breaks were not locked. j. 7/4/24 at 3:15 PM found on the floor in his room. k. 7/8/24 at 7:26 PM, he was found on the floor in his room. The dinner tray was on the bedside table. And the wheel chair beside him. l. 7/12/24 at 8:30 PM found on the floor in his room. One shoe under his legs and one shoe under his head. Appears that he took his shoes off and got out of the wheel chair. m. 7/16/24 at 3:45 AM, found in his room on his knees in front of the bed. He was unable to say what happened. n. 7/18/24 at 3:00 PM found on the floor in his room, feet bent under him. I was trying to get on the floor. o. 7/12/24 at 9:00 PM found on flood on his knees in room facing recliner helped him into recliner. On 7/25/24 at 7:20 AM, the Director of Nursing (DON) said that she was aware of the problem of all of the falls that Resident #39 had and this week she was going to propose weekly root cause analysis meetings to determine what could be done differently. She acknowledged that interventions had not been implemented and care planned.

Based on clinical record review, facility policy review, staff, and resident interviews the facility failed to have a nurse assess a 1 of 3 residents (Resident #3) after a fall, prior to moving him or put appropriate interventions in place when he experienced a change in condition of increased pain, new bruising, and swelling. The staff found Resident #3 on his knees in his room on Friday 5/19/23, while on the floor he complained of pain. A Certified Nurse Aide (CNA) reported he could not stand to see the resident uncomfortable, so he moved him to the bed before getting the nurse. When the nurse assessed the resident he denied pain, but said it did hurt before he got off the floor. He started to request as needed (PRN) pain medication on Saturday 5/20/23 and received at least a dose of pain medications each day until 5/24/23. After he started having pain on 5/20/23 (Friday), the nurse faxed the physician to update them on Resident #3's change in condition. The facility did not receive a response until 5/22/23 (Monday) with an order for an x-ray. Resident #3 had the x-ray on 5/22/23 at the hospital. The facility waited two days before contacting someone about the results of the x-ray. On 5/24/23, Resident #3 we went to the hospital due to the x-ray results revealing that he had a right femur fracture. Resident #3 went five days after falling before the facility determined that he fractured his bone around the new hardware he received the week before. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #3 required extensive assistance of two persons for transfers, walking in his room, and locomotion. Resident #3 received a scheduled pain medication regimen with an as needed (PRN) medication received, offered, or declined during the five day lookback period. His pain made it hard for him to sleep at night, limited his day to day activities, and he rated his pain as moderate. The MDS listed that he fell prior to his admission that resulted in a major surgery. Since his admission he experienced one fall that resulted in a major injury. The MDS included diagnoses of displaced spiral fracture of right femur, anemia, and renal failure. The Care Plan focus area documented Resident #3 was at high risk for falling because he had gait and balance issues because of a recent right femur fracture. The care plan contained the following interventions: a. 6/15/23: Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility b. 7/5/23: Follow-up with his orthopedic provider as scheduled c. 6/15/23: Keep needed items within reach d. 7/5/23: Resident ambulates with assistance from one staff with a wheelchair e. 6/15/23: Review information on past falls and attempt to determine cause of the falls. The Care Plan Focus revised 6/15/23 indicated that Resident #3 had an actual fall on 5/19/23 with no noted injury due to poor balance with self-transferring in his room. On 5/22/23 observation revealed bruising on his right inner thigh to his lower extremity. On 5/24/23 Resident #3 went to the hospital. On 5/26/23 the hospital diagnosed him with a periprosthetic fracture, a broken bone that happens around a previously repaired fracture, around the internal prosthetic, artificial substitute, right knee joint. The Interventions instructed the following: a. 5/18/23: Continue interventions from the at-risk plan. b. 5/24/23: Determine and address causative factors of the fall. c. 5/25/23: Keep call light within reach and encourage to use his call light and ask for help. d. Revised 6/15/23: Keep his wheelchair close to his bed to give safe transfer if attempts to self-transfer. Resident can be noncompliant with transferring from bed to chair or wheelchair. The Care Plan Focus revised 6/15/23 recorded that Resident #3 had pain related to right femur fracture. He used oxycodone with acetaminophen (opioid pain medication), intramuscular (IM injection) Toradol (reduce swelling pain medication), and cyclobenzaprine (muscle relaxers to help with pain). On 8/2/23 at 1:30 PM the Administrator provided Resident #3's admission Nursing Data Collection assessment dated [DATE] at 8:52 PM. The assessment included the following skin impairment on admission: right trochanter (hip) had a surgical incision site with a dressing in place. The wound appeared clean, dry, and intact. The Daily Skilled assessment dated [DATE] at 12:25 AM indicated that Resident #3 had no concerns related to edema. The notes section remained incomplete or blank. The note lacked concerns related to skin integrity issues. The Fall Incident Report dated 5/19/23 at 10:40 PM detailed that the aide reported to Staff C that he found Resident #3 on his knees beside his bed. When the nurse entered the room, she observed Resident #3 in bed alert and oriented. The staff got Resident #3's vital signs, which appeared within normal limits (WNL). Resident #3 denied any pain at that time, but did add that at the time his fall he felt pain in his right leg. Resident #3 stated he tried to get into bed from his chair and started to go down, so he slid down to his butt next to his bed. After getting to the floor, he got on his knees to try and get up. He said he pushed his call light but did not want to wait any longer. After assessing Resident #3, the nurse encouraged him to use his call light and be patient. In addition, the nurse planned to advise the staff to do more frequent rounds. The nurse notified his family and doctor of the fall and that he had no new injuries. The Health Status Note dated 5/19/23 (Friday) at 11:18 PM written by Staff C, Agency Registered Nurse (RN), described that the staff found Resident #3 on his knees by his bed in his room. The Certified Nurse Aide (CNA) notified the nurse. The nurse assessed his vitals and charted in his Electronic Health Record (EHR). Resident #3 reported that he tried to go to bed on his own but he started to fall, so he slid down to the floor on his bottom. After he got on the floor, he got to his knees when the CNA found him. Resident #3 denied pain at that time but did report that his right leg injury did hurt at the time of the fall. The assessment revealed no bleeding, bruising, redness, or swelling to his left leg. The Daily Skilled assessment dated [DATE] at 1:08 AM indicated that Resident #3 had no concerns related to edema. The notes section remained incomplete or blank. The note lacked concerns related to skin integrity issues. The Health Status Note dated 5/20/23 (Saturday) at 6:51 PM written by Staff E, RN, listed that Resident #3 fell on the night shift of 5/19/23 around 10:00 PM. On 5/20/23 around 3:00 PM, Resident #3 reported that he had pain. When the nurse asked where he had pain, he showed the nurse his right side. The nurse noticed he had a lot of bruising on his right inner thigh all the way down to his right lower calf with black and blue areas. Resident #3 added that he did not have that before. He did have surgery to his femur a week ago. The Daily Skilled assessment dated [DATE] at 3:26 PM indicated that Resident #3 had no concerns related to edema. The notes section remained incomplete or blank. The note lacked concerns related to skin integrity issues. A facsimile (fax) sent to the physician on 5/20/23 listed that the nurse had a concerned due to Resident #3 falling after just having surgery a week before. The note included a request for any new orders? The Advanced Registered Nurse Practitioner (ARNP) responded with questions regarding why he had surgery, as they did not have notes in his chart. Then they questioned if he had any difficulty with walking or moving his leg? If so, get an x-ray. The fax included a note dated 5/22/23 that he went to the hospital for an x-ray. The Daily Skilled assessment dated [DATE] at 6:46 AM listed that Resident #3 had edema present to his right hip post-surgical site. The wound section included documentation of a right hip incision, that appeared clean, dry, and intact. The assessment described that Resident #3 received as needed (PRN) pain medication to treat his pain. The Health Status Note dated 5/22/23 (Monday) at 11:20 AM written by Staff E recorded that the nurse went to see how Resident #3 was doing due to his fall over the weekend. Resident #3 reported that he had pain and trouble walking after his fall. The nurse sent a fax to the physician over the weekend with concerns. The physician sent a fax back today that stated if the resident had difficulty walking or moving his leg, they need to get an x-ray. The nurse made an appointment with x-ray in town. Resident left the facility to be seen at the hospital for an x-ray. The Daily Skilled assessment dated [DATE] at 12:43 AM indicated that Resident #3 had no concerns related to edema. The notes section remained incomplete or blank. The note lacked concerns related to skin integrity issues. The Daily Skilled assessment dated [DATE] at 1:00 AM indicated that Resident #3 had no concerns related to edema. The notes section remained incomplete or blank. The note lacked concerns related to skin integrity issues. The Health Status Note dated 5/24/23 (Wednesday) at 3:35 PM written by the Assistant Director of Nursing (ADON) reflected that the nurse called the clinic to see if Resident #3's x-ray had been addressed. The clinic informed the nurse that the x-ray results were sent to the physician's clinic on 5/22/23 (Monday). The nurse obtained a copy of the x-ray results and sent them to Resident #3's orthopedic doctor for review. Review of Resident #3's EHR revealed an order dated 5/24/23 at 5:52 PM. The facility received a verbal order from the ARNP on call for the physician to send Resident #3 to the hospital for evaluation for significant bruising to left inner thigh after fall at bedside transferring from the recliner to his bed independently with his walker. The Verbal Order dated 5/24/23 at 5:57 PM received by the ADON from the ARNP directed the facility to send Resident #3 to the emergency room (ER) for evaluation due to his significant bruising to his left inner thigh after his fall. The Emergency Department (ED) Provider Note dated 5/24/23 at 6:50 PM reflected that Resident #3 had an open reduction internal fixation (ORIF, a type of surgical repair) of his right hip on 5/18/23. After his repair, he transferred to the nursing facility on 5/19/23 and fell on [DATE]. At that time, the facility notified his primary care provider. Resident #3 went to the local clinic for imaging on 5/22/23. A two-view x-ray of his right femur revealed a comminuted distal femoral diaphysis fracture (fracture straight across the bone or into many pieces) status post ORIF. Displaced fracture fragment laterally and superior margin of the fracture comparison with prior exams recommended clinical correlation and follow-up recommended. The DON learned of the x-ray report and attempted multiple times to reach the primary care provider without success. Resident #3 went to another hospital to be evaluated. The Health Status Note dated 5/25/23 at 8:24 AM indicated that the nurse called the ER for an update on Resident #3. He went to the medical-surgical floor overnight for observation, then transferred to another hospital in the morning for an orthopedic consult. The Health Status Note dated 5/25/23 at 4:46 PM indicated that Resident #3 would have surgery the morning of 5/26/23. Resident #3's June 2023 Medication Administration Record (MAR) included an order dated 5/18/23 for oxycodone-acetaminophen 5-325 milligrams (mg), give two tablets by mouth every 4 hours PRN for pain. The order directed to give one to two tablets every four to six hours PRN related to a right femur fracture. The MAR included documentation indicating that he received the medication on the following days: - 6/19/23 at 9:11 PM pain rating of 0, follow-up documentation listed it as effective - 6/20/23 at 10:01 AM pain rating of 4 out of 10, follow-up documentation listed it as effective - 6/20/23 at 5:01 PM pain rating of 4 out of 10, follow-up documentation listed it as ineffective - 6/21/23 at 10:52 PM pain rating of 7 out of 10, follow-up documentation listed it as effective - 6/22/23 at 5:41 PM pain rating of 5 out of 10, follow-up documentation listed it as effective - 6/23/23 at 4:53 AM pain rating of 8 out of 10, follow-up documentation listed it as effective - 6/23/23 at 9:36 AM pain rating of 7 out of 10, follow-up documentation listed it as effective - 6/23/23 at 5:24 PM pain rating of 8 out of 10, follow-up documentation listed it as ineffective - 6/24/23 at 5:41 AM pain rating of 8 out of 10, follow-up documentation listed it as effective On 8/1/23 at 2:59 PM attempted to call Staff E. Due to no answer, left a voicemail and sent a text message. On 8/1/23 at 3:05 PM Staff D, Agency CNA, reported that the nightshift ran late that night. At about 10:30 PM he saw that Resident #3 had his call light on. When he went in to his room, he found him on the floor on his knees next to his bed with a pillow under his knees. He had no way to get help because the other staff went to the front of building and he did not have anyone down his hall. Resident #3 did not have the option to call out for help and he had excruciating pain. So, Staff D assisted him, by himself, to the side of his bed. Once he knew Resident #3 was comfortable he went and got the nurse so she could assess him and get him completely in bed. When asked how he acted his shift before his fall, he responded that someone told him in report about Resident #3 being basically independent, recovering from surgery, and due to discharge the next day. Staff D felt the resident was pretty with it and could get to his recliner which was less than 10 feet from his bed. Staff D denied that Resident #3 complained of pain during his shift. After he fell , he experienced a lot of pain while he on the floor. After he got in bed, he did not complain of pain. When asked to describe how he assisted Resident #3 from the floor to his bed alone, Staff D responded that he knelt next to Resident #3 on one knee and they each placed one arm around the back of each other's neck. With Resident #3's good leg they both stood up and got him to sit in bed. Resident #3 did not have not non-skid socks on at the time, just regular socks. His walker was nearby but it must have gotten out of his hands. The resident did not say where his pain was but would assume his knees and/or hip. The last time he saw Resident #3 before his fall was around 9:30 PM-9:45 PM when they passed out snacks and water. At that time, he sat in his chair and said he would let the staff know when he was ready for bed. On 8/2/23 at 10:56 AM the ADON stated that Resident #3 went to the local hospital for an x-ray. She did not know why it took two days to get the results of the x-ray. She reported that she worked on the MDS reports and did not stand by the fax machine all the time. As she recalled, she remembered asking why the report took so long and wondered where it was. She decided at that time to call the hospital to get the results. When she received the results, she notified the physician and Resident #3's orthopedic surgeon. When x-ray results are available they should be sent to the facility, but sometimes they send them to the ordering provider's office. She believed that was where the breakdown was and why the facility did not receive the results timely. When inquired if it is appropriate to move Resident #3 prior to a nurse completing an assessment, the ADON replied that she did not know that happened but that is not done at the facility. The staff should get the nurse and additional help with getting him up. She indicated that staff should use a Hoyer (full-body mechanical lift) to get Resident #3 off the floor, safely. On 8/2/23 at 12:43 PM Staff B, previous Director of Nursing (DON), indicated that sometimes the x-ray reports are sent to the facility, other times the staff must call for them. She added that sometimes the clinic sends the x-ray reports to the ordering physician. There's a little bit of a breakdown in that when they send the x-ray reports to the ordering physician. When questioned about the fall that took place on late Friday evening, Staff B responded that if the nurse had concerns and needed to notify the doctor what should they do; generally, would call the doctor if it's an emergency and is dependent on the nurse's assessment. When asked about what she would do if she observed new onset of bruising to his right inner thighs, Staff B responded that she believed he had some bruising on admission from his surgery. After she got informed that the nurse documented that Resident #3 indicated the bruising was new, she replied that she thought they called for a portable x-ray, sounded like they faxed the doctor for an order. Staff B was informed of no notes or orders located requesting the portable x-ray. When asked about the nurse sending a fax the doctor on a Saturday but the doctor did not write orders until Monday for an x-ray to be completed, should the nurse have done anything differently? Staff B stated the nurse should have called the ER. When asked if they did not call for the portable x-ray, should staff have done anything differently? Staff should have called the ER to get an x-ray. Staff B stated the staff are expected to go get the nurse so they can be assessed if they find a resident who fell . When asked if the resident could be moved prior to the nurse completing the assessment, she stated the nurse needs to do an assessment first. Once the assessment is done then they can get some help to move them. After learning that Staff D stated Resident #3 had excruciating pain and he did not feel comfortable leaving him there so he moved him before the nurse completed her assessment, Staff B questioned if he put that in his statement because it did not sound right. She added she did not know that and he did not put that in his statement. On 8/2/23 at 1:00 PM Staff C explained that when the CNA came to let her know that Resident #3 fell , she grabbed the vitals machine and went to his room. She noted Resident #3 in bed and had dark bluish bruising to his surgical site on his right hip, from his surgery. Resident #3 did not complain of pain at that time and he kept saying it was his fault. She educated him on waiting for help when he needed to transfer. She initiated neurological checks, those were fine all night and he appeared fine the rest of the night as well. She could not remember what he had on his feet. When asked what she would do if she noticed new bruising to his right inner thigh and that he had pain, she responded that she would call the provider. If the provider did not respond, she would call the DON for guidance. When x-ray results are available Staff C stated they are usually sent to the facility. On 8/2/23 at 1:54 PM observed Resident #3 lying in bed with his right foot on a wedge. When asked about the fall that took place after his admission to the facility, he stated that he sat in the big recliner in front of his window to the right of his bed. He activated his call light and got impatient, he thought his walker was within reaching distance. It appeared roughly four feet from him. When he went to reach for it while standing he went down to the ground. He could not remember how he landed but he did remember that he got a pillow to put under his knees on the floor. He noted his walker with him on the floor. A male staff member came in and picked him up off the ground. When asked if he had any pain, he replied that he could not remember because he just had his hip repaired. He also could not remember how long his call light was on that evening. Resident #3 stated the fall was his fault, he was just being impatient. On 8/3/23 at 3:57 PM reviewed the following with the Physician on the events that took place after Resident #3 came to the facility: - Arrived to the facility on [DATE] post right femur fracture repair, admission assessment documented surgical incision at right hip, with no bruising or swelling documented. - Friday, 5/19/23 at 10:40 PM found him on his knees by his bed. He attempted to self-transfer; Resident #3 did not have pain but his right leg did hurt when he fell . The nursing assessment did not reveal any bruising, redness, or swelling at that time. - Saturday, 5/20/23 around 3:00 PM Resident #3 complained of pain and showed the nurse where it hurt. He described that he had a lot of bruising on his right inner thigh all the way down to his right lower calf (black and blue). He added that he did not have that before. - Monday, 5/22/23 Resident #3 had pain and trouble walking after his fall. The facility sent a fax over the weekend with concerns, the ARNP faxed back that Monday. The ARNP directed that if he had difficulty walking or moving his leg for him to get an x-ray. The nurse made an appointment for him in town and he left facility for hospital to get x-ray. When inquired if the nurse on 5/20/23 should have done anything different when she noticed the bruising, the Physician explained that it depended on what other symptoms Resident #3 had. If the nurse called him, he would have told her to send Resident #3 to the ER for an x-ray. He did not recall if a portable x-ray was ordered for this resident. He started his vacation on 5/22/23 but would have been available Friday the 19th through Sunday the 21st had they called him. He added the facility has his cell phone and know to call him when needed. The staff member could have also called the ER as well. On 8/8/23 at 11:42 AM the DON stated if a resident fell , the staff is expected to get help. They should turn on the call light or get someone that may be nearby, they are not to leave the resident. After the nurse assesses the resident, then they can be moved. When she learned that the CNA moved Resident #3 before the nurse could assess him, she said he should not have done that and that she just heard that for the first time. At the time of the fall she was the Regional Nurse Consultant. When inquired who is responsible for obtaining x-ray results after a resident has an x-ray, the DON replied that the nurse who is following up on it should get the x-ray results. If the resident went to the ER it can take a bit to get the result but she would expect the staff to call within a couple hours to get the results. They can also call the hospital to get the medical records. When she first started as the DON, the hospital called her to inform her of the x-ray results. When informed that the staff waited two days to call for the results, the DON appeared surprised that the hospital did not call with them. If the resident started to experience pain that did not respond to pain medications, she expected the staff to follow up on that. If she noticed the new onset of bruising to his right inner thigh extending to his lower calf she would have called the doctor for orders. She added that the staff could also call her or the ER for any guidance. She explained that since she returned as the DON, her phone is busy with calls from staff. On 8/8/23 at 3:13 PM the Administrator stated that sometimes the x-ray reports are sent back with the resident but other times they will have to request them from medical records. Since he went to the ER for the x-ray the facility had to request them either that day or the following day. At the time of this incident, she was on leave and when she heard he fell on a Friday and x-rays did not get done until Monday she couldn't believe it. They should have notified the doctor to see what they should do after his fall that Friday. When the nurse noticed the new onset of bruising and pain on Saturday that nurse should have called the doctor. The doctor is always available and would answer his phone at all hours of the night. The Clinical Change in Condition Management policy dated June 2015 directed staff to contact the physician and provide clinical data and information about the resident's condition. The staff are to document the notification to the physician, the physician's response in the resident's medical record, and initiate any new physician orders. The nurse is to document the resident's condition and location on the 24-hour report. In addition, the nurse should verify that the family/responsible party got notified. Then review the resident at the next scheduled care management meeting as applicable.

Based on record review, staff interviews, and facility policy review, the facility failed to prove a timely assessment and implement additional interventions for 1 of 3 residents (Resident #1) reviewed. On 01/31/23, staff told the nurse on duty that Resident #1 had an oxygen saturation level of 74% and her lips were blue. The nurse told staff the resident was exhibiting a behavior because she was non-compliant with wearing her supplemental oxygen (kept removing it). The nurse failed to complete a physical assessment or provide additional interventions other that from ensuring her oxygen remained on, as the resident's oxygen saturation would return to her baseline (usual) when the resident remained in compliance with wearing her oxygen. The nurse reported she thought the resident exhibited behaviors which she said deterred her from completing an assessment and utilizing Resident #1's as needed (prn) orders to help the resident. The resident subsequently transferred to the emergency room (ER) and passed away three days later. The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 11/2/22 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3, which suggested the resident demonstrated impaired cognition. The MDS indicated she required extensive assist of two staff for bed mobility, transfers, and toilet use, and extensive assistance of one staff for dressing and personal hygiene. The MDS documented she did not wear oxygen during the 7-day review period. The MDS identified the resident had the following diagnoses: Parkinson's disease, anemia, heart failure, renal failure, diabetes mellitus, paraplegia, seizure disorder, anxiety, depression, bipolar, schizophrenia, respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). The Care Plan Focus area revised on 1/26/2023 documented Resident #1 had altered respiratory status related to ineffective gas exchange secondary to COPD. On 1/24/23, the facility added an intervention to the Care Plan that documented the resident removed her oxygen and directed staff to prompt the resident to keep her oxygen in her nose. The following intervention was initiated on 1/26/23 and guided staff to promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). The care plan contained the following resolved intervention: oxygen settings, oxygen via nasal cannula at 2 liters continuously, which was discontinued on 8/22/16 due to resident's noncompliance with wearing the oxygen. The Progress Notes included the following documentation related to Resident #1's respiratory issues: a. On 1/10/23 at 12:45 PM the Licensed Practical Nurse (LPN) documented Resident #1's resident's lips were purple and she was not eating lunch - vital signs were taken and her oxygen level was 75% on room air (RA). When encouraged to take deep breaths, her oxygen level came up to 88%. Oxygen applied at 2 liters (L) via nasal cannula to assist with oxygen intake. b. On 1/10/23 at 10:56 PM Resident #1 returned from the hospital with the following orders: 1) Oxygen at 2 L via nasal cannula to keep her oxygen saturations above 88% 2) Primary Care Provider (PCP) will visit on rounds on the 12th 3) Return to the emergency room (ER) if severe shortness of breath returns c. On 1/13/23 at 9:46 PM Resident #1 had excess secretions, could not talk - very little audible. She only allowed staff to use a tongue depressor once to clean out secretions. Staff asked the resident if she could suction her using the machine, Resident #1 shook her head up and down. Staff called, spoke with the on-call PCP, and received a verbal order to suction Resident #1 for secretions prn. Staff had difficulties suctioning Resident #1 and called Emergency Medical Team (EMT) assistance, who suctioned the resident as needed. Afterwards, she sounded better and her speech was normal, so the EMT's left the building. d. On 1/15/23 at 9:39 AM Resident #1's oxygen saturation levels were 88%-95% while on 3 L of oxygen via nasal cannula. Staff documented the resident had thick secretions, coarse lung sounds, and continuous coughing. PCP notified - will continue to monitor. e. On 1/18/23 at 12:03 PM received new order for Guaifenesin (help clear mucus) 400 milligrams (mg) every 4 hours PRN for cough or congestion for 10 days. Obtain an appointment if condition worsens. f. On 1/21/23 at 4:31 PM Resident had purple lips and her oxygen levels were below 70%. Staff had redirected her to her room so an assessment could be completed. She was in and out of consciousness with diminished lung sounds. Staff put on her supplemental oxygen at 2 L via nasal cannula. Staff was with her and took her vitals, her oxygen saturation was at 90% while wearing supplemental oxygen. For the next 19 minutes, she remained on oxygen, her lips came back to a flesh color, she was alert and oriented, and would speak when spoken to. Her oxygen saturation level bounced between 90% and 98% with the nasal cannula in place. Staff called and asked for the doctor on call to call back. The doctor returned the call and gave an order for a breathing treatment every 4 hours PRN due to shortness of breath and if she worsens she will need to go to the ER. Staff initiated a breathing treatment, then she went to dinner while on oxygen via nasal cannula. g. On 1/24/23 at 5:00 PM Staff A, Agency Licensed Practical Nurse (LPN) documented a late entry: on 1/25/22 at 5:49 PM nurse notified during report of Resident #1's oxygen saturation throughout the night. Staff went in to the resident's room, re-applied the resident's oxygen properly, and checked her oxygen saturation (90% while wearing nasal cannula). During lunch at approximately 11:30 AM, the Certified Medication Assistant told the nurse the resident's lips were blue. As the nurse started to head to the resident's room to get her oxygen, she instead asked a Certified Nursing Assistant (CNA) to get it. The CNA arrived quickly with the oxygen and placed the nasal cannula on the resident. Her saturation increased to 90% and the resident was awake and able to talk, but needed help eating her lunch, so the CNA sat with the resident to assist her with her meal. After lunch, staff assisted her to bed and applied her oxygen. Shortly after, the resident started to yell that she wanted to get up and did not want to stay in bed. Staff A went in to clarify what she was saying because it was difficult to hear from the nurse's station, she repeated herself. Staff A then went to tell the CNA that she wanted to get up for the afternoon. When they arrived back to the room, Resident #1 had fallen asleep with her oxygen on. At approximately 4:30 PM, a CNA went in to her room to assist her up for supper. She was still asleep, had blue lips and the CNA thought she looked gray. She reported her observation to the nurse. When Staff A arrived in the resident's room, her oxygen was off, her lips were blue, and she was breathing through her mouth. Staff A replaced the resident's oxygen and put the oxygen sensor on her finger. While the oxygen sensor was catching a signal, Staff A attempted to awaken the resident, who took a couple of deep breaths, moved a little bit, then went back into a sound sleep. Her O2 saturation was 86%, and after 1-2 minutes, her oxygen increased to 90% while on 2 L of oxygen. Staff A documented she checked on the resident during supper: her oxygen was still on and she looked more pink around the lips. Her lips returned to their natural color and her oxygen was still in place. h. On 1/24/23 at 7:14 PM Staff B Agency LPN documented she arrived to work at 6:00 PM and received report from the previous nurse. After report was completed, CNAs reported that Resident #1 did not seem like herself. Staff stated she was gray in color and oxygen saturations were in the upper 70's to low 80's. Upon entering the resident's room, she showed signs and symptoms of dyspnea, oxygen saturation was at 84%, she used abdominal muscles to breathe, capillary refills were between 3-4 seconds and lung sounds were diminished bilaterally. She would not respond to voices but was able to arouse with touch. The head of her bed was elevated to 45 degrees and her nasal cannula was placed in her mouth due to her mouth breathing. The oxygen flow level was increased to 5 L and her oxygen saturation increased to 94%. Staff B called 911 at 7:00 PM and the resident left the facility at 7:10 PM. i. On 1/25/23 at 12:23 AM Resident #1 was admitted to the hospital for hypoxia and placed on a BiPAP machine (assists with pushing air into the lungs). j. On 1/27/23 at 4:23 AM the hospital called and reported Resident #1 has passed away early in the morning. Review of the assessments tab in Resident #1's Electronic Health Record (EHR) revealed no documentation of assessments completed by staff on 1/24/23. On 1/31/23 at 11:07 AM, Staff B Licensed Practical Nurse (LPN) stated when she arrived, Staff A told her the resident has been up all day and that her oxygen saturations did drop down in the 70's and was kind of tired. A CNA came to her after report and stated Resident #1 did not look right and hasn't looked right all day. She told her Staff A did not do anything when they told her Resident #1's oxygen was good. When Staff B arrived in the resident's room, her oxygen was on and she was definitely gray in color. She put the pulse oxygen reader on and her oxygen was at 84-85% while lying flat in bed. She reported she raised the head of bed, increased her oxygen from 2 L to 5 L, and called the Director of Nursing to let her know what had been going on all day with Resident #1 and that staff had reported Staff A didn't do anything for the resident. The DON told her to put the nasal cannula in her mouth to assist with oxygen intake and this bumped her oxygen saturation up to 94%. Staff B then went to Resident #1's room right after report at 6:15 PM. She called 911 at 7:00 PM and the resident was on her way to the hospital at 7:10 PM. On 1/31/23 at 12:18 PM Staff D CNA stated Resident #1 was not acting herself on 1/24/23 as she is usually a jokester when you would walk in her room, she would just say hi beautiful it's good to see you, but she was not doing any of that. She noticed Resident #1 was not herself, she was lethargic - one of her eyes would not open, her words were slurred, and would not squeeze the CNAs her hands. At around 4:30 PM, she told Staff A what she had noticed about Resident #1. Staff D said she wanted Staff A, LPN to assess her, so staff knew whether or not to get her up in her wheelchair or not. Staff A went into Resident #1's room, but took her time to get there. Staff A put the pulse oximeter on her finger, said it was at 90%, and asked Staff D to assist her out of bed as this was a behavior. Staff D said Staff E, CNA and Staff F, CNA attempted to assist the resident up they had to take her oxygen off because it is short tubing and they did not want to strangle the resident. She indicated they left the pulse oximeter on the resident as they attempted to get the resident up and noted her oxygen saturation went down to 74%. They put her oxygen back on the resident and Staff D went to let the nurse know the resident's oxygen had dropped to 74%, they were not getting her, Staff A just said oh ok and continued to go to the other hall. Staff D opined that a low oxygen saturation is not a behavior and this was not right. After she got her residents up, she went and talked with the Administrator because she was very mad at that point. The Administrator stated she would investigate. After that, Staff D reported she felt she did what she could by reporting her concerns. When her shift ended, the resident was still in bed wearing her oxygen. She said she felt Staff A could have at least attempted something and not just say Oh, she's just having a behavior. On 1/31/23 at 1:31 PM Staff E CMA stated when she starts her shift she does vital signs. She went in to Resident #1's room about 4:45 PM to do her vitals, her oxygen was off, the head of her bed was elevated and her oxygen saturation was 84%. Her oxygen tubing was not even within reach to indicate she removed it herself and her oxygen concentrator was not even on. Staff E said she applied the resident's oxygen, went to another hall to get vitals on other residents with the intentions of coming back to check on Resident #1. She reported Staff A walked up to her, asked for her pulse/oximeter, and left. About 5:00 PM, she went up to the nurse's station and Staff D and Staff F had asked her to bring in her vital sign equipment to Resident #1's room. They told her Staff A told them to get her up but they did not feel comfortable. The CNA's mentioned they told the nurse when they tried to roll her, her lips turned purple and Staff A told them she was just in there and her oxygen was 90%. When Staff E put the pulse oximeter on her oxygen saturation was 86% with oxygen. While they all attempted to get her up, they left the pulse oximeter on her while they attempted to get her up in her wheelchair. They had to take her oxygen off because the tubing was short. It was only off for a split second and her oxygen dropped to 74% so they immediately put the oxygen back on her and told the nurse. Staff A told them this was ongoing today and it was just a behavior because she was just in there and her oxygen was at 90%. They told her they did not feel comfortable about getting her up but Staff A did not do anything. Staff E said when the oncoming nurse, Staff B, arrived, she completed an assessment, increased Resident #1's oxygen from 2 L to 5 L, put her nasal cannula in her mouth, ensured her head of bed was elevated at 45 degrees, and sent the resident to the hospital for evaluation. On 1/31/23 at 1:25 PM Staff F stated she went in to Resident #1's room about 5-5:30 PM to get her up for supper and her oxygen was on at that time. She had noticed she was not acting or looking right. She was the type of person you could joke, she would let you know if she did not want to be joked with, could be very vocal. They put the Hoyer sling under her and she did not say anything with was unusual for her. She would always say you don't know what you are doing, you are not doing it right. Her skin looked gray. They had someone get Staff A, she came in rubbed the resident's feet said they were cold, told staff to get her up, and then left. Resident #1's left eye would barely open and her right eye was closed. Staff A stated this was a behavior, it will be ok and to get her up. They went to change the resident and had to lower the head of the bed to roll her over, but she began to turn purple, so they elevated the head of her and applied her oxygen. They left the resident up in bed for a few minutes and her color went back to normal. They got Staff E to come in with the pulse oximeter to put on the resident while they attempted to get her up, and her oxygen saturation ranged from 72%-90% while they attempted to get her up. They all decided they did not feel comfortable doing so and needed to let the nurse know. Staff F stated Staff D went to let the nurse know but Staff A never came back to the room. Staff D indicated the nurse told her it was a behavior. Staff F stated she was upset and worried something was wrong with her. When Staff B came on shift they let her know what was going on and that they were concerned. Staff B went in, assessed her and sent her to the hospital. On 1/31/23 at 2:21 PM Staff A stated Resident #1 took off her oxygen which would make her oxygen saturations low, and she had taken it off several times on 1/24/23. She stated about 4:30 PM the CNAs came to her to let her know Resident #1's lips were blue. When she went in to her room, Resident #1's oxygen was off and her saturation was at 80%. Staff A reported put the resident's oxygen on and stayed in the room with her. Staff A kept trying to wake Resident #1 up because when she deep sleeps, she mouth breathes and does not take in the oxygen through her nose. Staff A said that after a few minutes, she checked Resident #1's oxygen saturation and it was 90%. The CNAs did not want to get Resident #1 out of bed because they did not feel comfortable with it and Staff A was fine with this. Staff A indicated at about 5-5:30 PM, she checked on the resident again and her oxygen saturation was 90-92% while wearing her oxygen. She added that when she gave report to Staff B, she informed her the resident was asleep, and although she had taken her oxygen off a lot and her oxygen saturations got low, but not critically low. Staff A reported that about couple weeks ago the resident's oxygen order was PRN but the order changed to continuous at 2 L; this was care planned and her doctor was aware of the behavior of taking off the oxygen. When asked if she completed an assessment aside from assessing the resident's oxygen saturation, she stated no because her oxygen saturations were coming back up to normal. She felt this was baseline for her because she had behaviors where she would take off the oxygen, so she did not see a need to do an assessment or listen to her lungs. She also stated she did not think it was necessary to give a PRN breathing treatment or notify the doctor of her oxygen saturations, blue lips, or reports of her looking gray because once the oxygen was on, because her oxygen saturation would come back to normal. On 1/31/23 at 3:15 PM the Administrator stated she talked with the CNAs that worked with Resident #1 the day of 1/24/23. They indicated they were concerned about Resident #1 around 4-4:30 PM when they went to get her up for dinner, noticed she was not responding to them, and said they told Staff A and the nurse went to her room. The resident's oxygen was not on, and when they put it on, her oxygen saturation went to 90%, then the nurse asked the CNAs to get Resident #1, but they did not feel comfortable getting her up for her meal. The oncoming nurse, Staff B, arrived and the same CNAs mentioned to her their concerns about Resident #1. Staff B assessed her and sent her to the hospital to be evaluated. When asked if the Administrator thought Staff A should have done more for Resident #1, she stated yes; typically a nurse would have done more, such as an assessment. On 2/1/23 at 1:05 PM Staff C CNA stated she went up front so she could go to break about 4:30-4:45 PM. While up there she heard Staff D ask Staff A to go assess Resident #1 because she was not acting right. She stated Staff A looked at the CMA and CNAs like they were stupid then went down another hall to pass medications to other residents. When asked if she ever saw Staff A act in this manner before, she stated when she first started at the facility she was really good, but now she acts like she does not care as much, in her opinion. When asked if Resident #1's oxygen orders were PRN or continuous, she stated the thought they were PRN. The oxygen usage was new for the resident and she would always take it off when she had to wear it. On 2/1/23 at 10:53 AM the Director of Nursing (DON) stated it was common for Resident #1 to take her oxygen off. There was an incident a few days ago where it was low and required a call to the doctor. When asked if a nurse was informed of Resident #1's oxygen saturation being below 88% what should be done, she stated the nurse should go assess the resident, get her oxygen saturation level, if she does not have her oxygen on it needed to be put on and the doctor would need to be notified. The DON indicated the assessment should include a full set of vitals, lung sounds, and the resident's respiratory status at that time. The DON acknowledged Staff A's actions were not acceptable. She had asked Staff A if she did an assessment and she told her the resident's lung sounds were diminished and she did not call the doctor because her oxygen went back up. She had an order for a PRN breathing treatment and she should have administered that. On 2/2/23 at 1:00 PM Resident #1's Primary Care Provider (PCP) stated you would think as assessment would have been completed if Resident #1's oxygen saturation has dropped down to the 70's. He did add that the resident was noncompliant with wearing her oxygen and if her oxygen was on at the time of her oxygen saturations being in the 70's 911 should have been called because that is not normal for Resident #1. The facility's Notification of Resident/Patient Change in Condition Procedure with a reviewed date of 11/19 instructed staff to do the following when a resident has experienced a change in condition: 1. Verify any current medical orders present to treat the change in condition 2. Implement intervention(s) as appropriate 3. Evaluate and document resident/patient response to intervention(s) 4. Review MAR for current orders, note any recent medication changes 5. Obtain and document vital signs 6. Complete a physical evaluation. Document results of physical evaluation in medical record and update care plan as indicated 7. Notify the Physician and family/resident representative at the earliest possible time if there is a change in condition (unless requested to do otherwise)

Based on observation, document review, and staff interviews, the facility's administrative staff failed to ensure that the facility staff failed to follow the van lift manufacturer's instructions when transporting 1 of 1 resident (Resident #1) who was injured in an accident involving the life to [CONDITION(S)]. The facility staff's failure to follow the lift manufacturer's instructions resulted in Resident #1's wheelchair rolling backwards out of the lift, resulting in Resident #1 striking their head against the ground, which resulted in Resident #1 developing potentially life-threatening bleeding in their brain. The facility's administrative staff identified 6 residents who required [CONDITION(S)]. Due to these findings, an Immediate Jeopardy (IJ) situation, which was an immediate threat to the residents' health and safety, was identified. Findings include: 1. Review of Resident #'1 Minimum Data Set (MDS), dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (showing Resident #1 had intact cognition). Resident #1 required extensive assistance from 1 staff member in order to transfer to or from bed; for assistance toileting; and transferring into or out of their wheelchair. Resident #1's medical diagnoses included diabetes mellitus; morbid obesity; peripheral vascular disease; and [CONDITION(S)]. Resident #1's care plan, updated 7/15/21 (a year prior to the accident), revealed that the facility staff identified Resident #1 was at risk of falls, related to their morbid obesity, severe [CONDITION(S)] joint disease of the lumbar spine, and [CONDITION(S)] disease. Resident #1 required hemodialysis (a medical procedure to remove toxins from the resident's blood) related to Resident #1's renal failure. Resident #1 required transportation to the [CONDITION(S)] facility on Mondays, Wednesdays, and Fridays. 2. Review of the facility staff's undated investigation, on 7/6/22, Staff E, transportation provider, drove Resident #1 to the [CONDITION(S)] facility using the facility's van with a mechanical wheelchair lift. While Staff E used the lift to lower Resident #1's wheelchair to the ground, the back gate (designed to prevent a wheelchair from rolling off the mechanical lift) opened. Resident #1 rolled off the back of the lift and the resident struck their head on the cement in the parking lot. During the investigation, Resident #1 reported their wheelchair brakes did not lock, but upon examination by the Maintenance Manager, Resident #1's wheelchair brakes actually locked. The facility staff's investigation concluded that Resident #1's weigh and top heavy disposition resulted in Resident #1 rolling backwards after the gate opened, which resulted in Resident #1 toppling backwards, striking their head on the concrete. The facility staff removed the van from service on 7/6/22. 3. During an interview on 9/21/22 at 4:25 PM, the Maintenance Manager indicated that the van lift loaded residents in and out of the van through the rear of the van. During the interview, the Maintenance Manager demonstrated the operation of the lift. The lift had a single point-of-contact, which used a latch located on only one side, (usually the left). The point of contact would disengage the locking mechanism when the point of contact came into contact with the ground/solid surface, and then engage the locking mechanism when it was not in contact with another surface The Maintenance Manager indicated the facility had 2 staff members, Staff D who worked full-time, and Staff E, who worked part-time. 4. On 9/28/22 at 8:30 AM, transportation provider Staff D said that he started working for the facility in October of 2021. At that time, the facility administrator trained him on the use of the van and the lift. He said that he was instructed to stand on the left side of the lift, with the left hand he managed the controls, and held the resident's wheelchair with his right hand while the lift was being raised and lowered to the ground. Staff D said that after the incident with Resident #1, he decided that it would be safer for the residents if he were to stand behind the resident and hold onto the wheelchair as the platform was raised and lowered. Staff D stated that the facility did not offer follow up training or competencies on the use of the van lift. 5. On 9/28/22 at 10:40 AM, transportation provider, Staff E said that he started working for the facility in 2014. He left employment for about 10 months and then returned in September of 2021 as a part-time employee. Staff E said that the facility provided education on the operation of the lift when he was first employed but when he returned to work in 2021, they had changed the model of lift that they used. He denied having any on-going training or competency testing since his rehire in 2021. 6. On 9/27/22 at 11:15 AM Resident #1 said that she had reported to staff that the locks on her wheelchair were not working. She said the day that she fell in the parking lot, Staff E had lowered the lift down and when it was about 2 feet from the ground, her wheelchair went backwards and she hit her head on the pavement. Resident #1 reported that she continued to have occasional headaches. She said that since the incident, Staff D was transferring her to [CONDITION(S)] and she felt safer because he would stand behind her wheelchair. 7. Observations on 9/28/22 at 11:53 AM of Resident #1's wheelchair used at the time of the fall revealed that the brakes engaged. 8. On 9/27/22 at 3:34 PM, the Maintenance Manager demonstrated how the wheelchair lift operated and pointed out the roll-stop latch at the top of the gate. He said that it was designed to latch when the roll-stop latch foot came in contact with the ground as well as the point of contact on the locking pin used to secure the outboard roll-stop. Staff C stated that the van was sent to the authorized dealer which performed an outer barrier hydraulic cylinder adjustment on 7/6/2022. 9. In an observation on 9/28/22 at 8:30 AM Staff D loaded a resident into the facility van with the use of the wheelchair lift. Staff D stood at the rear of the lift and held the resident's wheelchair from the back. The tires of the wheelchair were up against the automatic outboard roll-stop gate. As Staff D raised the platform, the roll-stop latch did not completely engage when the roll-stop foot cleared the pavement. Staff D pushed the wheelchair up further on the platform until the tires were no longer touching the gate. The latch then engaged and Staff D continued to raise the lift and loaded the resident into the van. Staff D said that he would check the van for functioning of the lights and oil levels once a week but since the incident with Resident #1 he had initiated weekly safety checks on the functioning of the lift also. 10. On 9/28/22 at 8:45 AM, Staff D stated that some of the wheelchairs did not fit all the way onto the platform of the lift. He said this was a problem especially with the larger residents. Staff D decided that it was safer for him to stand behind the platform and behind the resident to brace them in case of latch failure. 11. In an observation of the length of the deck plate on 9/28/22 at 4:30 PM, It was discovered that the length of the deck was 44 long at the shortest point and 47 long at the wheelchair points-of-contact. 12. Review of the manufacture's instruction manual for the BraunAbility Lift Series 06 . Commercial Wheelchair Lifts, model L918IB, dated 07/2002, revealed in part, Proper maintenance is necessary to ensure safe, trouble-free operation. Inspecting the lift for any wear, damage or other abnormal conditions should be a part of all transit agencies daily service program. Simple inspections can detect potential problems. The maintenance and lubrication procedures specified in this section must be performed by a Bruan authorized service representative at the scheduled intervals . Discontinue lift use immediately if maintenance and lubricating procedures are not properly performed, or if there is any sign of wear, damage, or improper operation. Further review of the manual indicated the wheelchair lift should receive service, including inspection of the point of contact, at least every 4 weeks. Additionally, the manual revealed that the facility staff should inspect the lift daily, and prior to using the lift for a resident, the facility staff should operate the lift 1 full cycle. During the test cycle, the facility staff should verify that that the front roll stop (point-of-contact) operated appropriately and that the front roll stop age functioned appropriately. 13. Review of the Motor Vehicle and Driver Safety Program, revised 2/21/12, revealed in part, Vehicle Maintenance: A copy of the . maintenance records should be placed in the motor vehicle glove box as well as the vehicle file. 14. The facility staff could not provide any documentation that the wheelchair lift underwent the required maintenance. 15. On 9/28/22 at 12:00 PM the administrator stated that she did not believe that the lift maintenance had been performed since they acquired the van from a sister facility in 2020. The facility lacked any records showing that regular maintenance checks were completed on the lift. 16. According to the hospital report dated 07/06/2022, Resident #1 was transported to the Emergency Department (ED) on 7/06/22 at 05:34 AM with reports of pain in the back of the head, neck, and left upper chest. The resident did not lose consciousness. The Glascow Coma Scale (GCS) was 15 (alert, oriented, and following commands). The resident's vital signs showed [CONDITION(S)] (heart rate 59) and blood pressure 139/63 while all other vital signs were within normal limits. A computed tomography (CT) of the head was performed and revealed a small to moderate subarachnoid hemorrhage in the right parietal area. A CT of the cervical spine showed [CONDITION(S)] disease but no acute fractures or dislocations and a CT of the chest showed no fractures, pneumothorax, nor pleural effusion. She was diagnosed in the ED with a subarachnoid hemorrhage following injury with no loss of consciousness. She was subsequently transported to UNMC (University of Nebraska Medical Center) emergency room trauma center. 17. A facility investigation indicated that Resident #1 returned on 7/9/22 to the facility and resumed their previous activity level. The on-site survey team provided the facility staff with the IJ Template on 9/28/22 at 5:30 PM. The facility staff removed the immedicacy on 9/28/22 by performing the following: a. Facility transfer van was taken out of service on 09/28/22 until a certified maintenance inspection can be completed. Alternative transportation has been secured on 09/28/22 for residents that go to the [CONDITION(S)]. b. An audit of facility wheelchairs was completed by Administrator/Designee on 9/28/22 to identify wheelchairs that have a width equal to or greater than 32.75 inches or a depth equal to or greater than 47 inches (with foot pedals if applicable). Residents with wheelchairs greater than the width and depth limit will have alternate transportation as needed. c. Facility transportation staff were provided education by the Administrator on 9/28/22 related to the requirements of safety inspections, using the manufacturer's Daily Preventive Maintenance Schedule. d. Administrator/Designee will complete audits daily for 14 days, then weekly for 2 weeks and monthly for 2 months to ensure Daily Preventive Maintenance Schedule continues to be completed per manufacturer recommendations. Administrator/Designee will complete audits monthly for 3 months to ensure new transportation staff continue to receive safety inspection education and scheduled certified maintenance inspections continue to be completed timely as required. Results of these audits will be presented to the facility QAPI meeting monthly for 3 months for review and recommendation as needed. The administrator is responsible for monitoring and follow-up. At the time of the survey, the scope and severity was at a K level, and has been changed to a E due to ensuring the facility staff follow their protocols for resident change of condition. II. Based on observation, document review, and staff interviews, the facility's administrative staff failed to ensure 2 of 2 reviewed residents (Resident #3 and Resident #9) received the required transfer assistance. Resident #9 required assistance with transferring. In two separate observations staff transferred the resident without the use of a gait belt. Resident #3 was at risk for falls and required the assistance of two for transfers. Staff reported that the resident's knees buckled when she was transferring her alone and she was not using a gait belt. The facility's administrative staff identified a census of 47 residents. Findings included: 1. According to the MDS dated [DATE] Resident #3 was readmitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive deficits). She required extensive assistance with the help of two for bed mobility, transfers, walking and toileting. She was mobile with the use of a walker and wheelchair and had diagnoses that included non-Alzheimer's dementia, malnutrition, anxiety disorder, and [CONDITION(S)] and muscle weakness. 2. The care plan initiated on 10/10/17 showed that Resident #3 was first admitted in October of 2017. The care plan was updated on 4/1/21 with a focus area of risk for falls related to unsteady gait and balance issues. The resident was found on the floor on 4/1/21, the intervention was to put a fall mat next to the bed. The resident was resistive to cares related to dementia and had unidentified pain. Staff were directed to monitor for non-verbal indications of pain. On 7/9/22 a note was added to the care plan indicating that the resident returned to the facility post-surgery related to a fracture with no fall. Her leg gave out during transfer and staff pivoted the resident into the wheel chair. She was transferred to the emergency room and found to have a fracture the next day. 3. On 9/26/22 at 3:48 PM Certified Nursing Assistant (CNA) Staff O said that she went to get Resident #3 up for the day on 6/27/22 around 10:00 AM. She said that she helped the resident sit her up on the side of the bed and put the walker in front of her. The resident stood up and took about 5 or 6 steps and knees started to buckle. Staff O said that she braced the resident with her knee and held onto her while she grabbed the wheel chair that was within arm's length, and pulled the wheelchair under the resident. She said that she did not have the gait belt on the resident. Staff O said that she wheeled her into the bathroom but the resident was not able to stand to get her onto the toilet so she bear hugged the resident and sat her on the toilet. 4. The Minimum Data Set (MDS) assessment for Resident #9, dated 7/28/22, documented admitted [DATE] with diagnoses of diabetes mellitus and congestive heart failure (weak heart muscle causing heart to not pump correctly). The MDS identified the resident required extensive assist of 1 staff for personal hygiene and extensive assist of 2 staff for transfers and toileting. The MDS indicated the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. 5. During an observation on 9/21/22 at 7:24 AM, Staff G, CNA assisted Resident #9 to stand from recliner by placing Staff G's left hand/arm under resident's right arm, at underarm, and lifted resident to a standing position, without a gait belt. 6. During an observation on 9/21/22 at 9:35 AM, Staff H, LPN assisted Resident #9 to stand from the recliner by placing Staff H's arm/hand under resident's right arm, at underarm, and lifted resident to a standing position, without a gait belt. 7. Resident #9's care plan initiated 8/25/22, documented the resident requires one assist with gait belt and walker or cane for transfers. 8. During an interview on 9/27/22 at 12:35 PM, Resident #9 stated most of the time staff use a gait belt to assist her to stand but not always. 9. During an interview on 9/27/22 at 12:45 PM, Sep 27, 2022 12:45 PM, Staff I, CNA stated Resident #9 is transfer of assist X 1 staff with a gait belt. 10. During an interview on 9/27/22 at 1:23 PM, the Occupational Therapist stated all residents assessed for transfers and Resident #9 is an assist X 1 with gait belt for all transfers. 11. Review of facility procedure titled, Gait Belt dated 01/13, documented purpose to minimize the risk of injury to the resident and caregiver while performing transfers and ambulating. 12. During an interview on 9/29/22 at 8:30 AM, the Administrator stated expectation to use gait belt with transfers.

Based on observations, interviews with staff and residents and record review the facility failed to provide consistent and adequate wound care to prevent the development and worsening of wounds for 1 of 3 residents reviewed (Resident #1). Resident #1 was at risk for wound development related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide the wound treatments as ordered, failed to contact the doctor when treatments were not completed and failed to consistently monitor the development of wounds. The resident had bilateral below the knee amputations. The facility reported a census of 47 residents. Findings include: 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. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of one staff for bed mobility and toileting and was totally dependent on one staff for transfers. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan updated on 7/15/21 showed that Resident #1 was at risk for falls related to [CONDITION(S)], severe [CONDITION(S)] joint disease of the lumbar spine, and [CONDITION(S)] diseases. The resident required hemodialysis related to renal failure and was at risk for skin impairments with history of diabetic ulcers, [CONDITION(S)], and [CONDITION(S)]. According to a Non-Pressure Weekly Skin Record dated 3/26/21 at 12:44, staff mentioned 55 areas of concern that were first identified on 2/6/21 and the doctor was notified on 3/26/21. The measurement section of the document included a measurement of 10 centimeters (cm) length x 10 cm width; it did not specify which area had been measured. From 3/26/21 through 6/29/21 weekly skin assessments lacked measurements or descriptions of wounds. One weekly skin assessment dated [DATE] at 11:43 AM indicated that the skin was intact. From 5/3/21 through 6/29/21 the nursing notes lacked any references to the condition of wounds or skin issues. Non-Pressure Weekly Skin Records included the following: 6/29/21 at 2:36 PM, right toe 2 cm x 1.5 cm. open area 6/29/21 at 2:38 PM, right ankle 10 cm. x 4.8 cm. open blister 6/29/21 at 2:43 PM. left foot blister 7 cm. x 2.5 cm. 6/29/21 at 2:45 PM, left hand first digit 1.5 cm x 1 cm 7/6/21 at 2:21 PM, left toe 6 cm x 3.1 cm x 1 cm (depth) stage III 7/6/21 at 2:21 PM left ankle 7.4 cm. x 5.6 cm. x 0.4 cm. stage III 7/6/21 at 2:21 PM top left foot 5 cm. x 2.4 cm. unstageable According to an untimed, podiatry note dated 7/8/21, the podiatrist saw Resident #1 on that date and noted that he/she saw the resident 8 months previous, and at that time, the resident had been fairly stable. The doctor noted that upon entering the room there was a foul smell emanating from the dressing that was wrapped from the resident's toes to just above her ankles. An evaluation of the right foot revealed that the entire right forefoot was cellulitic. She had extensive swelling with regard to her right second toe with an open wound at the proximal interphalangeal (between the toes) joint with exposed bone as well as what appeared to be an abscess around the second metatarsophalangeal joint (informally known as the toe knuckles). Upon evaluation of the left foot and ankle, the doctor found that she had an ischemic-looking (diminished blood supply) wound to the dorsal forefoot on the left side around the base of the first and second metatarsophalangeal joints. She also had what appeared to be degloving skin (large piece of skin and layer of soft tissue peeled from the body, The layer of skin does not receive blood supply) from the anterior left ankle there were aspects that looked as if the damage was down to the tendon. She also had a massive open wound to the lateral midfoot on the left side. The doctor noted that it looked like it extended deep and was most likely [CONDITION(S)] (infection in the bone) changes to the midfoot to the fifth metatarsal base or cuboid area. The podiatrist concluded that Resident #1 needed emergency admission to the hospital for intravenous antibiotic therapy and further workup. The podiatrist noted that with the condition of the wounds, he/she suspected that the resident may require below knee amputations. According to a discharge hospital report on 7/14/22 at 7:37 AM, Resident #1 came into the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The vascular surgeon was consulted and subsequently the resident had amputations of the right 1st and 2nd toes and Incision and Drainage (I & D) of the right foot completed on 7/10/22. A nursing note dated 7/14/21 at 10:23 PM stated that the resident returned to the facility on that date with wound vacuums applied to both feet. An order dated 7/15/21 at 3:45 PM directed staff to change the Wound Vacuum (WV) one time a day every Monday, Wednesday, and Friday. According to the Medication Administration Record/Treatment Administration Record (MAR/TAR) the WV did not get changed on August 7th. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 9/30/21 at 3:45 PM directed staff to apply a wet to dry dressing 0.125% dakins moistened gauze to wounds, then place dry gauze over and cover in kerlix, three times a day. According to the MAR/TAR the wet to dry treatment did not get completed 19 times in the month of October 2021. An order dated 11/11/21 at 9:59 PM showed that the wet to dry dressing treatment was changed to a daily rather than 3 times a day. According to the MAR/TAR the daily treatment did not get done twice in November and 5 times in December. The following is communication from the [CONDITION(S)] clinic: On 7/16/21 at 4:26 PM when the resident presented to [CONDITION(S)] the wound vacuum (WV) was beeping. The [CONDITION(S)] staff called the nursing home and they were told that they were expecting a new wound vacuum and it would be changed after treatment. On 7/28/21 at 4:36 PM The resident presented to [CONDITION(S)] with the WV beeping. Upon inspection they found that the lines had been clamped closed. [CONDITION(S)] staff unclamped the lines and it worked for the remainder of treatment. On 8/11/21 at 3:47 PM, when the resident arrived at [CONDITION(S)] the WV was leaking. [CONDITION(S)] staff was able to use paper tape to seal the tubing. On 8/20/21 at 2:14 PM, the resident presented with fluid leaking from her right foot. The wrapping was saturated and dripping to the floor. Staff reinforced the dressing with gauze and tape and called the nursing home to remind them that the dressing should be changed before the resident came to [CONDITION(S)] because it was an infection control issue. On 8/23/21 at 2:54 PM, when the resident came to [CONDITION(S)], the WV was beeping. Staff unwrapped the dressings to check the lines and clamps and found that there was a foul odor and drainage. On 8/25/21 at 3:15 PM the [CONDITION(S)] staff contacted the doctor for Resident #1 to update him/her about the on-going issues with the WV alarming and dressings in poor condition. The nursing home was contacted and responded that the resident often rubs the dressings off and turns off the WV when it alarms. On 8/30/21 at 3:10 PM continued issues with the WV leaking and foul odor to the feet. On 9/8/21 at 2:05 PM the resident presented to the clinic without the WV properly applied and on the right foot only. The left foot was wrapped and blood noted and gauze tucked between the toes. When the nursing home was contacted they responded that they did not have supplies for the WV and there was a delay because of the holiday. On 9/20/21 at 4:02 PM the staff noted that the resident had a very foul odor to the feet and the resident reported to [CONDITION(S)] staff that the WV had been broken for several days. On 9/27/21 at 3:26 PM the [CONDITION(S)] staff contacted the nursing home to inform them that the WV was leaking and there was drainage dripping from the protective boots. On 10/27/21 at 2:09 PM the resident reported to the [CONDITION(S)] nurse that the dressings on her feet had not been done correctly. She presented to the clinic with her feet wrapped in towels underneath the protective boots. The staff noted flies and gnats in and around the towels and boots. The Non-Pressure Weekly Skin Records from the facility included the following documentation from 8/11/21 through 2/2/22: On 8/11/21 at 9:49 AM, the right amputated toe area; 7 cm. x 6 cm. x 1 cm. On 10/7/21 at 2:46 PM, the right amputated toe area; 11 cm. x 0.8 cm. On 8/11/21 at 9:50 AM, the right lateral foot; 7 cm x 3.5 cm On 10/7/21 at 2:50 PM, the right lateral foot; 6 cm x 4.8 cm x 0.4 depth moderate drainage and odor. On 9/3/21 at 3:50 PM, the left lateral foot; 9.5 cm. x 3.5 cm. On 10/7/21 at 2:52 PM, the left lateral foot; 8.7 cm. x 6 cm. x 0.4 cm. drainage and odor noted. On 10/20/21 at 10:14 AM, the left lateral foot; 12 cm x 7 cm x 0.6 cm. depth. On 9/3/21 at 3:52 PM left top foot; 3 cm x 6 cm x 0.1 cm depth On 9/18/21 at 2:12 PM left medial foot; 10 cm x 4 cm x 0 moderate drainage. On 11/5/21 at 3:09 PM, right toe; 3 cm x 2.5 cm x 3.5 cm depth From 11/5/21 through 12/30/21, the chart lacked documentation with measurements or descriptions of wounds. On 12/30/21 at 3:49 PM; a. Right toe 5th digit measured 4.5 cm x 2.3 cm x 6 cm deep. B. Under the left great toe; 5 cm x 4 cm x 0.9 cm deep C. Under the left foot; 6 cm x 0.1 cm On 1/9/22 at 1:00 PM; a. lateral right foot; 7 cm x 2.8 cm x 2.3 cm depth. B. Inner left foot great toe; 5 cm x 3.5 cm with 2 holes On 2/2/22 at 6:30 PM, the left foot distal great toe measured 3.5 cm x 1.8 cm x 3 cm deep. The right great toe was 5 cm x 1 cm x 0.6 deep. Noted to have purulent drainage on bottom of right foot. According to a hospital report dated 2/22/22 Resident #1 was admitted on [DATE] for vascular surgery and discharged on [DATE]. The report showed that she had an amputation below the right knee on 2/15/22 and an amputation below the left knee on 2/18/22. On 9/27/22 at 11:15 AM Resident #1 said that she remembered her wound treatments before she had the Below Knee Amputations (BKA). She said that the treatments were not completed on a regular basis and there was one nurse that wouldn't do them at all. When the resident would remind the nurse that she needed the dressings changed, the nurse would tell her that she would do it the following day. She also remembered that the [CONDITION(S)] nurses were upset when they saw the condition of her dressings. On 9/21/11 at 11:21 AM LPN Staff P said that she was aware that a couple of staff were not doing the wound treatments but were documenting them as being done. She said that when she worked, she would date and initial the wrappings. When she would come in to work a couple of days later and it would still be her dated and initialed treatments on the wounds. She said that it happened when her shift followed LPN Staff J and LPN Staff K. On 9/22/22 at 10:40 AM LPN Staff J said that there was another nurse at the facility that did not get along well with her and had gone to the Director of Nursing (DON) and complained that she wasn't doing the wound care as ordered. Staff J said that she had been cleared of those allegations. She denied having any disciplinary actions in her personal file and said that there were not enough staff to work with the high acuity residents at the facility. Staff J said that she didn't have much interaction with Resident #1 because she worked in a different area of the facility. She said that the WV for Resident #1 was not removing the infection as it should so the doctor decided to go to a wet to dry dressing. She said that she didn't care for the WV very often and she didn't remember getting any education on the use of the WV. She said that staff were expected to just figure it out on their own. She said that the WV was difficult to manage because of the location of the wounds on the stumps where the toes had been amputated. Staff J said that she did not change the dressings in the morning before Resident #1 would go out to [CONDITION(S)] because it would have been done before she got to work at 6 AM. She didn't ever see that the dressing was soiled before the resident went to [CONDITION(S)] because the resident would wear a tent dress and had blankets on her lap. Staff J said that Resident #1 was noncompliant and would shut off the WV or unplug it. On 9/26/22 at 10:57 AM, LPN Staff K said that she had been educated on how to care for the high acuity residents and she felt that she could always ask for help. She said that she would stay later in her shift to make sure that she had her wound treatments completed. She said that she managed the WV okay but the supplies were not always in the room and she didn ' t know where to find them. She said that she had only been disciplined one time while at the facility, and that was for not wearing the face mask and goggles. A review of the employee files revealed that Licensed Practicing Nurse (LPN) Staff J was disciplined on 8/23/21 for not performing the wound treatments as ordered and documenting that it had been completed. The report was signed by Staff J on 8/22/21. On 11/6/21 she was written up for the same offense and the action plan was to follow up in two weeks. The chart lacked documentation that there was a follow up. On 2/2/22 Staff J had a third disciplinary action related to failure to complete dressing changes and documenting that it had been done. A review of the personal file for LPN Staff K revealed a statement from the Director of Nursing (DON) dated 10/1/21 that she spoke to Staff K about the dressing changes getting completed as ordered and the LPN responded that she would get those completed as ordered going forward. On 9/26/22 at 9:35 AM LPN Staff L said that many times she would be the only nurse on the floor working and it was difficult with the high acuity residents. She said that she would stay late to make sure her work was completed. She said that many times when she would come on for her shift, it was apparent that the wound treatments were not getting completed as documented. She knew this because she could tell that it had been the same dressing that she had put on the wounds when she worked days before. Staff L said that she had been adequately trained on the use of the WV but there were a couple of nurses that didn't know how to get a good seal so it wasn't hooked up correctly. Some would ask for help but there were others that would just let it go without trying to get it right. She said that Resident #1 would tell her you were the last one that touched that when she would manage the WV and she also told her that she had trouble getting the wound treatments completed when Staff L was not working. On 10/5/22 at 8:37 AM the Director of Nursing (DON) said that she had addressed the issue of wound treatments not getting completed. She said that a nurse came to her and reported that the treatments were not done. She confronted Staff J and Staff K and they both told her that they were doing them but she had to address it with both nurses on at least two separate occasions. The DON couldn't remember specifically but thought it was confirmed that treatments weren't done because the bandages were not dated. The DON said that she did not personally see an old dressing on the resident. She asked staff to come and get her if/when it was discovered but she didn't get the opportunity to personally see it. On 9/26/22 at 3:40 PM the medical director for the facility said that he had cared for Resident #1 for over 5 years and she had gone through periods when her wounds started to heal and then get bad again. He said that he made a referral to the vein specialist and had orders for antibiotics a couple of different times before her below knee amputations. He said that he may have been notified that the treatments were not getting done as ordered and that the WV was not working, but if it was during rounds, he may have forgotten and did not document. On 9/26/22 at 1:11 PM the Nurse Practitioner (NP) with the vein specialist's office said that they first saw Resident #1 in May of 2021 and then again in July when the toes were amputated. He said that they did not have documentation of contact with the nursing home regarding WV challenges. He was not aware that the dressing changes did not get completed as ordered. He said that if the WV was not working or not used properly and if the treatments had not been done as ordered and/or as needed, that could have changed the outcome of how the wounds healed. Review of an undated facility offered training on Wound Vac dressing changes revealed that only LPN Staff M and LPN Staff L were the only nursing staff members who signed the document as attesting they received the information.

Based on record review, staff interviews and facility policy review the facility failed to provide supplemental oxygen per physician's order for Resident #3 and Resident #6 when their oxygen levels were low enough to require ordered supplemental oxygen. Resident #6 was assessed and found to have an oxygen saturation of 69% and got as low as 45% before being sent to the ER and admitted with [CONDITION(S)]. The facility did not apply his PRN order of supplemental oxygen when his oxygen saturations were below 88%. Resident #3 had an oxygen saturation level of 83% on room air before the facility sent the resident to the emergency room (ER) and she admitted to the hospital with [CONDITION(S)]. The facility did not apply her as needed (PRN) order of supplement oxygen when her saturations were below 90%. These findings constituted Immediate Jeopardy to resident health and safety. The facility reported a census of 36 residents. Findings include: 1) According to Resident #6's admission Minimum Data Set (MDS) with a reference date of 1/14/21, revealed the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented he had a Brief Interview of Mental Status (BIMS) score of 12, indicating intact cognitive status. The MDS provided he required extensive assist of 2 staff for bed mobility, transfers, dressing, and toileting and was always incontinent of urine and bowels. Resident #6's care plan with a revision date of 12/20/2016 revealed he was independent with a walker for ambulation and staff were to provide increased supervision as needed for increased confusion, weakness, agitation or fatigue. Review of Resident #6's Electronic Health Record (EHR) revealed the following change in condition evaluation noted: -1/25/2021 1:00 PM following up change in condition evaluation: Resident had altered level of consciousness, sudden change in level of consciousness or responsiveness. Respiratory assessment relevant to change in condition due to labored/rapid breathing acute onset of change from usual pattern respirations of 26 labored. Things that make the condition or symptoms worse: oxygen saturations started at 69% after therapy was completed, oxygen saturation went up to 89% then at 1:00 PM his oxygen saturations were 45%. Therapy department notified Staff O LPN about low oxygen saturations and labored breathing; advised therapy to lay him down and take off his mask, and she reassessed 1 hour later. At that time his oxygen saturation had dropped to 45%. This nurse put oxygen on the resident and notified the doctor at 1:15 PM; received orders to have him sent to the emergency room (ER). Record review of Resident #6's EHR revealed the following Occupational Therapy Treatment Encounter Note dated 1/25/2021: resident was found sitting on wheelchair when approached by Occupational Therapy (OT) and was asked if he would wheel self and he agreed. Resident was able to propel wheelchair at 16 foot distance then resident OT for help and was assisted to get in the therapy room. Resident was looking initially fine, able to clean his face with stand by assist and was able to wash his hands with maximum assistance. Resident was observed to have a dazed look and appeared to have labored breathing. Oxygen saturations were checked and was at 69%, with a heart rate of 197 beats per minute. OT informed Staff O LPN about it. OT got another pulse oximeter to double check results, respiration rate was 41, oxygen saturations were at 74%, and heart rate was 122 beats per minute. Staff O still notified and OT took Resident #6 back to his room, removed his mask and oxygen saturations were at 80%, heart rate was 82 beats per minute. Resident was educated on proper breathing techniques. The Director of Nursing approached the resident, assessed him and advised resident to be put in bed. The CNA helped the OT because the resident was totally dependent on staff for the wheelchair to bed transfer. Self-feeding was completed with maximum assistance then fading to moderate assistance. Record review of Resident #6's EHR revealed the following Physical Therapy Treatment Encounter Note dated 1/25/2021: resident demonstrated difficulty breathing; nursing was aware, oxygen saturations at 71%. Resident wanting to eat and was assisted with eating a magic cup and requested another cup of coffee. Nursing had approved of resident's request. Resident appeared pale and shaky, nursing reported had called the hospital. CNAs informed of need for brief change; Physical Therapist Assistant (PTA) assisted with rolling and positioning for changing. Review of the hospital's ER note dated 1/25/2021 at 1:45 PM revealed report given to hospital staff from nursing home. The facility stated resident was found with oxygen saturations at 47% and had respiratory distress. They placed him on 2 liters of oxygen with no improvement. Apparently the resident was like that for about an hour before 911 was called. When they called for report the hospital nursing staff told the facility staff to bump his oxygen up to 6 liters. Record review of Resident #6's vital signs revealed on 1/25/2020 at 1:00 PM of an oxygen saturation of 45% on room air. Review of Resident #6's EHR under the orders tab revealed a PRN order for oxygen to be applied to keep saturations above 88%; with a start date of 8/25/2015. Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the visitor COVID screening log revealed the Emergency Medical Service (EMS) crew were screen in at 1:33 PM on 1/25/2021. During an interview on 2/3/2021 at 10:38 AM, the EMS Supervisor stated they were dispatched to the facility for Resident #6 on 1/25/2021 at 1:22 PM. They indicated the reason was the resident had low oxygen is what the nurse reported to the crew. The EMS crew charted upon their arrive he was alert and oriented to person, place; had a strong pulse; skin pink and work, no complaints of pain and they placed him on 15 liters of oxygen because he oxygen saturations of 88% then it went up to 98%. They documented his lung sounds were clear. During the staff interview on 2/3/2021 at 11:40 AM the OT was asked to talk about what happened on 1/25/2021 with Resident #6. She stated a couple of hours prior to working him, he was being moved from isolation room to a regular room. He had initiated to join a group activity and did just fine. When she went in to see him an hour later the CNA stated he was still up in his chair and was able to do therapy. When asked about what time she started working with him, she stated close to lunch about 12:00 PM was when she started to work with him. She added this was the only time she was available to see him. She stated he was still in his wheelchair and he indicated he was fine. During his therapy session he had wheeled himself 16 feet by propelling with his arms. She had assisted him to the therapy room. While they were in the therapy room, she noticed matter in his eyes and dirt on face. She gave him a washcloth and he was able to clean himself up and then washed his hands. After that she stated he started to look like needed more assistance; he looked dazed with labored breathing. She then checked his oxygen saturations and it was 69% on room with a heart rate of 119. She stated she took the resident to Staff O LPN to let her know and let her know she would get another pulse/oximeter to ensure it was accurate: 74% was his oxygen saturation, pulse was 124 and respirations were 41. Staff O instructed her to take him back to his room, remove his mask and had him do pursed breathing. When they rechecked his oxygen it was 88% and his heart rate was 82. The OT stated the Director of Nursing (DON) then came in to assess him; checked 02 sats and advised to get him to bed. The OT stated herself and Staff G assisted Resident #6 back in to bed. She stated once in bed, his food tray was close to coming, so she set him up. She stated he still seemed off; appeared lethargic but did assist him with eating what he could. She indicated that was when the physical therapist assistance (PTA) came in and assisted with his meal. The OT was asked if they put oxygen on his when they noticed he saturations were low, she stated they were planning on doing so because she saw Staff O go get a concentrator. She was asked if it was normal for Resident #6 to desat during his therapy sessions, she stated no. During a follow up interview on 3/3/2021 at 12:45 PM she was asked about what time she checked his oxygen saturations and got 69% with a heart rate of 119 she stated she did not remember the exact time but maybe about 11:50 AM. When asked about what time did you let Staff O know of her findings, she stated immediately after she got the readings, so 11:50 AM. She stated about 11:50-11:55 AM was when she rechecked his oxygen saturation and it was 74% on room air. That was when Staff O told her to take him to his room and remove his mask. After she removed his mask and did pursed breathing his oxygen was 80% at about 11:55 AM-12:00 PM, not sure on the exact time. She stated about 12:00 PM was when the DON came in and asked to get him in to bed and they had not put oxygen on him yet. The OT was able to look in her notes to see how long she was with the resident form the time her session started until the PTA took over, she stated 43 minutes. She indicated she did not overlap her time with the PTA, she left as soon as she came in. The OT was asked at what time was his oxygen saturation at 45%, she stated she did not know because she was not with him. During a staff interview on 2/3/2021 at 2:42 the DON stated she was notified by Staff G of resident appearing to have a hard time breathing. So she went in to assess him, found him in his wheelchair and his oxygen saturation was 88-90% initially. She stated his lung sounds were diminished in the bases and he was breathing shallow. Staff reported to her that he had been up in his wheelchair for a long time. She went to talk with Staff O in which she stated she had looked at him. The DON thought they should lay him down and she would check on him. She and Staff O walked back in to his room and his saturations were 84-86% on room air. That was when they instructed staff to lay him in bed. She stated Staff O called the doctor and got the order to send to him the ER. While they were assisting Resident #6 to bed they noticed he had soiled himself, so they assisted with cleaning him up and changed his dressings at that time as well. When asked what the lowest saturations she assessed she stated 84%. When asked if Resident #6 had oxygen on while she was assisting she stated not while she was there but remembered telling someone to go get a concentrator. The DON was asked about what time did she assist she stated maybe between 11:30 AM and 12:00 PM because Staff O was on the A cart starting medication administration. When asked what CNAs assisted she stated Staff G and Staff L. The DON stated he kind of desats to the lower 90's, previously. She added she could tell something was going on. The DON checked the visitor screening log and the EMS staff were screened at 1:28 PM before they went to see Resident #6. During a follow up interview on 3/3/21 at 11:47 AM the DON was asked about what time she first saw Resident #6, she stated around 1:00 PM when she went in a noticed he needed to be laid down. She stated he was not talking or being himself at that time. When asked what Resident #6's oxygen saturation was when she first saw him, she stated she did not have a pulse/oximeter with her and was trying to remember if he had one on his finger. But she was told before she saw him, his saturation was 88-89% on room air. The DON stated she went to get Staff O within a few minutes of initially going in to see him, then they assessed him together. She stated they went back in to his room about 1:05 PM and his levels were 84-86%. The DON was asked when his saturation down to 45% was, she stated she was not told of this. During a staff interview on 2/3/2021 at 3:07 PM the PTA stated on 1/25/2021 she went in to Resident #6's room between 11:50 AM and 12:15 PM. She stated the OT had been with him as she walked passed and looked in to see how he was doing. The OT was almost done working with him and he appeared to be short of breath, shaky, and pale. She stated he did not look right but he did eat part of his magic cup with her before the OT left. She stated he tried to use his utensils but shaky, easily fatigued, was having difficulty breathing. At that time Resident #6 put both of his hands on the bed, was done eating but wanted coffee never drank. The nurse Staff O was the nurse that sent him to the hospital. Staff changed his adult brief before he left in the ambulance, she assisted with rolling him. When asked what was the lowest his oxygen level was while she was with him, she stated 71% on room air and that was around 12:15 PM and that was a half hour before he left. When asked if the resident had oxygen on while she was with him she stated they did not put O2 on him while she was in there. If she had to guess when he left she would say 1:00 PM 1:30 PM. She was in the room, according to her therapy for minutes 39 minutes. She stated she did therapy for 15 minutes working with his legs other times was feeding, getting coffee and talking with the nurse. Previous sessions he was able to help move his legs. On that day there was no attempt to help, no firing of his muscles. She added he had been declining for a while. He was always very verbal, the week prior there muscle initiation and on 1/25/2021 there was nothing. During a follow up interview on 3/3/2021 at 10:19 AM the PTA was asked what time she initially went in to Resident #6's room, she stated 11:50-12:15 PM, he had just received his lunch. At that time she was told he was short of breathe and at 12:15 PM his oxygen was at 71% on room air. She was unsure what time the nurse came in to assess him. She stated she left the room about 12:30-12:45 PM, went down the B wing hall, and when she went back down the A wing hall about 45-50 minutes later he was out of the building. She stated the DON did not go in the room while she was in there with Resident #6 and did not recall if Staff O had obtained vitals. When asked if he had oxygen on while she was with him, she stated no. The PTA looked at her notes and stated she was with him for 39 minutes on that day. During a staff interview on 2/3/21 at 3:28 PM Staff G CNA asked if she worked the day Resident #6 had been sent out to the hospital, she stated it was his first day out of isolation. She stated she saw him working with therapy in the lobby which he enjoyed. Staff G stated the Occupational Therapist (OT) came and got her when his oxygen saturations started to drop. She provided that the OT went and notified the nurse in which she was told to lay him down then they sent him out to the hospital. She could not remember what his saturations were maybe in the 80's. Staff G was asked if the resident had oxygen on at any time, she stated she was pretty sure they got some on him while he was in bed. She provided when she was with him, he looked dazed, almost had stroke like symptoms. He was breathing kind of heavy in the chest like he struggling, she felt it got better once he laid down. When asked how long she was in the room she stated she was in there long enough to get in bed, changed his adult brief and stayed there with him until the ambulance came. She stated she was in there for maybe 30-40 minutes. When asked about what time this all started she started it started around lunch time because he was on the A wing and they get served first at about 11:45 AM. Staff G stated she did not remember when the ambulance came. Resident #6 was assessed and found to have an oxygen saturation of 69% and got as low as 45% before being sent to the ER and admitted with [CONDITION(S)]. The facility did not apply his PRN order of supplemental oxygen when his oxygen saturations were below 88%. 2) Review of Resident #3's quarterly Minimum Data Set (MDS) with a reference date of 10/29/2020 revealed she had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented she had a Brief Interview of Mental Status score (BIMS) of 13 indicating no cognitive impairment. The MDS documented she required extensive assistance of 1 for bed mobility; limited assistance of 1 staff for transfers, dressing, and toilet use. The MDS indicated she received oxygen and [CONDITION(S)] cares. Review of Resident #3's care with a revision date of 12/17/2019 revealed she had a [CONDITION(S)] related to a traumatic injury sustained during a car accident. Review of Resident #3's Electronic Health Record (EHR) revealed a change in condition summary that included a pulse oximetry reading of 83 % on room air on 12/6/2020 at 10:29 AM. It was documented that she had altered level of consciousness and increased confusion. Review of Resident #3's EHR revealed a progress note dated 12/6/2020 at 1:32 PM indicated she admitted to hospital for c-difficile and [CONDITION(S)]. Review of #3's December 2020 Treatment Administration Record (TAR) revealed she had the following PRN orders: - Oxygen PRN if having signs and symptoms of shortness of breath to keep saturations at or greater than 90%; with a start date of 3/27/2017. PRN order was not signed out during the month of December 2020. - Oxygen PRN 2 liters via nasal cannula as needed for acute shortness of breath or when oxygen saturations are >89%; with a start date of 2/23/2019. PRN order was not signed out during the month of December 2020. During a staff interview on 2/25/21 at 10:31 AM Staff N Licensed Practical Nurse (LPN) was asked to talk about the morning she sent Resident #3 to the hospital on 12/6/2020. She stated with all of COVID stuff, she had gone downhill because she could not get out and move like to. She was constantly sleeping and that morning she was hard to arouse, she told her she did not feel well. Staff N stated she just was not herself. When asked what time she assessed her, she stated she did not remember what time but it was during the morning pass and she was the first one, so maybe between 7-8 AM. Does not remember if she faxed or called the doctor but she would have notified the doctor. Staff N was asked if she called or sent a note to the doctor, she stated she must have called because it was not much longer after she assessed the resident she was sent to the ER. Staff N was asked if she applied oxygen, she stated she does not remember if she put oxygen on or not. During a staff interview on 4/6/2021 at 11:26 AM the DON was asked if Resident #3 should have had oxygen put on when her saturations were 88%, she stated Staff N would have put it on her but may have forgotten to chart about it. The facility was notified of the Immediate Jeopardy on 3/4/21. The IJ was removed on 3/5/21 when the facility submitted an acceptable removal plan and the scope and severity was lowered from a J to a D. The facility's removal plan documented the following actions: 1) The Assistant Director of Nursing (ADON) assessed current residents for symptoms of shortness of breath (SOB) and low O2 sats and found no problems with either SOB or low O2 sats. 2) The ADON provided education to licensed nurses on 3/5/21 regarding timely assessment of respiratory status, low O2 sats, and timely application of supplemental oxygen. Any nurse not educated on 3/5/21 was not allowed to work until the above education was completed. 3) The DON will review current residents' O2 sats 2 times daily for 4 weeks, then 5 days per week for 8 weeks to ensure each resident is being assessed in a timely manner with supplemental oxygen applied as needed according to physician orders. The DON will report the findings to QAPI committee meeting monthly for 3 months for review and recommendations as needed.

Based on observation, clinical record review, facility's investigative files review, staff interviews and policy review the facility failed to ensure 2 of 4 residents reviewed (Resident #2 and #4) were free of accidents. The facility failed to utilize a Hoyer sling while assisting Resident #2 in the shower room, which resulted in a fall ultimately leading to a fracture. The facility also failed to ensure Resident #4's wheelchair was reclined back with her foot pedals on, which resulted in a fall ultimately leading to a fracture as well. The facility reported a census of 36 residents. Findings include: According to Resident #2's quarterly Minimum Data Set (MDS) with a reference date of 3/24/2020 revealed she had the following diagnoses: cancer, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], anxiety, depression, [CONDITION(S)], and [CONDITION(S)]. The MDS documented no falls since admission/entry or reentry. The MDS documented a Brief Interview of Mental Status (BIMS) score of 12 indication no cognitive impairment. Resident required extensive assistance for 2 staff for bed mobility, total dependence of 2 staff for transfers, dressing, toilet use, personal hygiene, and bathing. The MDS documented she had impairment on one side to upper and lower extremities. The MDS listed the use a wheelchair for Resident #2. Review of Resident #'2 care plan with a revision date of 5/27/2020, revealed she used a Hoyer lift for transfers. The care plan indicated she preferred to have a sling left underneath her in her wheelchair. The care instructed staff to use a mesh shower sling and use of Hoyer for bathing in the whirlpool. The care plan indicated she was dependent of 1 staff for bathing and staff were to provide a bath or shower two times weekly. Observation on 2/23/2021 at 9:58 AM revealed Resident #2 lying in with a fall mat to the left of her bed. Review of Resident #2's Electronic Health Record (EHR) revealed no fall assessment had been completed from 9/3/2019 until 5/26/2020. The facility provided a fall report with a date of 5/14/2020 at 5:40 PM completed by Staff E Licensed Practical Nurse (LPN) with the following information: - Nursing description: resident lowered to the floor this morning in the shower room. No injuries notes. Resident was assisted by 2 staff to the whirlpool chair. The PCP was notified. - Resident description: stated she fell in the shower, denied pain. - Immediate action taken: assist of 2 staff to get off of the floor, range of motion (ROM) was within normal limits (WNL). Staff instructed to use a Hoyer in the shower from now on. The Director of Nursing (DON) checked in, noted the shower chair brake was not fully functioning in the lock mode. A request was sent to the maintenance department about the malfunctioning brake. Also, Certified Nursing Assistant (CNA) educated to use mesh Hoyer lift pad that can stay on the resident during a whirlpool and assist with transfers. - Predisposing environmental factors-wet floor. Predisposing situation factors-during transfer. Review of Resident #2's EHR revealed the following progress note: 5/14/2020 at 5:35 PM-she was lowered to the floor this morning in the shower room, no injuries. Resident was assisted by 2 staff to shower chair. The Primary Care Provided (PCP) was notified. Review of the facility's investigation revealed the following written statements: - Staff M CNA wrote she was dressing Resident #2 after a whirlpool was given. She and Staff L CNA were repositioning the resident when the whirlpool chair started to slide backwards. She noticed the back brake did not engage and Resident #2 began to slide off the whirlpool chair. Staff M and Staff L lowered her safely to the ground. Staff M thought she had heard if a resident was lowered to the floor, it was okay to put the resident back into the chair. Then return the resident to their room so the nurse could assess the resident in their room. As soon as she returned the resident to her room she notified the nurse. - Staff L wrote on 5/14/2020 she and Staff M had dressed Resident #2 after her shower. Staff M leaned her forward on the whirlpool chair so she could pull her pants up. Staff M was standing directly in front of her and Staff L stood behind and off to the side of the chair a little. Staff L pulled on her pants and Staff M stated Resident #2 was starting to slip. Staff L then lifted up on her pants more and the chair slid backwards. Staff L stepped forward and they sat the resident on the floor or actually she sat on Staff L's feet. Staff L and Staff M then got the Hoyer, put the sling under her and lifted her off of the floor and in to her wheelchair. After they took Resident #2 to her room, Staff M went and let the nurse know what had happened. - Staff E LPN wrote on 5/14/2020 it was reported by the CNAs during morning report, about 6:30 AM (ish) that Resident #2 was lowered to the floor in the shower room. Resident #2 slid down the front of the whirlpool chair. When the CNAs reported they had lowered her to the floor, the resident was already in her room, in her wheelchair. During her assessment Resident #2 denied pain and ROM was normal for her, upper and lower extremities noted no redness or swelling. The statement was signed and dated on 5/19/2020. - Staff K previous Maintenance Director wrote the CNA/bath aide reported to him that the brakes did not work on the lift chair for the whirlpool tub. The left brake did not work so it was taken out of service and 2 new locking [NAME] were ordered. They were replaced on 5/21/2020. - Initial Statement for Resident #2's occurrence-on 5/14/2020 she was lowered to the floor during a transfer from the whirlpool to the whirlpool scale chair. The whirlpool chair moved as the CNAs were transferring Resident #2; it was noted at that time that the whirlpool chair lock had disengaged. The CNAs then lowered her to the floor. The incident was reported to Resident #2's nurse who then completed an assessment. Resident #2 did not complain of pain and no injuries were noted. Staff put a sling under her, lifted her with the Hoyer lift, and put her into her wheelchair. The Maintenance Director removed the whirlpool chair from service to order a new part. Resident had no complaints of injury since the incident. On 5/17/2020, Resident #2 had an elevated temperature and low oxygen saturations. A breathing treatment was completed and oxygen was applied. Two nurses assessed Resident #2 and per the DON instructions called her PCP to update him. He requested she be sent to the emergency room (ER) for further evaluation to rule out pneumonia. The facility received a call from the hospital stating Resident #2 had a [CONDITION(S)] and reported to them she had been dropped. Facility continuing the investigation. - Final Report Summary for Resident #2 Occurrence- on 5/14/2020 resident was lowered to the floor during a 2 person transfer from whirlpool to a whirlpool scale chair. The whirlpool chaired moved as the CNAs were transferring Resident #2. The CNAS reported that the whirlpool chair had one of the locks disengage during the transfer, causing the whirlpool chair to move during the transfer. The CNAs then lowered her to the floor. During the investigation it was noted that the CNAs had placed a sling under her, lifted her with a Hoyer lift and put her in her wheelchair. Resident #2 was then returned to her room and they reported the incident to her nurse, as they were returning her to her room. The nurse completed report and then assess the resident. It was noted that the resident had no complaints of pain nor did she have any signs/symptoms of injury. The PCP and resident's representative was notified. The DON imitated an in-servicing nursing staff on fall and possible injury precautions. Maintenance was notified on 5/14/2020 that the shower chair lock had disengaged during a transfer. He inspected the shower chair to discover no problems. In discussing on 5/15/2020, it was noted that it was the whirlpool chair and not the shower chair. He immediately checked the whirlpool chair and noted one lack was not working properly all the time. He removed it from service and ordered the new casters with locks. They were placed on 5/21/2020. The resident had mentioned to the CNAs working on the afternoon of 5/16/2020 that she was dropped in the bathroom and her legs hurt. The Registered Nurse (RN) on duty went directly to her room to assess. The nurse checked her legs and noted no signs/symptoms of injury. The resident denied pain and stated she wanted her pudding. On 5/17/2020 Resident #2 had an elevated temperature and low oxygen saturations. A breathing treatment was given and oxygen was applied. Two nurses assessed the resident and per the DON instructions, the PCP was updated and requested she be sent to the ER for further evaluation to rule out pneumonia. The facility received a call from the hospital stating she had a [CONDITION(S)] and that she had reported to them that she had been dropped. The ER nurse reported that they were sending her on to a major hospital for surgery. The facility's investigative file included a sheet titled Fall Education with the following information: The facility concerns any change in elevation of a resident a fall. This includes, but is not limited to residents rolling out bed onto the floor mat and lowering to the floor by staff. When a fall occurs, to include the noted areas above, a resident is not to be moved until a nurse has assess the resident. There is to be no exception. After the nurse has assessed the resident, he/she will give direction on whether or not to move the resident. The nurse will notify the DON of the incident immediately. The nurse will complete a Risk Management Assessment to include contacting the physician, contacting the family, and any interventions put in place. The interdisciplinary team will review the risk management report the following business day to address any further interventions that may need to be implemented and update the care plan. The investigative file also contained an employee coaching form dated 5/22/2020 for Staff L and Staff M: - Standard to be addressed and reason for coaching: on 5/14/2020 both staff members had a resident in a whirlpool chair attempting to dress her in the chair. The Hoyer sling was not in place. While dressing the resident the lock disengaged, resulting in the resident sliding forward to the floor with the CNAs guiding her. The CNAs then used the Hoyer to put the resident in her wheelchair without notifying the nurse. The resident was not assessed until after she was back in her room. - Coaching plan that both employee and the coach can agree upon to help employee meet the standard: 1. Residents who are Hoyer lifts are to be have the mesh lift pads while in the whirlpool chair/bath at all times, 2. A resident may never be moved from the floor without a nurse assessing and giving the ok to be moved. The facility provided the narrative and impression for the x-rays that were taken of Resident #2's left lower extremity on 5/17/2020. The impression: left intertrochanteric femur fracture. Review of the orthopedic attending progress note dated 5/20/2020 revealed after discussion with Resident #2's family, they were in agreement with proceeding with non-operative management. In light of her current medical condition, chronic co-morbidities, mental condition, and non-ambulatory status, they believe the nonoperative management is the most appropriate treatment courage. Review of the maintenance orders log for 1/2020 through 10/2020 revealed on 5/22/2020 the shower tub chair does not completely lock was reported. No other reports of the shower tub chair malfunctioning was noted on the log. During a staff interview on 2/24/21 at 1:57 PM Staff F CNA was asked when should a Hoyer sling be removed from under a resident and she stated if the resident is in bed or in their recliner. Staff F stated after a nurse assesses a resident should they move after a fall. During a staff interview on 2/24/21 at 2:47 PM Staff G CNA was asked when should Hoyer slings remain under a resident, she stated normally they are taken out unless they are getting back up. She added if the resident is up in their wheelchair or recliner they stay under them. She stated staff can take them out during shower/bath unless they have shower slings. When Staff G was asked when a resident can be moved after a fall, she stated after a nurse assesses them. During a staff interview on 2/26/21 at 10:06 AM Staff E LPN was asked what Resident #2' assistance level was at the time of the incident on 5/14/2020, she stated she required a Hoyer lift for transfers. She was asked to explain what happened that day in the shower room, she stated she was in report at shift change, when Staff L and Staff M came out to tell her Resident #2 had slid out of her chair and they lifted her back in chair. Later they told her they had transferred her, she had slid down the shower chair and placed their arms under her arms to pick her back up. Staff E stated they were not to do transfers unless they used a Hoyer with her, so she was unsure why they did what they did. She stated this took place in the shower room and she thought they were transferring from one chair to a shower chair. She was not sure if they were going to shower her or if it had been done. Staff E was asked what he assessment revealed, she stated when in her room, some pain with rolling. She stated her extremities were per her norm; she was stiff and not moving well which was normal for her. Staff E stated Resident #2 did like to exaggerate, get tearful, upset (even if you tell her how pretty she was). She did not dismiss any pain, but was hard to determine if it was real or exaggeration. When asked if Resident #2 had complained of any pain she stated she did not remember anything out of her norm. She did have scheduled pain medications and also received them as needed (PRN) which was not abnormal for her before the fall. Lastly, she stated the CNAs did not report anything out of the resident's norm. During a staff interview on 3/5/2021 at 11:30 AM Staff M was asked what Resident #2's assistance level at the time of her fall in May of 2020, she stated total assist of two staff with a Hoyer lift. When asked to describe what happened on 5/14/2020, she stated was filling in as the bath aide that day. She had Resident #2 on the shower chair with no sling. She stated about 7:00 AM she took Resident #2 to the shower room and gave the resident a shower. She and Staff L were getting Resident #2 dress while in the shower chair. Staff M stated she had be shown to tuck the adult brief between the resident's legs and one person leans the resident forward to help pull up brief and pants. She stated as they did this the shower chair was locked and Staff M stated she was in front of the resident leaning her forward. She had her arms locked under her armpits and most of Resident #2's body weight was leaning on her. She stated they leaned her far enough forward to get her brief and pants on. When asked if it was typical to get residents dressed in the shower room before going to their room stated it was. She reiterated the shower chair was locked and when they were pulling her pants up the chair pushed back. She assumed the brakes had malfunctioned. She stated while Resident #2 was on the floor, they got nurse told her what happened, then went back to the shower room to put the sling under her and used the Hoyer to position her in to her wheelchair and took her to her room. Staff M was asked if the Hoyer sling was not under the resident while she was in the whirlpool chair, she stated it is known not to have a sling under the residents while dressing them in shower room; at least that was what she was told. When asked if it was normal practice to take the Hoyer sling out during cares, she stated yes. Staff M was asked to describe the whirlpool chair, she stated they used to weigh residents and it looked like a floating toilet bowl. When asked if the brakes were locked prior to the transfer she stated no. Staff M stated to lock the chair in place you stepped down on the lock and to unlock it you put your food under the lock and push up. Staff M was asked why Resident #2 was moved before a nurse could assess her, she stated the nurse assessed after she back to the room, Staff E LPN. She stated they told the nurse before they moved her that she had fall. When asked if nurses are to assess a resident after a fall, before they are moved, she stated they are to be assessed prior to moving them. Staff M stated it was not normal to move a resident after a fall before a nurse could assess them. Staff M stated the resident did not complain of pain during the transfer, nor did she have nonverbal signs of pain. Staff M stated after the incident the facility provided education about the use of a sling when working with a resident that used a Hoyer lift. Staff M was read her statement and she stated that sounded about right. During a staff interview on 3/5/2021 at 11:52 AM Staff L was asked what Resident #2's assistance level was in May of 2020 she stated she required assist of 2 staff with a Hoyer lift. Staff L was asked to describe what happened on 5/14/2020 in the shower room with Resident #2. She stated Staff M had completed her shower and assisted with getting her dressing in the shower chair. She stated they leaned Resident #2 forward on shower chair to pull her pants up, the resident slid off chair and they sat her on the floor. She stated Staff M helped lean her forward by standing in front of Resident #2 and Staff M was on her side more towards the back to help her lean forward. She stated when she stated to fall, they sat Resident #2 on Staff L's feet on the floor. When asked if Resident #2 sat down quickly or slowly, she stated they sat her down slowly. When asked if the resident complained of pain during or after being lowered to the floor she stated she did not. She stated Staff M went to the get the nurse, did not believe the nurse came to assess her. She and Staff M put the Hoyer sling under her, lifted her up off the floor and placed her in in her wheelchair and put her in bed. Staff L stated once she was in bed the nurse then came in to assess her. She stated the nurse was Staff D. Staff L was asked if the Hoyer sling was under Resident #2 while she was in the Hoyer sling, she stated it was normal to not have the sling under them during bath/shower. She stated she did believe the policy was updated to have the sling under them at all times after this incident. When asked if the brakes were locked prior to the transfer she stated they were locked however one of the breaks did not function properly. When would engage to lock it would not catch to help keep that wheel from moving. She stated there were two brakes on the back wheels and one did not always catch to keep it from moving. She added you did not know it didn't catch until you tried to move the chair. When asked if the chair moved prior to her falling she stated yes, it moved slightly before she fell . When asked if Staff M noticed it too, she stated she honestly couldn't say if she noticed it. Staff L was asked if she should have stopped what they were doing to grab help or a sling once she noticed the chair move she stated when she noticed the chair had moved she supposed she should have stopped and got a sling instead of moving forward. Staff L was asked how the break disengaged she stated it had been that way for a while, have had issues with that chair before. When asked if the maintenance department knew about it, she stated there were several slips filled out and the Maintenance Director knew about it. When asked who can fill out a slip she state anyone can fill out a slip in the facility. When asked if she did, she stated more than likely she had filled out a slip for the chair. When asked if Resident #2 was moved to her wheelchair before she the nurse was notified she stated yes. When asked why Resident #2 was moved before a nurse could assess her she stated she was moved because when Staff M went to get the nurse the resident told them she was fine and did not hurt anywhere. Staff M told the nurse what had happened and Staff E stated that if she was lowered to floor then they could get her up, take her to room and should would check her out. When asked if it was normal to move residents after a fall before a nurse could assess, she stated as long as they were lowered to the floor you could move them. She added it varied on whether not to move them, depending on who was working. She stated that she was told that if it was a definite fall the residents need to be assessed, if they were lowered to floor with no injuries, staff can move them before being assessed. She stated she was unsure because there had been too many changes in management and everyone gave different direction. When asked if Resident #2 had complained of pain after the fall, while moving her she stated not. Staff L was asked if Resident #2 looked like she was in any pain, she stated she had not complaints even after they moved her to her bed. Staff L stated after the incident happened she was educated on the use of Hoyer slings, mesh ones to be used and to take residents back to their rooms to be dressed. They also educated her on if any resident is found on the floor they need assessed before being moved. The education was provided by the DON. Staff L was read her statement and she stated it was accurate and if she said something differently it was because it happened almost a year ago. During a staff interview on 3/11/21 at 3:29 PM Staff K previous Maintenance Director was asked what was wrong with the whirlpool chair that Resident #2 slid out of, he state he thought one of the rear wheels was not locking properly. He added this was the first time he had heard of this issue. He stated once he noticed the issue, he took it out of service and put a new locking wheel on it. Staff K was asked to describe the locking mechanism, he stated you step down on the lever to lock it. He stated it wasn't broke it just was not stopping the wheel anymore on the one side. Staff K was asked what staff were to do when they noticed equipment issues, he stated there was a work order system, write it up and tape it to his door. He stated for the most part staff would do write ups and let him know. Lastly he stated he had to talk with them about doing write up notes so they would do them when they found things that needed repaired. During a staff interview on 4/6/2021 at 12:21 PM the DON was asked if staff are supposed to leave the Hoyer slings under a resident while up in a chair whether it be a recliner, wheelchair or other type of chair; she stated yes, the sling is supposed to remain under the resident. The DON stated at the time of Resident #2's fall in the shower room staff were to use a mesh shower sling. The DON was asked to walk through the process of giving a resident a bath or shower that required a Hoyer lift, she stated: the staff would ensure the sling is on, give shower/bath while on, dry and dressed in the shower room with a sling on at all times. Lastly she stated if they are unable to get them dressed in the shower room, staff can take the residents back to their rooms to assist with dressing. Review of the facility's Lifting Devices with a revision date of 3/2017 revealed the purpose of a lifting device is to provide safe and proper use of lifting devices used for resident transfers. 2. According to Resident #4's annual Minimum Data Set (MDS) with a reference date of 7/27/2020, the following diagnoses were documented: [CONDITION(S)], hypertension, [CONDITION(S)], Alzheimer's disease, stroke, and dementia. The MDS indicated Resident #4 had severe cognitive impairment when making daily decisions, had difficulty focusing attention, disorganized thinking, hallucinations, delusions, and behavioral symptoms directed towards others. The MDS indicated she required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, personal hygiene and extensive assistance of 1 staff for eating. It was documented that she was frequently incontinent of urine and always incontinent of bowel. Review of Resident #4's care plan revealed the follow focus group: at risk for falls related to impaired cognitive status and urinary incontinence, had a history of falls. She bends over in her wheelchair and messes with her shoes which puts her at risk for falling out of her wheelchair. The focus area listed a revision date of 1/28/2020. The care plan listed the following intervention: staff are to ensure resident's foot pedals are in place on wheelchair at all times unless transferring or out of her wheelchair, with a revision date of 9/1/2020. Record review of Resident #4's Electronic Health Record (EHR) revealed a fall report dated 8/30/2020 at 1:49 PM. The incident description documented the following: the nurse was called to her room by a Certified Nursing Assistant (CNA). Resident #4 was found lying on the floor in a partial seated position, approximately two feet from her wheelchair. Her wheelchair was beside the dresser and the foot of the bed. Her wheelchair was tilted forward and had no foot pedals on her wheelchair, they were lying on the side chair in her room. Review of the facility's investigative file revealed the follow staff statements: - Staff C LPN wrote on 8/30/2020 at 1:35 PM this nurse was alerted CNAs that resident was found on the floor in her room. This nurse responded. The resident's wheelchair was in a full upright position and her foot pedals were absent from her wheelchair. Resident #4 was lying on the floor on her left side, vitals obtained. Resident did not complain of pain. Resident's ROM was examined and was WNL for her. No grimacing or moaning noted. Resident assisted in to her bed, positioned for comfort. The DON, PCP and family were all notified. No injuries evident, nursing will continue to monitor. Neurological checks were completed per protocol since incident was not witnessed. Prior to evening meal Resident #4 complained of neck pain and Tylenol was administered which was effective. After the evening meal, this nurse discovered she was sitting in her room in her wheelchair again in the full upright position. Staff C reclined the wheelchair and the CNAs placed her to bed shortly after this. Education was provided to the CNAs about the importance of reclining the back on Resident #4's wheelchair. Staff C signed her written statement. - Staff D CNA wrote on Sunday the 30th after she assisted Resident #4 with her lunch in the dining room, she reclined her wheelchair and left the dining room. She then put Resident #4's mask on and moved on to the next resident in the dining room. She was the only aide in there at that time. She told the aides after the residents were done eating that she needed to use the restroom. When she come out of the bathroom, she heard an aide say to the nurse that Resident #4 was on the floor. When she entered her room, after being told she was on the floor, the wheelchair was against the sink in the room and there were no foot pedals on her wheelchair. Resident #4 was on the floor and the Staff C, Staff G and Staff F had assisted the resident off of the floor. Staff G stated she would get the lift and the nurse stated they could get her off of the floor. Staff D signed her statement. - Staff E LPN wrote on 8/303/2020 at about 1:00PM this nurse was called to A-wing to assist with a fall. When she went in to Resident #4's room, she was lying in bed. Staff C stated resident was on the floor with her head between the bed and dressing at the foot of her bed. When she entered the resident's room the wheelchair was sitting up with some tilt in the forward position and the resident's foot pedals were in a chair that was by the closet. The CNAs explained to her that the resident was left in her room with the foot pedals on and wheelchair tilted back. All 3 aides stated the wheelchair was tilted back and the foot pedals were on the wheelchair when they left the room. This nurse checked with therapy to see if anyone was with Resident #4 and she stated no, she was not on their scheduled. Staff E signed her statement. - Staff F CNA wrote on 8/30/2020 she had assisted Resident #4 to her room after lunch, around 1 pm. When she left Resident #4 in her room, she reclined her wheelchair, had her foot pedals on and sat her next to her bed. She stated she went back down the hall towards the dining room an asked the other aides if anyone was left in the dining room to be pushed back to their room. They both told her no. Staff F stepped outside for a break and back in. She and Staff G went in to another resident's room to get them toileted. They left that room with trash and linens, then told staff G she would meet her in Resident #4's room. She threw the trash and linens in their cart and started to head to Resident #4's room when she saw Staff G had come out and stated she was on the floor. They told the nurse, Staff C and she came to assess Resident #4. When Staff F walked in to Resident #4's room, she was sitting on the floor, leaning to the left up against her TV stand. When she was told Resident #4 was on the floor she went in to her room and found the chair to be upright like when she is eating meals and her foot pedals were not on her wheelchair. Staff F signed her statement. Review of the facility's investigative file revealed the following summary: On Sunday 8/30/2020 the charge nurse was called to Resident #4's room by a CNA that found the resident lying on the floor in a partial seated position approximately 2 feet from the wheelchair beside the dresser and foot of the bed. The wheelchair was tilted forward with no foot pedals present. Resident's wheelchair is one that reclines. An assessment was completed with no apparent injury. ROM was WNL for Resident #4. Resident was assisted into bed and vitals obtained. A work order was initiated for maintenance to check the wheelchair for proper functioning. Resident was showing signs of pain to her left hip on 8/31/2020 and a facsimile was since to her PCP by the charge nurse. The PCP responded on 9/1/2020 to obtain a 2 view x-ray of her left hip. The report revealed a displaced subcapital fracture presumably acute. Further review of the facility's investigative file revealed two teachable moment forms. In the information reviewed section is stated when returning resident to her room, she is to have her wheelchair tilted back and her foot pedals are to be on her wheelchair. Both forms were dated 9/1/2020 at 10:00 AM and signed by the Director or Nursing, Staff F and Staff G CNA on 9/3/2020. During a staff interview on 2/24/21 at 1:57 PM Staff F was asked if Resident #4 liked to transfer on her own, she stated no and that she required extensive assistance of 2 staff and when she started to decline they did a sit to stand, then started using a Hoyer lift. Staff F was asked while Resident #4 was her wheelchair, it is supposed to be reclined she stated yes, whenever she is in it. Staff F was asked if her foot pedals were supposed to be on while in her wheelchair, she stated yes. She added otherwise staff would not be able to push her down hallway. Staff F stated they are to leave them on her wheelchair at all times unless they were transferring her. Staff F was asked if she could remove the foot pedals herself, she stated she did not think she would be able to remove them but she could grab them because she used lean over and grab at her shoes and that is why they have her in a tilt chair. During a follow-up interview on 2/25/2021 at 12:34 PM Staff F was asked if she took the resident to her room she stated yes. She indicated she backed her up, tilted her back, turned on her TV and went to see if anyone else needed out of the dining room. Staff F was asked how she left the resident once in her room; she stated the wheelchair was in an upright position and her foot pedals were one. Staff F stated she positioned her next to her bed. When asked how long she was on break she stated about 7-10 minutes, long enough to smoke. Staff F was asked how long after she put Resident #4 in her room did Staff G find Resident #4 on the floor she stated she is not sure because they assisted anothe [TRUNCATED]

Based on record review, policy review, resident, physician and staff interview, the facility failed to provide care and treatment in accordance with professional standards of practice for 1 of 3 residents reviewed (Resident #2). On 1/24/20, Resident #2 admitted to the facility from the hospital with [DIAGNOSES REDACTED]. During her stay at the facility, she was hosptalized on [DATE], returned to the facility on [DATE], and sent to the hospital again on 2/16/20. The facility failed to administer scheduled medications as prescribed, failed to monitor blood sugar levels as prescribed, and failed to monitor the resident's weight as prescribed, which was verified by the resident's Primary Care Provider (PCP) in an interview on 2/24/20. The facility reported a census of 28 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 1/27/20, Resident #2 had [DIAGNOSES REDACTED].>[MEDICAL CONDITION], heart failure, high blood pressure, renal (kidney) insufficiency, diabetes, [MEDICAL CONDITION] (disease that alters brain function or structure), [MEDICAL CONDITION] (irregular heart rhythm), and an implanted cardiac defibrillator. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicated the resident displayed no cognitive deficits. The MDS documented the resident required either supervision or extensive assistance of one staff for activities of daily living (ADLs). The MDS also documented the resident required insulin injections and anticoagulant medication (blood thinner). Review of a care plan with a revision date of 2/17/19 revealed a [DIAGNOSES REDACTED]. According to the care plan, education staff should provide education to the resident, family, and/or caregiver regarding the importance of compliance to prevent complications of the disease. The care plan also directed staff to monitor the resident's dietary compliance. The after Visit Summary related to the resident's 1/12/20 - 1/24/20 hospitalization directed the resident's blood sugar goal should range between 100-180. Check before meals and at bedtime unless the resident's Primary Care Provider (PCP) orders something different, and refer (Resident #2) to Nutritional Services for diabetes and failed nurse education. Hospital Discharge medication orders [REDACTED] 1. Apixaban 5 mg tab by mouth (po) twice a day (BID) for irregular heart rhythm. Give next at bedtime (HS) 1/24/20. 2. Aspirin 81 mg tablet po daily (QD) for heart health. Give next dose in a.m. on 1/25/20. 3. Calcium/Vitamin D 500 mg/200 units tablet po BID for [MEDICAL CONDITION]. Give next dose at HS on 1/24/20. 4. Carvedilol 6.25 mg tablet po BID with meals for blood pressure and heart rate. Next dose due evening 1/24/20. 5. Ezetimibe 10 mg tablet po at HS for cholesterol with next dose due at HS on 1/24/20. 6. [MEDICATION NAME] 20 mg tablet po BID for heartburn with next dose due in the evening on 1/24/20. 7. [MEDICATION NAME] 325 mg tablet po QD with breakfast as iron supplement with next dose due 1/25/20 in a.m. 8. [MEDICATION NAME] 20 mg tablet po QD for [MEDICAL CONDITION] (swelling) with the next dose due 1/25/20 in a.m. 9. [MEDICATION NAME] ([MEDICATION NAME]) insulin 10 units QD with breakfast for type 1 diabetes with the next dose due on 1/25/20 in a.m. 10. [MEDICATION NAME] (Humalog) insulin 4 units 3 times daily (TID) with meals for type 1 diabetes with next dose due in the evening of 1/24/20. 11. [MEDICATION NAME] 60 mg/24 hour tablet po QD for chest pain with next dose due on 1/25/20 in a.m. 12. [MEDICATION NAME] 40 mg tablet po at HS for cholesterol with next dose due at bedtime on 1/24/20. A fax sent to the PCP dated 1/25/20 requested the PCP to specify any other orders for Resident #2 in to hospital discharge. ordered: a diabetic, low salt diet, weights 3 times per week (M-W-F), and blood sugar checks 4 times a day before meals and at bedtime. The January 2020 Medication Administration Record [REDACTED] a. Staff gave the 1st dose of Aspirin 81 mg. on 1/26/20 instead of 1/25/20. The MAR indicated [REDACTED]. Staff wrote insulin not required. b. Staff gave the 1st dose of Ezetimibe 10 mg at HS on 1/25/20 instead of 1/24/20. c. Staff gave the 1st dose of [MEDICATION NAME] 325 mg in a.m. on 1/26/20 rather than 1/25/20. d. Staff gave 1st dose of [MEDICATION NAME] 20 mg in a.m. on 1/26/20, not 1/25/20 as ordered. e. Staff gave the 1st dose of [MEDICATION NAME] Insulin 10 units in a.m. on 1/26/20 instead of 1/25/20. The MAR indicated [REDACTED]. f. Staff gave the 1st dose of [MEDICATION NAME] 60 mg/24 hour in a.m. on 1/26/20 instead of 1/25/20 as ordered. g. Staff gave the 1st dose of [MEDICATION NAME] 40 mg at HS on 1/25/20, not 1/24/20. The MAR indicated [REDACTED]. h. Staff gave the 1st dose of Apixaban 5 mg in a.m. of 1/26/20 instead of HS on 1/24/20. The MAR indicated [REDACTED]. The resident did not receive the medication in evening on 1/25/20 due to medication not available, or on 1/28/20 with no explanation documented by staff. i. Staff gave the 1st dose Calcium/Vitamin D 500 mg/200 units in the evening on 1/25/20 instead of bedtime on 1/24/20. The MAR indicated [REDACTED]. j. Staff gave the 1st dose of Carvedilol the evening of 1/25/20 instead of the evening of 1/24/20 as ordered. The MAR indicated [REDACTED]. According to the MAR, the resident did not receive the medication 1/25/20 in the a.m. because staff did not schedule it on the MAR indicated [REDACTED] k. Staff gave the 1st dose of [MEDICATION NAME] on the evening of 1/25/20 rather than the evening of 1/24/20 as ordered, because staff did not schedule it, 1/25/20 due to medication unavailable, 1/28/20 with no explanation, and 1/29/20 due to resident hospitalized . The MAR indicated [REDACTED] l. Staff gave the 1st dose [MEDICATION NAME] on 1/25/20 in the evening rather than 1/24/20 as ordered. The MAR indicated [REDACTED]. According to the MAR, the resident did not receive the medication on the mornings of 1/25/20 because they had not scheduled it to be given yet. m. Staff administered the 1st dose of [MEDICATION NAME] Insulin 4 units at lunch on 1/25/20 (blood sugar 483) instead of on the evening of 1/24/20 as ordered. The MAR indicated [REDACTED]. n. According to the MAR, staff checked the resident's blood sugar at 4:00 p.m. on 1/24/20 as ordered. The MAR indicated [REDACTED]. The MAR indicated [REDACTED] Review of the January 2020 Treatment Administration Record (TAR) documented staff failed to check Resident #2's weight on Monday, 1/27/20 because staff did not schedule it to be done. An EMAR Orders Administration Note dated 1/24/20 at 5:00 p.m. noted Resident #2 admitted to the facility. The author wrote she documented her entry after some time without a specific time of admission. According to the note, the resident reportedly broke her wrist, some ribs and her pelvis after she fell at home and a diabetic specialist followed her for diabetes. Health Status Notes revealed: a. On 1/25/20 at 11:19 a.m., staff documented they entered all of Resident #2's medications into the computer. The nurse contacted the pharmacy and they reported they would deliver all medication that night. b. On 1/25/20 at 11:53 p.m., staff documented the resident's medication arrived during her shift and she gave 4 units of Humalog at bedtime. The nurse noted resident's heartbeat irregular and lung sounds diminished, with swollen lower legs and ankles. c. On 1/26/20 at 10:45 p.m. documented the resident as an insulin dependent diabetic. The nurse noted that the resident's lungs were diminished and she had swollen lower legs and ankles. d. On 1/28/20 at 2:54 a.m. documentation an order that directed a diabetic, low salt diet, weight 3 times weekly, and check blood sugars before meals and at bedtime. e. On 1/28/20 at 11:20 a.m., the resident displayed shortness of breath and her lungs sounded tight. The nurse also documented administered 2 puffs from a breathing treatment. According to the documentation, the resident reported only slightly improved symptoms with continued shortness of breath. The nurse obtained a physician's orders [REDACTED]. f. On 1/28/20 at 11:43 a.m. documented [MEDICATION NAME] 40 mg given as ordered. The nurse documented the resident's heart rate at 104 beats per minute with a blood oxygen level at 96% on 2 liters of supplemental oxygen. The nurse coached the resident to pursed lip breathe and take slow, calming breaths through her nose. g. On 1/28/20 at 4:25 p.m., the resident's condition seemed to improve that afternoon. The nurse documented the resident continued with shortness of breath and rapid breathing and the nurse awaited the physician's return call. h. On 1/28/20 at 4:46 p.m. documented the nurse obtained an order to send the resident to the ER (emergency room ). The document titled Weight Summary showed Resident #2's January weights as 135 lbs. on 1/26/20 at 12:11 p.m. and 135 lbs. on 1/27/20 at 8:15 a.m. The After Visit Summary regarding hospitalization for acute on chronic systolic heart failure between 1/29/20 - 2/5/20 identified a goal to keep the resident's blood sugar level in the 100-180 range and to check her blood sugar before meals and at bedtime unless instructed by her doctor. The physician described the resident's discharge condition as stable. The summary directed the resident should follow-up with her PCP in 1 to 2 weeks and any of the following should be reported; temperature, severe uncontrolled pain, extreme fatigue, difficulty breathing, persistent nausea and vomiting, and signs of infection. The physician ordered daily weights after the resident's first void and before breakfast and report a gain of 3 lbs. in 24 hours or 5 lbs. pounds from discharge hospital weight. Also, contact provider if resident showed signs/symptoms of fluid overload: weight gain, shortness of breath, difficulty breathing with exertion, cough, new/increased swelling in lower legs, shortness of breath while lying flat, new or increased oxygen needs, and increased fatigue or weakness. The summary directed a resident with Type 1 diabetes should receive insulin and make all efforts to receive a consistent carbohydrate diet. The 2/5/20 Hospital Discharge Medication Orders directed: 1. Apixaban 5 mg tablet po BID with the next dose due at bedtime that night. 2. Aspirin 81 mg tablet po QD with the next dose due the next morning. 3. Calcium/Vitamin D 500 mg/200 units po BID with the next dose due that evening. 4. Carvedilol 6.25 mg tablet po BID with meals with the next dose due that evening. 5. Ezetimibe 10 mg tablet po at HS with the next dose due at bedtime that night. 6. [MEDICATION NAME] 20 mg tablet po BID with the next dose due at bedtime that night. 7. [MEDICATION NAME] 325 mg tablet po QD with breakfast with the next dose due the next morning. 8. [MEDICATION NAME]6 units injected QD with breakfast for Type 1 diabetes the next dose due the next morning. 9. [MEDICATION NAME]3 units injected TID with meals for type 1 diabetes with the next dose due the next afternoon. 0. 10. [MEDICATION NAME] 60 mg/24 hour po QD with the next dose due the next morning. 11. [MEDICATION NAME] 40 mg po at HS with the next dose due at bedtime that night 12. Ropinirole 0.25 mg tablet, 3 tablets po HS with the next dose due at bedtime that night. 13) [MEDICATION NAME] 20 mg tablet po QD with the next dose due the next morning. A Health Status Note dated 2/5/20 at 1:30 p.m. documented the resident readmitted from the hospital. A Health Status Note dated 2/6/20 at 4:43 a.m. documented the resident's bedtime blood sugars 448. The nurse obtained an order to administer 15 units of insulin now. A follow up test revealed the resident's blood sugar results as 339. An EMAR Orders Administration Note dated 2/5/20 at 6:15 p.m. documented Ropinirole 0.25 mg. as unavailable. An EMAR Orders Administration Note dated 2/8/20 at 10:31 p.m. directed staff to weigh the resident daily and contact the PCP with 2 lb. gain in one day or a 5 lb. gain in a week k related to heart failure. The nurse documented they had not checked the Resident's weight before breakfast; therefore it would not be accurate. A phone order dated 2/9/20 at 9:25 a.m., noted by the nurse on 2/13/20, directed staff to inject [MEDICATION NAME] 10 units QD for Type 1 diabetes. A phone order dated 2/9/20 at 9:28 a.m., noted by the nurse on 2/13/20, directed staff to inject [MEDICATION NAME] 5 units TID for Type 1 diabetes. A phone order dated 2/9/20 at 9:30 a.m., noted by the nurse on 2/13/20, directed staff to inject [MEDICATION NAME] 5 units one time only for a blood sugar reading of 562 until 2/9/20 at 11:59 p.m. A Health Status Note dated 2/9/20 at 9:34 a.m. revealed staff contacted the on-call doctor to report a blood sugar level of 562. The nurse obtained a new order to increase [MEDICATION NAME]to 10 units every morning and increase [MEDICATION NAME]to 5 units with each meal and 5 extra units now. An EMAR Orders Administration Note dated 2/9/20 at 10:31 p.m. revealed the resident's weight had not been checked before breakfast. The Doctor's Orders and Progress Notes dated 2/11/20 at 2:04 p.m. contained orders as follows: 1) Obtain daily weights for 2 weeks and fax results to the PCP's attention on Thursdays. 2) Give insulin after meals, never before. Hold meal time insulin if Resident #2 eats less than 25% of her meal. 3) The Resident reported she is not receiving evening meal insulin on a regular basis. She is Type 1 diabetic and requires regular timely insulin administration to avoid death. 4) Please ensure Resident #2 is on a no added salt and diabetic diet. She needs both; not one or the other. 5) Administer 5 units of [MEDICATION NAME] once now for a blood sugar reading of 528. Re-check her blood sugar in 2 hours and call the PCP with the results. Staff documented on the order that they called the PCP at 4:30 p.m. to clarify and received an order to re-check the Resident's blood sugar and administer 5 units if it measured higher than 400. The nurse documented the Resident's blood sugar level as 193 at that time. A Health Status Note dated 2/11/20 at 5:12 p.m. documented receipt of a fax from the resident's PCP regarding the residents diet, insulin, and weights and an order to administer 5 units of [MEDICATION NAME] for a blood sugar level of 528. The order directed staff to re-check the blood sugar in 2 hours and notify PCP of results. The nurse documented that she had not given the 5 units of [MEDICATION NAME] because she had not observed a blood sugar result that high on her shift. The nurse consulted the PCP to know to do since she had not given the 5 extra units of [MEDICATION NAME], had not re-checked in 2 hours or called back. The PCP ordered her to check Resident #2's blood sugar now and administer 5 units of [MEDICATION NAME] if the blood sugar level was over 400. The PCP also ordered her to call him back after re-checking the Resident's blood sugar in 2 hours. The nurse documented Resident #2's blood sugar as 193. A phone order dated 2/12/20 at 8:15 a.m., noted by the nurse on 2/13/20, directed staff to inject [MEDICATION NAME] 5 units additional STAT (immediately) for high blood sugar. A phone order dated 2/12/20 at 8:17 a.m., directed the resident to receive [MEDICATION NAME] 5 units one time only after breakfast until 2/12/20 at 11:29 a.m. for a high blood sugar reading. A Health Status Noted dated 2/12/20 at 8:20 a.m., documented a blood sugar reading of 500 before breakfast. The nurse obtained an order to administer 5 units of insulin in addition to the scheduled dose, and another 5 units after the resident ate breakfast. The PCP also ordered the nurse to call with the blood sugar results before lunch. A Health Status Noted dated 2/12/20 at 10:39 a.m., the nurse documented resident's blood sugar still high. She then notified the PCP of uncontrolled blood sugars. Fax correspondence dated 2/12/20 at 1:25 p.m. notified the PCP the resident had lost 11 pounds. The nurse documented the resident's 1/26/20 weight as 135 pounds and her 2/5/20 weight as 124 pounds. The nurse also notified the PCP that the resident consumed anywhere between 0-50% of her no added salt (NAS) diet. The PCP documented that he attributed her weight loss to treatment of [REDACTED]. The Doctor's Orders and Progress Notes dated 2/13/20 noted the resident's weight as 136.8 pounds. The PCP ordered: 1. Change [MEDICATION NAME] to 12 units QD. 2. Change [MEDICATION NAME] to 7 units TID after consumption of 50% of the resident's meals. 3. [MEDICATION NAME] 20 mg by mouth once today. 4. Fax the resident's blood sugar log to the PCP on 2/19/20. A Health Status Note dated 2/13/20 at 1:25 p.m. documented the resident's PCP saw her on routine rounds. The nurse documented she discussed blood sugar management and new dosing with the PCP, and he wanted to get her blood sugar levels down into the 200's. An EMAR Orders Administration Note dated 2/13/20 at 7:17 p.m. noted Ezetimibe 10 mg was unavailable. A Health Status note dated 2/14/20 at 3:49 p.m. documented the nurse called the PCP after getting 3 consecutive HI blood sugar readings. The nurse obtained an order to give 6 units fast acting insulin (Humalog) and recheck blood sugar in 2 hours. A Health Status Note dated 2/14/20 at 11:53 p.m. documented that the resident had eaten an ice cream snack, potatoes for lunch and a cookie. The nurse noted that she observed 4 consecutive HI results when she tested the resident's blood sugar level. According to the nurse's documentation, another RN obtained an order to administer 5 units of Humalog now and recheck it in 2 hours; at which time the resident's blood sugar measured 577. The nurse documented that administered the scheduled insulin and the resident did not eat much for her evening meal, but stated she felt so much better. The resident slept most of the evening before her blood sugar was checked again; at which time it measured 270. A Health Status Note dated 2/15/20 at 2:45 a.m. documented a blood sugar reading of HI and the resident with decreased responsiveness. The nurse documented the resident's vital signs as temperature 99.6 F., respirations 24 (breaths per minute) and shallow, blood pressure 112/60 and oxygen level 94%. She described the resident as being weak and unable to ambulate. Documentation revealed the resident had not been given the after meal insulin, so she administered it. After consulting an on-call doctor, the nurse rechecked the blood sugar in 20 minutes per order; which she documented as HI. The nurse documented the resident did not respond to her but whimpered throughout their encounter. The resident could not answer questions. An order was obtained to send the resident to the ER. EMAR Orders Administration Note dated 2/15/20 at 7:51 p.m. documented staff missed checking Resident #2's blood sugar before supper. The nurse documented the current reading as HI. A phone order dated 2/16/20 at 12:37 a.m. authorized the facility to send the resident to the ER immediately for persistent [MEDICAL CONDITION] with continued decreased level of consciousness. A Health Status Note dated 2/16/20 at 4:13 a.m. documented the resident was admitted to the hospital for further observation. A review of the February 2020 MAR indicated [REDACTED] 1. Staff administered the 1st dose of Aspirin 81 mg. by mouth for heart health on the morning of 2/8/20 instead of 2/6/20 as ordered. The MAR indicated [REDACTED]. 2/9/20, 2/10/20 and 2/11/20 doses were not administered without an explanation and 2/14/20 due to the resident refusal. 2. Staff administered the 1st dose of Ezetimibe 10 mg. by mouth for cholesterol at bedtime on 2/5/20 as ordered. The MAR indicated [REDACTED]. 3. Staff faxed daily weights to PCP on Thursday 2/13/20 related to [MEDICAL CONDITION] as ordered on [DATE]. 4. Staff administered [MEDICATION NAME] 10 units on the mornings of 2/9/20 through 2/13/20 as ordered (MAR initialed for both 8 and 10 units on 2/9/20) on 2/9/20. 5. Staff administered [MEDICATION NAME] 12 units for type 1 diabetes on the mornings of 2/14/20 and 2/15/20 as ordered on [DATE]. 6. Staff administered the 1st dose of Ropinirole 0.25 mg. for restless leg syndrome at bedtime on 2/6/20 instead of 2/5/20 as ordered. Medication documented as being unavailable. 7. Staff did not administer the dose of Calcium/Vitamin D 500 mg./200 units on 2/8/20, 2/9/20, 2/12/20 and 2/13/20 with no explanation or due to the medication being unavailable. 8. Staff administered [MEDICATION NAME] 4 units TID at lunch on 2/5/20 instead of 3 units as ordered on [DATE]. Staff administered 3 units in the evening of 2/5/20 and TID on 2/6/20 through the morning dose on 2/9/20; at which time they discontinued that dose with a blood sugar level of 562. 9. Staff administered [MEDICATION NAME] 15 units one time only on 2/5/20 at 10:00 p.m. for a blood sugar reading of 448. 10. Staff administered [MEDICATION NAME] 5 units one time only on 2/8/20 at 9:29 a.m. for a high blood sugar reading. 11. Staff administered [MEDICATION NAME] 5 units one time only on 2/9/20 at 9:41 a.m. for a blood sugar reading of 562. 12. Staff administered [MEDICATION NAME] 5 units TID at lunch on 2/9/20 through the lunch dose on 2/11/20 as ordered on [DATE]. 13. Staff administered [MEDICATION NAME] 5 units TID (if Resident #2 ate at least 25% of her meal) starting in the evening on 2/11/20 through the lunch dose on 2/13/20; at which time they discontinued that dose with a blood sugar level of 459. 14. Staff administered [MEDICATION NAME] 5 units immediately on 2/12/20 at 8:25 a.m. for a high blood sugar reading. 15. Staff administered [MEDICATION NAME] 5 units one time only after breakfast on 2/12/20 at 9:08 a.m. for a high blood sugar reading. 16. Staff administered [MEDICATION NAME] 20 mg in addition to Resident #2's normal dose immediately for [MEDICAL CONDITION] on 2/13/29 at 4:45 p.m. 17. Staff administered [MEDICATION NAME] 7 units TID at lunch (if Resident #2 ate at least 50% of her meal) starting at supper on 2/13/20 through the lunch dose on 2/15/20. 18. Staff administered [MEDICATION NAME] 6 units one time only on 2/14/20 at 5:36 p.m. 19. Staff checked the resident's blood sugar before meals and at bedtime starting at 4:00 p.m. on 2/5/20 through 11:00 a.m. on 2/15/20. The MAR indicated [REDACTED]. Documentation revealed the 9:00 p.m. blood sugar reading as 5000. Review of the February 2020 Treatment Administration Record (TAR) revealed it failed to direct staff to weigh the resident after the resident's first morning urination (void) and before breakfast as ordered on [DATE]. The TAR failed to contain documentation that indicated the staff weighed the resident daily as ordered. The TAR also failed to contain documentation that verified staff faxed the resident's blood sugar log to the PCP on 2/19/20 as ordered. A document titled Weight Summary documented the resident's February weights as follows: 1. 2/12/20 at 8:24 a.m. = 135.1 pounds. 2. 2/13/20 at 9:46 a.m. = 136.8 pounds. 3. 2/14/20 at 8:23 a.m. = 134.7 pounds. 4. 2/15/20 at 12:14 p.m. = 136.5 pounds The 2013 Blood Glucose Testing procedure to monitor blood glucose level directed staff to verify the physician's orders [REDACTED]. The policy also directed staff to document the blood glucose level on the MAR indicated [REDACTED]. During an interview on 2/24/20 at 12:45 p.m., the Director of Nursing (DON), stated staff are to fax admission orders [REDACTED]. The DON described their admission process as broken. When asked, the DON also stated staff should check the emergency medication kit (e-kit) for medication on hand to ensure medication can be administered as prescribed. She added staff should call the pharmacy if specific medications are not in the facility/e-kit, and pharmacy can deliver them STAT if necessary. The DON stated the pharmacy delivers by midnight and they are pretty good about getting the medication here in a timely manner. The DON stated she spoke to the doctor about making sure insulin was administered as prescribed and informed him they were working on the processes. During an interview on 2/24/20 at 2:54 p.m. with Resident #2's PCP, he stated he expected the facility to notify him of a high blood sugar reading. The PCP stated he did not write specific orders about when to notify him, but facilities usually have a policy with the threshold somewhere between 300 and 500, and he certainly expected to be notified for any reading over 500. The PCP also stated he would have expected the facility staff to check the resident's blood sugar and administer all medications as ordered, especially after a lengthy hospitalization for [MEDICAL CONDITION] as Resident #2 had prior to her 1/24/20 admission to the facility. The PCP said medication and diet adherence would probably be the greatest factors in preventing re-admission to the hospital, and not tracking blood sugar and not receiving medications as ordered could have potentially contributed to the resident being re-hospitalized after her 1/24/20 admission. The PCP reported uncontrolled diabetes could potentially be a risk factor for developing infection such as pneumonia, and added [MEDICAL CONDITION] (high blood sugar) is an independent predictor for morbidity and mortality in pneumonia. The PCP said [MEDICAL CONDITION] and the resulting complications directly resulted in Resident #2 being hosptalized on [DATE]. He stated pneumonia and [MEDICAL CONDITION] were factors that contributed to that hospitalization , and the 2/15/20 hospitalization could be directly attributed to blood sugar control. The PCP said he expected staff to followed physician's orders [REDACTED]. In an interview on 3/9/20 at 10:58 a.m., the Nurse Consultant stated the resident's blood sugars had been out of control and she felt relieved that they called the doctor and sent her to the hospital. The Nurse Consultant reported the facility did not accept the resident back after her second hospitalization because her blood sugars were too brittle (variable, hard to manage), and added they had too many temporary agency nursing staff in the building and could not meet Resident #2's needs. On 3/12/20 at 11:00 a.m. the Dietary Supervisor reported in an interview she had worked as a cook in the facility for a couple of years, left for approximately 9 months, and came back about a week ago as the Supervisor. The Dietary Supervisor stated the difference between a diabetic diet and a regular diet are a smaller scoop size for starches, a smaller or different dessert than a regular diet, and they either do not receive bread and butter or just get a half of a slice. The Dietary Supervisor stated a regular diet also has lower sodium and does not differ from a no added salt diet. The Dietary Supervisor stated the diets are followed carefully as far as she knows. She stated she could only speak for herself because there were no other cooks on the shift she worked but only the cook plates the food. She stated there is no record of what type of diet a resident gets served on any particular day they just follow the order. The Dietary Supervisor stated she can only assume a resident got served the type of diet the physician ordered.

Based on clinical record review, facility policy review and interviews, the facility failed to always complete and document accurate and timely assessments and provide interventions for 2 of 4 resident records reviewed (Resident #1 and Resident #3). Resident #3 admitted to the facility on [DATE]. The resident's Progress Notes failed to contain an admission assessment to determined the resident's baseline condition at the time of her arrival to the facility. review of the resident's medical record revealed [REDACTED].#3 underwent significant changes in condition, including a temperature of 103.9. This resulted in acute hospitalization and treatment for [REDACTED]. The resident returned to the facility on [DATE]. However, she was transferred back to the hospital after requiring intubation and transport via emergency medical helicopter on 9/25/19. At that time, the resident was admitted to the Intensive Care Unit with a temperature of 101.2 degrees F. Resident #3 passed away at the hospital on [DATE]. This constituted an Immediate Jeopardy to resident health and safety. The facility identified a census of 46 current residents. Findings include: 1. The Admission Record for Resident #3 documented the resident admitted to the facility on [DATE] from another nursing facility with [DIAGNOSES REDACTED]. The resident's Progress Notes failed to contain a head-to-toe admission assessment to determine the resident's baseline condition at the time of her arrival to the facility. The Baseline Care Plan completed 9/4/19, completed by the MDS Coordinator/director of nursing (DON) documented the resident was alert and cognitively intact, and communicated verbally. The resident was dependent on 2 staff and a mechanical full-body lift for transfers, required set-up assistance for eating, and required observation for behaviors. The Care Plan also the documented the resident demonstrated both bowel and bladder incontinence. The Progress Notes entry completed by Staff L, a corporate employee registered nurse (RN), on 9/8/19 at 5:15 PM for an effective date of 9/6/19 at 7:00 PM (late entry) documented the resident was lethargic with an oxygen saturation of 96 % on room air, lungs clear and had no cough or shortness of breath. The entry also documented the resident had no intake at dinner. Review of the Medication Administration Record [REDACTED]. The order specifically requested for staff to address if the resident could make needs known and speak in complete sentences, and, if not, what staff did to meet the resident's needs. The entry also documented labs and a urinalysis (UA) had been requested. During interview on 10/3/19 at 3:05 PM the DON stated she entered the nursing order for the head-to-toe assessment every shift for the resident because when she worked part of shift as charge nurse on 9/6/19, CNA staff had reported to her the resident did not seem to be as alert and active as she had been on the day she entered the facility. She stated did not personally assess the resident, but wanted to alert nursing staff to monitor the resident and expected them to follow the nursing order. She stated she did not follow-up with charge nurses or CNA's to check on the status of the resident after she entered the nursing order on 9/6/19. Review of the Progress Notes revealed no head-to-toe assessment, or assessment of the resident's abilities as directed by the nursing order, documented on 9/6, 9/7 or 9/8. An Order Details dated 9/5/19 at 11:24 AM documented the facility received an order from the resident's primary care physician to draw a hemoglobin A1C, lipid panel, [MEDICAL CONDITION] stimulation hormone (TSH) level and basic metabolic profile every 6 months starting on the 5th of the month. The Progress Notes Entry completed by Staff L on 9/8/19 at 5:16 PM for an effective date of 9/6/19 at 9:00 PM (late entry) documented blood drawn from the resident's right hand and taken to the hospital by a facility certified nursing assistant (CNA). Review of the resident's clinical record revealed no lab results for this lab draw that had been ordered by the physician. During inquiry on 10/3/19 a medical records representative of the hospital reported the hospital had not received or processed a blood specimen from Resident #3 on or during 9/5-9/7/19. A Progress Notes entry completed on 9/7/19 at 5:15 PM by Staff P, RN former facility employee, documented the resident's blood sugar measured 500 and sliding scale insulin given by subcutaneous injection. The Progress Notes entries after this date are as follows: a. 9/7/19 at 6:19 PM entry completed by Staff P documented the resident's blood sugar measured 441. Staff gave 25 units (u) of Humalog insulin and contacted the resident's primary care physician. b. 9/8/19 at 7:33 AM entry completed by Staff P documented the resident was in bed and lethargic with a blood sugar of 228. c. 9/8/19 at 8:35 AM entry completed by Staff P documented the resident was in bed, lethargic and does not awaken easily. The resident's oxygen saturation level measured 84% and the resident started on oxygen at 2 liters per minute (LPM) per nasal cannula. Review of the resident's clinical record revealed no notes or entries that showed staff had contacted the physician for an order to administer oxygen. d. 9/8/19 at 9:38 AM entry completed by Staff P documented the resident's oxygen saturation level as 86 % on 2 LPM oxygen and the resident sent to the emergency room after order received from the resident's primary care physician. e. a late entry created 9/9/19 at 5:04 AM by Staff Q, licensed practical nurse (LPN) staffing agency employee, for an effective date of 9/7/19 at 10:00 PM documented the resident in bed with eyes her closed, but did respond to painful stimuli by opening her eyes. The entry further documented staff would continue to monitor for any changes. f. 9/9/19 at 3:58 AM entry documented the resident admitted to the hospital with [REDACTED]. The Patient Care Report completed by the emergency medical services (EMS) dated 9/8/19 at 10:10 AM documented the resident found unresponsive with left facial droop and labored breathing. EMS had rated the resident's initial condition as critical. The Emergency Department (ED) Provider Note dated 9/8/19 at 11:58 AM documented nursing home staff reported the resident had been acting differently with loss of consciousness, unresponsive for possibly greater than 6 hours. The notes showed the resident presented in the emergency room as unresponsive even to deep sternal rub, with questionable facial droop noted. The resident's temperature measured 103.9 degrees, heart rate 119, respirations 48, nonresponsive pupils and a blood sugar of 475. The hospital's Authorization for Transfer dated 9/8/9 documented the resident transferred to ICU in another medical facility for the [DIAGNOSES REDACTED]. The Synopsis report completed by a physician at the receiving hospital on [DATE] at 2:45 M documented the resident unresponsive to painful stimuli, eyes are open at forced gaze to the left and the resident assessed to have the following medical problems: acute [MEDICAL CONDITION] severe dehydration [MEDICAL CONDITION] [MEDICAL CONDITION] metabolic [MEDICAL CONDITION] UTI The synopsis further documented the residents acute mental status change appeared to be due [MEDICAL CONDITION] (infection in the bloodstream) or diabetic ketoacidosis rather than a stroke. During interview on 10/17/19 at 9:40 AM Staff P stated she could not recall the resident but said that anything she would have done for the resident would be documented in the Progress Notes. Review of the daily scheduled revealed Staff G,CNA assigned to the resident's hall on 9/5/19 on the 6 AM-2 PM shift. During interview on 10/3/19 at 10:40 AM Staff G stated she only cared for the resident 1 time when she first admitted to the facility and she could not recall anything unusual with the resident. During interview on 10/3/19 at 2:06 PM Staff B, CNA, stated she worked with the resident the day she admitted to the facility and a couple of days later. Review of the schedule revealed Staff G assigned to care for the resident on 9/4 and 9/6. She stated the resident was alert, and although she did not initiate conversation she would answer questions and did try to assist herself during care. She stated the resident did feed herself the day she came in but a few days later when she worked with her she required assistance. The resident acted sleepy but she was not sure if that was normal for the resident or not. During interview on 10/16/19 at 2:36 PM Staff R, CNA, stated she recalled working with the resident on 2 days before she went to the hospital. Review of the schedule revealed Staff R assigned to the resident on 9/6 and 9/7. She stated the resident appeared really lethargic and did not answer questions and had trouble comprehending what staff said to her, She stated she reported this to the DON because she had not been sure if this was normal for the resident. She worked with Staff B and she thought the resident acted more lethargic than the day she came in. She stated the resident remained in bed for supper because she was so tired. The resident readmitted to the facility from the hospital on [DATE]. The Progress Notes entry completed by Staff D, licensed practical nurse (LPN) at 6:31 PM documented the resident noted to have decreased appetite to day and also some congestion. Staff D sent a fax to the resident's physician regarding these findings. The next Progress Notes entry completed by Staff E, agency staff LPN, on 9/25/19 at 2:15 AM documented staff observed the resident with shallow, quick breaths and a oxygen saturation level of 76% on room air at approximately 9:30 PM on 9/24/19. Staff [NAME] documented she applied oxygen to the resident at 2 LPM and her oxygen saturation between 82-87%. The note documented the previous shift nurse stated the resident may have aspirated (no notes identified in the progress notes to corroborate this). The resident's vitals signs measured 98.9 degrees, respirations 24 and blood pressure 120/70 and the resident's pulse fluctuating between 56-120. The resident continued with shallow, quick breaths and fluctuating oxygen saturation levels. Staff [NAME] checked the resident's blood sugar, and repeated it, and the glucometer determined the results as HI. At midnight Staff [NAME] documented she called the DON and left a message and then called the administrator who told her he wanted the resident to be seen in the emergency room . Staff [NAME] increased the resident's oxygen flow to 3 LPM. Staff [NAME] contacted the hospital in town and a physician directed her to call the resident's physician who is associated with another hospital. Staff D then called the primary care physician's affiliated hospital and received an order at 1:00 AM to send the resident to the hospital in town. The Patient Care Report dated 9/25/19 documented the ambulance personnel dispatched to the facility at 1:09 AM and at the patient's side at 1:13 AM. The resident's skin, warm, pale and clammy, lungs sound decreased with rhonchi/wheezing bilaterally, had sinus [MEDICAL CONDITION](rapid heart rate) and the resident was unresponsive The resident's pulse measured 120, blood pressure 114/74, respirations 24 and labored, oxygen saturation 81% and blood sugar reading of 576. The narrative note documented the staff at the facility reported the resident had had an oxygen saturation level of 70-80% since approximately 7:30 PM the evening before and also reported the resident may have aspirated last night. The paramedic applied oxygen at 15 LPM and also intubated the resident. The ambulance personnel turned care of the resident over to medical helicopter personnel at 1:55 AM. The hospital history and physical reported dated 9/25/19 at 6:22 AM documented the resident arrived to the hospital via medical helicopter on mechanical ventilation and remained unresponsive to painful stimuli. The resident's most recent vitals signs were temperature of 101.2 degrees F, heart rate 107, respirations 30, blood pressure 97/51 and oxygen saturation 94% and on a ventilator. The resident presented with the principal problem of altered mental status with [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and significant abdominal distension, possibly due to bowel obstruction. The resident was admitted to the ICU, and passed away on 10/6/19 at the hospital. Review of the schedules revealed Staff G, certified nursing assistant (CNA) assigned to the resident on the 6 A-4 PM shift on 9/24/19 and she and Staff F, CNA worked together to care for her. Staff G stated that when they got the resident up in the morning, it looked like she had something in her mouth that looked like cottage cheese. She reported this to Staff D, charge nurse. Staff G stated Staff D later told her she cleaned out the resident's mouth and got out what looked like peaches. Staff G stated the resident sounded rattley and was very lethargic and she reported that to Staff D as well. Staff G stated she did not get the resident up for lunch because of her lethargy. Later on in the day Staff G stated she observed Staff D in the hallway outside the resident's door. Staff D told her she could not do a good assessment of the resident while she lay in bed. She and Staff F told Staff D they would get the resident out of bed so she could assess her but reported Staff D never responded to the offer. She and Staff F asked Staff D several times that day to check on the resident because of her change in condition, and added in the last 3-4 months it has been difficult to get charge nurses to follow up on the concerns they bring to them. During interview on 10/3/19 at 1:40 PM Staff F stated she and Staff G worked together on 9/24/19 on the 6 AM-2 PM to care for the resident. She stated the resident sounded raspy and lethargic; she stated when the resident looked at her she said appeared she looked through her. She and Staff G talked to the resident but she did not respond. When the assisted the resident up for the day they noted she had what appeared to be melted medications on the side of her mouth. She reported this to Staff D, charge nurse. Staff F stated she and Staff G reported the resident's change of condition to Staff D every time they cared for the resident. During interview on 10/16/19 at 6:10 PM Staff J, CNA stated she cared for the resident on 9/24/19 on the 2 PM-10 PM shift. Staff J stated the resident leaned to the side when she sat in her wheelchair. The resident would not stay awake when she fed her and tapped her on the arm and asked her to wake up; she said the resident would rouse, take a bite and then doze off again. She stated she reported this to Staff E. Staff J reported the resident had really labored breathing. She said the resident usually lay in bed on her back with her hands on her chest and would look at staff, but on this day the resident breath in deeply and was puffing. Staff J said she thought the resident's oxygen saturation level tested at 74% as she checked it. She reported this to Staff [NAME] and she applied oxygen to the resident. She stated Staff [NAME] directed her to check the resident's oxygen saturation level every 20-30 minutes and she did so. Around midnight the resident's saturation level was around 83%. She reported this to Staff E, who took the resident's temperature and then left the room to make calls; she stated she knew the nurse had to call around to get the resident assistance. She stated the resident changed quickly in 4 hours. The resident usually would usually look at them when speaking and moved her head towards them; on this day the resident did not. During interview on 10/16/19 at 4:35 PM Staff I, CNA, stated she worked 6 PM-6 AM on 9/24-9/25/19. Staff reported to her the resident did not feel well and had not eaten. She tried to get the resident to eat and drink but the resident would not accept anything. She stated it was hard to get the resident to wake up and she breathed abnormally. She stated she reported this to Staff E, temporary agency LPN. Between 8:30-9:30 PM she entered the resident's room to check on her and noticed the resident breathed loudly, deeply and slowly and she could not wake her up. She stated the resident would not respond to either her or Staff [NAME] She reported to Staff [NAME] the resident's was not breathing right. She checked the resident's oxygen saturation and it measured 76%. She reported this to Staff [NAME] and she said she would put oxygen on her. Staff [NAME] directed her to check the resident's oxygen saturation level throughout the shift. Staff I stated she did so and reported the readings to Staff [NAME] about every half hour. Around midnight the resident's oxygen saturation level dropped and it do not seem the oxygen help the residents. She reported Staff [NAME] checked on the resident and then left the room to make phone calls. During interview on 10/15/19 at 12:40 PM Staff D reviewed the resident's nursing order which directed a head-to-toes assessment of the resident every shift and acknowledges she did not complete an assessment of the resident on 9/24/19, but did measure the resident's vital signs. She stated Staff G reported to her the resident did not have a good appetite and she left the resident in bed at lunch. She stated the resident had nasal congestion but there were other residents in the facility with the same thing. She stated she did clean the outside of the resident's mouth and along the inner gum line on one side after staff asked her if she had given the resident medications because there was something in and on her mouth and got a whitish old substance out of her mouth. She stated she did not recall she reported to oncoming nurse Staff [NAME] the resident may have aspirated and not sure why she would have said that she did. During interview on 11/1/9 at 11:45 AM Staff D stated many residents at the facility had upper respiratory symptoms which included cough and congestion. She thought maybe the resident had the same thing. She stated she might have checked the resident's oxygen saturation level but does not recall what the result may have been. She did go to the resident's room to complete a lung assessment but could not complete it because the resident lay in bed on her back. She stated she did not ask for assistance to complete the assessment and could not recall if Staff F and/or G offered to get the resident out of bed to do her assessment. Staff D stated she knew the resident did not feel well and she faxed the doctor at the end of her shift to inform him of the resident's throat and nasal congestion. During interview on 10/15/19 at 6:20 PM Staff [NAME] stated 9/24/19 was the 2nd day she worked in the facility and her 2nd day as a temporary agency nurse. She stated she received no orientation to the facility and not familiar with residents. She stated that during report on 9/24/19 Staff D told her to watch the resident closely as may have possibly aspirated but she did not asked her any details and Staff D did not offer any. She stated CNA staff reported the resident acted differently and had shallow respirations. She applied oxygen to the resident. She stated she checked the resident's oxygen saturation level but did not document it. Around midnight she increased the resident's oxygen to 3 LPM because an on-call physician at the local hospital told her to do so but she did not document the call and did not write the order for it. She stated she checked the resident's blood sugar and the meter read HI' but she did not review the glucometer manual to find out the meter's parameters. The user guide for the facility's blood glucose monitoring system directed the following: Page 38: Caution: If you see HI or LO displayed the patient's blood glucose level may be above 600 mg/dL (milligrams/deciliter). Repeat the blood glucose test. If you receive the same result, contact the patient's physician or healthcare provider. She stated she had to make several calls to get an order to send the resident to the hospital. She did not call 911 because in other facilities when she had worked you could not send a resident to the hospital without a physician order. The facility's Oxygen Administration policy dated 1/13 directed the following: Procedure: 1. Verify physician's orders [REDACTED]. flow rate duration of use (PRN (as needed), continuous, etc) parameters for monitoring oxygen saturation, as indicated The facility's Pulse Oximetry (oxygen saturation test) policy dated 1/13 directed the following: Procedure 1. Verify physician's orders [REDACTED]. pulse biometry with or without oxygen continuous or spot check 15. Document the following: date and time type of probe used oxygen saturation reading oxygen concentration, or liter flow, as applicable describe if resident/patient was at rest or exercising respiratory rate resident/patient response to the procedure 17. Notify the physician of any changes or concerns. The facility's Clinical Change in Condition policy dated 6/2015 directed the following: Overview The Interdisciplinary team strives to identify and manage all resident's/patients that are experiencing a change of condition. Daily observation and communication is important in identifying changes in a resident/patient that requires further investigation. Daily observation includes, but is not limited to: participation in daily routines physical assessment (i.e., cardiovascular, respiratory, mental status, neurological) behavior mobility comfort level response to medications Procedure 1. Assess resident/patient clinical status when a change of condition is identified. This may include but is not limited to: vital signs lung sounds pulse ox (oxygen saturation level) mental/neurological status bowel sounds skin color, turgor, temperature pain 2. Review the resident/patient medical record including but not limited to: primary [DIAGNOSES REDACTED].>lab work medication changes changes in nutritional status advance directives allergies [REDACTED]. Review resident/condition with an RN. A telephonic review is acceptable. Note: If situation requires emergency attention this is not applicable. 4. Contact the physician and provide clinical data and information about the resident/patient condition Documented notification and physician response in the resident/patient medical record. Initiate any new physician orders. 2. The MDS dated [DATE] documented [DIAGNOSES REDACTED].#1. The same MDS documented the resident unable to complete a Brief Interview of Mental Status test, experienced hallucinations and delusions and required extensive assistance for completion of all activities of daily living. The care plan problem initiated 1/14/19 identified the resident has impaired cognitive function/dementia or impaired thought processes and directed staff to communicate with the resident/family/caregivers regarding resident capabilities and needs. The care plan problem initiated 1/14/19 documented the resident requested a do not resuscitate (DNR) order and directed staff to notify the family or resident condition changes. A Progress Notes Entry dated 9/22/19 documented the resident on follow-up for fall with no injury noted. No signs or symptoms of pain. Temperature 97.2 F, Pulse 70, Respirations 18, Blood Pressure 114/68. The next Progress Notes entry dated 9/24/19 at 2:38 PM documented the resident's temperature was 99.1 degrees F, with a moist cough and sleepy that day. The resident's lungs sounds were clear at that time and family was aware of resident condition. A Progress notes entry completed by the facility restorative aide dated 9/25/19 at 7:09 AM documented the resident's exercise program not completed on 9/24/19 as the resident did not feel well and would attempt it today as resident allows. The Emergency Department (ED) Provider Note dated 9/26/19 documented the resident admitted to the hospital for suspected lower respiratory infection. The Discharge Disposition documented the resident transferred back to the nursing facility on 9/28/19 with [DIAGNOSES REDACTED]. Review of the resident's record revealed no full or complete assessments with regard to the resident's condition or respiratory status. The facility abated the Immediate Jeopardy on 10/4/19 by implementing the following actions: 1. The Director of Nursing and/or RN designee educated all licensed nursing staff regarding the assessment requirements for change of condition, completing vital signs, oxygen therapy and obtaining orders, monitoring signs and symptoms of [MEDICAL CONDITION]/[DIAGNOSES REDACTED], assessments, physician notification, admission process, admission medication entry, timely medication administration, Alert Charting and accurate and timely documentation initiated 10/3/19. The education was given prior to nurses working their next shift. A Change of Condition Alert was added to the clinical whiteboard process to identify residents with change of condition requiring assessment and follow up. Initiated baseline assessments of residents that will be validated by the Director of Nursing or Designee in the morning clinical meeting going forward. 2. The facility put a plan in place to complete audits regarding regarding changes in condition to ensure assessments and vital signs were completed, the physician was notified in a timely manner, and follow-up charting was completed. They also audited the admission process for current residents that had been admitted within the last 30 days to ensure an admission assessment was completed, medication orders were entered and administered in a timely manner with physician verification, and verify new admission shift charting had been completed by the licensed according to guidelines. In addition, a baseline assessment was completed on each resident in the building. 3. The facility informed the Medical Director of this plan its findings. The facility Director of Nursing will complete audits for 7 days weekly for 3 weeks and monthly for 2 months to validate that staff continue to follow the facility's process for Change of Condition and Admission Process. Ongoing compliance will be validated through medical record review in the morning clinical meeting.

Based on clinical record review, policy review, and interviews with staff and physician, the facility failed to ensure one (1) of three (3 ) residents received services to maintain the highest physical wellbeing. Record review and staff interviews revealed the facility failed to complete adequate assessments of Resident #1's decline in condition and [MEDICAL CONDITION]. Record review revealed Resident #1 normally independent with ambulation (to and from bathroom and for meals); however staff interviews revealed a decline in the resident's urinary needs, decline in mobility and increased pain when standing and needing more assistance with activities of daily living. Record review revealed the resident sent to the emergency room per his/her family request and required hospitalization for his/her care. The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] listed [MEDICAL CONDITION], depression, weakness, difficulty walking and cognitive communication deficit among Resident #1's diagnoses. The MDS noted Resident #1 scored 5 out of 15 on the BIMS (brief interview for mental status), which indicated severe cognitive impairment. According to the MDS, PRN (as needed) pain medication had been prescribed for occasional pain Resident #1 rated as 7 on a scale of 1 to 10. The MDS noted that Resident #1 required the limited assistance of one person to transfer between surfaces, including to or from bed, chair, wheelchair or standing position. According to the MDS, Resident #1 also required the limited assistance of 1 person to walk in his/her room with a walker. The assessment noted he/she had not been considered steady, but could stabilize without staff assistance. The resident also required limited assistance of 1 person to get dressed. The MDS revealed Resident #1 required the supervision of one person for personal hygiene and toileting. The 7/14/16 revised care plan noted Resident #1's needs should be anticipated and met. The care plan also noted Resident #1 had an ADL (activities of daily living) self-care deficit related to stroke, dementia, fatigue and [MEDICAL CONDITIONS]. As a result, supervision should be provided PRN for increased confusion and agitation. The 7/28/16 revised care plan instructed staff to administer medication as ordered. The 12/6/16 care plan noted Resident #1's risk of unidentified pain related to arthritis. According to the care plan, the resident's normal activities should not be interrupted by pain. The care plan instructed staff to identify, record and treat the resident's existing conditions which may cause increased pain and/or discomfort. The care plan also instructed staff to monitor and document for probable cause of each pain episode and remove/limit the cause where possible. The care plan further instructed staff to monitor, record and report any non-verbal sign and/or symptom of pain; like changes in breathing, vocalizations, mood and/or behaviors, facial expressions or body postures. According to the care plan, staff should notify the physician if interventions are unsuccessful or if the current complaint exhibited a significant change from the resident's past experience of pain. The care plan noted that the nurse should be notified of any change in usual activity attendance. The Order Summary Report dated 2/28/17 documented one to two tablets of Tylenol 500 mg (milligram) should be taken by mouth every 6 hours as needed for complaints of pain. The May 2017 MAR (Medication Administration Record) documented that one to two tablets of Tylenol had been administered to Resident #1 on only two occasions between 5/1/17 and his/her discharge date of [DATE]. The MAR indicated [REDACTED]. A Progress Notes under a Health Status Note dated 5/3/17 identified TED hose (compression socks) had been ordered with directives to apply in the morning and removed at bedtime. A doctor's order/progress note dated 5/10/17 documented that Resident #1 had been seen for swelling ([MEDICAL CONDITION] in ankles), [MEDICAL CONDITION] and Alzheimer's dementia. The note also documented labs had been checked and new orders included [MEDICATION NAME] (water pill) 20 milligrams at noon every day, increased water consumption and to elevate the resident's legs in bed twice a day. The physician ordered staff to notify him if Resident #1 had not gotten better in 10 to 14 days. A Progress Notes under Health Status Note dated 5/14/17 by Staff A, LPN (licensed practical nurse) indicated Resident #1 had swelling to his/her right knee and 3+ [MEDICAL CONDITION] (numerical scale of 1+ to 4+ that describes impressions left on the resident's swollen skin after being pressed on (4+ being the worst)) on both feet. The resident's feet were up in the recliner with an ice pack applied to the knee. The resident exhibited some facial grimacing as the nurse applied lotion to his/her legs. A Progress Note under Health Status Note dated 5/15/17 by Staff B, RN (Registered Nurse) indicated that Resident #1's bilateral (both) lower extremity [MEDICAL CONDITION] continued at 3+ with right knee swelling. According to the document, the resident's pedal (foot) pulses were palpable (able to be felt), extremities were warm with capillary refill less than 3 seconds (color returned after the nurse stopped squeezing the toes). The resident continued on [MEDICATION NAME] 20 mg. An appointment had been made for Resident #1 to see the doctor on 5/16/17 at the family's request. A Progress Note under Health Status Note dated 5/15/17 by Staff C, LPN, revealed that with a doctor's order, Resident #1 went to the ER (emergency room ) for [MEDICAL CONDITION] at 3:15 p.m. per the family's request. Staff C also noted that he called the ER at 7:15 p.m. and received information that Resident #1 had been admitted to the hospital for [MEDICAL CONDITION]. The Patient Care Report dated 5/15/17 authored by the Ambulance Service noted they arrived at the facility on 5/15/17 at about 3:15 p.m. According to the paramedic's assessment, an IV had been started and IV pain medication had been administered for severe pain. The assessment revealed the resident had tenderness/pain in his/her pelvis, [MEDICAL CONDITION] and pain in his/her left hip, ankle and knee and right ankle. The resident also had lower left abdominal pain. The paramedic also noted family members informed him that Resident #1 had [MEDICAL CONDITIONS]. According to the paramedic, the resident's lower extremities had substantial [MEDICAL CONDITION] from the knees down, but no redness. Initially the resident denied pain when asked, but pointed to his/her left mid abdominal area when asked where he/she felt pain. The paramedic noted that family thought he/she might have fallen recently, but did not know for sure. The paramedic documented Resident #1 yelled out in severe pain when he moved his/her legs. The paramedic had not noticed any swelling or deformities to his/her legs. The paramedic documented he noticed dried dark urine on the back of the resident's t-shirt. He also said Resident #1's room had a strong urine smell to it. When they rolled the resident, they noticed a strong ammonia/urine smell and urine soaked clothes from the middle of Resident #1's back to the backs of his/her legs. The paramedic noted that Resident #1 yelled in pain when 6 people lifted him/her from the recliner to the cot. According to the paramedic, the resident's vital signs were WNL (within normal limits). He said Resident #1 had not tolerated the ride very well, so he administered another dose of IV pain medication just as they arrived at the ER. The ER note dated 5/15/17 at 4:27 p.m. and authored by the ER RN documented Resident #1 arrived with family accompaniment and complaints of [MEDICAL CONDITION] and leg pain. The Objective Statement noted the resident had transported by ambulance to the ER from the facility with increased lower leg [MEDICAL CONDITION] since yesterday. According to the report, nursing home staff stated Resident #1 started [MEDICATION NAME] 20 mg on 5/11/17 without improvement. The RN also documented 3+ to 4+ [MEDICAL CONDITION] to feet and 1+ to 2+ to both lower legs which are painful to touch. The RN also noted Resident #1 smelled of urine and his/her clothes were soiled with wet and dry urine. According to the RN, family members indicated the resident had been in his/her recliner since Saturday. Finally, the doctor instructed the report should be faxed to Resident #1's PCP (primary care physician). The ER Provider Note dated 5/15/17 at 4:22 p.m. and authored by the ER physician noted Resident #1 complained of [MEDICAL CONDITION] and leg pain. According to the physician the resident's presenting symptoms were abdominal distention, constipation, nausea and urinary incontinence with pain rated 9 out 10. The Objective Statement noted that Resident #1 had been transported to the ER with severe left leg pain, bilateral leg swelling and abdominal distention. According to the report, Resident #1 had been assessed as positive for 3+ [MEDICAL CONDITION] and joint pain/swelling. The Doctor's Physical Exam noted the resident as well appearing, well nourished, awake, alert/oriented to person, place, time/situation and not in apparent distress. According to the abdominal exam, his/her abdomen was firm, distended and positive for guarding. The physician noted hypoactive bowel sounds in all four quadrants. The exam also included that Resident #1's skin had been assessed as a normal color, warm, dry, intact and no evidence of trauma. Indications for left hip X-rays were documented as hip pain with no known trauma. The results were noted as mild [MEDICAL CONDITION] changes of the left hip and a possible minimally displaced [MEDICATION NAME] aspect of the greater trochanter (thigh bone). The report listed [DIAGNOSES REDACTED]. (Anasarca is defined as extreme generalized [MEDICAL CONDITION], is a medical condition characterized by widespread swelling of the skin due to effusion of fluid. ) The resident's disposition was stable as being admitted to the medical surgical floor of the hospital. The Hospital Admission Note dated 5/15/17 at 9:29 p.m. and authored by the RN indicated Resident #1 had been admitted from the ER for a UTI (urinary tract infection). According to the document, the last time Resident #1 had been known to be well was 5/13/17. The document noted that due to the resident's current level of function he/she required assistive equipment and person for ambulation, bathing, dressing, toileting and transferring. The RN noted that Resident #1 had been walking independently until last weekend when he/she had a change in functional level. The RN documented that the resident complained of acute pain/discomfort. A list of Current/Past Medical History included Alzheimer's, stroke, [MEDICAL CONDITION] ([MEDICAL CONDITION], distended colon, arthritis and an occasional episode of urinary incontinence. The report noted that no pressure ulcers had been observed during admission. An interview on 6/28/17 at 9:30 a.m. with Resident #1's Primary Care Physician (PCP) stated he had not received the ER report as the ER physician had instructed. According to the PCP, his records indicated he visited Resident #1 on 5/10/17 for [MEDICAL CONDITION] secondary to inactivity among other things. The PCP also said Resident #1 had arthritic knees, swelling in bilateral lower extremities with slight discomfort, but no acute distress when he visited the resident. The PCP accessed a death certificate on the computer and stated cardio [MEDICAL CONDITION] failure and [MEDICAL CONDITION] among the causes of death for Resident #1. Further discussion indicated that he had never observed Resident #1 being unclean during any of his visits. An interview on 6/28/17 at 10:46 a.m. with the ER doctor revealed she saw Resident #1 on 5/15/17 at 4:22 p.m. for bilateral lower extremity [MEDICAL CONDITION], pain and abdominal distention. The doctor stated Resident #1 reeked of urine. When asked, the doctor stated if he/she couldn't have been kept any cleaner, he/she should have been sent sooner. The doctor also stated Resident #1 should have been sent to ER sooner based on his/her physical condition. An interview on 6/22/17 at 9:50 a.m. with the Interim Administrator/DON revealed they sent Resident #1 to the ER for [MEDICAL CONDITION]. She said his/her family sent the resident somewhere else so they do not have summary of discharge. According to the DON, Resident #1's family member came to the facility and alleged Resident #1 had been left in pee pants for 3 days. According to the DON, the family member's accusations were false; they did not leave him in pee pants for 3 days. An interview on 6/26/17 at 10:30 a.m. with Staff C revealed he had just started his 2:00 p.m. to 10:00 p.m. shift on 5/15/17 when Resident #1's family approached him and said they wanted something done about the resident's swollen legs. Staff C said he had been off work over the weekend. According to Staff C, Resident #1 had a doctor's appointment in the next day or two. The LPN said evidently other nurses weren't doing much because it was just [MEDICAL CONDITION] and the resident had an appointment. According to the LPN, the DON said Resident #1 should not be sent out because he/she had an appointment to be seen for [MEDICAL CONDITION]. Staff C said the facility had a new corporate protocol in which staff should contact the DON and talk about exhausting everything they could do for residents within the facility before sending them out. The LPN said he told the family about the appointment and if they wanted to contact the doctor to have Resident #1 sent to ER she could, which she did. The LPN said he spoke to the doctor's nurse who gave him the telephone order. According to Staff C, he and a couple other staff assisted 3 EMS workers to lift Resident #1 from the recliner to the gurney once they arrived. When asked what his assessment of Resident #1 revealed, Staff C said Staff B had been an extra nurse that day and she completed the assessment and entered it into the computer. Staff C said he could smell urine, but nothing that would have indicated he had been sitting in it for too long. Staff C said once they lifted the resident the stench was awful. The family complained of the resident sitting in the recliner for days and being soaked in urine. Staff C said the resident had expressed so much pain when they lifted him/her he did not say the resident should be cleaned up before being transported. Staff C said he questioned Staff G after the fact who said she knew the resident had [MEDICAL CONDITION]. According to Staff C, Staff G reported the resident would not have been able to walk without assistance that day. On 6/26/17 at 11:00 a.m. with Staff G, RN revealed she worked 5/15/17. Staff G said another nurse had assessed Resident #1. She recalled family members were adamant about Resident #1 being sent to the ER. According to Staff G, she agreed because the resident was not in good shape. Staff G said if she remembered right, the resident's abdomen had been slightly distended (bloated), their vital signs were not WNL (within normal limits), he/she had an elevated temp and complained of not feeling good. The RN recalled Resident #1's family saying he/she had not been acting like him/herself. Staff G said she had been in charge of the hall where Resident #1 resided that day, but the extra nurse dealt with it because the situation required so much attention. Staff thought the family had been there since about 10:00 a.m. or 11:00 a.m. An interview on 6/26/17 at 11:30 a.m. with Staff B, revealed that she remembered 5/15/17 when Resident #1's family member wanted the resident to been seen by the doctor for swelling of an arthritic knee and [MEDICAL CONDITION] in both of his/her lower legs, despite just having been seen by the doctor the week before. According to Staff B, the family member seemed a little upset, she contacted the clinic at the family member's request and informed them as she left the building. The RN did not have a scheduled time and date of appointment yet, but she contacted the family member again and relayed that information when she received it. The RN said she had not heard from the resident's family until Resident #1's son/daughter and another family member arrived at the facility at some time about shift change. Staff B said she heard some commotion and overheard the family telling another nurse they were going to call the ambulance themselves. Staff B said she assessed Resident #1 at 1:06 p.m. According to the RN, the family had not been there during the assessment and she did not smell urine or notice Resident #1 being wet at that time. Staff B also said there had been no discussion about Resident #1 being wet or smelling like urine earlier. Staff B said she had been Resident #1's nurse over the weekend and realized he/she had [MEDICAL CONDITION]. The RN said he/she had developed [MEDICAL CONDITION] the week before and had [MEDICATION NAME] prescribed. According to Staff B Resident #1 remained independent over the weekend before being sent to ER, but she had not asked him/her to get up. The RN said the resident had not reported any pain until Sunday. According to Staff B, a family member informed her Resident #1 had swelling and pain, at which time an ice pack and bio freeze (topical pain reliever) had been applied by her and the on-coming nurse. Staff B said she did not recall Resident #1 having a foul odor or wet clothes on either Sunday or Monday. According to Staff B, she could not recall if the resident wore different clothes over the weekend, but did recall he/she never appeared to be extremely unkempt or disheveled. An interview on 6/26/17 at 12:45 p.m. with Staff D, CNA, revealed that she worked 2:00 p.m. to 10:00 p.m. on Saturday 5/13/17, Sunday 5/14/17 and Monday 5/15/17. According to the CNA, Resident #1 had been feeling icky for a few days prior to being sent toER on [DATE]. Staff D said she told the nurse (Staff A) on Saturday 5/13/17. Staff D also said the day shift told her Resident #1 had not gotten up for breakfast or lunch and had not gotten up much during the day. Staff D told them she would check on Resident #1. According to Staff D, when she and a coworker physically attempted to get the resident up, he/she would not stand. The CNA said Resident #1 had not complained of pain, so they had a room tray sent. Staff D said the resident historically had been independent with toileting, and the daytime CNAs had not said anything had changed. The CNA said she asked Resident #1 and he/she seemed confused. She said she checked the resident, but he had been dry. Staff D said she told the nurse she thought Resident #1 had been getting up independently because of being dry. According to Staff D, they went to get Resident #1 up for dinner, but he/she could not get up. Staff D said she thought that was weird because the resident had always been independent. She picked up his/her dinner tray and said Resident #1 declined when asked if he/she wanted to go to the bathroom. Staff D said she checked him/her again about a half an hour later and the resident had still been dry. She said he/she had not eaten or drank much from the dinner tray, so she thought that could account for why he/she remained dry. According to Staff D, she passed that onto the oncoming shift. When the CNA reported to work on Sunday, she noticed Resident #1 had on the same clothes he/she wore the day before, as he/she often did. Staff D said the resident had been independent and had always been good about picking out his/her own clothes and getting dressed by him/herself. The CNA also said the resident typically remained continent. She said the daytime staff told her at shift change that he/she had not been getting up much and they assumed he/she had been toileting independently. Staff D said she checked him/her shortly after 2:00 p.m. on her first rounds and discovered Resident #1 had been incontinent of urine. She said she got a new pad, brief and pants and cleaned him/her up by herself. According to Staff D, the resident complained of leg pain the whole time she helped him/her. The CNA said Resident #1 would not let her change his/her shirt. She said the shirt remained dry. The CNA said once she sat him/her back down, she pulled up his/her pant leg and went and got Staff A. Staff D said they put an ice pack and a blanket on the resident. Staff D said the resident had not eaten anything for dinner. She said Resident #1 remained dry and had not gotten up from the recliner for the remainder of the shift. Staff D said she passed that information onto the overnight shift during report. When the CNA reported to work on Monday 5/15/17, she went into Resident #1's room with the off-going CNA, Staff E. At that time they realized Resident #1 had been incontinent of urine again, which Staff E denied knowing. According to Staff D, Resident #1 seemed very confused, so she went and got the nurse, Staff C, who said let's try to get him/her cleaned up. Staff D said she, Staff E and Staff C started to put the recliner down and Resident #1 immediately screamed in pain. Staff D said the resident had the same pants on that she changed him/her into the day before. According to Staff D, Resident #1's family member came into the room about that time. Staff D said she excused herself so the family member could talk to the nurse According to Staff D, she told the family member Resident #1 smelled of urine and his/her clothes were wet. Staff D said the family member said not to move Resident #1 because of being in so much pain. The CNA said she, Staff C and another staff member they recruited helped the ambulance crew lift Resident #1 onto the gurney once they got there about 20 minutes later. Staff D said the ambulance crew started an IV and gave the resident some pain medication before being moved. According to Staff D, Resident #1's family member was very angry that his/her medical issues had not been addressed sooner. Staff D said Resident #1 had a history of [REDACTED]. Staff D said she reported to the nurse how she found the resident wet and it did not seem like the day shift had been helping the resident toilet. Staff D mentioned that once they laid the recliner back she noticed how it had been completely soaked; like a puddle. A subsequent interview on 6/26/17 at 1:45 p.m. with the DON revealed they had noted the change in Resident #1's status on the 24 hour report. She said Resident #1 had a history of [REDACTED]. An interview on 6/26/17 at 2:00 p.m. with Staff H, CNA revealed that she arrived at the facility about 1:45 p.m. on 5/15/17 and stated Resident #1 sat in the recliner and had been complaining of pain. Staff H said she heard the resident get mad because they were messing with him/her. According to the CNA, she had been off that weekend. She said she remembered the resident being fine the last time she worked. Staff H said she had been standing outside the resident's room when they transferred him/her onto the gurney According to her, when they loaded him onto the gurney she saw the resident had been wet. She said he/she had been wet enough that she thought he/she should have been changed before she got there. Staff H said she could only recall one time that she had to help Resident #1 into the bathroom since the end of February when she started at the facility. An interview on 6/26/17 at 2:30 p.m. with Staff A revealed that she worked with Resident #1 on the 2:00 p.m. to 10:00 p.m. shift over the weekend before he/she had been sent to theER on [DATE]. Staff A remembered getting report from Staff B on Sunday 5/14/17 at shift change. According to Staff A, Resident #1's family member wanted to talk to her. According to Staff A, they went into Resident #1's room and the family member asked her what she thought about her parent's knee. Staff A said she told her she had not finished getting report and had not worked with Resident #1 much before then. Staff A said she involved Staff B because she worked with Resident #1 that day. According to Staff A, Staff B told the resident's family member the doctor had recently prescribed [MEDICATION NAME]. Staff A said she and Staff B put ice on Resident #1's knee right then and there in the family member's presence. Staff A said she asked the resident's daughter what she wanted to do. According to Staff A, the resident's son/daughter indicated s/he agreed it would be sufficient to continue monitoring his/her parent's condition. When asked about Resident #1 staying in his/her room that night, Staff A stated Resident #1 frequently stayed in his/her room and sometimes did not go to the dining room for meals. According to Staff A, the CNAs were all aware that Resident #1 had been staying in his/her room and that his/her knee was being treated with ice packs. The LPN said Resident #1 historically had occasional episodes of incontinence and they would help him/her. Staff A said changes in a resident's status gets documented on the 24 hour report. An interview on 6/26/17 at 12:10 p.m. with Staff E, CNA (certified nursing assistant), revealed that she denied working the 6:00 a.m. to 2:00 p.m. shift on 5/15/17 prior to Resident #1 being sent to the ER. As the interview continued, Staff E recalled she did work that day, and said she knew Resident #1 had been having knee problems that day because someone told her. Though Staff E had been assigned to Resident #1's hall that day, she said about the only time they have to help him/her is when he/she has problems with his/her knee. Staff D said she did not help Resident #1 that day. An interview on 6/27/17 at 7:15 a.m. with the DON revealed that daily head to toe assessments are only done for skilled residents. According to the DON, weekly skin assessments are done on all other residents. The DON said Nurses are not expected to do a head to toe assessments on their shifts. The DON said they only chart by exception (only chart things that are not WNL (within normal limits)). When asked if the care plan should be changed to reflect changes in a resident's status, the DON said yes, when the need arose, even on weekends. The DON denied knowing that Resident #1 had occasional episodes of urinary incontinence. According to the DON, if Resident #1's condition changed, his/her care plan should have been revised to reflect those changes and address his/her needs. According to the DON, she did not believe staff communicated the changes that occurred that weekend very well. The DON said Resident #1 had been admitted to their facility with arthritic knee pain and that was normal for him/her. The DON agreed it was possible the resident's condition had gotten worse than they had ever seen before due to the progression of the disease. A subsequent interview on 6/27/17 at 8:40 a.m. with Staff E revealed that historically, Resident #1 had only been incontinent a couple of times to her knowledge. The CNA said she never had to help Resident #1 clean him/herself up after an episode of incontinence or assist him/her to the toilet. Staff E said the resident usually did all that by him/herself. Staff E denied being told anything about Resident #1's change in status or needing assistance. Staff E said she peeks in on residents that are independent. The CNA said Resident #1 ate meals in his/her room a lot. When asked how she would be able to tell if Resident #1 was having problems when she peeked in on him/her. Staff E said she usually checked on residents if she noticed they were not in the dining room at meal time, even those that did not usually eat in the dining room. Staff E said she asked Resident #1 if he wanted breakfast the morning of 5/15/17. According to Staff E, the resident wanted to eat in his/her room. The CNA said she did not remember what or how much the resident ate that day. When asked about Staff D's account of how she and Staff D found Resident #1 soaked in urine during shift change on 5/15/17, Staff E said she could not recall the incident. Staff E also said she could not recall Staff D's account of how Resident #1 screamed in pain as she, Staff D and Staff C began the attempt to clean the resident up about the time Resident #1's family member came to see him/her. An interview on 6/27/17 at 9:00 a.m. with Staff F, CNA, revealed that she worked with Resident #1 a lot because she always had good luck with him/her. Staff F said if she noticed Resident #1 had not been getting ready for meals, she made a point to prompt him/her. The CNA said the resident typically went to the dining room for meals as long as she made the effort to encourage him/her and walk with him/her instead of just saying he/she refused to go, like other staff do. Though she had not been assigned to Resident #1's hall that weekend. An interview on 6/27/17 at 9:15 a.m. with Staff K, CNA, revealed that although she worked 5/13/17 through 5/15/17, she did not recall working with Resident #1 during that time. Staff K said towards the end of his/her stay, he/she required a little more help getting dressed, going to the bathroom, getting up out of the recliner to stand and putting on his/her socks and shoes. Staff K said she knew she had not worked with him/her at all on the Monday he/she got sent out. She remembered coaxing him/her to go to the dining room, but he/she did not. According to Staff K, staying in his/her room to eat would not have been considered unusual. Staff K also remembered having to help Resident #1 get up to go to the bathroom. According to the CNA, she very well could have done that on both Saturday and Sunday. Staff K said she did not remember if the resident had been incontinent, but she could say with certainty that he/she had gotten up to go the bathroom on both Saturday and Sunday. The CNA said she did not remember Resident #1's family visiting over the weekend. Staff K said the resident had been more independent, but over the last couple weeks she noticed he/she needed more help. According to the CNA, he/she had not been one to use his/her call light, but would summon a staff person walking by if he/she needed something. Staff K said she had not really heard that Resident #1 had been having more trouble than usual in report for those couple weeks preceding the resident's discharge. An interview on 6/27/17 at 10:00 a.m. with Staff I, CNA revealed she knew Resident #1 had been sleeping a lot and had also been hard to arouse to for him/her to eat. Staff I thought she had been told the resident had a UTI, but could not remember for sure. The CNA said Resident #1 had been relatively independent, but thought therapy had been working with him/her because of having more pain in his/her legs. Staff I said she had been noticing that Resident #1 needed more help with everything. According to the CNA, Resident #1 had not been taking him/herself to the bathroom and needed more help the weekend before being sent out to the ER. The CNA said as she recalled, they just stood him/her up and changed him/her after having been incontinent. Staff I said she could not remember if she told the charge nurse or not. She also said she did not think she had been hearing anything about Resident #1's change in condition during report. According to Staff I, she did not remember hearing that he/she required more attention for toileting or checking and changing him/her. An interview on 6/26/17 at 12:25 p.m. with Staff J, CNA revealed that although she worked the day shift on 5/15/17, she did not remember helping Resident #1 with anything in particular. A subsequent interview on 6/27/17 at 2:40 p.m. with Staff D revealed that she could not account for why she documented Resident #1 had been continent the weekend before he/she had been sent to the ER. Staff D wondered if she had gotten so accustomed to charting that Resident #1 remained continent that she inadvertently documented that when in fact he/she had definitely been incontinent as she previously told this surveyor. Staff D said while she assisted Resident #1, she had not noticed any bruising or did not have any knowledge if he/she had fallen. The CNA stated that she got him/her to stand up for about 5 minutes on Sunday 5/14/17 while she got his/her pants and brief changed. She recalled the resident being confused and she could tell it hurt him/her to stand. Staff D said

Based on observation, record review, family and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from physical or environmental hazards to themselves (Resident #1). The wander guard alarm did not always sound when residents left the building but would alarm upon return into the building. The facility identified 10 residents who wore wander guard devices (to alert staff if resident left through an alarmed wander guard door) and the facility reported a census of 51 residents. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 8/9/16. Resident #1 had [DIAGNOSES REDACTED]. The resident scored a 4 on a BIMS (Brief Interview for Mental Status) evaluation which identified severe cognitive impairment. The MDS indicated Resident #1 required extensive assistance of 1-2 staff for transfer, ambulation, and hygiene and utilized a walker or wheelchair for mobility. The MDS Balance During Transitions and Walking assessment indicated the resident unsteady, only able to stabilize with staff assistance when moved from seated to standing position, walking with assistive device, moving on and off the toilet, and surface to surface transfer. The MDS indicated the resident had 2 or more falls since the prior assessment. A Wandering and at Risk for Elopement assessment identified Resident #1 as a high risk for wandering. The assessment indicated Resident #1 had known exit seeking/history of exit seeking and expresses a desire to leave. The Care Plan dated 8/8/16 identified a problem of elopement risk/wanderer as evidenced by disoriented to place and time with interventions which included; distract the resident from wandering by offering pleasant diversions, food, conversation, identify pattern of wandering, monitor resident frequently, document wandering behavior and attempted diversion interventions, check wander guard is on and functioning every shift. Review of the clinical record indicated on 9/11/16, staff observed Resident #1 in the parking lot unattended by facility staff. Staff interviews as follows: On 9/14/16 at 10:59 a.m. Staff A, LPN, stated Resident #1 has a wanderguard, a device worn by the resident that will alarm to notify staff when near the wanderguard alarm system. Resident #1 wanders and informs staff he/she is going home. Usually the alarm sounds and staff respond and redirect the resident. On the 9/11/16 day shift, Resident #1 informed his/her friend the he/she was going home. Staff A was uncertain if the resident was able to recall directions home due to a traumatic brain injury. Staff A stated on 9/11/16 at approximately 3:20 - 3:25 p.m. Staff A observed Resident #1 sleeping in his/her room. Staff A stated on 9/11/16 at approximately 4:00 p.m. Staff C, certified nursing assistant (CNA), notified her that Staff D found Resident #1 walking in the parking lot unattended by staff. Staff A did not hear an alarm sound and unaware Resident #1 exited the facility. Staff A stated nursing staff are to check wanderguards every shift to ensure proper function, however, she does not always check them (wander guard) because it is time consuming. Staff A stated she ' s aware the wander guard alarm did not always sound when residents were identified as elopement risk. Staff A stated the resident would wear a wanderguard for safety exit the facility, however there is a 30 second window when all alarms are disabled after a black button is pushed. (Staff and visitors are required to push a black button prior to entering or exiting the building to disable the alarm). On 9/14/16 at 3:22 p.m. Staff C, CNA, stated on 9/11/16 at approximately 3:15 p.m. - 3:30 p.m. she observed Resident #1 resting in his/her room. Staff C stated as she walked with a resident down the hall, she heard a quiet alarm. Staff C stated she assisted the resident to their room and then returned to Resident #1's room. Staff C stated she observed Resident #1 not in his/her room or bathroom. Staff C stated she observed the resident ' s personal alarm placed between the pillows in an attempt to quiet the alarm. Staff C stated the resident ' s pretty good about parking the alarm between pillows. She recalled once the resident cut the alarm cord with nail clippers. Staff C stated that Staff A went to the front of the building to look for the resident. As she approached the nurse ' s station, Staff D entered the facility with Resident #1. Staff C stated Resident #1 had a wander guard device on, which should trigger the wander guard alarm to sound, however, at times the wanderguard alarm does not sound as residents with the device exit the facility. On 9/14/16 at 5:25 p.m. Staff D, CNA, stated on 9/11/16 at approximately 3:45 p.m. she returned from break. As she approached the front nurse ' s station, she looked out the window and observed Resident #1 walking in the parking lot with a walker. Staff D stated she did not hear alarms sounding prior to observing the resident in the parking lot. Staff D stated she knew Resident #1 had a personal alarm that should sound if he/she doesn't bury or hide the personal alarm. Staff D stated she observed Resident #1 on the edge of the east side of the parking lot. Resident #1's friend approached the resident at the same time. Resident #1 informed the friend he/she was going home. The resident's friend redirected him/her and they returned inside the facility. Upon reentry to the facility, the wanderguard alarm sounded.Staff D was aware the wanderguard alarm did not always sound when residents wore a wanderguard device and exited the facility, however, does sound when they return inside. On 9/14/16 at 2:37 p.m. Staff B, volunteer, stated on 9/11/16 she left the facility at approximately 3:45 - 4:00 p.m. and observed a resident rapidly walking in the parking lot towards the street. As she began to exit her vehicle to approach the resident, a staff member exited the facility and approached Resident #1. The volunteer was not sure she heard an alarm, however, was aware that prior to exiting the facility, visitors must push a black button so alarms don't sound. On 9/14/16 at 11:38 a.m. Staff F, registered nurse (RN), stated on 9/11/16 she was sitting at the front nurse ' s station and observed Staff D enter the facility with Resident #1. She did not hear an alarm sound prior to this, and had not observed anyone at the nurse ' s station to turn the alarm off. Staff F stated Resident #1 wore a wander guard device to alert staff to exit seeking attempts. Staff F stated she noticed the wander guard system does not always sound when residents wore a wander guard and exited the facility, however, does sound upon return inside. Staff F stated 2 housekeepers reported the wander guard door alarm did not sound when they assisted residents that smoke outside the facility approximately 2 weeks ago (8/31/16). On 9/14/16 at 1:24 p.m. Staff E, housekeeping, stated when she assisted residents outside to smoke, one resident's wander guard bracelet did not always trigger to sound and alert staff. Staff E stated she reported this to the charge nurse, who stated she would notify the maintenance staff. Staff E could not recall the date. On 9/14/156 at 7:00 p.m. Staff H, CNA, stated on 9/11/16, she worked the day shift before Resident #1 exited the facility. Staff H stated she did not hear an alarm sound prior to Resident #1's exit. She did not observe Resident #1 prior to exiting the facility. On 9/15/16 at 10:17 a.m. Staff I, CNA, stated the door alarm will sound if activated by a wander guard device. Staff I stated the wander guard alarm sounds to alert staff if the black button is pushed. Staff I was aware Resident #1 definitely wanted to go home that day. On 9/15/16 at 2:03 p.m. Staff J, CNA, stated Resident #1 always wants to go home or make phone calls. On 9/14/16 at 9:04 a.m. the Administrator and Assistant Director of Nursing (ADON) stated on 9/11/16 Staff A notified the Director of Nursing (DON) Resident #1 was found in the parking lot. A head to toe assessment was completed and revealed Resident #1 did not sustain an injury. During the Administrator and ADON's investigation, they determined the wander guard system did not always sound appropriately when a wander guard device passes through the wanderguard alarm. They notified the alarm company for repair and placed a staff person at the front door for 24 hours per day until the alarm system functioned. On 9/14/16 at 8:45 a.m. observation identified the door alarm sound after opened. A red light flashed on the door alarm bar behind the front nurse ' s station as the door alarm sounded. Staff A, licensed practical nurse (LPN) stood near the medication cart in the front east hall near the nurse ' s station. Staff A did not respond to the door alarm, and did not deactivate the sounding alarm. At 8:47 a.m. the payroll staff approached the surveyor and asked if had recently entered the facility. The payroll staff did not look out the door prior to deactivating the sounding alarm. Observation of the parking lot on 9/14/16 at 12:43 p.m. identified 2 rows of cars parked in front of the building. The parking lot was approximately 1 inch lower than the sidewalk on the north side of the facility. The surface of the parking lot had uneven areas. Approximately 50 yards north of the facility observation identified a busy east/west street with a speed limit of 25 miles per hour. There was no fence between the city street and facility. The street connected Highway 59 and the hospital. Further observation identified Highway 59, a busy 4 lane highway, approximately 2 blocks west of the facility. Note: At the time of the complaint investigation, the complaint was coded at a K immediate and serious jeopardy. By 9/14/16, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the E level. The facility had the alarm system repaired and a system put into place for the Maintance department to perform daily checks of the door alarms. The Administrator provided in-service training for procedures when an alarm sounds. The in-service training was provided to nursing, dietary and maintenance personnel. As of the 9/16/16 exit conference, the facility continued to need to: · Continue to provide in-service training to all employees regarding procedures when the door alarms sound. · Continue to monitor staff to assure compliance with the facility policy/procedure for elopements. · Continue to monitor the checking of door alarms and wander guard devices.

Based on record review, staff and physician interviews and review of the facility policy/procedures, the facility failed to adequately monitor the use of [MEDICATION NAME] and ensure the resident did not receive the [MEDICATION NAME] medication when the laboratory test (INR) was not in therapeutic levels for one of 8 residents reviewed. The facility reported a census of 54 residents. Findings include: 1. Resident #5 had a Minimum Data Set (MDS) assessment tool with a reference date of 2/16/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had short and long term memory problems and moderately impaired for daily decision skill. The Care Plan, updated on 9/18/15 identified a focus area for the use of [MEDICATION NAME] due to [MEDICAL CONDITION]-stroke. The Care plan directed and included interventions as: staff to administer medications as ordered, draw laboratory tests as ordered and report to the physician for review. The facility ' s Clinical Programs Manual for Medication Management dated 05/2014 and Anticoagulant Management 3F-9.0 identified the Director of Nursing and Medical Director as responsible for the oversight and management of anticoagulant therapy administration in the facility to ensure safe and effective practices for monitoring and administering therapy. The Clinical Programs Manual for Documentation, dated 05/2014, Form Completion Directions 3F-9.1 Anticoagulant Flow Sheet, purpose is to assist staff in the ongoing monitoring of anticoagulant therapy and licensed nurses are responsible to complete the instruction are as follows; 1. Enter resident/patient name, physician, and room number on the top of the form. 2. Enter the supporting [DIAGNOSES REDACTED]. 3. Enter the desired PT/INR ([MEDICATION NAME] time/International Normalized Range) range. 4. Enter date. 5. Enter the PT/INR result. 6. Enter the anticoagulant name and dosage. 7. Enter the date next lab is ordered. 8. Enter name of physician notified the date and time. 9. Identify if there is any change in physician order. 10. Place in front of the Medication Administration Record [REDACTED]. 11. Forms are to be files in the resident/patient ' s medical record. The anticoagulant flow sheet for Resident #5 lacked supporting [DIAGNOSES REDACTED]. The facility ' s documentation form titled, 5 Minute Meeting, dated 2/29/16, and presented by the Director of Nursing (DON). The DON relayed to staff to please make sure you (the nurses) are reviewing the INR books at the very beginning of every shift, and should not administer [MEDICATION NAME] without knowing the recent INR. Five nurses attended the meeting. The Quality Assurance Process Improvement (QAPI) committee meeting minutes dated 3/11/16, indicated the Medical Director had concerns with [MEDICATION NAME] for Resident #5. The DON clarified the resident ' s missing doses had been due to lack of the medication. The hospital document titled Clinical Summary Final Report dated 1/15/16 indicated the physician discharged the resident from the hospital on [DATE]. The Final Report reflected medications and included and order for [MEDICATION NAME] (generic [MEDICATION NAME]) 4 mg tablet, 2 tablets daily and [MEDICATION NAME] 1 mg tablet on Monday, Wednesday and Friday. The Medication Administration Record [REDACTED]. A phone order dated 2/9/16 at 4:44 p.m. from the physician directed the staff to obtain an INR today and one time a day for [MEDICATION NAME] use until 2/10/16. The INR registered at 1.1 and the physician ordered [MEDICATION NAME] 12 milligrams every day and check INR daily. The nurse ' s Progress Notes dated 2/9/16 at 5:10 p.m. identified the nurse received an order from the physician and to check INR now. The note indicated the INR to be 1.1 and received orders for [MEDICATION NAME] 9 milligrams every day, starting now. The nurse did not note the phone order until 2/13/16. A physician phone orders (Duplicate) dated 2/9/16 at 5:12 p.m. identified the order for the administration of [MEDICATION NAME] 9 mg by mouth one time day (instead of the 12 milligrams). The February MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 2/13, 2/14 and 2/15, the MAR indicated [REDACTED] The Nurse ' s Notes dated 2/10/16 at 11:45 a.m. identified the resident was transferred by ambulance to the hospital. The resident had a Temperature of 102.6 (normal 98.6) pulse 76 (normal 60-100), respirations 18 (normal 16-20) and had bilateral diminished lung sounds. The hospital notified the facility that the resident had a urinary tract infection. The hospital Patient Discharge Instructions sheet dated 2/16/16, ordered [MEDICATION NAME] 4 mg tablet 2 tablets daily. The nurse noted the orders on 2/17/16. The February MAR indicated [REDACTED]. The [MEDICATION NAME]/INR and [MEDICATION NAME] log form dated 2/19/16 identified the INR to be 4.4 and the current [MEDICATION NAME] order to be 12 mg every day. The PCP directed staff to draw a new INR on 2/23/16 and to hold [MEDICATION NAME] for 1 day then give [MEDICATION NAME] 9 mg every day. An entry in the nurse ' s Progress Notes dated 2/25/16 at 3:15 p.m. indicated the resident ' s INR was obtained and 4.7. The nurse sent the results to the physician and awaiting a response. The MAR for February identified the nurse administered [MEDICATION NAME] 9 mg every day but held on 2/19 and given 2/20, 2/21, 2/22, 2/23, 2/24, 2/25, and 2/26. The MAR indicated [REDACTED]. The nurse ' s Progress Notes dated 2/26/16 at 11:04 a.m. indicated the nurse called the nurse at the hospital and reported the INR results of 2/15/16. The hospital nurse replied she would give the physician the information. The nurse ' s Progress Notes dated 2/27/16 at 11:31 a.m. indicated the nurse called the on call physician in the emergency room . The nurse received a physician ' s order to recheck the INR at this time and call with results. The results of the INR were 6.2. The nurse received a physician ' s order to hold the [MEDICATION NAME] till the INR below 3.5 and to check INR each day and inform the primary care physician. The nurse removed the [MEDICATION NAME] from the medication cart. The note also identified the resident had some bright red bleeding this a.m. The resident had approximately three 4 by 4 gauze squares mostly covered with blood. The nurse applied pressure to the area and no further bleeding occurred. The on call physician stated to call immediately if bleeding restarts and nurse as unable to stop the bleeding. The nurse ' s Progress Notes dated 2/27/16 at 9:36 p.m. identified the dressing around the [DEVICE] site with small amount of serosanguinous (a discharge thin and red) drainage noted and the dressing had been changed. The [MEDICATION NAME]/INR and [MEDICATION NAME] log form dated 2/28/16 identified the INR as 3.2 and current [MEDICATION NAME] dose as 8 mg Monday, Wednesday and Friday with 9 mg all other days and to check the INR in 1 week. The lab data anticoagulation form dated 2/29/16 identified the target range to be 2.0 - 3.5. The INR result of 3.3 with current dose of 9 mg daily. The physician changed the order to 9 mg Monday, Wednesday and Friday with 8 mg all other days and to check the INR in 1 week. The March MAR indicated [REDACTED]. The March MAR indicated [REDACTED]. The nurse ' s Progress Notes dated 3/2/16(Wednesday) at 8:30 p.m. identified a call placed to the physician regarding the evening dose of [MEDICATION NAME]. The nurse received a new order to hold the dose until tomorrow, and then give today ' s dose and tomorrow ' s dose as well. No need to redraw INR until scheduled. The nurse ' s Progress Notes dated 3/2/16 at 8:30 p.m. indicated when the nurse went to administer the resident ' s [MEDICATION NAME] 8 mg tablet; she did not have the medication. The nurse placed a call to the physician and the nurse explained she still did not have the medication to administer. The physician directed the nurse to discontinue the current [MEDICATION NAME] order and administer 15 milligrams of [MEDICATION NAME] out of the E-Kit (Emergency Kit). The physician ordered the nurse to recheck the INR in the early a.m. and fax the results to the clinic for further administration instructions so the pharmacy could be notified in a timely manner. A telephone order dated 3/3/16 at 8:39 p.m. directed the nurse to administer [MEDICATION NAME] 15 mg one time. The March MAR indicated [REDACTED] The nurse ' s Progress Notes dated 3/4/16 at 8:24 p.m. Indicated an INR of 1.2. The nurse received orders to administer [MEDICATION NAME] 15 milligrams today and tomorrow and then [MEDICATION NAME] 9 milligrams every day. [MEDICATION NAME] (injectable anticoagulant) subcutaneous today and recheck INR on 3/7/16. The March MAR indicated [REDACTED]. The nurse ' s Progress Notes dated 3/7/16 at 10:41 a.m. indicated the INR as 6.3. The nurse notified the PCP. The nurse ' s Progress Notes dated 3/7/16 at 11:09 a.m. indicated the nurse received a physician ' s order to hold the [MEDICATION NAME] today and recheck INR tomorrow. The Nurse ' s Notes dated 3/8/16 at 6:26 a.m. (noted as late entry). The resident ' s INR checked and registered 6.8. The nurse faxed the physician ' s office with the results and awaiting response. The nurse ' s Progress Notes dated 3/8/16 at 3:42 p.m. received a fax from the physician to hold the [MEDICATION NAME] today and recheck INR on 3/9/16 and call results. The [MEDICATION NAME] log form dated 3/9/16 identified the INR as 4.8 and the physician directed the staff to hold the [MEDICATION NAME] and recheck again on 3/10/16. The nurse ' s Progress Notes dated 3/10/16 at 5:45 p.m. Identified the resident ' s INR as 3.3. The nurse received new orders to administer [MEDICATION NAME] 9 milligrams today and recheck INR on 3/11. The nurse ' s Progress Notes dated 3/11/16 at 4:04 p.m. identified the resident ' s INR as 2.0. The nurse received orders to administer [MEDICATION NAME] 9 mg Monday, Wednesday and Friday and [MEDICATION NAME] 8 mg the other 4 days. The orders directed the INR to be rechecked on 3/14. The March MAR indicated [REDACTED]. The nurse ' s Progress Notes dated 3/14/16 at 7:13 p.m. identified the INR 2.6 and no change in [MEDICATION NAME] dose and to recheck the INR on 3/17/16. The nurse ' s Progress Notes dated 3/16/16 at 9:30 a.m. identified the INR as 4.0 and the nurse sent a fax to the physician. The nurse ' s Progress Notes dated 3/16/16 at 11:20 indicated the nurse received new order to hold [MEDICATION NAME] and recheck INR 3/17/17. On 3/17/16 at 1:30 p.m. Staff C (Licensed Practical Nurse) was interviewed and explained the facility ' s process when a resident returns from the hospital or a new admission. Staff C explained she would check the orders, then another nurse would double check the orders and the DON would do a final check. Staff C acknowledged she checked the orders for Resident #5 in January and February when the resident returned from the hospital. On 3/17/16 at 11:51 a.m. the former DON (Director of Nursing) was interviewed and acknowledged she worked at the facility until 2/10/16. The DON stated she could not be sure who dropped the ball on the [MEDICATION NAME] order and the resident did not receive [MEDICATION NAME] for about 1 month until a nurse wondered why the resident did not receive the [MEDICATION NAME]. On 3/21/16 at 1:01 p.m., Staff D, (registered nurse) was interviewed and stated Resident #5 had bleeding around the [DEVICE] site. Staff D stated the [DEVICE] had been intact. She acknowledged she called the PCP on call and received new orders. On 3/21/16 at 7:04 p.m. Staff E (licensed practical nurse) was interviewed and stated the resident ' s bleeding from the [DEVICE] site was passed on (to next nurse) in report. Staff E stated anytime a resident would have a high INR, they would check the resident closely for bleeding. Staff E acknowledged the resident did have some bleeding around the [DEVICE] site. She felt it had been enough the dressing needed to be changed. On 3/21/16 at 1:30 p.m. Staff F, (licensed practical nurse) was interviewed and stated she had passed the information on in report about the bleeding around the [DEVICE] site. Staff F stated she did not observe any bleeding. On 3/17/16 at 10:40 a.m. the physician was interviewed and stated there have been a lot of problems with the [MEDICATION NAME] orders for Resident #5. The physician stated the facility gave the resident [MEDICATION NAME] with a high INR. The physician stated he would have wanted them to hold the [MEDICATION NAME] if above 3.5 to 4.0 or more and call him. On 3/21/16 at 4:08 p.m. the physician was interviewed and stated he did not think Resident #5 had [MEDICATION NAME] effects from giving the [MEDICATION NAME] with a high INR test. The physician stated the facility had a problem with a few nurses not knowing when to hold [MEDICATION NAME] with high INR results and I would expect the nurse to call anytime with high INR results before giving the [MEDICATION NAME]. .

Based on record review, observation and staff interviews, the facility failed to provide timely assessment and interventions for residents with an onset of adverse symptoms which represented a change in physical condition for 4 of 11 residents reviewed (Resident #1, #8, #9, #19. The facility identified a census of 60 residents. Findings include: 1. Resident #9 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 9/15/15. The MDS reflected the resident had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility, transfers and toilet use. According to the MDS the resident not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking and surface-to surface transfer. They MDS identified the resident had impairment on 1 side of the lower extremity and required the use of walker and wheelchair. The Care Plan dated 9/23/15 directed the staff to provide extensive assistance of 1 staff for transfers and ambulation. Provide cues to the resident to reach back for the chair. The interventions further directed the staff that if the resident resistive or refusing to stand, then to try again later. The interventions directed staff to re-approach, and if the resident resists standing, then may use sit/stand lift for transfer. Review of the Hospital Radiology Report dated 11/14/15 identified the resident with a slight comminuted and mildly displaced intertrochanteric [MEDICAL CONDITION] right femur (hip). Review of the Document identified #378 dated 11/14/15 at 10:13 AM indicated the nurse was called into the resident ' s room. The resident laid in bed with the right leg bent at the knee and rotated outward. The right thigh swollen and warm to the touch. Review of the Progress Notes dated 11/14/15 at 7:54 AM revealed the nurse called to the resident's room to look at his/her right leg. Leg swollen and warm to the touch. The resident had the leg bent at the knee and would not straighten the leg out. The resident yelling in pain when the leg moved or touched. The nurse called the physician and received an order to send to the emergency room for x-ray. The Progress Note lacked documentation of previous assessment of the resident's leg from 11/9/15 through 11/14/15. During an interview with Staff B, RN (Registered Nurse) on 11/19/15 at 11:20 AM she stated that she had been notified by staff that the resident's leg looked funny, swollen, warm and had pain. She went to the resident's room. The right leg swollen, warm to touch and bent outward. She tried to move the leg and the resident hollered out. Prior to that day she had seen the resident in passing but did not do an assessment on him/her. Staff B stated she had been notified by administration that staff had said the resident voiced pain in the foot during the week. Staff B stated on Saturday 11/14/15, the staff reported to her that the resident had been lowered to the floor on 11/9/15. During an interview with Staff F, CNA (Certified Nursing Assistant) on 11/19/15 at 2:30 PM she stated that she remembered on Wednesday she had worked with the resident and when moved he/she winced and would not walk. She stated that she reported it to Staff B, RN and she said OK. During an interview with Staff H, CNA on 12/2/15 at 2:40 PM she stated that she worked with the resident after 11/9/15. Staff H stated she gave the resident another shower and when she lifted the right foot, the resident said owe, owe. Staff H stated she told Staff B about it and that the resident looked like he/she had a [MEDICAL CONDITION]. Staff B took the resident's vital signs and left. Staff B stated the resident had been okay. The sit to stand lift was required because the resident did not want to walk or transfer. Staff H stated that Staff B informed her that the resident was okay (alright). Staff had to use the sit to stand lift because the resident did not want to walk or transfer. During an interview with Staff A, CNA on 12/2/15 at 2:30 PM she stated that she did not work with the resident again until Thursday 11/12/15. She could tell something not right and the resident's leg bent and laid outward. No one said anything happened to cause it. She told an evening nurse about it (not sure which one). She said the nurse lifted the pant leg and looked like a bit of swelling but said it looked ok (alright). During an interview with Staff J, CNA on 12/2/15 at 5:20 PM she stated that a staff member possibly Staff H, CNA (not sure who) asked her to look at the resident's foot for possible pain. She then stated that she turned over to the next nurse to look at due to the resident had ingrown toenails in the past and she assumed it had been that. 2. Resident #19 had a MDS with a reference date of 11/2/15 which reflected the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident required limited assistance with dressing and extensive assistance with toilet use. According to the MDS, the resident had an impairment on 1 side of the upper extremity. According to the MDS the resident required pain medications as needed. The Care Plan dated 11/5/15 revealed the resident had both acute and chronic pain related to arthritis and [MEDICAL CONDITION] joint disease. The Care Plan directed staff to anticipate the resident ' s need for pain relief and respond immediately to any complaint of pain. Review of the facsimile to the physician dated 9/22/15 revealed an order for [REDACTED]. The order also directed staff to cancel all other [MEDICATION NAME] orders. Review of the Pharmacy Sheet dated 11/9/15 revealed the order and delivery for [MEDICATION NAME] 10/325 mg every 4 hours as needed for pain. The Pharmacy Sheet dated 11/13/15 revealed the order and delivery for [MEDICATION NAME] 5/325 mg every 6 hours as needed for pain. Review of the MAR (Medication Administration Record) dated 11/1/15 through 11/31/15 revealed no pain medication administered from 11/6/15 through 11/12/15. Review of the Assessment of pain every shift on a scale of 1 to 10 revealed the following assessments: a. 11/6/15 rated at 5. b. 11/7/15 rated at 6. c. 11/8/15 rated at 5. d. 11/10/15 rated at 4. Review of the Progress Notes dated 11/11/15 at 10:38 AM revealed staff faxed a note to the physician's office informing her the pharmacy need a new script for the resident's [MEDICATION NAME]/APAP 5/325 mg. The Progress Notes failed to identify any further requests for the pain medication. During an interview with Staff B, RN on 12/3/15 at 10:40 AM she stated that the facility could not get the doctor to respond to facsimiles. The facsimiles are located in the chart or in a book if not filed yet. All telephone calls are documented in the nurse ' s notes. She further stated they could not get the pain medication for the resident. During an interview with the Pharmacy on 12/3/15 at 4:20 PM she stated that they had received the physician written prescription dated 11/9/15 for [MEDICATION NAME] 10/325 mg. Several calls were made on 11/9/15 between the facility and the physician's office. The physician's office stated the physician wanted the resident to have the [MEDICATION NAME] 10/325 mg. She further stated the pharmacy had not been aware the resident had not been receiving pain medication. They became aware after the resident's family member had questioned it. The pharmacy obtained the script from the physician and delivered the [MEDICATION NAME] 5/325 mg and removed the [MEDICATION NAME] 10/325 mg from the facility. During an interview with the Director of Nursing (DON) on 12/9/15 at 8:20 AM she stated that the mix up with the resident's medications occurred when the physician made rounds and signed the order on 9/22/15. The physician's office did not have a copy of that order since the fax did not need to be sent. She stated she had made several calls to the physician's office and pharmacy on 11/9/15 and she had not been involved after that. The DON stated she had not been aware the resident did not have any pain medication until the family member brought it to her attention. During an interview with the resident's family member on 12/10/15 at 8:25 AM identified she/he received a call from the resident on Thursday 11/12/15. The family member went to the facility on [DATE] at approximately 4:30 PM and the resident had been in tears and told him/her that had been without pain medication since earlier in the week. The resident had complained of shoulder pain. The family member went to nursing staff and found the facility had [MEDICATION NAME] 10 mg tablets but did not have 5 mg tablets and did not administer any of the medication. The DON had not been aware the resident had not received any medication and ensured that it had been delivered to the facility and administered that afternoon. 3. According to the MDS with a reference date of 8/25/15, Resident #8 had [DIAGNOSES REDACTED]. According to the MDS, the resident had a Brief Interview for Mental Status score of 15. A score of 15 identified the resident had no cognitive impairments. The MDS identified the resident required limited assistance with transfers and toilet use. According to the MDS the resident had a diabetic ulcer. The MDS identified the resident with an admission date of [DATE]. The Care Plan dated 6/26/15 directed staff to evaluate wound for: size, depth, margins: periwound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene. The Care Plan directed staff to document the progress in wound healing on an ongoing bases and to notify the physician as indicated. Review of the Admission Physician order [REDACTED]. a. Cleanse right Achilles and right lateral ankle with normal saline, pat dry, apply skin prep to periwound, apply alginate to wound bed, cover with gauze and secure with Kling, change on non-[MEDICAL TREATMENT] days daily. A document titled Doctor's Orders and Progress Notes dated 6/18/15 at 5:25 PM identified the Wound Clinic Nurse noted the following: a. Injury to right lateral ankle. Wound measures approximately 2.3 cm (centimeters) by 0.9 cm. Minimal serous sanguineous drainage noted. Wound bed non-granulating, 50 % yellow slough noted to wound bed. Peri wound skin intact. Noted 1-2 plus [MEDICAL CONDITION] to the bilateral lower extremities. Recommendations include: a. Normal saline irrigation, Aguacel AG to wound, [MEDICATION NAME], Kerlix, Coban to secure, change daily. b. Surgical consult appointment made with physician for 6/25/15 at 8:30 AM c. Monitor wound for signs/symptoms of infection. e. Elevate legs to help reduce swelling. f. Monitor nutrition and protein to promote wound healing. g. Monitor blood sugars to promote wound healing. h. Please contact wound clinic with any questions or concerns. The facility staff noted the orders on 6/18/15. The Doctor's Order and Progress Notes dated 7/2/15 at 11:50 AM reflected the following new orders: a. No whirlpool baths-may shower. b. Apply Santyl after wound rinsed with 0.25% Dankin's solution then saline. Cover wound with saline moistened gauze and change daily. c. Apply Aguacel AG with a few drops of saline to moistened it to the left Achilles area and change daily. d. [MEDICAL CONDITION] wear daily but off only at night. Review of the facility Admission Assessment (completed 5/28/15) identified the right outer ankle diabetic ulcer measured 2.3 cm (centimeters) by 1.8 cm. The right back ankle diabetic ulcer measured 1 cm by 1.2 cm. Review of the Weekly Skin assessment dated [DATE] at 2:06 PM identified the document not completed. Review of the Weekly Wound assessment dated [DATE] at 2:40 AM identified the right outer ankle as a Stage III. The assessment identified the wound as not measured and described with yellow (slough), serosanguinous drainage, intact surrounding skin and pain at site. Review of the Weekly Wound assessment dated [DATE] at 4:36 PM revealed the right outer ankle as Stage IV. The wound measured 3 cm by 2.5 cm with depth of 1.2 cm. The area tunneling with bone exposed, wound bed with moderated amount of slough with small necrotic area. The area with odor and yellow (slough) and serous drainage. The surrounding skin intact and pain at site. Review of the TAR (Treatment Administration Record) identified weekly wound measurements to be done every Thursday for wound monitoring completed on 6/4/15 and 6/11/15. The TAR did include documentation of wound treatment completed: Cleanse right Achilles and right lateral ankle with normal saline, pat dry, apply skin prep to peri wound, apply alginate to wound bed, cover with gauze and secure with cling, change on non-[MEDICAL TREATMENT] days. Every Sunday, Tuesday, Thursday, Saturday for wounds. Review of the Medical Record revealed no documentation of wound assessment from 5/28/15 through 6/18/15. Review of the Hospital Discharge Orders dated 10/28/15 through 11/11/15 revealed the resident hospitalized for [REDACTED]. Review of the Progress Notes dated 6/10/15 at 4:06 PM revealed the wound clinic appointment made for 6/18/15. Until then continue the same treatment. The Progress note dated 6/18/15 documented the resident returned from an appointment with the wound nurse with orders to irrigate with normal saline, cover with [MEDICATION NAME] and Kerlix. The note also documented a surgical consult set up with the Physician for 6/25/15 at 8:30 AM. During an interview with the ADON (Assistant Director of Nursing) on 12/10/15, she concurred that no documentation of wound assessment in the medical record for the weeks of 6/4/15 and 6/11/15. She further stated that wound assessment expected to be completed weekly. She stated that the resident had not been cooperative and made it hard to do an assessment. During an interview with the Wound Nurse on 12/17/15 at 2:50 PM she stated that the resident had been initially seen at the clinic on 6/18/15. The Wound Nurse set up an appointment for a surgical consultation right away for 6/28/15 due to the appearance of the wound. She stated it had been felt that the wound clinic should have been contacted sooner. On 6/25/15 the facility called the wound clinic and stated that they had not been aware of the appointment that morning and the appointment had to then be rescheduled to 7/2/15. She further stated that the standard normal practice expected completion of weekly assessments of wounds. 4. Resident #1 had a MDS with a reference date of 8/25/15. The MDS reflected Resident #1 had [DIAGNOSES REDACTED]. The same MDS documented the resident required extensive assistance for completion of transfer, bed mobility, dressing, hygiene, toileting and totally incontinent of bowel and bladder. The Care Plan, revised on 10/13/14, identified the resident had a problem with constipation related to poor fluid intake, decreased mobility, medication side effects, diminished appetite and pain and directed staff follow facility bowel protocol for bowel management with the goal for the resident to have a normal bowel movement at least every three days. The Bowel Assessment completed on 9/28/14 and reviewed on 8/26/15 documented the resident had no apparent bowel elimination pattern, all or almost of the time incontinent episodes and had a history of [REDACTED]. Review of the Bowel and Bladder Chart Detail report for November, 2015 for Resident #1 revealed the following concerns: a. The resident had a bowel movement BM on 11/2 and not again until 11/6 (4 days) b. The resident had a BM on 11/17 and no BM until 11/21 (4 days). The MAR indicated [REDACTED]. c. The resident had a BM on 11/23 and not again until 11/27 (4 days)

Based on observation, clinical record review, interviews and facility records, the facility failed to provide timely interventions to aid in the prevention of skin breakdown and promote healing of Resident #3's left heel pressure ulcer; and failed to notify Resident #3's physician of an adverse change in the resident's left heel pressure ulcer condition. Concerns were identified for two (2) of six (6) residents (Residents #3 and #2). The facility identified a census of 50 residents. 1. According to the MDS (Minimum Data Set) assessment dated [DATE] Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility, transfers and toilet use. The care plan identified Resident #3 had the following Diagnoses: [REDACTED]. The resident's care plan identified he/she needed assistance with managing his/her cares and had a pressure sore on his/her left heel (being treated) with a [DEVICE] (VAC/V.A.C.) (vacuum assisted closure). The care plan dated 1/22/13 and discontinued on 1/31/13 directed staff to provide treatment as ordered by the physician and apply wound VAC (vacuum-assisted closure) on the left heel. The care plan also revealed the nurse to do weekly skin assessment and watch skin closely and report any red areas immediately. According to a web search for wound VAC at http:// www.kci1.com/KCI1/vactherapy, the V.A.C. therapy promotes wound healing through Negative Pressure Wound Therapy (NPWT). The V.A.C. therapy delivers negative pressure (a vacuum) at the wound site through a patented dressing; this helps draw wound edges together, removing infection material and actively promoting granulation. The V.A.C clinical guidelines reference source for the V.A. C. therapy identify points to remember when using the V.A.C. therapy including but not limited to the following: a). If no response or improvement in wound is observed within two weeks, reassesses the treatment plan b). Seek advice/support from local VAC representative as needed. The vascular physician's letter dated 2/4/13 identified Resident #3's wound had been examined that day. The physician identified there was some mild-to-moderate [MEDICATION NAME] debris at the base of the wound. The wound is much more superficial. The physician identified the resident was getting the benefit from the [DEVICE] assisted closure (VAC) therapy. The physician recommended the wound VAC therapy continue for now. The vascular physician's letter dated 2/18/13 revealed Resident #3's wound VAC was removed. The physician documented there is good granulation tissue to the point where the wound is very superficial in the majority of the area; however, there is an area with a moderate amount of [MEDICATION NAME] debris. The physician documented the resident's feet are warm. The physician noted it does appear that some of the black sponge that was used to bring the suction pad in a more manageable area was directly on the skin, causing some skin irritation on the area.The wound was derided with scissors as well as a curette down to healthy appearing granulation tissue. The wound VAC should be replaced when he/she returns to the care facility and will see him/her on 3/18/13. The V.A.C clinical guidelines reference source dated 12/2012 for the V.A. C. therapy identify the following warning: Always count the total number of pieces removed from the wound and ensure the same number of foam pieces are removed as were placed. Foam left in the wound for greater than the recommended time period may foster ingrowth of tissue into the foam, create difficulty in removing foam from the wound or lead to infection or other adverse event. Resident #3's nurse's notes dated 3/8/13, at 9:31 p.m. revealed the wound V.A.C. changed due to blood clot in tubing. The resident had been reminded several times not to unplug machine from wall due to machine will eventually shut itself off due to battery dying. Bright red blood noted when changing vac. The notes identified the resident tolerated well and his/her feet elevated with no complaints. The weekly wound assessment written by the DON dated 2/21/13 documented the wound 2 cm in length by 2 cm in with. The weekly wound assessment written by the ADON dated 3/6/13 documented the wound 2 cm in length and 3.3 cm in width. The same ADON documented on the 3/13/13 weekly wound assessment the wound at a Stage II with length 3 cm (centimeters) by 3 cm with noted increase in length but decrease in width. The ADON noted the wound now black (eschar). The document identified the wound nurse phoned and plans to see the resident for suggestions. The guidelines listed indicators of effective V.A.C. therapy including the following: Wound measurement should begin to decrease as the active state of healing continues. Weekly wound measurements should be performed and documented per institution's protocol for comparison and to effectively assess for healing. A steady decrease in wound dimensions should be noted every week. The V.A.C therapy clinical guidelines reference revealed the therapy is contraindicated for patients with: Necrotic tissue with eschar present. A specific note indicated: after debridement of necrotic tissue and complete removal of eschar, V.A.C. therapy may be used. The daily wound documentation sheets from 3/13/13, 3/14/13 and 3/15/13 identified the resident wound VAC intact. The nurse ' s notes dated 3/13/13, 3/14/13 and 3/15/13 to 3:40 p.m. identified the wound VAC remained running and intact per order. The nurse's notes dated 3/15/13 written by the wound nurse identified the pressure ulcer on left heel, unstageable with 75% black necrotic tissue in center. The nurse documented the resident denies much pain and the wound had a slight odor. The nurse identified the DON determined the measurements. The wound nurse offered recommendations for the left heel ulcer debridement of necrotic tissue by either Santly ointment under (wound) VAC dressing applies or surgical/sharp debridement. The wound nurse documented to continue VAC and off-loading, float heels and continue to monitor blood sugars, etc. for signs and symptoms of infection. The wound nurse noted the facility should contact her with any questions or deterioration. The wound V.A.C. guideline listed indicators if a wound had been progressing well from dressing change to dressing change but then deteriorated rapidly to consider the following intervention and where necessary seek the guidance/expertise of a specialist. 1). Check the therapy hour meter to ensure the actual number of therapy hours received match the number of recommended therapy hours. 2). Check for small leaks with a stethoscope or listening for a [MEDICATION NAME] noise. 3). Clean the wound more thoroughly during dressing changes. 4). Evaluate for signs and symptoms of infections and if present, treat according. 5). Change dressing often, ensure that it is being changed at least every 48 hours. 6. Examine the wound and debride as necessary. Debride the wound edges if they appear non-viable or rolled under as this may inhibit the formation of granulation tissue and migration of [MEDICATION NAME] cells over an acceptable wound base. 7. Assess for osteo[DIAGNOSES REDACTED] and if present treat accordingly. (Resident #3's clinical record identified the only interventions was examining the wound.) The wound nurse completed the following assessment on 3/15/13 and documented her recommendations to the physician: Left heel ulcer-pressure with current treatment wound vac. Measurement per staff L x W x D (length x width depth). 25% granulation on edges 75% black/yellow slough in center Recommendation abridgement of necrotic tissue by either Santyl ointment under VAC dressing or surgical debridement. The physician's responds dated 3/18/13 revealed the resident had great granulation tissue on last visit and now with large amount of necrosis. Why was I not contacted? The report also stated the resident may need a [MEDICAL CONDITION]. The daily wound documentation dated 3/16/13, 3/17/13 and 3/18/13 documented the wound VAC intact. The nurse ' s notes dated 3/16/13 and 3/17/13 documented the wound VAC running and intact. The January & February 2013 Treatment (TAR) record revealed the following: wound VAC to left heel change 3 times as with a start date of 1/15/13. The March 2013 TAR record now described the following: wound VAC to left heel - change 3 times a week. Cleanse left heel with NS-place black sponge just over wound (not touching intact skin) cover with [MEDICATION NAME] and place suction over black sponge. The TAR documented on 3/18/13, the wound VAC treatment had been discontinued. The vascular physician's letter dated 3/18/13 documented he assessed Resident #3 on 3/18/13 and reported the following: Last time he saw Resident #3 had been 2 weeks ago, he/she had excellent granulation (connective tissue that forms on the surface of a wound during the healing process) tissue of the left heel wound and the wound was also very superficial. The physician noted, today he removed the [DEVICE]-assisted closure (VAC) and there is a large amount of necrotic debris. The physician documented it (the wound) is very fowl smelling. The physician documented it appears we have lost all the ground that we had gained with the wound VAC. It should also be noted that the suction disk is directly over the wound, causing worsening pressure ulceration; whereas we had bridged it in the past. The physician wrote he ' s was totally baffled as to why the wound had worsened so much and no one bothered to contact him. The physician reported he (then) discussed this with the head nurse at the nursing home and she stated she had changed the wound VAC last Monday (3/11/13) and there was good granulation tissue with minimal debris. The physician changed the treatment to wet-to-dry dressing and noted the resident would be admitted to a hospital for debridement and possibly below-the-knee amputation. The V.A.C clinical guidelines reference source dated 12/2012 for the V.A. C. therapy identify specific dressing techniques called Bridging Technique. The advantage of bridging would allow the placement of the Pad and tubing in an appropriate location based on wound size, wound type and wound location. For foot wounds on the heel of the foot, the guidelines recommended it is best to use a bridging technique to ensure that additional pressure is not applied as a consequence of the placement of the tubing and or the pad. This involves using foam to allow placemen of the pad or tubing on the dorsum of the foot. Review of the History and Physical dated 3/20/13 revealed the resident had been getting treatment for [REDACTED]. Review of the Nurse's Notes dated 3/27/13 revealed the resident returned to the facility with the left leg amputated approximately 4 inches below the knee. Interviews: During an interview with the vascular physician on 4-19-13 at 8:52 AM he stated he expected to be notified of a change in the resident ' s wound right away. The physician stated he was following Resident #3 closely. The physician stated the resident went to the clinic on 3/18/13 and he saw that the wound VAC placed on the wound incorrectly. The physician stated we had been (previously) bridging the wound VAC over the wound, and (when he observed it) they had the suction directly on the black sponge which caused pressure on the wound. The physician stated he took the wound VAC off and was shocked with the condition of the wound. The wound went from nice granulation tissue in the wound base to deteriorated. The wound needed to be debrided. The facility used a wound nurse and she gives direction to the facility. The change (placement of the wound VAC) did not come from him. The physician stated the resident ' s foot required amputation due to osteo[DIAGNOSES REDACTED] (infection and inflammation of the bone or bone marrow) of the calcaneus bone. He stated that he was not aware of the date that the facility noticed the wound decline but that he should have been the one notified and not the wound nurse. During an interview with Staff M, LPN (Licensed Practical Nurse) on 4/2/13 at 10:30 AM she stated that Staff K saw a change in the wound condition on March 15, 2013 she notified the wound care nurse who came to look at the wound on 3/15/13. The wound care nurse wrote up her recommendations and she sent them with the resident to the physician for an appointment on 3/18/12. She stated she did not call the physician as they can never get through to him. She further stated that it is the facility nurse responsibility to notify physicians with change in wound. She also stated that she did not send a facsimile to the physician. Another interview on 4/2/13 at 1:45 pm., Staff M reported we were bridging on top of the foot another time ran up the leg bridging. Staff M reported the bridging tubing on the leg made indentation. Staff M reported Staff J and someone else had told her they could do this. Staff M reported can take the disk to the heel and put the disk over the dressing. Staff M reported it was never on the wound itself-was draping sponge and then draping. Staff M reported Staff J and the prior DON taught her this. During an interview with Staff J on 4/2/13 at 1:50 p.m. she reported the VAC representative told us that ' s the way it should be (as previously described by Staff M). A follow up interview with Staff M on 5/12/12 at 9:00 a.m. she reported Staff J called the representative and was told it was ok to use the foam on top of the wound. Staff M reported she didn ' t know when, but they had gotten the ok. Staff M reported the bridging method changed to the suction on the top of the foam over the wound. During an interview with Staff J, RN (ADON) on 4/2/13 at 1:50 p.m. she stated that she called the representative for the wound VAC on a Saturday (unsure of the date) and they had instructed to change the dressing due to it not working for more than a few seconds. The change would continue suction better and would be better on the wound. During an interview with Staff J, RN (ADON) on 5/1/13 at 3:10 p.m. she reported she did not see the wound but had seen it on Saturday. Staff J stated the wound looked fully (meant to be granulating). Staff J stated she did not see any necrosis. Staff J reported seeing the facility had been bridging the wound. Staff J reported the physician did not specify bridge or not bridge and they had no (physician ' s) order to determine (whether the wound should be bridged or not). Staff J reported she had initially called the VAC representative company and talked about specific heel wounds(s). During an interview with Staff J, RN on 5/2/13 at 9:00 a.m. she stated that she could not find any documentation of the phone conversation with the wound VAC representative. She also stated that she may have taken a phone call a weekend that she was on call and told staff to try this or that and did not document it. Staff J stated she thought they stopped bridging a long time ago- since January. During an interview with Staff K, RN (ADON) on 4/2/13 at 11:00 a.m. she stated that she did the wound measurements on 3/13/12 and noticed a change. She stated that she discussed the change with Staff M and the Director of Nursing and instructed Staff M to notify the resident's physician. The Director of Nursing (DON) then instructed Staff M to notify the wound care nurse to ask to assess the wound. (The Department could not reach the prior DON as she was no longer working at the facility and the facility staff were unable to provide a contact information for her.) During an interview with the wound care nurse on 4/2/12 at 1:35 PM she stated that she had not seen the resident's wound since November (2012) and had been notified to assess the wound. She was not sure of the date of notification by the facility. She assessed the wound on 3/15/12 and made recommendations. The center of the wound looked like it needed debridement. She did not have a conversation with the facility about placement of the wound VAC and left the wound uncovered and the facility applied the wound VAC. During an interview on 5/2/13 at 8:52 a.m. with the wound VAC representative she stated that wounds that are located on the heel are recommended to have placement of the suction to be bridged to prevent pressure points. She stated the contraindication concern with the necrotic tissue results in not effective treatment. She also stated that she had previously begged to conduct in-service for the staff at the facility numerous times by telephone and in person since she started her position in July 2012 but the DON denied/refused the opportunity. She also stated that she did not receive questions by the facility in relation to the application of the wound VAC for the resident. During an interview with Staff M, LPN on 5/12/13 at 9:00 a.m. she stated that Staff J had called the wound VAC representative and received instruction to change the dressing from bridging to suction on top of foam over the wound. (A reference for debridement at: Wound Care, A Collaborative Practice Manual for Health Professionals, third edition copyrighted 2007 by Sussman-Bates-Jensen; Chapter 8, pages 197 and 198: " As tissue die, they change in color, consistency and adherence to the wound bed. As necrotic tissue increase in severity, the color progresses from white/gray to tan or yellow and finally to brown or black.... Debridement refers to some outside force to remove the dead tissue." (Eschar is defined as dead tissue that is cast off from the surface of the skin ; and necrotic a form of cell injury that results in the death of cells in living tissue.) 2. According to the MDS assessment dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility and toilet use. The care plan dated 9/12/12 directed staff to assist the resident with commode use. Review of the Nurse's Notes revealed no documentation of open areas. Observation on 4/2/13 at 10:00 AM revealed Staff A, CNA (Certified Nursing Assistant) and Staff B, CNA assisted the resident to the commode for toilet use. The resident voided and staff assisted him/her to a standing position and provided peri care with wipes. The resident noted to have 3 superficial open areas on the buttocks. 2- approximately 1 cm (centimeter) areas on the left buttock and 1-approximately 2 cm superficial open areas on the right buttock. During an interview with Staff J, RN (Registered nurse) on 4/3/13 at 9:10 AM she stated that the resident did not have skin sheets and did not have open areas. Observation with Staff J and Staff K, RN revealed the resident did have 2 superficial open areas of the left buttock. The area to the right dried over. Staff J provided incontinent care to the peri rectal area and used the same wipe and wiped over the open areas. Staff concurred the areas were open.

Based on clinical record review and staff interviews, the facility failed to supervise and implement interventions or check the functioning of alarms (Resident #19) to protect 2 of 5 resident reviewed who were identified for as at risk for falls. The facility did not follow the plan of care and ensure the resident wore foot wear (Resident #18). The facility identified a census of 69 residents. Findings include: 1. Review of the MDS (Minimum Data Set) dated 7/15/11 for Resident #18 identified [DIAGNOSES REDACTED]. The assessment identified Resident #18 with a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS reflected Resident #18 required limited assistance of one person for bed mobility, walking in the resident's room, locomotion, dressing, and toilet use. The MDS documented during the 7-day assessment period ending on 7/15/11 Resident #18 required extensive assistance of 2 persons for transfer and the extensive assistance of 1 person for walking in the corridor on the unit. Review of the Care Plan with a goal date of 8/21/11 identified a problem for a potential for falls related to decline in activities for daily living and cognition (inability to recognize safety issues or make safe judgment calls). Interventions included to anticipate the resident's needs secondary to his/her short term memory uses and probable non-use of call light secondary to him/her not remembering instructions. The Interdisciplinary Fall Risk Care Plan dated 6/10/2011 directed staff to attempt to determine the cause for the fall and take steps to prevent falls from happening again. The plan indicated the resident needed to wear proper fitting shoes with non-slick soles. Review of an Incident Report dated 6/9/11 at 7:45 PM documented Resident #18 had been found sitting on the floor in front of the recliner with his/her back near the wall. The resident stated had been walking, and feet slipped out from under and fell backwards, hitting head on the wall. Staff noted no injuries and the intervention for the fall documented on the incident report were for staff to monitor for new injuries/pain for 72 hours. The resident's care plan indicated physical and occupational therapy to screen the resident for services. Review of an Incident Report dated 7/3/11 at 9:40 AM indicated the resident wore only nylons (stockings) and slipped and fell in the bathroom. The resident stated that he/she had hit head and neuro-checks were initiated. The Incident Report indicated a new intervention to re-educate the resident to wear shoes prior to transfer or ambulation. The resident's care plan did not contain any further interventions. The resident complained of left hip soreness. Review of an x-ray report dated 7/5/11 indicated degenerative changes with no fracture or dislocation. Review of an Incident Report dated 7/22/11 at 7:20 PM documented Resident #18 had been found on the floor with his/her back against the recliner with legs straight out in front of the resident. The incident report and care plan did not contain further interventions. Review of the Nurse's Notes dated 7/23/11 at 2:50 AM indicated the resident had voiced pain when standing. The physician was notified and orders received to send to the emergency room . The Nurse ' s Notes indicated the resident had not worn shoes and had one plus edema (swelling) present in the feet. The resident had hit first finger on left hand which resulted in puffiness and bruises present. Resident #18 had been transferred to another city following a fractured left hip. On 7/28/2011 at 11:15 a.m., Staff C (Certified Nursing Assistant) stated the resident had declined quite a bit and required assistance out of bed and to the restroom. Staff C identified the resident as having confusion. On 7/8/2011 at 10:45 a.m. Staff A (Registered Nurse) stated the resident used a call light and then staff would assist. The resident was described as difficult to get out of bed and required the assistance of 1 staff person for activities of daily living. The facility did not initiate interventions to decrease falls following 2 prior falls and hospitalization for pneumonia. 2. Review of the MDS assessment dated [DATE] for Resident #19 documented [DIAGNOSES REDACTED]. The MDS documented a BIMS score of 8 indicating moderate cognitive impairment. The MDS documented Resident #19 required the extensive assistance of 1 person for bed mobility, transfer, walking in the room, locomotion on and off of the unit, toilet use, and personal hygiene. Review of the Care Plan with a goal date of 9/1/11 identified Resident #19 with a potential for falls related to the need for extensive assist, psychotropic meds, and unsafe safety judgment related to short term memory loss. Interventions listed to reduce falls include a pressure alarm in bed and chair. The Care Plan directed that alarms are to be checked daily and in good working order. Batteries are to be replaced as needed. Review of an Incident Report dated 7/8/11 at 6:05 AM documented Resident #19 found lying on floor in bedroom by a CNA (Certified Nursing Assistant) next to bed with body alarm off and bed alarm off. The report did not indicate the resident received injury. Review of the MAR (Medication Administration Record) dated 7/11 for Resident #19 did not contain documentation staff checked the resident's alarms. Interview with the Acting DON (Director of Nursing) on 7/28/11 at 9:40 AM indicated that she expected nurses to check the alarms every shift and that documentation is done on the MAR. Alarms are to be checked. to make sure that they are on and functioning properly.

Based on clinical record review and staff interviews, the facility failed to ensure that fall interventions were maintained to prevent injury to 1 of 3 residents reviewed for nursing supervision (Resident # 8). The facility identified a census of 66. Findings include: 1. Review of the MDS (Minimum Data Set) assessment dated [DATE] for Resident #8 documented [DIAGNOSES REDACTED]. The assessment documented a BIMS score of 10, indicating moderate cognitive impairment. The assessment documented s/he needed extensive assistance for bed mobility and transfers and did not walk. The resident did not have a recent history of falls. The Care Plan dated 8/25/11 documented Resident # 8 had the potential for falls related to a history of falls. The plan contained an intervention dated 8/15/11 instructing use of a pressure bed alarm and a wheelchair alarm. Review of an Incident Report dated 8/30/11 at 6:30 a.m. for Resident #8 documented the nurse found him/her on the floor and the resident in bed prior to the fall. The Incident Report did not indicate any alarm had sounded at the time of the fall . The report documented the resident re-opened a skin tear on the left wrist, obtained a new skin tear which measured 2 cm (centimeters) by 2 cm on the right elbow and a scab came off a wound to their forehead. The area of the report titled treatment or new interventions described treatment to the injured areas and stated "need mat on floor and pressure alarm to bed". Review of the Incident Report 24 hour follow-up dated 8/31/11 written by the interim DON documented the resident used a personal alarm; however the alarm string was too long so the alarm did not sound. The follow-up recorded staff removed the personal alarm and placed a pressure pad alarm. Review of an Incident Report dated 9/5/11 at 10:20 PM documented Resident #8 slid out of bed and sat on the floor. The report documented the bed alarm not going off, s/he still had an arm on the bed and the personal alarm tape had come off. The report did not document the use of a pressure pad alarm implemented on 8/31/11. Interventions included re-taping of the personal alarm and placing a pillow under the sheets on the bed until bolsters are received. A 48-hour follow up on the Incident report documented the resident still had complaints of pain in the rib and back area on the left side. Nurse's Notes dated 9/6/11 at 1 a.m. documented that on 9/5/11 at 10:30 p.m. the resident slid out of bed and sat on the floor. The resident sated s/he tried to get up to get a coat. Staff noted a small skin tear on the resident's right arm. Review of the Care Plan documented an intervention of bed pillow used until bolsters arrive. An intervention dated 9/9/11 dated 9/9/11 identified bolsters on bed.