Every finding on record at Glen Haven Village

Based on clinical record review, observations, staff interviews, facility investigation review and policy review the facility failed to ensure the residents were free of significant medication errors when medication were given to residents from another residents medication card and failure to prime an insulin pen to 6 of 8 residents reviewed (Resident #6, #32, #34, #9, #56 and #64). The facility reported a census of 65 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of Resident #6's Electronic Health Record (EHR) titled, Orders documented no physician's order for alprazolam. 2. The MDS dated [DATE] revealed Resident #32 had a BIMS of 15 indicating no cognitive impairment. Resident #32's MDS also documented diagnoses of major depression and anxiety disorder. Review of Resident #32's EHR titled, Orders documented a physician's order for alprazolam 1mg take a half tablet (0.5mg) 3 times daily as needed. Review of Resident #32's document titled, Controlled Substance Administration Record documented a count for alprazolam 1mg take a half tablet (0.5mg) on 6/28/26 at 4:45 PM to be 12 tablets remaining. Review of Resident #32's document titled, Controlled Substance Administration Record documented a count for alprazolam 1mg take a half tablet (0.5mg) on 6/29/26 at 6:30 PM to be 10 tablets remaining with the count corrected by Staff I, Registered Nurse (RN). Review of a photo of Resident #32's medication card (bubble pack) for medication alprazolam 1mg take a half tablet (0.5mg) revealed 10 tablets remained. 3. The MDS dated [DATE] revealed Resident #34 had a BIMS of 2 indicating severe cognitive impairment. Review of Resident #34's EHR titled, Orders documented no physician's order for alprazolam. Review of video footage from the evening of 6/28/26 to 6/29/26 revealed the following: At 12:18:54 AM Staff O walks into the unit and immediately opens the narcotics book and starts flipping pages. At 12:20:32 Staff O opens the narcotics drawer and begins removing medications, Staff O looks through the bubble packs. At 12:21:31 Staff O popped out 2 medications from the same bubble pack. Staff O went to the narcotic book, Staff O looked for a pen gasped, Staff O did not sign the narcotics book, Staff O looked at the watch flipped through the book, Staff O looked at the pages, flipped through pages of the book and did not sign anything, Staff O placed the medications in 2 different medications cups. Staff O explained she was getting the resident something, Staff O then stated If they don't calm down, call me. At 12:27:28 Staff O entered a resident's room with medications, Staff O asked the resident did you swallow it and the resident said yes. At 12:31:50 Staff O went to the next resident's room with the other medication cup in hand. Review of video footage from the over night of 6/28/26 to 6/29/26 revealed the following: At 12:33 AM Staff O entered Resident #6's room and stated I've got your anxiety medicine. Resident #6 asked what it is called, Staff O stated lorazepam, just a half of one; we're going to try 0.25 mg, a very little dose, Staff O stated we are going to try it because we need to, Staff O stated let's take a bite. Resident #6 stated I want to know where it came from. Staff O explained the doctor wrote an order for it and it is to start today. Staff O stated it's after midnight, you're still awake and we are going to try the medicine. Resident #6 stated I ain't got a new medication. Staff O explained this is the new one, Resident #6 states will you back down for a minute, Staff O stated you knew about this. You told me about it. At 12:34:20 AM Staff N, Certified Nursing Assistant (CNA) entered the room. Resident #6 said I can refuse it so I did not tell you about it. Which kind is it? Staff O stated this is your new lorazepam, that you're supposed to start taking to help you sleep especially at night, Resident #6 said what is the medication's other name, Staff O said I'll go get a print out for you. At 12:34:47 AM Staff O left the room. Staff N stated Staff O just told you what you're on, and it's after midnight, and you're wound tighter than I don't know what. The nurse is getting a print out. At 12:35:27 AM Staff O returned without anything in hand. Staff O stated so we can try this or we can try an injection. Do you want the injection, Resident #6 said no I don't need an injection. Staff O explained Lorazepam I'll write it down. I'm trying to give you the medicine the doctor ordered. At 12:36:52 AM Staff N left the room. Staff O stated Ma'am, Ma'am I have to get more printer paper; there is not enough to print off. Resident #6 stated I'm going to call my son. Staff O stated you're going to call your son at midnight? Okay, we're going to go through all this for a pill. It's midnight. I'm going to go and I'm going to come back, ma'am. This is ridiculous. At 12:38:21 AM Staff O left the room with medication and a spoon in her left hand. Staff O stated (outside the room, down the hallway) Yeah, I'm going to have to try later (talking to Staff N at the end of the hall). At 12:41:15 AM Resident #6 stated the staff is upset I'm not taking the medication (on the phone with her son). On 7/8/26 at 2:04 PM Staff J, Registered Nurse (RN) / Care Coordinator stated she was called by the nurse that was coming on duty on 6/29/26 at 6:00 PM and Staff M RN called and told her the count was off by 2 tablets for alprazolam for Resident #32. Staff J asked if someone gave it and did not sign it out. Staff J stated Resident #32 had gone to the hospital so she did not get the medication. Staff J stated Staff K, RN and her counted the next morning and that was when she and Staff K started the investigation. Staff J explained that was when they found out if there was a documentation error. Staff J stated Staff L, Licensed Practical Nurse (LPN) completed the count the morning of 6/29/26. Staff J stated Staff L explained Staff O, LPN forgot to sign Resident #32's alprazolam out and the count was 10 tablets that morning. Staff J stated per the narcotics book the count was not correct. Staff J stated that was when it was left by Staff L and caught later that same day. Staff J explained the video was reviewed to determine where the medications went. Staff J stated that was when there was an observation of Staff O who gave an as needed (PRN) medication to Resident #6 and #34. Staff J stated she texted Staff O if she had given (PRN) alprazolam while she was at work. Staff J then opened her phone and read the text message back to the Surveyor. Stated I believe so and I can pick up a shift if needed. Staff J stated she then texted Staff O did you give the medication to someone who didn't have an order?. Staff J stated Staff O responded to the text with she did not believe so and she could fix it. On 7/8/26 at 2:21 PM Staff K, RN / Care Coordinator stated on the morning of 6/29/26 Staff M the oncoming nurse noticed Resident #32's alprazolam was off by 2 tablets. Staff K explained Staff L told her Staff O stated she needed to fill out the as needed alprazolam for Resident #32. Staff K explained Staff L thought Staff O corrected the narcotics count for Resident #32 but walked away and did not review it. Staff K explained the evening of 6/29/26 between shifts Staff L and Staff M RN realized Resident #32's alprazolam was off again by the same amount 2 they notified Staff J who was the nurse on call and Staff J and Staff L talked. Staff K explained that was when it was discovered Staff O had given 2 and needed to record them. Staff K stated Staff J instructed them to correct the count and would look further into the incident the following morning. Staff K explained the next morning she looked into the incident. Staff K stated that was when the video of the evening of 6/28/26 was reviewed and it was discovered Staff O had attempted to give Resident #6 and #34 Resident #32's PRN alprazolam. On 7/8/26 at 4:38 PM Staff L, LPN stated she counted with Staff O the morning of 6/29/26. Staff L stated she counted 4 houses (residential units) that day. Staff L stated Staff O was reading the narcotic book and Staff L was reading the medication cards. Staff L stated the count was off for Resident #32 and said something to Staff O and signed something out in the narcotics book, Staff L explained when Staff M came in at 6:00 PM she noticed the count was off for Resident #32. Staff L stated Staff O just agreed with her and did not know if that was the same concern she had noticed. Staff L stated it looked like the count was right because Staff O was just agreeing with her when the count was completed. Staff L stated she would not have known what the difference was between the medication card and the narcotic book because she was looking at the medication card and Staff O was looking at the book and just agreeing. On 7/9/26 at 8:27 AM Staff M, RN stated she was the oncoming nurse at 6:00 PM - 10:00 PM on 6/29/26. Staff M explained the count was being completed and the count was not correct. Staff M explained Resident #32's alprazolam was off by 2 tablets. Staff M stated there were 10 and the narcotic count book documented 12 tablets. Staff M stated she pulled up the electronic medication administration record for Resident #32 to see when the medication was last given for Resident #32 and the time that was in the computer system as well as the time on the signed paper matched. Staff M stated that was when she knew there was a discrepancy. Staff M stated they did not find the medications anywhere and searched everywhere. Staff M explained Resident #32 had been sent out the morning of 6/29/26 at 9:00 AM. Staff M stated she fixed the count and called Staff J. Staff M explained Staff J said there was something else they were looking into that happened the night before. On 7/9/26 at 9:09 AM Staff N, Certified Nurse Assistant (CNA) stated she worked the overnight shift of 6/28/26. Staff N explained Resident #6 and #34 were very anxious. Staff N stated she asked Staff O if the residents had any Xanax or could she give the residents both something. Staff N stated Staff O put the medication in apple sauce or pudding. Staff N stated Staff O gave the medication to Resident #34 and came back out and said Resident #6 refused. On 7/10/26 at 12:59 PM Staff N stated she was scared to say anything but Staff O had her give the medication to Resident #34 because she had a better rapport. Stated she was just following the order from Staff O. Staff N stated Staff O had tried multiple times. Staff N explained she was scared to come out and say something because she was scared of what might happen. Staff N stated Staff O stayed in the hall when she gave the medication and could see her. Staff N stated Staff O was the RN and totally wanted the medications given and did not want it to come out later that a CNA gave the medication. Review of the document titled, 6.28.26 Abuse Investigation documented during the narcotic count at approximately 6:00 a.m. shift change on 6/29/26, with Nurses, Staff L, LPN and Staff O, LPN it was identified that the controlled substance count for Xanax (alprazolam) was incorrect, with two tablets unaccounted for. Staff O informed the oncoming nurse that she needed to document administration of two Xanax tablets she had reportedly given so that the narcotic count would be accurate. The oncoming nurse left the area, and Staff O did not complete the required documentation or reconcile the narcotic count. The discrepancy remained unresolved and was again identified during the 6:00 p.m. shift change. At that time the two nurses on duty notified Staff J, RN who escalated the concern for investigation. A subsequent investigation was conducted by Staff K, Care Coordinator for cottage 247, including review of facility camera footage, resident interviews, medication records, and interviews with staff members who were on duty. Based on the findings, it was determined that Staff O administered a Xanax tablet to another resident who did not have a current physician's order for the medication at approximately 12:20am on 6/29. The investigation also found that Staff O attempted to administer Xanax at approximately 12:35am to a second resident, who likewise did not have a physician's order; however, that resident refused the medication, preventing administration. Once these findings were noted, the Administrator was made aware immediately at approximately 1130am on Tuesday June 30th. On 7/7/26 at 12:33 PM the Administrator stated it was determined that Staff O removed the missing alprazolam from Resident #32's medication card and tried to administer the medications to 2 other residents. The Administrator stated one of the residents refused and the other resident took the medication. The Administrator stated Resident #32 was currently at the hospital and the facility would replace the 2 medications at the facility's expense. On 7/9/26 at 1:14 PM the Administrator stated she would like to have seen medications administered to the appropriated resident. 4.The MDS dated [DATE] documented Resident #9 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #9's EHR titled, Order Summary Report documented a physician's order for Oxycodone 5 mg tablets to take 2 tablets (10 mg) by mouth every 4 hours as needed for pain. 5. The MDS dated [DATE] documented Resident #56 had a Brief Interview for Mental Status (BIMS) of 3 indicated severe cognitive impairment. Review of Resident #56's EHR titled, Order Summary Report documented a physician's order for Lantus Solos Injection 100/ml to inject 60 units subcutaneously daily for diagnosis of type 2 diabetes mellitus. Observation on 7/7/26 at 9:11 AM revealed Staff F, Registered Nurse (RN) assisted Resident #56 from the dining room table to a private room to administer insulin. Staff F, did not perform proper hand hygiene, applied gloves, applied needle to the tip of multidose insulin pen, failed to prime needle before dialing multidose pen to 60 units, cleansed abdomen with an alcohol swab and administered 60 units subcutaneously to Resident #56, gloves removed and hand hygiene performed. 6. The MDS dated [DATE] documented Resident #64 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #64's EHR titled, Order Summary Report documented a physician's order for Oxycodone tablet 10 mg to take one tablet by mouth every four hours routinely for pain. Observation on 7/6/26 at 11:58 AM revealed Staff G, Certified Nurse Assistant/Certified Medication Assistant (CNA/CMA), performed hand hygiene and accessed the narcotic locked box to retrieve medications for Resident #64. Staff G removed two 5 mg Oxycodone medication cards, identified cards as Resident #64's and dispensed one 5 mg tablet from each card. When documenting the narcotic count, Staff G identified a discrepancy and requested assistance from Staff F Registered Nurse (RN). Staff F determined that Staff G had dispensed one 5 mg tablet from Resident #64's card and one 5 mg tablet from Resident #9's card. Staff G failed to verify the resident's identity against the medication cards prior to dispensing the medication. Staff F and another nurse destroyed the medication dispensed in error, and Staff G completed the administration of the correct 10 mg dose for Resident #64. Interview on 7/7/26 at 9:30 AM Staff F stated she does not prime any of her insulin pens before dialing the pen to the amount of units ordered before administering the insulin to any of her Residents. Interview on 7/8/26 at 12:12 PM the Director of Nursing (DON) stated he would expect to see the nurses prime every insulin needle with 2 units prior to dispensing the ordered units to the residents. Review of facility provided competency titled, Insulin Pen Competency provided to facility nurses for education documented the performance objective to wipe pen end with alcohol wipe; apply needle-Do not remove the cap turn dial at bottom of pen to a 2 and hold release button; release needle air and will have droplets of medication. Turn the dial to the correct number for correct dosage and verify the order of medication. Review of a facility provided policy Revised 7/6/26 titled, Medication Administration Policy and Procedure documented it was the policy of the facility to maintain a safe and competent medication management system that is based on best practice and the care process of the residents that includes: recognition of the problem/need, assessment, diagnosis (es), medication administration, management, monitoring and revising the individualized, person-centered approach to care as well as documentation consistent with standards of medication management and administration standards. The objective of the Medication Management Policy is to promote a safe and accurate medication management system for each individual resident, to ensure a system for accurate process of assessment, planning, implementation and monitoring/evaluation and staff competency to promote quality of care, increase resident safety and safeguard against adverse events. The attending physician, interdisciplinary team, resident and/or resident representative will plan approaches that include both medications and non-pharmacological interventions based upon the resident's individualized medical conditions, choices and needs. Behavioral interventions are individualized, non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical or psychosocial wellbeing. Medication Error: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician or physician extender. The person who prepares the dose for administration is the person who administers the dose.

Based on observation, resident interview, staff interviews, and policy review the facility failed to provide food at an appetizing temperature. The facility reported a census of 65 residents. Findings include: 1. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognitive functioning. Interview on 7/06/26 at 3:17 PM with Resident #40 revealed the food does not taste good at the facility, and it is often cold when it is served. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #41 documented a Brief Interview for Mental Status (BIMS) score of 15, indicated no cognitive impairment. Observation on 7/8/26 at 7:58 AM revealed Staff A, Kitchen Aide, performed hand hygiene, prepared a bowl of oatmeal with warm water, stirred the contents, and microwaved the bowl. Staff A removed the oatmeal from the microwave and placed it on the counter without checking the temperature after microwaving. Staff A stated an intent to add sugar and serve the meal to Resident #41. At the surveyor's request, Staff A measured the temperature at 131 degrees Fahrenheit and reheated the oatmeal. Staff A then recorded a post-microwave temperature of 186 degrees Fahrenheit and delivered the meal to Resident #41. 3. The MDS dated [DATE] for Resident #64 documented a BIMS score of 15, indicated no cognitive impairment. Observation on 7/8/26 at 8:18 AM revealed Staff A prepared pancake batter using mix, milk, an egg, and oil. Staff cooked the pancakes, plated two pancakes, added syrup and silverware, cut the pancakes, and secured the lid. Staff stated an intent to serve the meal to Resident #64. The surveyor requested a temperature check. Staff A measured 157 degrees Fahrenheit, then reheated the plate in the microwave. Staff A measured 188 degrees Fahrenheit after reheating and delivered the tray to Resident #64. On 7/8/26 at 8:30 AM Staff A stated he forgot to obtain the temperature after preparing the meal for Residents #41 and #64. On 7/8/26 at 8:41 AM Staff B, Certified Dietary Manager (CDM), stated he would expect temperatures to be obtained before serving meals to residents. Review of an undated, facility-provided policy titled, Glen Haven Village Record of Food Temperatures documented that hot foods will be held at 135 degrees Fahrenheit. Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees Fahrenheit for at least 15 seconds before holding for hot service. No food will be served that does not meet the food code standard temperatures.

Based on observations, staff interviews and policy reviews the facility failed to store, prepare, and serve food in accordance with professional standards. The facility did not label and date open food items, follow best-by dates, discard expired food items and did not perform hand hygiene prior to or during food services. The facility reported a census of 65 residents.Findings Include:Continuous observation on 7/6/26 at 10:15 AM revealed food items in multiple different freezers without open dates including food items of cinnamon buns, diced chicken, bacon, sausage patties, chicken patties, chicken strips, garlic bread, waffles, and egg patties. Observations revealed seasonings without open dates including pink salt, dry BBQ season stubs and pimenton. Observation revealed food items in multiple different refrigerators with expired dates and without open dates including cocktail sauce with an open date of 12-11-25, lemonade and ice tea without open dates and thicken apple juice with an open date of 1/12/26. Seasoning's observed with expired dates included onion powder without an open date and a best by date of 7/2/24 and crushed pepper with an open date of 11/25 and best by date of 6/25/25. Continuous observation on 7/7/26 at 10:56 AM revealed Staff D, Kitchen Aide, removing fried chicken from the oven and placing it on a cutting board before returning it to the oven. Staff D, applied gloves without performing hand hygiene. Staff D cut the chicken and used tongs retrieved from the countertop to place the chicken into the food processor. After processing the chicken, Staff D removed the lid, added two red scoops of chicken gravy, and processed the mixture to achieve a smooth, pudding-like consistency. Staff D added a chicken broth paste and water mixture to the processor while wearing the same gloves. Staff D, removed the gloves, performed hand hygiene, and transferred the processed food into a bowl. Staff D covered the bowl with a paper towel and placed it on the counter. Staff D rinsed the processor in the sink without soap and placed it on the drying rack, while the lid was washed in soapy water and rinsed. Staff D subsequently removed green beans from the oven, used a slotted scoop to transfer them into the food processor, and returned the remaining beans to the oven. Staff D added a chicken paste and water mixture to the beans, processed them until smooth, and added three pumps of liquid thickener before processing again. Staff D transferred the green beans to a bowl using a spoon, rinsed the processor and lid, and placed them on the drying rack without performing hand hygiene.Observation on 7/8/26 at 7:58 AM revealed Staff E, Kitchen Aide, handling toast from the toaster with bare hands. Staff E buttered the toast, placed it on a plate, wrapped silverware in a napkin, and served the plate to a resident without performing hand hygiene or wearing gloves.On 7/6/26 at 10:15 AM, Staff B, Certified Dietary Manager (CDM), confirmed that facility expectations require staff to perform hand hygiene before applying gloves, handling food, or preparing food for residents.Review of facility provide policy without a date titled, Glen Haven Village Hand Washing Policy Dietary documented dietary Staff will wash hands before starting work, when returning to work, after smoking, eating, drinking, after visiting restrooms, after handling garbage or poisonous compounds, and at other times hands have been soiled. Dishwashers should always wash their hands before handling clean dishes. Hand washing facilities should be readily accessible and equipped with paper towels and soap.

Based on clinical record review, observation, facility investigation review, facility policy review and staff interviews the facility failed to protect a resident from misappropriation a resident's medications for 1 of 3 residents reviewed (Resident #32). The facility reported a census of 65 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] revealed Resident #32 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Resident #32's MDS also documented diagnoses of major depression and anxiety disorder.Review of Resident #32's Electronic Health Record (EHR) titled, Orders documented a physician's order for alprazolam 1mg take a half tablet (0.5mg) 3 times daily as needed.Review of Resident #32's document titled, Controlled Substance Administration Record documented a count for alprazolam 1mg take a half tablet (0.5mg) on 6/28/26 at 4:45 PM to be 12 tablets remaining.Review of Resident #32's document titled, Controlled Substance Administration Record documented a count for alprazolam 1mg take a half tablet (0.5mg) on 6/29/26 at 6:30 PM to be 10 tablets remaining with the count corrected by Staff I, Registered Nurse (RN).Review of a photo of Resident #32's medication card (bubble pack) for medication alprazolam 1mg take a half tablet (0.5mg) revealed 10 tablets remained.Review of video footage from the evening of 6/28/26 to 6/29/26 revealed the following: At 12:18:54 AM Staff O walks into the unit and immediately opens the narcotics book and starts flipping pages.At 12:20:32 Staff O opens the narcotics drawer and begins removing medications, Staff O looks through the bubble packs.At 12:21:31 Staff O popped out 2 medications from the same bubble pack. Staff O went to the narcotic book, Staff O looked for a pen gasped, Staff O did not sign the narcotics book, Staff O looked at the watch flipped through the book, Staff O looked at the pages, flipped through pages of the book and did not sign anything, Staff O placed the medications in 2 different medications cups. Staff O explained she was getting the resident something, Staff O then stated If they don't calm down, call me. At 12:27:28 Staff O entered a resident's room with medications, Staff O asked the resident did you swallow it and the resident said yes.At 12:31:50 Staff O went to the next resident's room with the other medication cup in hand.On 7/8/26 at 2:04 PM Staff J, Registered Nurse (RN) / Care Coordinator stated she was called by the nurse that was coming on duty on 6/29/26 at 6:00 PM. Staff M RN called and told her the count was off by 2 tablets for alprazolam for Resident #32. Staff J asked if someone gave it and did not sign it out. Staff J stated Resident #32 had gone to the hospital so she did not get the medication. Staff J stated Staff K, RN and her counted the next morning and that was when she and Staff K started the investigation. Staff J explained that was when they found out if there was a documentation error. Staff J stated Staff L, Licensed Practical Nurse (LPN) completed the count the morning of 6/29/26. Staff J stated Staff L explained Staff O, LPN forgot to sign Resident #32's alprazolam out and the count was 10 tablets that morning. Staff J stated per the narcotics book the count was not correct. Staff J stated that was when it was left by Staff L and caught later that same day. Staff J explained the video was reviewed to determine where the medications went. Staff J stated that was when there was an observation of Staff O who gave an as needed (PRN) medication to 2 other residents. Staff J stated she texted Staff O if she had given (PRN) alprazolam while she was at work. Staff J then opened her phone and read the text message back to the Surveyor. Stated I believe so and I can pick up a shift if needed. Staff J stated she then texted Staff O did you give the medication to someone who didn't have an order?. Staff J stated Staff O responded to the text with she did not believe so and she could fix it. On 7/8/26 at 2:21 PM Staff K, RN / Care Coordinator stated on the morning of 6/29/26 Staff M the oncoming nurse noticed Resident #32's alprazolam was off by 2 tablets. Staff K explained Staff L told her Staff O stated she needed to fill out the as needed alprazolam for Resident #32. Staff K explained Staff L thought Staff O corrected the narcotics count for Resident #32 but walked away and did not review it. Staff K explained the evening of 6/29/26 between shifts Staff L and Staff M RN realized Resident #32's alprazolam was off again by the same amount of 2, they notified Staff J who was the nurse on call and Staff J and Staff L talked. Staff K explained that was when it was discovered Staff O had given 2 and needed to record them. Staff K stated Staff J instructed them to correct the count and would look further into the incident the following morning. Staff K explained the next morning she looked into the incident. Staff K stated that was when the video of the evening of 6/28/26 was reviewed and it was discovered Staff O had attempted to give 2 residents Resident #32's PRN alprazolam. On 7/8/26 at 4:38 PM Staff L, LPN stated she counted with Staff O the morning of 6/29/26. Staff L stated she counted 4 houses (residential units) that day. Staff L stated Staff O was reading the narcotic book and Staff L was reading the medication cards. Staff L stated the count was off for Resident #32 and said something to Staff O and signed something out in the narcotics book, Staff L explained when Staff M came in at 6:00 PM she noticed the count was off for Resident #32. Staff L stated Staff O just agreed with her and did not know if that was the same concern she had noticed. Staff L stated it looked like the count was right because Staff O was just agreeing with her when the count was completed. Staff L stated she would not have known what the difference was between the medication card and the narcotic book because she was looking at the medication card and Staff O was looking at the book and just agreeing. On 7/9/26 at 8:27 AM Staff M, RN stated she was the oncoming nurse at 6:00 PM - 10:00 PM on 6/29/26. Staff M explained the count was being completed and the count was not correct. Staff M explained Resident #32's alprazolam was off by 2 tablets. Staff M stated there were 10 and the narcotic count book documented 12 tablets. Staff M stated she pulled up the electronic medication administration record for Resident #32 to see when the medication was last given for Resident #32 and the time that was in the computer system as well as the time on the signed paper matched. Staff M stated that was when she knew there was a discrepancy. Staff M stated they did not find the medications anywhere and searched everywhere. Staff M explained Resident #32 had been sent out the morning of 6/29/26 at 9:00 AM. Staff M stated she fixed the count and called Staff J. Staff M explained Staff J said there was something else they were looking into that happened the night before. On 7/9/26 at 9:09 AM Staff N, Certified Nurse Assistant (CNA) stated she worked the overnight shift of 6/28/26. Staff N explained there were 2 residents that were very anxious. Staff N stated she asked Staff O if the residents had any Xanax or could she give the residents both something. Staff N stated Staff O put the medication in apple sauce or pudding. Staff N stated Staff O gave the medication to one of the residents and came back out and said she would give the other one to the other resident. Review of the documents titled, 6.28.26 Abuse Investigation documented during the narcotic count at approximately 6:00 a.m. shift change on 6/29/26, with Nurses, Staff L, LPN and Staff O, LPN it was identified that the controlled substance count for Xanax (alprazolam) was incorrect, with two tablets unaccounted for. Staff O informed the oncoming nurse that she needed to document administration of two Xanax tablets she had reportedly given so that the narcotic count would be accurate. The oncoming nurse left the area, and Staff O did not complete the required documentation or reconcile the narcotic count. The discrepancy remained unresolved and was again identified during the 6:00 p.m. shift change. At that time the two nurses on duty notified Staff J, RN who escalated the concern for investigation. A subsequent investigation was conducted by Staff K, Care Coordinator for cottage 247, including review of facility camera footage, resident interviews, medication records, and interviews with staff members who were on duty. Based on the findings, it was determined that Staff O administered a Xanax tablet to another resident who did not have a current physician's order for the medication at approximately 12:20am on 6/29. The investigation also found that Staff O attempted to administer Xanax at approximately 12:35am to a second resident, who likewise did not have a physician's order; however, that resident refused the medication, preventing administration. Once these findings were noted, the Administrator was made aware immediately at approximately 1130am on Tuesday June 30th.On 7/7/26 at 12:33 PM the Administrator stated it was determined that Staff O removed the missing alprazolam from Resident #32's medication card and tried to administer the medications to 2 other residents. The Administrator stated one of the residents refused and the other resident took the medication. The Administrator stated Resident #32 was currently at the hospital and the facility would replace the 2 medications at the facility's expense. Review of facility provided policy revised 6/2/23 titled, Abuse and Neglect documented that 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 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. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent.

Based on clinical record review, observation, staff interview, facility investigation review, and facility policy review the facility staff administered psychotropic medications without an order to residents who were up at night to sedate them for 2 out of 7 residents reviewed (Resident #6, and #34). The facility also failed to have a duration or rationale for a resident with a psychotropic medication (Resident #8). The facility reported a census of 65 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of Resident #6's Electronic Health Record (EHR) titled, Orders documented no physician's order for alprazolam. 2. The MDS dated [DATE] revealed Resident #34 had a BIMS of 2 indicating severe cognitive impairment. Review of Resident #34's EHR titled, Orders documented no physician's order for alprazolam. Review of video footage from the evening of 6/28/26 to 6/29/26 revealed the following: At 12:18:54 AM Staff O walks into the unit and immediately opens the narcotics book and starts flipping pages. At 12:20:32 Staff O opens the narcotics drawer and begins removing medications, Staff O looks through the bubble packs. At 12:21:31 Staff O popped out 2 medications from the same bubble pack. Staff O went to the narcotic book, Staff O looked for a pen gasped, Staff O did not sign the narcotics book, Staff O looked at the watch flipped through the book, Staff O looked at the pages, flipped through pages of the book and did not sign anything, Staff O placed the medications in 2 different medications cups. Staff O explained she was getting the resident something, Staff O then stated If they don't calm down, call me. At 12:27:28 Staff O entered a resident's room with medications, Staff O asked the resident did you swallow it and the resident said yes. At 12:31:50 Staff O went to the next resident's room with the other medication cup in hand. Review of video footage from the over night of 6/28/26 to 6/29/26 revealed the following: At 12:33 AM Staff O entered Resident #6's room and stated I've got your anxiety medicine. Resident #6 asked what it is called, Staff O stated lorazepam, just a half of one; we're going to try 0.25 mg, a very little dose, Staff O stated we are going to try it because we need to, Staff O stated let's take a bite. Resident #6 stated I want to know where it came from. Staff O explained the doctor wrote an order for it and it is to start today. Staff O stated it's after midnight, you're still awake and we are going to try the medicine. Resident #6 stated I ain't got a new medication. Staff O explained this is the new one, Resident #6 states will you back down for a minute, Staff O stated you knew about this. You told me about it. At 12:34:20 AM Staff N, Certified Nursing Assistant (CNA) entered the room. Resident #6 said I can refuse it so I did not tell you about it. Which kind is it? Staff O stated this is your new lorazepam, that you're supposed to start taking to help you sleep especially at night, Resident #6 said what is the medication's other name, Staff O said I'll go get a print out for you. At 12:34:47 AM Staff O left the room. Staff N stated Staff O just told you what you're on, and it's after midnight, and you're wound tighter than I don't know what. The nurse is getting a print out. At 12:35:27 AM Staff O returned without anything in hand. Staff O stated so we can try this or we can try an injection. Do you want the injection, Resident #6 said no I don't need an injection. Staff O explained Lorazepam I'll write it down. I'm trying to give you the medicine the doctor ordered. At 12:36:52 AM Staff N left the room. Staff O stated Ma'am, Ma'am I have to get more printer paper; there is not enough to print off. Resident #6 stated I'm going to call my son. Staff O stated you're going to call your son at midnight? Okay, we're going to go through all this for a pill. It's midnight. I'm going to go and I'm going to come back, ma'am. This is ridiculous. At 12:38:21 AM Staff O left the room with medication and a spoon in her left hand. Staff O stated (outside the room, down the hallway) Yeah, I'm going to have to try later (talking to Staff N at the end of the hall). At 12:41:15 AM Resident #6 stated the staff is upset I'm not taking the medication (on the phone with her son). Review of Resident #32's document titled, Controlled Substance Administration Record documented a count for alprazolam 1mg take a half tablet (0.5mg) on 6/28/26 at 4:45 PM to be 12 tablets remaining. Review of Resident #32's document titled, Controlled Substance Administration Record documented a count for alprazolam 1mg take a half tablet (0.5mg) on 6/29/26 at 6:30 PM to be 10 tablets remaining with the count corrected by Staff I, Registered Nurse (RN). Review of a photo of Resident #32's medication card (bubble pack) for medication alprazolam 1mg take a half tablet (0.5mg) revealed 10 tablets remained. On 7/8/26 at 2:04 PM Staff J, Registered Nurse (RN) / Care Coordinator stated she was called by the nurse that was coming on duty on 6/29/26 at 6:00 PM at Staff M RN called and told her the count was off by 2 tablets for alprazolam for Resident #32. Staff J asked if someone gave it and did not sign it out. Staff J stated Resident #32 had gone to the hospital so she did not get the medication. Staff J stated Staff K, RN and her counted the next morning and that was when she and Staff K started the investigation. Staff J explained that was when they found out if there was a documentation error. Staff J stated Staff L, Licensed Practical Nurse (LPN) completed the count the morning of 6/29/26. Staff J stated Staff L explained Staff O, LPN forgot to sign Resident #32's alprazolam out and the count was 10 tablets that morning. Staff J stated per the narcotics book the count was not correct. Staff J stated that was when it was left by Staff L and caught later that same day. Staff J explained the video was reviewed to determine where the medications went. Staff J stated that was when there was an observation of Staff O who gave an as needed (PRN) medication to Resident #6 and #34. Staff J stated she texted Staff O if she had given (PRN) alprazolam while she was at work. Staff J then opened her phone and read the text message back to the Surveyor. Stated I believe so and I can pick up a shift if needed. Staff J stated she then texted Staff O did you give the medication to someone who didn't have an order?. Staff J stated Staff O responded to the text with she did not believe so and she could fix it. On 7/8/26 at 2:21 PM Staff K, RN / Care Coordinator stated on the morning of 6/29/26 Staff M the oncoming nurse noticed Resident #32's alprazolam was off by 2 tablets. Staff K explained Staff L told her Staff O stated she needed to fill out the as needed alprazolam for Resident #32. Staff K explained Staff L thought Staff O corrected the narcotics count for Resident #32 but walked away and did not review it. Staff K explained the evening of 6/29/26 between shifts, Staff L and Staff M RN realized Resident #32's alprazolam was off again by the same amount of 2, they notified Staff J who was the nurse on call and Staff J and Staff L talked. Staff K explained that was when it was discovered Staff O had given 2 and needed to record them. Staff K stated Staff J instructed them to correct the count and would look further into the incident the following morning. Staff K explained the next morning she looked into the incident. Staff K stated that was when the video of the evening of 6/28/26 was reviewed and it was discovered Staff O had attempted to give Resident #6 and #34 Resident #32's PRN alprazolam. On 7/9/26 at 9:09 AM Staff N, Certified Nurse Assistant (CNA) stated she worked the overnight shift of 6/28/26. Staff N explained Resident #6 and #34 were very anxious. Staff N stated she asked Staff O if the residents had any xanax or could she give the residents both something. Staff N stated Staff O put the medication in apple sauce or pudding. Staff N stated Staff O gave the medication to Resident #34 and came back out and said Resident #6 refused. Staff N stated Staff O gave the medication to Resident #34 and came back out and said she would give that one to Resident #6. Staff N stated Resident #6 refused the medication and wanted the paper work. Staff N stated Resident #6 continued to refuse and the medication was not given. Staff N stated she went in the room with Resident #34 and watched Resident #34 get the medication from Staff O. Staff N stated Resident #34 said at first she was not going to take it and she did not need that. Staff N explained Staff O told her something else like it was for her health or something and appeared she was trying to give the medication anyway she could but did not say it was for anxiety. Staff N stated Staff O had her come out of Resident #34's room and had her help convince her to take the medication. Staff N stated Staff O told her when Resident #34 refused to not start fighting with her and Resident #34 said I'm not taking that. Staff N stated Resident #34 said you can't make me take that and said I'm going to call my husband. Staff N stated as soon as Resident #34 opened her mouth that Staff O shoved the medication in her mouth in the middle of the conversation. Staff N said then they left the room and Staff O was like I'm going to Resident #6's room to give her some medication. Staff N stated she told Resident #6 that her anxiety was through the roof and that would help assuming the nurse knew what she was doing. Staff N explained Staff O argued with Resident #6 and Resident #6 was arguing back. Staff N stated Resident #6 requested the other name of the medication because she didn't take that. Staff N stated Resident #6 wanted to call her son and then did call her son. Staff N stated Staff O said if you want we can give you an injection to Resident #6. Staff N stated Resident #6 did not want an injection or the pill. Staff N stated Staff O said she would print the order but never did. Staff N stated Staff O told Resident #6 that it was ordered and the other name was lorazepam. Staff N stated the interaction made her uncomfortable and left the room before the nurse left. Staff N explained she never felt Staff O's actions crossed into abuse or that she should have notified the supervisor. Staff N stated Staff O seemed very deceptive when administering both Resident #6 and #34's medications. On 7/10/26 at 12:59 PM Staff N stated she was scared to say anything but Staff O had her give the medication to Resident #34 because she had a better rapport. Stated she was just following the order from Staff O. Staff N stated Staff O had tried multiple times. Staff N explained she was scared to come out and say something because she was scared of what might happen. Staff N stated Staff O stayed in the hall when she gave the medication and could see her. Staff N stated Staff O was the RN and totally wanted the medications given and did not want it to come out later that a CNA gave the medication. Review of document titled, 6.28.26 Abuse Investigation documented during the narcotic count at approximately 6:00 a.m. shift change on 6/29/26, with Nurses, Staff L, LPN and Staff O, LPN it was identified that the controlled substance count for Xanax (alprazolam) was incorrect, with two tablets unaccounted for. Staff O informed the oncoming nurse that she needed to document administration of two Xanax tablets she had reportedly given so that the narcotic count would be accurate. The oncoming nurse left the area, and Staff O did not complete the required documentation or reconcile the narcotic count. The discrepancy remained unresolved and was again identified during the 6:00 p.m. shift change. At that time the two nurses on duty notified Staff J, RN who escalated the concern for investigation. A subsequent investigation was conducted by Staff K, Care Coordinator for cottage 247, including review of facility camera footage, resident interviews, medication records, and interviews with staff members who were on duty. Based on the findings, it was determined that Staff O administered a Xanax tablet to another resident who did not have a current physician's order for the medication at approximately 12:20am on 6/29. The investigation also found that Staff O attempted to administer Xanax at approximately 12:35am to a second resident, who likewise did not have a physician's order; however, that resident refused the medication, preventing administration. Once these findings were noted, the Administrator was made aware immediately at approximately 1130am on Tuesday June 30th. On 7/7/26 at 12:33 PM the Administrator stated it was determined that Staff O removed the missing alprazolam from Resident #32's medication card and tried to administer the medications to Resident #6 and #34. The Administrator stated Resident #6 refused and Resident #34 took the medication. On 7/9/26 at 1:14 PM the Administrator stated she would like to have seen medications administered to the appropriate resident. 3. Review of Resident #8's MDS dated [DATE] revealed a readmission to the facility on 3-14-26 from a short-term general hospital stay. The MDS further indicated Resident #8 utilized antianxiety medication during the seven day look back period. Review of the EHR page titled, Clinical Physician Orders revealed an order for Lorazepam 0.5mg to give 1/2 tablet (0.25mg) by mouth every 4 hours PRN (as needed) for anxiety. Further review of this order revealed that it was ordered on 6/4/26 with no end date. Review of Resident #'8s June MAR revealed that as needed Lorazepam was given the 27th, 28th, and 29th. Review of Resident #8's July MAR revealed that as needed Lorazepam was given on the 1st of the month. Interview 7/07/26 at 1:00 PM with Staff H LPN/Care Coordinator confirmed the order for the PRN Lorazepam was ordered on 6/4/26, and further confirmed that there was no end date specified for the medication. Interview 7/07/26 at 1:11 PM with the DON revealed that the facility was going to send a clarification for a stop date for the Lorazepam that is used as necessary. The DON further revealed that Lorazepam should have an end date, and be reviewed by the physician. Review of a facility provided document titled, Psychotropic Care Plan Worksheet with a created date of 1/1/23 indicates that if the resident has a PRN psychotropic medication does the facility have an order to continue the medication with a duration and rationale? Review of facility provided policy revised 6/2/23 titled, Abuse and Neglect documented that 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 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 clinical record review, observations, staff interviews, and policy review the facility failed to have a medication error rate of less than 5% related to the failure to follow the appropriate procedure for medication administration and failure to properly prime an insulin needle to ensure patency for 3 of 5 residents reviewed. The facility reported a census of 65 residents.Findings Include:1. The Minimum Data Set, dated [DATE] documented Resident #9 had a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment.Review of Resident #9's EHR titled, Order Summary Report documented a physician's order for Oxycodone 5 mg tablets to take 2 tablets (10 mg) by mouth every 4 hours as needed for pain.2. The MDS dated [DATE] documented Resident #56 had a BIMS of 3 indicating severe cognitive impairment. Review of Resident #56's EHR titled, Order Summary Report documented a physician's order for Lantus Solos Injection 100/ml to inject 60 units subcutaneously daily for diagnosis of type 2 diabetes mellitus.Observation on 7/7/26 at 9:11 AM revealed Staff F, Registered Nurse (RN) assisted Resident #56 from dining room table to private room to administer insulin. Staff F, did not perform proper hand hygiene, applied gloves, applied needle to the tip of multidose insulin pen, failed to prime needle before dialing multidose pen to 60 units, cleansed abdomen with an alcohol swab and administered 60 units subcutaneously to Resident #56, gloves removed and hand hygiene performed. 3. The MDS dated [DATE] documented Resident #64 had a BIMS of 15 indicating no cognitive impairment.Review of Resident #64's EHR titled, Order Summary Report documented a physician's order for the medication Oxycodone tablet 10 mg to take one tablet by mouth every four hours routinely for pain. Observation on 7/6/26 at 11:58 AM revealed Staff G, Certified Nurse Assistant/Certified Medication Assistant (CNA/CMA), performed hand hygiene and accessed the narcotic locked box to retrieve medications for Resident #64. Staff G, removed two 5 mg Oxycodone medication cards, identified cards as Resident #64's and dispensed one 5 mg tablet from each card. When documenting the narcotic count, Staff G, identified a discrepancy and requested assistance from Staff F Registered Nurse (RN). Staff F determined that Staff G, had dispensed one 5 mg tablet from Resident #64's card and one 5 mg tablet from Resident #9's card. Staff G, failed to verify the resident's identity against the medication cards prior to dispensing the medication. Staff F and another nurse destroyed the medication dispensed in error, and Staff G, completed the administration of the correct 10 mg dose for Resident #64.On 7/7/26 at 9:30 AM Staff F, stated she does not prime any of her insulin pens before dialing the pen to the amount of units ordered before administering the insulin to any of her Residents. On 7/8/26 at 12:12 PM the Director of Nursing (DON) stated he would expect to see the nurses prime every insulin needle with 2 units prior to dispensing the ordered units to the residents. Review of undated facility provided competency titled, Insulin Pen Competency provided to facility nurses for education documented the performance objective to wipe pen end with alcohol wipe; apply needle-Do not remove the cap turn dial at bottom of pen to a 2 and hold release button; release needle air and will have droplets of medication. Turn the dial to the correct number for correct dosage and verify the order of medication.

Based on observations, staff interviews and policy review the facility failed to implement universal infection control measures related to improper hand hygiene during medication administration as well as failure to disinfect the glucometer device used to monitor blood sugars in between resident uses. The facility reported a census of 65 residents. Findings Include: Observation on 7/7/26 at 8:35 AM revealed Staff F, Registered Nurse (RN), obtained a manual blood pressure from a resident sitting in the dining room. After blood pressure was obtained Staff F returned to the medication cart, removed medication cards and began to dispense medication into the medication cup without performing proper hand hygiene. Staff F proceeded to administer medications to the resident.Observation on 7/7/26 at 8:45 AM revealed Staff F retrieved medications from a resident's room in a locked cabinet, returned with medications to the medication cart and began to dispense medications into a medication cup without performing proper hand hygiene. Staff F proceeded to administer medications to the resident.Continuous observation on 7/7/26 at 8:53 AM revealed Staff F obtained a blood sugar reading from a resident and placed the glucometer in the top drawer of the medication cart without disinfecting the device. At 9:11 AM, Staff F retrieved the glucometer device from the medication cart, obtained a blood sugar reading from a different resident, and returned the device to the top drawer of the medication cart without disinfecting it.Observation on 7/7/26 at 9:20 AM revealed Staff F retrieved medications from a locked cabinet, returned to the medication cart, unlocked it, and placed the medications inside. After locking the cart, Staff F walked to the medication refrigerator to retrieve insulin, returned to the cart, unlocked it, and dispensed medications into a cup without performing proper hand hygiene. Staff F proceeded to administer the medications to the resident. Staff F assisted the resident from the dining room table into a private room to administer insulin. Upon entering the private room Staff F applied gloves without performing proper hand hygiene and administered insulin to the resident.Interview on 7/7/26 at 8:58 AM Staff F stated that the facility only has one house glucometer that is used on every resident in each household and denied that residents had their own personal glucometer device. Staff F explained she should have cleansed the glucometer device in between using the device on the residents. Interview on 7/8/26 at 12:12 PM the Director of Nursing (DON) stated his concerns with improper disfection of the glucometer device in between residents and stated it should always be cleansed in between each residents use. The DON further explained his concerns with improper hand hygiene during medication administration.Review of a facility provided policy dated 1/26/26, titled, Blood Glucose Policy documentated after use on each patient the meter should be cleaned and disinfected with sani wipes. Cleansing of the maching included cleaning the whole maching with a super sani cloth (purple top) with the solution equaling a 1:10 concentration of bleach and water. If visible blood is present then two wipes must be used with one to clean and one to disinfect. Allow the machine to air dry and the machine is to be cleansed between each resident.Review of a facility provided policy dated 5/23 titled, Infection Control Policy documented standard and transmission-based precautions to be followed to prevent the spread of infections including hand hygiene by staff with direct care, handling resident care equipment and the environment, the use of correct personal protective equipment (PPE) and the routine cleansing and disinfection of care equipment including shared equipment.Review of a facility provided policy dated 3/31/26 titled, Hand Hygiene Policy and Procedure documented staff to perform hand hygiene in resident care areas, with direct patient contact, before and after gloves are applied and when hands are visibly soiled.

Based on Electronic Health Record (EHR) review, document review, staff interview, family interview and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by not obtaining a Urinalysis (UA) in a timely manner and failing to notify the physician of the failed attempt for 1 of 3 residents (Resident #1). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, dated 9/23/25 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. Review of Resident #1's document dated 12/1/25 titled, Physicians Referral Form documented findings / recommendations for a UA and culture if positive. Review of Resident #1's EHR titled, Orders documented a physician's order for a one time UA with culture and sensitivity with a start date of 12/1/25 and an end date of 12/6/25.Review of Resident #1's EHR titled, Lab Administration Report documented a physician's order for a UA with culture and sensitivity one time for UTI signed off as completed by Staff A, Registered Nurse (RN) on 12/7/25.Review of Resident #1's EHR dated 12/1/25 at 3:40 PM titled, Progress Notes entered by Staff A documented a physician's referral form with new orders for UA, culture if positive,Review of Resident #1's EHR dated 12/2/25 at 9:53 AM titled, Progress Notes entered by Staff B, Care Coordinator documented review of referral form from appointment on 12/1/25 with orders for UA, culture if positive.Review of Resident #1's EHR dated 12/7/25 at 7:26 AM titled, Progress Notes entered by Staff A documented completed rounds with Resident #1. Resident #1 was not making herself understood. Confused on where she currently was. Resident #1 had stated she was at the hospital. When Resident #1 was asked her name and started naming off random numbers. A call was placed to Resident #1's daughter. Resident #1's daughter would like to come to the facility and see mother before making any decisions. Review of Resident #1's EHR dated 12/7/25 at 5:16 PM titled, Progress Notes entered by Staff A documented a call was placed to the hospital lab for results on Resident #1's UA. Order obtained for UA per provider request from 12/3/25 and results showed findings of Urinary Tract Infection (UTI). On call provider notified of abnormal UA and change in mental status. Order for Macrobid 100mg twice a day for 7 days. Review of Resident #1's document dated 12/7/25 titled, Urinalysis documented white blood cell results of 51-100 with a reference range of 0-2. Urinalysis further documented possible contamination of specimens. Review of Resident #1's document dated 12/7/25 titled, Nursing Fax Communication documented a physician's order for Macrobid 100mg twice a day for 7 days.On 12/17/25 at 2:43 PM Staff A, RN stated the faxes for a lab will come through on the facility email and nurses are supposed to print them out and have them ready for the next shift. Staff A stated the order was usually sat on the desk in the nurses office. Staff A stated if it was a physician fax it would be written down for what the physician wants. Staff A stated she did not remember the day of 12/7/25. Staff A acknowledged she knew the facility had orders to obtain a UA for Resident #1. Staff A stated the order was usually always sitting on the desk. Staff A stated she did not remember completing a straight catheterization on Resident #1. Staff A stated she notified the family, the family came to the facility and took the lab to the hospital. Staff A stated Resident #1 had chronic kidney disease. Staff A stated she did not know if the facility had a procedure for how long before a physician should be notified of the inability to obtain a UA. Staff A stated in this case she knew the facility was trying. Staff A stated night shift was notified the UA was still needed for Resident #1. Staff A repeated she was not sure how long to wait before notifying the physician the UA was unable to be obtained. Staff A stated she would wait up to 48 hours before requesting a straight catheter or notifying the physician that the UA was not obtained. Staff A stated the she had told the Certified Nurse Assistants that were working with her that morning that Resident #1 still needed to have a UA obtained. Staff A stated the family had asked if the UA was obtained when they entered the facility that morning.On 12/17/25 at 9:45 AM Resident #1's granddaughter stated Resident #1 went to the primary care physician for a follow up that was before 12/7/25. Resident #1's granddaughter stated her mother was called from Staff A who stated they wanted to send Resident #1 to the hospital. Resident #1's granddaughter said her mother wanted the family to come up and assess to ensure Resident #1 needed to go to the hospital. Resident #1's granddaughter stated when she arrived Resident #1 knew their names and was not confused. Resident #1's granddaughter explained she had asked Staff A if the facility had obtained the UA and Staff A replied no Resident #1 had not voided enough in the last 5 days. Resident #1's granddaughter then questioned if the output was so low why didn't the facility contact Resident #1's physician. Resident #1's granddaughter stated Staff A explained the facility did get a UA but put it in a stool sample kit and the lab did not take it. Resident #1's granddaughter stated the CNA said if she knew Resident #1 needed a UA she would have put a hat in the bathroom. Resident #1's granddaughter stated if the facility did not get the UA in a timely manner why was the physician not notified. Resident #1's granddaughter stated communication with the staff was very pleasant. Resident #1's granddaughter stated Resident #1 had been waiting 5 days to have a UA obtained, which seemed like a very long time. On 12/17/25 at 3:49 PM Staff C, Certified Medication Assistant (CMA) acknowledged she had worked with Resident #1 on the morning of 12/7/25. Staff C explained that morning she had gone in to get Resident #1 out of bed for the morning. Staff C stated Resident #1 had a change in her speech and the way she was acting. Staff C stated she notified the nurse of the change in Resident #1. Staff C stated Staff A notified the family and the family came up to the facility. Staff C stated she had no idea there was an order for a UA and Staff A had not told her that morning. Staff C stated Staff A requested help with straight catheterization on Resident #1 to provide assistance. Staff C repeated Staff A did not tell her that a UA was needed for Resident #1. Staff A explained she had no idea or else she would have placed a hat in the toilet to obtain the UA when she got Resident #1 up in the morning. On 12/17/25 at 12:55 PM Staff B, Care Coordinator stated when sending orders anything abnormal the staff would fill out SBAR with a summary form and send them to the physician then the physician will fax it back with any orders. Staff B stated once they fax it back it comes to the facility's email, those faxes are printed by the charge nurse or the care coordinator and then summarize what the SBAR was about in a progress note. Staff B explained the care coordinators double checked the order to ensure all the labs are put in and the family is notified. Staff B stated once everyone was notified the care coordinator would enter a progress note for double checking. Staff B stated the order for labs are found on the lab tab on the EHR. Staff B stated the nurses are supposed to review the tab every shift. Staff B stated if the lab was unable to be obtained the expectation was to notify the physician. Staff B stated if a UA is ordered and the resident is occasionally incontinent can be difficult to obtain. Staff B stated if the staff were unable to obtain a UA through clean catch would request for a straight catheterization. Staff A stated she would have expected the UA for Resident #1 would have been obtained in less than 6 days or the physician would have been notified. On 12/17/25 Staff B acknowledged lab orders were documented for a UA completed for Resident #1 on 12/1/25. Staff B also acknowledged the UA was not obtained until 12/7/25. On 12/17/25 at 4:20 PM the DON stated his expectation was the UA would have been obtained prior to 12/7/25 for Resident #1 if the UA was ordered on 12/1/25. The DON stated the facility does not have a policy or procedure for how quickly a lab should be obtained but the facility followed professional standards for obtaining a UA.

Based on clinical record review, facility investigation review, staff interviews, and policy review the facility failed to protect residents from accidents and injuries for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 64.Findings include: Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of anxiety disorder, and Alzheimer's disease. The MDS then revealed a Brief Interview for Mental Status (BIMS) score of being incomplete. The MDS further revealed Resident #2 was totally dependent on staff for assistance with eating, oral hygiene, toileting hygiene, shower/bathing, dressing, personal hygiene, rolling right to left while in bed, and transferring. The MDS dated [DATE] reflected Resident #2's was rarely/never understood. Review of the Electronic Healthcare Record (EHR) tab titled, Progress Notes dated 9/3/25 at 3:07 PM revealed that there was a nurse stat called at 7:56 AM to Resident #2's room. Staff A Registered Nurse (RN) entered Resident #2's room to see a staff holding cloths on Resident #2's forehead on the right side. When the cloths were removed it was noted that Resident #2 had a laceration measuring 4 centimeters (CM) x 1cm x 0.5cm. Staff A noted that there was bruising above Resident #2's right eyebrow. Staff A revealed that staff reported Resident #2 was being rolled in bed and the brakes were not locked on the bed. It was further noted that Resident #2 rolled in bed and hit their head on the concrete wall. Staff A then notified hospice services, who in return notified the physician. Staff A noted that the hospice nurse then reported that Resident #2 may need sutures/staples. Staff A noted that the physician gave an order to send Resident #2 to the hospital for treatment and evaluation. Further review of the EHR page titled, Progress Notes dated 9/5/25 at 1:10 PM revealed the facility received a report from the hospital that Resident #2 was admitted to the hospital on [DATE] for a laceration to the right side of the forehead with 4-5 sutures and small subdermal hematoma. The Nurse at the hospital reported that Resident #2 had a black eye and was being discharged from the hospital on 9/5/25. Review of a facility provided document titled, Resident #2 Injury Investigation dated 9/3/25 revealed upon investigation of the bed, the locking mechanism (pedal brake lock) on Resident #2's bed did not engage the brakes, although the individual wheel locks were functioning properly and the bed was able to be locked leading to the root cause of the brakes not being checked prior to cares. Interview 9/24/25 at 11:10 AM the Administrator revealed that Staff B Certified Nursing Assistant (CNA) was repositioning Resident #2 in her bed getting her ready for her shower, and went to move the resident with a sheet to help roll the resident. The Administrator revealed the paddle brake was not working properly, and the CNA did not confirm that the bed wheels were locked. When Staff B went to move the resident the resident rolled, and Resident #2's head hit the wall as the bed moved. Staff B caught the resident, and kept the resident on the bed, but the resident did obtain a head laceration. The Administrator then revealed that the bed was replaced. Interview 9/24/25 at 11:15 AM with Staff A RN revealed there was a nurse stat call to Resident #2's home on 9/3/25, and she was the first nurse to respond. Staff A then revealed that she was directed to Resident #2's room, and Staff B was holding a rag on Resident #2's forehead. Staff A then revealed that she looked under the rag, and there was a head laceration under the rag. Staff A further revealed that Staff B was rolling the resident in the bed, and the wheel locks were not locked causing the bed to move when the staff went to reposition the resident. Staff A revealed this was when Resident #2 hit her head on the wall. Staff A then revealed that Resident #2 did not hit the floor as Staff B caught her and kept her on the bed. Staff A then revealed that the bed wheel locks were not working properly. Staff A revealed that Resident #2 was on hospice and the hospice nurse was notified who then came to the home and sent the resident out to the hospital. Interview 9/24/25 at 11:45 AM with Staff C RN revealed that she was notified on 9/3/25 around 8:00AM that Resident #2 had hit her head and would probably need sutures. Staff C revealed that Resident #2 was alert per her baseline, and that the bleeding was pretty scant when she arrived. Staff C did note that there was blood on the fitted sheet of the bed. Staff C then revealed that Resident #2 was in a shirt and had no brief as Staff B was getting Resident #2 ready for the day when the incident occurred. Staff C then revealed that the CNA had told her that the bed moved during the transfer. Staff C then revealed she attempted to lock the bed with the pedal brake, which did not work. Staff C further revealed that she pointed out the fact the bed brakes weren't working properly. Follow up interview 9/24/25 at 12:20 PM with the Administrator revealed that her expectation would be for staff to lock the brakes on the beds when repositioning or transferring residents. Interview 9/24/25 at 12:34 PM with Staff D, Director of Maintenance and Housekeeping, revealed he had got the call all four brakes on Resident #2's bed worked independently, but the foot pedal break system did not operate appropriately. Staff D then revealed the foot pedal would engage, but the rubber stopper was worn. Staff D further revealed the individual wheels of the bed would lock. Staff D revealed the beds are not inspected to ensure the beds are operating properly. Staff D then revealed he would look at the beds if a work order was submitted, but does not do routine checks on the beds without a work order.Interview 9/24/25 at 2:45 PM with Staff B revealed that she was the CNA the morning of the incident with Resident #2. Staff B revealed that she was getting Resident #2 ready for a shower and had got a chuck pad for Resident #2's wheelchair, and then went and got the mechanical lift. Staff B revealed that she went to roll Resident #2 and Resident #2 was stiffer that morning, and her knees were hitting the wall. Staff B then revealed that she went to use the draw sheet to help assist with rolling the resident, and when she pulled on the sheet the bed moved and Resident #2 started to fall between the bed and the wall. Staff B further revealed that it all happened very quickly and she reached out to catch resident #2 so she didn't fall to the floor. Staff B further revealed that when she got Resident #2 back safely on the bed is when she noticed the laceration to the forehead of resident #2. Staff B then revealed that she placed a wet washcloth on the wound and hit the call light. Staff B further revealed that nobody was coming so she left the washcloth on the area on Resident #2's forehead and went to the dining area to get another CNA to call a nurse stat. Staff B revealed that Staff A RN came to the unit and helped clean the area, and called hospice who deemed they should send Resident #2 out to the hospital for sutures. Staff B revealed that after the incident she checked the brakes on the bed with the hospice nurse and it was noted that the inside wheel closest to the wall wasn't locked, and that the pedal system wasn't working properly. Staff B further revealed that it was reported to the maintenance manager and the bed was replaced immediately. Staff B then revealed that she should have checked the brakes on the bed prior to getting Resident #2 up. Interview 9/25/25 at 11:48 AM with the Director of Nursing (DON) revealed that he would have liked to have seen the staff check that the brakes were locked prior to transferring or repositioning the resident. The DON further revealed they did not have a policy, but it was part of the yearly competencies to make sure that beds are locked before transferring or repositioning residents. Review of a facility provided document titled, Pre-Procedure Safety Skills Checklist dated 9/4/25 revealed:Check that bed is locked and in the lowest safe position before beginning.

Based on observations, staff interviews and clinical record review the facility failed to provide adequate treatment and interventions to prevent the worsening of pressure ulcers for 1 resident (Resident #23) and failed to implement interventions timely for 2 of 4 residents reviewed (Resident #23, #15). Staff failed to apply the pressure-reducing boots for Resident #23 and failed to document or follow up on a new area for Resident #23 and #15. The facility reported a census of 65 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. 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #23 was unable to participate in a Brief Interview for Mental Status (BIMS) assessment. He had severe memory problems, and impaired cognitive skills. The resident was totally dependent on staff for eating, toileting, dressing, rolling over, and transfers. Resident #23 was at risk for pressure injury and did not have any ulcers at the time of the assessment. His diagnoses included; deep venous thrombosis, neurogenic bladder, secondary Parkinsons, chronic embolism and thrombosis of deep veins of lower extremities, chronic kidney disease. The Care Plan for Resident #23, last revised on 8/7/24, showed that the resident was at risk for fluid volume depletion/excess edema, and was on diuretic therapy. Nursing was to monitor for edema. He had chronic pain related to arthritis and neuropathy in the bilateral lower extremities, nursing was to encourage and assist to position for comfort. The resident was at risk for skin breakdown related to impaired mobility, pain and use of compression stockings. Nursing was to assist with wearing heel protectors at all times and floating heels while in bed to prevent pressure sores. Staff were to observe skin and any wounds for changes such as redness, tenderness, drainage and to notify the physician. The Braden assessment dated [DATE] for Resident #23 documented he was at moderate risk for pressure related skin breakdown. On 6/2/25 at 12:44 PM, a Hospice Nurse Aide (HNA) attended to the resident and removed his stockings. The resident was not wearing edema-wear hose, the skin on his feet was tight and his lower extremities were swollen. On his left distal foot/heel area, there was an undated wound dressing patch. Medial to the patch was an uncovered, open red ulcer on his heel. On the 2nd and 3rd toes of the left foot there were small open blisters. The medial side of his right ankle contained an unblanchable red area. The HNA was not aware if any of these sores were new or if they were being treated. The documents titled: Skin Integrity Events revealed the following: a. On 3/18/25 at 1:39 PM, the resident had red moist area to bilateral groin and tips of toes dry and cracked. No other areas documented. b. On 5/6/25 at 6:55 PM, the resident had a new wound measuring 2 centimeter (cm) x 2 cm. It was intact, not open. The intervention implemented was skin prep and heel protectors. c. On 5/17/25 heels and toes not checked, no measurements. d. On 5/24/25 left heel 5 cm x 3.3 cm. brown center the medial aspect of skin injury tissue was black in color and 2 cm x 2 cm. the second and third toes 0.2 cm x 0.2 cm. A review of the clinical record revealed an order dated 4/14/23 that Resident #23 would wear bilateral heel protectors at all times. An on-going observation on 6/3/25 revealed the following: a. At 11:20, Staff pushed the resident to the lunch table. He was wearing gripper socks, no edema wear and no protective boots. b. At 1:30 PM, the resident was still in the wheel chair. It was tipped back slightly, he was sleeping. His feet were unsupported, dangling, not on the foot rest. c. At 3:30 PM, the resident was in the same position in front of the television in the dining area. His feet were dangling, not on foot pedals. His legs were swollen. d. At 4:20 PM, the resident was still in the wheel chair, in front of the television. His legs dangling. He was leaning forward in the chair with his head hanging down and reaching into the air for unseen items. A Nursing Note dated 6/4/25 at 2:25 PM, showed two new areas distal to the larger wound on the left heel that measured 0.5 cm x 0.5 cm. The area was pink surrounding the wound where the dressing tape maybe tearing the skin. The chart lacked mention of the new area on the right heel, and lacked documentation that the doctor or Hospice had been contacted regarding the new open wounds. On 6/5/25 at 8:02 AM, Staff O, Care Coordinator, provided wound treatment changes for Resident #23. The patch on his left heel was not dated and it was soaked with serosanguinous fluid. Staff O acknowledged that it was macerated. She said that the nurse on the previous day, had noticed that the wound was getting worse and they would contact hospice. The area on the left heel measured 2 cm. x 1.8 cm. in the center with two smaller areas nearby measuring 0.7 cm. x 0.6 and 0.5 cm. x 0.5 cm. When directed to the right heel, Staff O look at it and agreed that it was unblanchable, and it measured 2.6 cm x 1.4 cm. Staff O acknowledged that the protective boots must be on at all times. On 6/5/25 at 10:26 AM, Staff O CC said that she ordered a support board for the wheel chair for Resident #23. She said that his feet should not be dangling, and this was concerning for his chronic edema. Staff O said that the resident needed to be repositioned more often. According to a facility policy titled; Skin Integrity and Wound/Pressure Injury Prevention/Treatment/Observation and Documentation, dated June of 2020; preventative measures encourage repositioning, heel protectors. All nurses would be responsible for ensuring the Care Plan and interventions were updated and monitor to ensure interventions were carried out as planned. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #15 scored 10/15 on the Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The document revealed diagnoses of cerebrovascular accident/transient ischemic attack/stroke, Non-Alzheimer's dementia, coronary artery disease, and asthma/chronic obstructive pulmonary disease (COPD)/chronic lung disease. The assessment disclosed the resident required partial/moderate assistance for transfers, and independence with rolling left/right, and lying to/from sitting. The document revealed the resident was at risk for pressure ulcers/injury, did not have a pressure ulcer/injury, and no other skin problems or wounds. The document indicated the resident utilized skin and ulcer/injury treatments including pressure reducing devices for chair and bed. The resident did not receive Hospice services. The Electronic Medical Record (EMR) Skin Assessments for Resident #15 revealed the following: -On 1/19/25 red areas noted to the top of bilateral feet 1st digits. The resident denied pain. -On 1/23/25 tips of bilateral feet, 1st digits noted to have red areas. -On 1/30/25 tips of bilateral feet, 1st digits noted to have red areas. -On 2/6/25 red areas noted to bilateral feet 1st digits, the tip of them. -On 2/14/25 no concerns with feet. -On 2/20/25 red areas noted to bilateral feet, 1st digits. -On 2/28/25 no concerns with toes. -On 3/5/25 left foot, 1st digit noted to have a black area that measures approximately 1.2 cm in diameter. Right foot, 1st digit noted to have a scabbed area that measures approximately 0.5 cm in diameter. No drainage noted from either digit. Requested that the resident be seen by the wound nurse during rounds. Also a request had already been sent for a podiatry appointment. -On 3/6/25 left foot, 1st digit noted to have a black area that measures approximately 1.2 cm in diameter. Right foot, 1st digit noted to have a scabbed area that measures approximately 0.5 cm in diameter. No drainage noted from either digit. The Braden Scale, dated 1/11/25, revealed the resident was not at risk. The Progress Notes revealed on 2/24/25 a referral was generated for podiatry for the right foot; the 5th digit was long, loose, and fungal. The Progress Notes revealed notification to the physician with new orders on 3/6/25 for painting Betadine to scabbed areas on bilateral great toes twice daily until healed. Note on 3/6/25 also revealed referral to hospice services. Observed on 6/2/2025 at 12:27 PM Resident #15 seated in her recliner with a blanket cradle tent at the foot of the bed. On 6/2/25 at 12:27 PM Resident #15's daughter stated the resident had pressure areas on her toes that were now healing. The family member stated the resident has a preference for having several blankets, and believed the blankets were applying pressure to her toes. The daughter stated the staff were now getting the resident up into her recliner more and the resident has a tent that keeps the blankets off of her toes. On 6/4/25 at 2:50 PM Staff J, Registered Nurse (RN)/Care Coordinator (CC) revealed she was not aware of the resident's skin condition until 3/5/25. Staff J stated when there was a change in skin condition the Care Coordinator and/or the physician should be notified. The staff stated it would have been acceptable to use a fax notification as it was not an emergency. Staff J stated she did not know what stage the wound was when she was notified as she did not stage the wound. On 6/4/25 at 3:32 PM Staff B, Director of Nursing (DON) stated the Care Coordinator should have been aware of the reddened toes either by reviewing the Skin Assessments or by notification from the nurse completing the assessment. On 6/5/25 at 9:35 AM the Administrator stated she expected if toes were reddened there would have been some intervention(s) put into place. The facility Skin Integrity and Wound/Pressure Injury Prevention/Treatment/Observation and Documentation Policy, dated 6/20, revealed all team members were responsible for preventing, caring and providing treatment for skin integrity issues. The document disclosed all impaired skin integrity concerns/skin care the physician should be notified immediately and documented. The document further revealed all nurses were responsible for monitoring for changes in condition, implementing interventions, and updating the Care Plan to prevent skin breakdown.

2. According to the MDS dated [DATE], Resident #3 had a BIMS score of 15 (intact cognitive ability). He was independent with eating and required supervision and touch assistance with transfers. He had highly impaired hearing ability. His diagnoses included neurogenic bladder, diabetes mellitus, aphasia, anxiety communication deficit. The Care Plan updated on 4/24/25, showed that Resident #3 was at risk for choking related to dysphagia staff would offer a regular, mechanical soft diet. The resident had significant anxiety and wanted to know what to expect throughout the day. He was deaf, and it was important for him to be involved in his cares. Writing material was provided to the resident, he was able to write and understand short phrases. On 6/4/25 at 6:00 AM, with the use of writing materials kept in the back pocket of his wheel chair, Resident #3 communicated that he was not aware that there were meal options if he preferred something other than what was being served. Resident #3 wrote that he didn't like corn or peas but he did not know what substitutes he could have for a vegetable. 3. According to the MDS dated [DATE], Resident #7 had a BIMs score of 15 (intact cognitive ability). He was independent with eating, toileting, dressing and hygiene. His diagnoses included diabetes mellitus and anxiety disorder, The Care Plan updated on 6/3/25, showed that he had anxiety and did not like disruptions in scheduled. Staff were to encourage him to participate in care his cares by asking questions. The resident had autism and had difficulty in social interactions. On 6/2/25 at 2:30 PM, Resident #7 said that he was not aware of food substitute options at meals. He added: I don't know what would happen if I didn't eat what they served me. On 6/4/25 at 6:00 AM, Staff P, CNA said that she was not sure of food options that residents had for meals if they didn't like what was being served. She did not know where the options were listed. On 6/3/25 at 2:00 PM, Staff Q, Cottage Cook, said the options for residents included: hamburger patty, peanut butter or deli meat sandwich or soups. She acknowledged that these options were not posted anywhere for the residents to see daily. On 6/3/25 at 2:30 PM, the Dietary Manager provided a list of alternatives that included sandwiches, soups and cereal. He said this list was not posted or given to the residents but kept in a binder in the kitchen areas. He said there were some items that residents could request other foods, but it would be limited related to availability. He said that the residents didn't have a menu to fill out, they know to look at the black board where the meals are posted and that the kitchen knows their likes and dislikes. On 6/3/25 at 3:00 PM, the Administrator said that the staff carry pocket care plan that included the residents' preferences. Staff were expected to check those to see if there was anything on the menu that they didn't like. She said they don't post the optional menu because the residents would then think that these were their only options and they can have whatever they would like to eat. The Administrator said that in the small cottage environment, the staff know the residents well, that included their foods preferences. An undated document included in the admission packet showed that resident food preferences would be considered and staff would assist the residents to exercise their choice in what they eat and drink. Based on observation, resident interview, staff interview and policy review the facility failed to provide food that accommodates the resident preferences and provide an appealing option for residents who chose not to eat food that was initially served to them or requested a different meal choice for 2 of 20 residents reviewed (Resident #3, #7 and #56). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 0 indicating Resident #56 was rarely/never understood. The MDS also indicated Resident #56 was deaf. On 6/3/25 at 11:35 AM an observation of lunch service with Staff C, Hostess/Cook revealed all food removed from the oven and placed on the stove top. Observation revealed no alternative food prepared for lunch at that time. Review of undated document titled, Substitutes for Meals hanging on the refrigerator facing the interior of the kitchen unable to be seen by staff or residents outside of the interior of the kitchen. On 6/4/25 at 11:52 AM observation of Staff F, Certified Nursing Assistant (CNA) presented a lunch meal to Resident #56. Resident #56 picked up the corn and shook his head left to right that indicated no. Staff F asked Resident #56 if he didn't like the corn and Resident #56 shook his head no again. Staff F returned the corn to the kitchen and told Staff C Resident #56 refused the corn. On 6/4/25 at 12:25 PM Staff C acknowledged corn was not on Resident #56's pocket care plan for a dislike but he did not want corn for lunch on 6/4/25. Staff C stated she would usually offer the resident something if they refuse the vegetable. Staff C acknowledged she did not offer Resident #56 an alternative. Staff C explained the CNA did not say she asked Resident #56 if he wanted an alternative either. Staff C acknowledged she should have asked Resident #56 if he wanted an alternative and she did not. On 6/4/25 at 12:40 PM Staff F acknowledged that she did not offer Resident #56 anything else when he refused the corn on 6/5/25. Staff F stated she would typically offer the resident an alternative but did not offer an alternative vegetable on 6/4/25 to Resident #56. Staff F stated she thought the alternative was usually a vegetable medley that also contained corn. Staff F stated she did not know what would be offered if the resident did not want corn because the medley would also contain corn. On 6/3/25 at 12:06 PM Staff A Certified Nursing Assistant/Certified Medication Assistant (CNA/CMA) stated helps with lunch service when at the facility. Staff A stated the residents knew what the meal was by reading the menu board. Staff A stated no staff ask the residents what they want for the meals or if they want an alternate. Staff A stated if it is set in front of them and they don't like it the cook will find an alternative. Staff A stated there was not an alternative menu that the residents are aware of if they do not like what they are having. On 6/3/25 at 12:11 PM Staff G, CNA stated sometimes the residents say they do not like what was served as the meal. Staff G stated she would offer a sandwich or something else. Staff G stated there were only sandwiches provided as an alternative. Staff G stated there was not a list of alternatives for the resident to choose from. Staff G stated if the cook was busy she would make the sandwich or the cook would make it. On 6/3/25 at 12:15 PM Staff H, Registered Nurse (RN) the menu is listed on the wall and if the resident asks they will get them something different. On 6/3/25 at 2:28 PM Staff D, Certified Dietary Manager (CDM) stated since the facility changed to the new menu there has not been as many substitutions. Staff D stated just the meal on the board was usually prepared. On 6/4/25 at 10:21 AM Staff E, Registered Dietitian stated the alternate food items were not posted anywhere but the hostess is supposed to know and to use a pocket care plan for likes and dislikes.

Based on observations, family interview, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 16 residents reviewed (Resident #15 and Resident #24). The facility failed to revise the interventions for a resident who sustained a burn and a resident who had a pressure area develop. The facility reported a census of 65 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #15 scored 10/15 on the Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The document revealed diagnoses of cerebrovascular accident/transient ischemic attack/stroke, Non-Alzheimer's dementia, coronary artery disease, and asthma/chronic obstructive pulmonary disease (COPD)/chronic lung disease. The assessment disclosed the resident required partial/moderate assistance for transfers, and independence with rolling left/right, and lying to/from sitting. The document revealed the resident was at risk for pressure ulcers/injury, did not have a pressure ulcer/injury, and no other skin problems or wounds. The document indicated the resident utilized skin and ulcer/injury treatments including pressure reducing devices for chair and bed. The resident did not receive hospice services. Observed on 6/2/2025 at 12:27 PM Resident #15 seated in her recliner with a blanket cradle tent at the foot of the bed. Observed on 6/3/25 at 12:28 PM Resident #15 was seated in her recliner when Staff I, Registered Nurse (RN), provided Betadine treatment for a pressure area on the left great toe. The blanket cradle was observed at the foot of the bed. Observed on 6/4/25 at 7:15 AM Resident #15 in bed with a blanket cradle in place at the foot of the bed. On 6/2/25 at 12:27 PM Resident #15's daughter stated the resident had pressure areas on her toes that were now healing. The family member stated the resident has a preference for having several blankets, and believed the blankets were applying pressure to her toes. The daughter stated the staff were now getting the resident up into her recliner more and the resident has a tent that keeps the blankets off of her toes. Resident #15's Medication/Treatment Administration Record for 6/25 revealed an order for a blanket tent to keep blankets off the feet with start date of 5/21/25, and wound care to left great toe with start date of 6/2/25. Resident #15's Pocket Care Plan, provided 6/4/25, identified skin interventions of barrier cream to intergluteal cleft and buttocks BID, air mattress with blanket cradle, and reposition frequently as the resident allows. Resident #15's Care Plan dated 6/3/25 revealed a problem area, risk for pressure injury related to impaired mobility, poor nutrition and need for staff assistance with a start date of 9/11/24 and revision on 6/3/25. The approaches for staff intervention included nursing to complete weekly skin assessments with wound details and measurements. The primary care physician (PCP) notified of new and worsening wounds. The document disclosed the resident to be assisted with repositioning at least every 2-3 hours. The Care Team to monitor for signs of skin breakdown and notify nursing of any concerns. The document revealed the start dates for the approaches at 9/21/24. The resident's Care Plan further revealed a problem area of risk for falls edited on 6/3/25. The problem area revealed an approach start date of 4/24/25 with a 4/23/25 unwitnessed fall out of bed without major injury with the air mattress removed from bed for safety with a creation date of 4/28/25. The Electronic Medical Record (EMR) Progress Notes revealed on 3/6/25 during a Care Conference discussion of the use of an air mattress and blanket cradle due to new wounds on the resident's toes. The document with an entry on 3/8/25 revealed the air mattress was delivered. The Progress Note dated 4/24/25 revealed Hospice exchanged the air mattress for a foam mattress. The facility failed to update the Pocket Care Plan and Care Plan to reflect Resident #15's current needs. The Pocket Care Plan reflected the use of an air mattress that was removed on 4/24/25. The Care Plan failed to identify interventions put into place for treatment of pressure injuries to the resident's toes. On 6/4/25 at 2:50 PM Staff J, RN/Care Coordinator (CC), stated the blanket cradle is reflected on the Pocket Care Plan and on the nurses orders. The blanket cradle should be reflected on the Care Plan. On 6/4/25 at 3:32 PM Staff B, Director of Nursing (DON), stated he expected the Care Plan to reflect the interventions needed to provide care to the resident. On 6/5/25 at 9:49 AM a Hospice representative stated the blanket cradle was delivered on 3/12/25. 2. According to the MDS assessment dated [DATE] Resident #24 could not complete the BIMS. The staff assessment revealed the resident had short term and long term memory problems, and moderately impaired cognitive skills for daily decision making. The resident had diagnoses of coronary artery disease, hypertension, and chronic pain. The resident required setup for eating. Observed Resident #24 on 6/2/25 at 12:10 PM drinking coffee with a noon meal. Observed Resident #24 on 6/4/25 at 9:00 AM have a cup of coffee on the dining table. Resident #24's Progress Note dated 12/22/24 revealed the resident spilled a cup of coffee and sustained red blistering areas on bilateral inner upper thighs that were approximately the size of a soft ball. Resident #24's Pocket Care Plan, provided 6/5/25, revealed the resident loved coffee and to place 3-4 ice cubes in it before serving. Resident #24's Care Plan dated 6/3/25 revealed a problem area with a start date of 4/17/20 for a nutrition risk that was edited on 6/3/25. An approach for the problem area revealed thin liquids and enjoyed coffee throughout the day created on 9/16/24. The facility failed to update the Care Plan to reflect the burn on 12/22/24 and the interventions put into place. The Care Plan further failed to identify interventions that had been trialed and refused by the resident, and responses made by the family regarding the burn. On 6/4/25 at 3:08 PM Staff J stated was on vacation at the time of the incident and the Pocket Care Plan should have the recommendation following the burn. On 6/4/25 at 4:34 PM the Administrator stated the facility has a priority to update the Pocket Care Plan as it is what the direct care staff utilize to keep the residents safe and to provide care. The Administrator stated the Care Plan should have more information and they should be updated timely. The Administrator stated the Care Plans should be updated maybe in a week or 2 following the update to a Pocket Care Plan. The Administrator stated the facility is in the process of moving from MatrixCare to PointClickCare electronic documentation platform and with that the Care Plan will revise and change. The facility Skin Integrity and Wound/Pressure Injury Prevention/Treatment/Observation and Documentation Policy, dated 6/20, revealed the nurses would monitor for change in condition and implement interventions, and update the Care Plan as needed to prevent skin breakdown. The facility Hot Liquids Safety Policy, dated 5/15/24, revealed interventions related to hot liquids would be individualized and noted on the resident's Care Plan. The facility Comprehensive Care Plans Policy, dated 6/6/25, revealed all services are identified in the resident's comprehensive assessment and meet professional standards of quality. The document disclosed it would be reviewed and revised by the interdisciplinary team after each comprehensive review and quarterly MDS assessment, and alternative interventions will be documented as needed.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not completing assessments for 1 of 16 residents (Resident #24) reviewed. The facility reported a census of 65 residents. Findings include: According to the MDS assessment dated [DATE] Resident #24 could not complete the BIMS. The staff assessment revealed the resident had short term and long term memory problems, and moderately impaired cognitive skills for daily decision making. The resident had diagnoses of coronary artery disease, hypertension, and chronic pain. The resident required setup for eating. The Progress Note dated 12/22/24 revealed Resident #24 spilled a cup of coffee and sustained red blistering areas on bilateral inner upper thighs that were approximately the size of a soft ball. Review of Assessments completed from 1/1/24 to 6/5/25 revealed the facility failed to complete a Hot Liquids Risk Assessment for Resident #24. Observed Resident #24 on 6/2/25 at 12:10 PM drinking coffee with a noon meal. Observed Resident #24 on 6/4/25 at 9:00 AM have a cup of coffee on the dining table. On 6/4/25 at 10:28 AM Staff E, Registered Dietitian, stated she was unaware of any resident having a burn related to coffee spillage. The staff stated she was unaware of the facility policy/procedure regarding serving of coffee and temperatures. On 6/4/25 at 3:08 PM Staff J stated she was on vacation at the time of the incident. The staff was unable to produce a Hot Liquids Risk Assessment for the resident. On 6/4/25 at 3:24 PM Staff B stated Hot Liquids Risk Assessment should be completed upon admission and quarterly. The DON stated he could not locate a Hot Liquids Risk Assessment for Resident #24. On 6/4/25 at 9:00 AM the Administrator stated there should have been a Hot Liquids Risk Assessment completed for Resident #24. The facility Hot Liquid Safety Policy reviewed/revised 5/15/24 disclosed all residents were assessed for their ability to handle containers and consume hot liquids as part of their. It was noted this sentence was incomplete and no further details on assessment were provided in the policy.

Based on observations, resident interviews, staff interviews and policy review the facility failed to provide food at an appetizing temperature to 2 of 20 residents reviewed (Resident #6 and #30). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set MDS dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 6/2/25 at 12:31 PM Resident #6 stated the meat, vegetable, and potatoes will be served cold. Resident #6 stated the food had been served cold in the last week. 2. The MDS dated [DATE] revealed Resident #30 had a BIMS score of 13 indicating no cognitive impairment. On 6/2/25 at 12:33 PM Resident #30 stated the food that should be warm is served cool or cold at least once a week. Resident #30 stated the staff would warm it up but she did not ask. On 6/3/25 at 11:35 AM an observation of lunch service with Staff C, [NAME] revealed all food removed from the oven and placed on the stove top. Staff C did not turn the stove top on. On 6/3/25 at 11:36 AM Staff C obtained temperatures of the food. The temperature of the beef stroganoff was 165 degrees, mashed potatoes 203 degrees, chuckwagon corn 197 degrees, low sodium beef for 2 mg sodium diet 166 degrees and cream corn for mechanical diet 166.2 degrees. A continuous observation of lunch service on 6/3/25 from 11:35 AM - 11:55 AM revealed Staff C plated the lunch meal and the CNA staff took the plates to the residents. Staff C placed the last plate in the microwave, turned the microwave on, removed the plate from the microwave and gave the plate to a CNA to take to Resident #30. The temperature of the food placed in the microwave was not checked. On 6/3/25 at 11:55 AM post service temperatures were obtained by Staff C. The temperatures revealed the corn had a temperature of 158 degrees, mashed potatoes 121 and beef stroganoff 130 degrees. On 6/3/25 at 11:56 AM Staff C stated she placed the plate in the microwave because she thought the food might be cold. Staff C acknowledged that she did not obtain a temperature of the food removed from the microwave prior to sending the food out to the resident. Staff C explained she should have obtained the temperature of the food placed in the microwave prior to sending the food to the resident. Staff C stated the food in the microwave should have been at least 165 degrees after being microwaved. Staff C stated her expectation was a minimum of 135 for holding temperatures of the food on the stove. Staff C acknowledged the stove top was not on and the back burner did not work because the knob was broken off. Staff C stated she was not sure if anyone was aware the back burner did not work. Staff C stated it had been broken for a while and she did not tell anyone. Staff [NAME] stated Resident #30 will complain when the food is served cold and frequently does. On 6/3/25 at 2:28 PM Staff D, Certified Dietary Manager (CDM) stated Staff C stated his expectation was 150 degrees or above for holding temperature of food during meal service. Staff D stated his expectation was the temperatures would have held and the stove top would have been on to ensure the temperature would maintain an appropriate holding temperature. Staff D stated residents did complain about the food being cold. Staff D stated it was usually the same 2 residents in house 138. On 6/4/25 at 10:21 AM Staff E, Registered Dietitian stated Staff C reheated the plate and served it and did not recheck the temp prior to serving the plate. Staff E stated the facility policy stated the temperature should be checked to ensure the temp is 165 degrees or above. Staff E stated temperatures should be held at 135 or above during meal service. Staff E stated the temperature of the meat at the end of service concerned her. Review of undated document titled, Food Temperatures documented all hot food items would be served to the resident at the temperature of at least 120 degrees at the time the resident received the food. Hot food items may not fall below 140 after cooking unless it is an item which is to be rapidly cooled to below 40 degrees and reheated to at least 165 degrees prior to serving. Normally hot foods will be 165 - 180 degrees or higher when removed from the cooking heat source. If held at 160 - 180 degrees this would ensure serving to the residents at 140 degrees or above. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking.

Based on observation, Electronic Health Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with an indwelling catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed (Resident #30). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #30 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating moderate cognitive impairment. The MDS also indicated use of an indwelling catheter. Review of the EHR titled, Care Plan, dated 4/19/24 documented Resident #30 had an indwelling catheter and required EBP precautions. Resident #30's team will follow EBP precautions. EBP supplies would be available in Resident #30's room for staff to utilize when providing care. Review of the EHR titled, Orders, dated 8/7/23 documented physician orders for catheter cares each shift, change catheter bag weekly and change 18 Fr all silicone catheter monthly. An observation on 6/3/25 at 2:10 PM of Resident #30's catheter bag emptied revealed Staff A, Certified Nursing Assistant / Certified Medication Assistant CNA/CMA completed hand hygiene, applied gloves, did not apply a gown, obtained a barrier, applied barrier to the ground, placed graduated cylinder on the barrier, cleansed catheter tip with alcohol wipe, emptied urine into graduated cylinder, cleansed catheter tip with alcohol wipe, closed the catheter tip, graduate taken into the bathroom, graduate emptied into the toilet, 650mL removed from graduate, gloves removed, and hand hygiene completed. On 6/4/25 at 5:04 PM the Director of Nursing (DON) stated the facility's expectation was that a gown would be donned during catheter care or contact with a catheter at all. The DON acknowledged that Resident #30 was on EBP. The DON acknowledged Resident #30 utilized a catheter. The DON acknowledged that a gown should have been worn during catheter care for Resident #30. Review of policy implemented 4/1/24 titled, Enhanced Barrier Precautions Policy and Procedure documented EBP are used in conjunction with standard precautions and expand the use of personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Residents will be placed on EBP with indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include but are not limited to central lines, urinary catheters, feeding tubes and tracheostomies.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to transfer a resident with a gait belt and the resident fell resulting in an injury for 1 of 10 residents (Resident #1) reviewed for falls and safe transfers. The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #1 dated 7/2/24 reflected the Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. The resident required partial/moderate assistance for transfers, ambulation, and lower body dressing. In the past 7 days of the assessment period the resident used a walker and wheelchair. During the previous 5 days of the assessment period Resident #1 received scheduled pain medication and as needed (PRN) pain medication. The resident was frequently incontinent of bladder and occasional incontinence of bowel. The resident had diagnoses of heart failure and renal insufficiency. The document further revealed the resident took an anticoagulant medication. Resident #1's Care Plan had an identified problem area of risk for falls related to incontinence, need for staff assistance for transfers, pain and weakness. Approaches for staff to utilize included ensuring call light and frequently needed items were within reach, and placement of the lift recliner remote in the side pocket. Resident #1's pocket care plan at the time of the fall reflected the resident required staff assist x1 for activities of daily living (ADLs), and transfers with assistance x1. The Care Plan also identified the resident at risk for complications related to anticoagulant (blood thinner) therapy. It directed staff to assess for episodes of excessive bleeding/bruising and to notify the physician. The Active Orders for Resident #1 revealed the resident was on warfarin (blood thinner) 3mg oral every day. The email dated 7/24/24 to the staff of Resident #1's cottage, nursing department, and Staff G, Registered Nurse (RN), Care Coordinator from the therapy department provided instructions to staff that the resident required assistance of 1 staff for ambulation with a front wheeled walker and left (L) knee brace to and from the bathroom (room only). The electronic health record (EHR) revealed on 8/13/24 at 11:02 AM Staff G, RN, Care Coordinator, responded to a nurse stat call. The document revealed Resident #1 was seated on the floor with her backside to the toilet, legs in front of her, and a laceration to the back of her head. Staff H, Certified Nursing Assistant (CNA), was seated on the floor next to the resident. The document revealed the resident was responding at baseline; however, due to the resident taking an anticoagulant medication was sent to the emergency room via 911 services and admitted to the hospital. The Event Report document within the EHR dated 8/13/24 at 11:34 AM revealed Resident #1 sustained a ground level fall in the bathroom. The document indicated the resident had no complaints of pain post fall and sustained a laceration to the back of the head. Assessment of Resident #1 included vitals, range of motion, neurological check, facial muscle movement, upper extremity movements/grasps, lower extremity range of motion, pupil size/response/shape, and speech. The document revealed the resident's walker was in the bathroom, and the resident was wearing tennis shoes. The document indicated the primary care provider was called and a phone order was received for sending the resident to the hospital. The resident's son and daughter were called and notified of the fall, and the resident was transferred to the hospital. Resident #1's hospital record dated 8/13/24 to 8/16/24 revealed diagnoses of intraventricular hemorrhage, scalp laceration and closed head injury without loss of consciousness. An observation on 9/20/24 at 12:07 PM revealed Staff A, CNA, utilized an EZ Way Lift (weight bearing mechanical lift) for transferring Resident #1 from the wheelchair (w/c) in her bedroom to the bathroom/toilet and from the toilet to the resident's recliner. On 9/20/24 at 10:57 AM Staff I, Physical Therapist Assistant (PTA) stated Resident #1 prior to the fall on 8/13/24 required minimum to moderate assistance for sit to stand sequence, and once standing the resident required contact guard assist for ambulation using a front wheeled walker (FWW). Staff I stated the cottage staff were instructed to ambulate the resident using a FWW and L knee brace for bathroom/bedroom distances. The staff stated the resident had decreased compliance with use of the knee brace before the fall. Staff I stated staff should have had at least 1 hand on Resident #1 at all times. Staff I stated the use of gait belt is a facility requirement for all transfers. The staff stated since returning from the hospital, therapy had assessed the resident and recommended the use of an EZ Way Lift for all transfers as the resident was no longer safe for stand pivot transfers or ambulation due to knee pain and crepitus. Staff stated an email was sent to the cottage staff in July with instructions for room distance ambulation with the resident. On 9/20/24 at 12:15 PM Staff A stated prior to the fall in August, Resident #1 was able to ambulate to the bathroom with a gait belt and FWW. The staff stated a gait belt was required for all transfers. On 9/20/24 at 12:24 PM Resident #1 stated she did fall in the bathroom and cut the back of her head. The resident stated her feet just started sliding and she fell . The resident stated she did not like to wear her knee brace and was not wearing a gait belt at the time of the fall. On 9/20/24 at 12:43 PM Staff G, RN, Care Coordinator, stated on 8/13/24 she assessed Resident #1 post fall. The staff stated the resident did not have a gait belt or the knee brace on. Staff G stated the resident had a laceration on the back of her head, was conscious, and at baseline cognitively. The staff stated the resident had complaints of pain in her knees prior to the fall and would not consistently wear her knee brace. Staff G stated that since returning from the hospital the resident was changed to the use of the EZ Way Lift due to decreased strength and safety. The staff stated all staff were to use a gait belt with all residents when completing transfers. Staff G stated the gait belt was required to be on the staff at all times when working. The staff stated the facility provided gait belts for staff to use while at work, and the cottages had extra gait belts if needed. On 9/20/24 at 2:34 PM Staff H, CNA, stated she assisted Resident #1 to the bathroom. The staff could not recall whether a gait belt was utilized walking to the bathroom. Staff H stated she did not use a gait belt following toileting and when starting to walk back to the resident's bedroom. The staff stated Resident #1 lost her balance, and she was not prepared for that and could not stop the fall. Staff H stated the resident had her FWW with her. Staff H stated she had turned her attention to obtain the resident's glasses from the counter when the resident lost her balance and fell . Staff H stated she was aware of the facility policy requiring the use of gait belt when transferring residents, but at the time was not thinking the steps through as clearly as she should have. The staff did recall receiving the email regarding the resident's assistance needs for transfers and ambulation. On 9/20/24 at 4:36 PM Staff E, CNA, stated staff should always use a gait belt when transferring a resident, and they had recent re-training on the use of gait belts and transfers. On 9/21/24 at 8:25 AM Staff F, CNA, stated staff should always use a gait belt when transferring residents and that she had recent training on transfers and gait belts. On 9/20/24 at 9:45 AM the Administrator stated the facility policy required staff to utilize gait belts for all transfers. The Administrator stated the facility had implemented competency checks during nurse manager rounds, and did a re-training on gait belt use following the fall. The facility provided document, Glen Haven Village Safe Lifting/Transfers, revised 2/21, revealed all non-mechanical transfers require gait belt usage. The document further revealed that staff should wear a gait belt on their person at all times to ensure they were readily available.

Based on clinical record review, staff interviews, camera footage review and facility policy review the facility failed to assure residents were free from significant medication errors for 1 of 7 resident reviewed (Resident #24). The facility reported a census of 65 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of high blood pressure, Diabetes Mellitus (DM) and hemiplegia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The Care Plan for Resident #24 dated 12/1/23 showed the following: - I have the potential for hypoglycemia and hyperglycemia episodes secondary to the diagnosis of DM. - I have the potential for complications related to antiplatelet therapy. - I may have difficulty verbally expressing my needs due to my diagnosis of vascular dementia and recent stroke which affected my vocal cords. The June 2024 Medication Reconciliation Form showed the following medications were administered by Staff D on 6/9/2024 for the 7 PM medication pass: Ferrous Sulfate 325 milligrams (mg) for iron deficiency Metformin 500 mg for diabetes Metoprolol 25 mg for rheumatoid arthritis The MDS assessment dated [DATE] for Resident #13 documented diagnoses of high blood pressure, Parkinson's Disease, seizure disorder and depression. The MDS showed a BIMS score of 10 which indicated a moderately severe cognitive impairment. The Care Plan for Resident #13 dated 6/13/24 showed the following: - I am at risk for complications related to antiplatelet therapy. - I am at risk for adverse consequences related to receiving psychotropic medications for the treatment of depression and bipolar disorder. - My team will administer my anti-seizure medication The June 2024 Medication Reconciliation Form showed the following medications were administered on 6/9/2024 for the 7 PM medication pass: Aspirin 81 mg to prevent blood clotting Cephalexin 250 mg for infection Divalproex DR 500 mg for convulsions/seizures Lamotrigine 100 mg for convulsions/seizures Latanoprost 0.005% eye drops for dry eyes Primidone 50 mg for convulsions/seizures Risperidone 1 mg for bipolar depression Trazadone 100 mg for depression and to treat thought processes and behavioral disorders in people with perceptual disorders. Vitamin D3 25 mcg In an interview on 7/9/24 at 12:32 PM, Staff B, Licensed Practical Nurse (LPN), Care Coordinator stated, she received a phone call overnight from Staff C. She said, I'm not sure but I think the nurse gave the wrong meds to the wrong resident. Staff C explained, Resident #13, reported the nurse came into her room. Resident #13 observed Staff D, Registered Nurse (RN) open her roommate's medication cabinet door (Resident #24), then left the room. Resident #13 stated, the nurse didn't give her the medications. After the call Staff B then called Staff D and asked the nurse, who's medications she gave in room three? Staff D replied, she just got done giving room [ROOM NUMBER] meds. Staff B stated, Staff D was unsure who exactly she gave meds to, but said that she matched residents with pictures, and matched the medications to the MAR. Staff B stated, she told her to monitor the resident just in case she gave wrong meds. Staff B reported despite sending another nurse over to the cottage, they were unable to determine if a medication error occurred. Staff B stated, she came in the next morning for a cottage meeting, they noticed a change in condition in Resident #24, so they called the primary care provider (PCP). The PCP ordered a Risperdal and Depakote level and they were drawn. The test results showed Resident #24 had both medications in her system. Resident #24 didn't have orders for Risperdal and Depakote but her roommate did. We knew then the medication error occurred. Staff C reported the resident was a little more tired than usual. In an interview on 7/9/24 at 3:28 PM, Staff C, Certified Nursing Assistant (CNA) reported Resident #13 and #24 shared a room. Staff C observed Staff D, Registered Nurse (RN) give medications to Resident #24 in the day room. Later as Staff C assisted the roommate, Resident #13, to bed she asked if the resident received medications yet. Resident #13 replied, no. Resident #13 stated she observed the nurse in her medication cabinet and removed the medications from the card containers then left the room. When Staff C told Resident #13 that it was odd the nurse gave her roommate medications and not her. Resident #13 replied, she never saw her go into Resident #24's cabinet. I'm 100% sure. Staff C called Staff B, Licensed Practical Nurse (LPN), Care Coordinator to report Resident #24 may have incorrectly received Resident #13's medications. After the call Staff C found Resident #24 in the day room with her head resting down by her knees and vomit from her knees to the floor. Resident #24 reported her head hurt. Staff C and Staff D then assisted Resident #24 to her room. While in the room Staff C observed Staff D access Resident #24's medication cupboard. Staff C heard Staff D remove medications from each container. Staff C stated, she clearly remembered Staff D attempted to hide the medications with her pointer finger and pinky finger using her left hand. She could not see any pills but the way Staff D held her hands made her think she was hiding them. After that Staff D immediately put her hands down into her pants pockets. Staff C stated, Staff D helped put Resident #24 to bed and left the room. When asked about the Resident's #24 symptoms, Staff C replied, the resident was not throwing up prior to administration that she observed. After that the resident threw up a total of three times after she got meds. The resident also said that her head hurt. In an interview on 7/9/24 at 4:17 PM, the PCP stated, in terms of life threatening, Resident #24 getting Resident #13's medications and psych meds wasn't an imminent danger type of situation but it did throw her for loop for 3 days. The PCP stated he would characterize it as serious but not life threatening. In an interview on 7/10/24 at 12:03 PM, Staff B, LPN, Care Coordinator, reported the day following the medication error Resident #24 requested to stay in bed for meals. Staff B reported, Resident #24 didn't want to get up when staff attempted to get her up for meals. Staff B reported, per documentation, the resident failed to consume meals on 6/9/24, staff assisted the resident to take sips of water. The Progress Note on 6/10/24 at 6:34 AM for Resident #24 showed the following: Called to check on and assess a resident who was reported to have vomited a moderate amount of brown mucus like emesis. Resident observed sitting at the dining table noted with generalized weakness, was awake, lethargic but responsive to tactile stimuli. Resident assisted back to bed and was agitated and combative during transfer and assessment. The Risperidone Lab test collected on 6/10/24 for Resident #24 showed a blood level of 10.9 nanograms/milliliter (ng/ml). Review of the June 2024 MAR for Resident #24 showed Risperidone not ordered. The Depakote lab test collected on 6/10/24 for Resident #24 showed a blood level of 22.1 ng/ml. Review of the June 2024 MAR for Resident #24 showed Depakote not ordered. The Point of Care History for Resident #24 showed the following for the day after the medication error on 6/10/24: How did the resident transfer? Activity did not occur. How did the resident move off the unit? Activity did not occur. The timeline of camera footage for the evening of 6/9/2024 the following was noted: At 6:36 PM Staff D, RN took Resident #24's blood pressure At 6:49 PM Staff D took medication cup into Resident #24's room without the computer. After a few moments the nurse returned to her cart with medications. Staff D placed some of the pills from her hand into a pill crusher sleeve and crushed them, she then opened a capsule pill and emptied the contents into the medication cup along with the crushed pills. At 6:52 PM Staff D walked back toward room [ROOM NUMBER], when she returned she added pudding to the crushed pills in a med cup. At 6:53 PM Staff D approached Resident #24 in the lounge where she sat and administered the medication. By 7:25 PM Resident #24 started to slouch over in her wheelchair in the lounge. At 7:39 Staff C, CNA walked into the lounge and asked Resident #24 what is going on. As Staff C stepped closer to Resident #24 she noticed the vomit. At 7:45 PM Staff D walked out of the hallway where the room is at, the closing of the medication cabinet is audible. Staff D stated, need to give her medications. As Staff D entered the hallway carrying medications, Staff D asked Staff C for assistance with Resident #24. Staff D stated, I can usually get her by herself but she won't sit up. At this time Staff D returned to the room twice, the second time she returned with a drinking cup and what appears to be another med cup. The Medication Administration Policy and Procedure last revised October 2023 identified the following: 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of the attending physician or physician extender. 3. If a dose seems excessive considering the resident ' s age and condition, or a medication order seems to be unrelated to the resident ' s current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and /or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 4. Medications are administered at the time they are prepared. Medications are not pre-poured. 5. Medications are administered without unnecessary interruptions. 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered. Methods of identification include: a. Checking photograph attached to medical record b. Asking resident to say his/her name c. If necessary, verifying resident identification with other facility personnel 8. Hands are washed before and after administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. 9. At least 4 (four) ounces of water or other acceptable liquid are given with oral medications unless fluid restrictions apply. 10. Medications are administered within one hour before or one hour after scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by prescriber, routine medications are administered according to the established medication administration schedule for the facility. 11. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 12. Medications supplied for one resident are never administered to another resident. 14. For resident ' s not in their rooms or otherwise unavailable to receive medication on the pass, the nurse will not leave medications in the room unattended ever. The nurse will return at a later time to administer medications. 15. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. 16. Identify medication related monitoring and documentation necessary for: Adverse Consequences/Events related to medication use Efficacy Side-Effects In an interview on 7/11/24 at 9:10 AM, the Administrator reported the facility terminated Staff D, RN for not following proper medication administration procedures and because she was not honest about the medication error. The Administrator reported there were many steps in the medication administration process Staff D failed to follow that placed residents at risk.

Based on observations, resident interviews, and staff interviews the facility failed to provide privacy during personal care to 1 of 3 residents reviewed (Resident #15). The facility also failed to respect each resident's dignity to 4 of 10 residents reviewed (Resident #1, #3, #13 and #44) throughout all care and services provided. The facility reported a census of 65 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #15 entered the facility on 5/9/16. The MDS also documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 7/10/24 at 2:42 PM Resident #15 stated she would have liked the window shut, especially with another resident outside that could see in the window. Resident #15 stated she did not feel abused in the situation but did feel like it was undignified to leave the window open. Resident #15 stated leaving the window open bothered her. On 7/10/24 at 1:00 PM an observation revealed Staff K, Certified Nursing Assistant (CNA) and Staff L, Licensed Practical Nurse (LPN) during a change of wound vacuum dressing on Resident #15. During the wound vacuum change the curtain at the foot of Resident #15's bed was not drawn. Observed the resident seated in a chair with the ability to see the window from the chair. On 7/10/24 at 2:51 PM Staff L stated normally she would shut the window when providing cares to Resident #15. Staff L stated the expectation was privacy is given to the resident during all cares. Staff L acknowledged the window was open when providing care to Resident #15. On 7/10/24 at 3:19 PM the DON stated the facility's expectation was for the staff to close the doors or curtains to provide dignity and privacy for the resident. On 7/10/24 at 7:30 AM the Administrator stated the facility taught dignity based on the residents rights - the facility did not have a separate policy regarding dignity specifically. 44420 2. The MDS assessment dated [DATE] documented Resident #1 entered the facility on 8/25/23. The MDS also documented a BIMS score of 15 which indicated no cognitive impairment. The facility's investigation regarding Staff A, CNA dated 3/15/24 at 3:45 PM showed the facility asked the following questions and Resident #1's reply: a. Do you have any concerns with the staff of the cottage? Resident #1 replied, Yes Staff A. The investigation recorded the following statements: i. Don' t like her. ii. She is mean. iii. Does not talk to me when I talk to her. 3. The MDS assessment dated [DATE] documented Resident #3 reentered the facility on 1/7/19. The MDS also documented a BIMS score of 15 which indicated no cognitive impairment. The facility's investigation regarding Staff A, CNA dated 3/15/24 at 3:45 PM showed the facility asked the following questions and Resident #3's reply: a. Are you being treated badly or disrespectfully by any of the staff that work in this cottage? Resident #3 replied, Yes. The investigation recorded the following statements: i. She treated me bad, and others bad. ii. She was rough. iii. Then she left for the day. I was happy. 4. The MDS assessment dated [DATE] documented Resident #13 entered the facility on 12/15/23. The MDS also documented a BIMS score of 10 which indicated moderately impaired cognition. The facility's investigation regarding Staff A, CNA dated 3/15/24 at 3:45 PM showed the facility asked the following questions and Resident #13's reply: a. Are you being treated badly or disrespectfully by any of the staff that work in this cottage? Resident #13 replied, Yes Staff A. The investigation recorded the following statements: i. Refuses to provide ice water in the room. ii. Called me a whiner. iii. Does not respond when I talk to her. 5. The MDS assessment dated [DATE] documented Resident #44 entered the facility on 2/17/24. The MDS also documented a BIMS score of 12 which indicated moderately impaired cognition. The facility's investigation regarding Staff A, CNA dated 3/15/24 at 3:45 PM showed the facility asked the following questions and Resident #44's reply: a. Are you being treated badly or disrespectfully by any of the staff that work in this cottage? Resident #44 replied, Part of the time. The investigation recorded the following statements: i. Does not respect my choices. ii. Sometimes is sassy. iii. Tells me it is time to go to dinner even if I ask to wait. iv. Will only give me thin pads In an interview on 7/8/24 at 12:52 PM, Staff B, Licensed Practical Nurses (LPN), Care Coordinator revealed residents in the cottage reported Staff A, Certified Nursing Assistant performed care in a rough manner. Staff B stated, resident didn't feel it was intentional. Staff B stated, Staff A did not return to the cottage after that and residents felt safer after Staff A left. In an interview on 7/9/24 at 3:10 PM, Staff P, CNA reported she observed an incident in the kitchen, when Staff A, CNA told a female resident that she didn ' t need to use the call light so much, and the resident needed to hold it. Staff P explained the resident called out to use the bathroom multiple times and Staff A told her to hold it. Staff P couldn't recall which resident. In an interview on 7/9/24 at 7:50 PM, Staff E, CNA stated, she never saw Staff A, CNA talk rudely to residents. In an interview on 7/10/24 at 11:16 AM, Staff N, LPN stated, Staff A could be a bit snappy. We would have to get on her sometimes. In an interview on 7/10/24 at 11:21 AM, Staff O, Hostess, stated Staff A was rude when it came to the residents watching TV. In an interview on 7/11/24 at 8:43 AM, the Administrator reported she expected staff to treat residents with dignity in their home. The Administrator stated, We investigated immediately, completed interviews and terminated when the residents confirmed a pattern of behavior that was not respectful.

Based on electronic record review (EHR), staff interviews, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or approaches for use of anticoagulant therapy and diuretic therapy for 2 of 5 residents reviewed (Resident #38 and #43). The facility reported a census of 65 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #43 entered the facility on 2/17/21. The MDS also documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS revealed diagnoses of essential (primary) hypertension and localized edema. Review of Resident #43's Care Plan revealed no problems, goals or approaches to use of a diuretic. Review of Resident #43's MDS dated [DATE] revealed use of diuretic. Review of Resident #43's Physician Orders in EHR revealed furosemide 40 mg by mouth daily at 10:00 AM started 6/3/24. On 7/9/24 at 1:53 PM Staff F, LPN stated Resident #43's diuretic was discontinued when she was in the hospital and then the diuretic was restarted about a month ago. Staff F stated the facility's expectation was the use of a diuretic would have been in Resident #43's Care Plan. On 7/9/24 at 2:46 PM the Director of Nursing (DON) stated the facility's expectation was that Care Plans would have included use of an anticoagulant for Resident #38 and use of diuretic for Resident #43. Review of a document provided by the DON revised 9/13 and titled, Glen Haven Village Care Planning - Interdisciplinary Team documented the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team. 48004 2. The MDS assessment dated [DATE] for Resident #38 revealed diagnoses of coronary artery disease, hypertension, and transient ischemic attack. Review of Resident #38's Physician Orders revealed an order for Xarelto (an anticoagulant) 20 mg 1 tablet by mouth every day with a start date of 2/1/24. Review of Resident #38's Care Plan revealed no comprehensive care plan for the use of an anticoagulant. During an interview 7/09/24 at 2:35 PM with Staff F Licensed Practical Nurse (LPN) revealed she was the person who completes the Care Plans for Resident #38's unit. Staff F then revealed her expectation would be for anticoagulants to be on Care Plans.

Based on electronic health record review, policy review, resident interview, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care for 1 of 3 residents reviewed (Resident #34). The facility reported a census of 65 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #34 entered the facility on 4/1/21. The MDS also documented a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. On 7/8/24 at 12:55 PM Resident #34 stated her family does not come and are not invited to care plan conferences. Resident #34 stated that she did not get invited to care plan conferences either. On 7/10/24 at 12:47 PM Staff I, Recreation Coordinator stated the last care conference for Resident #34 was completed January of 2024. Staff I stated Staff J, Resident Services Director was the person that schedules the care conferences. Staff I stated that the care conferences should have been completed every 3 months. Staff I stated that the care conferences for Resident #34 were not completed every 3 months. On 7/10/24 at 2:15 PM Staff J, Resident Services Director stated she was unable to find any documentation that care conferences were held every three months for Resident #34. Staff J stated she was unable to find any more care conferences than was available on the EHR titled, Care Conference for Resident #34. Staff J stated care conferences should be completed quarterly within 2 weeks of MDS completion. Staff J stated the facility now had a new system in place since this concern was brought to her attention by the survey team. On 7/10/24 at 3:15 PM the Director of Nursing (DON) stated care plan conferences were expected to be completed quarterly with the MDS schedule. The DON acknowledged that Staff J stated she was unable to find any documentation that care conferences were held every 3 months for Resident #34. Review of policy, titled Glen Haven Village Care Planning - Interdisciplinary Team documented The resident, the resident's family and/or the resident's legal representative guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

Based on observation, record review, facility policy/procedure review, and staff interviews, the facility failed to ensure that each resident received adequate nursing supervision and assistive devices to prevent hazards for 2 of 7 residents reviewed (Residents #34 and Resident #56). On 12/24/21, Resident #34 eloped (when a resident exits the facility without staff knowledge or permission) from the facility. A short time later, facility staff noticed the resident walking in front of the facility near the road and brought her back to her cottage. Although the door alarm activated when Resident #34 left the facility, neither of the staff in the cottage responded to the alarm as soon as it activated because they were in rooms (a resident room and a bathroom) and could not hear it. When the staff person in the bathroom walked into the hallway, she heard and responded to the alarm, but failed to fully investigate the reason the alarm had sounded in accordance with facility policy. This resulted in an Immediate Jeopardy to resident health and safety. Resident #56 had a history of transferring herself without assistance which resulted in falls. A fall mat was left at the resident's bedside, but the facility identified it contributed to accidents. The facility directed staff to remove the mat, but staff failed to do so. The resident again attempted to transfer herself, stumbled around the fall mat, and sustained a pubic ramus fracture and a right humeral fracture. The facility reported a census of 61 residents. 1. According to the Minimum Data Set (MDS) assessment tool dated 11/21/21, Resident #34 had diagnosis that included dementia with Lewy Bodies, anxiety disorder, and major depressive disorder. The MDS identified the resident scored 2 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which indicated she experienced severe cognitive impairment. The MDS documented the resident exhibited physical behaviors directed toward others such as hitting on 1 to 3 days of the 7-day look back period. The MDS also documented Resident #34 exhibited wandering behavior on a daily basis during the 7-day look back period. The Elopement Risk assessment dated [DATE] identified Resident #34 as at risk for elopement. Resident #34's Care Plan updated 11/118/21 described the resident as at risk for weight loss and revealed she wandered through the facility with a significant diagnosis of dementia. The facility failed to address the elopement risk identified on 11/16/2021 and also did not include elopement interventions in the resident's plan of care. The care plan informed staff the resident could become disruptive and directed them to provide comfort measures for basic needs. The care plan also informed staff of the resident's history of hallucinations, delusions, and paranoia. A Progress Note dated 12/23/2021 at 11:54 AM, documented Resident #34 approached Staff M, Certified Nursing Assistant (CNA), about the bruising she had noticed on her lower extremities. The nurse completed a full skin assessment and observed scattered, unmeasurable bruising on the right and left buttock area, a 4 cm x 3 cm area to the left inner knee and a dark purple/black area on the left, upper outer thigh that measured 16 cm x 13 cm. The nurse documented the resident denied pain and revealed she documented the bruising event and notified the Care Coordinator. The nurse added her intention to send a Situation, Background, Assessment, and Recommendation (SBAR) to the doctor and to notify power of attorney (POA). A Progress Note dated 12/18/2021 at 11:01 AM, documented CNA reported Resident #34 wandered into another resident's room at 630 AM and was hitting the occupant's bed with her cane. The CNA separated the residents and called the nurse, who attempted to calm the resident. However, the resident continued to wander through the house trying to leave through the exits while carrying an empty laundry basket with her. This nurse persuaded the resident to go to her room and she eventually lay in bed and stayed in the room. The nurse attempted to give resident PRN [MEDICATION(S)] but the resident would not take it, so the nurse dissolve pill in water and place [MEDICATION(S)] in OJ she drinks for breakfast. Will continue to monitor. No cough, sore throat, SOB, increased weakness or lethargy noted. No cyanosis noted around lips. A Progress Note dated 12/11/2021 at 04:06 AM, documented the CNA called and reported the resident wandered into another resident's room and started going through the other resident's closet. Both residents started becoming verbal and cursing at each other. CNA reported she got in the middle and Resident #34 hit her hand. After the resident was easily redirected out of the room. No other behaviors were noted on this shift. In a Progress Note dated 12/08/2021 at 4:48 PM, the facility Administrator documented the Care Coordinator notified her the resident was attempting to elope and staff in the cottage was having a hard time redirecting her. The Administrator arrived to find the Assistant of Resident Services Director sitting in a chair just inside the vestibule with Resident #34 standing inside the vestibule with tears in her eyes. The resident appeared distressed. The Administrator attempted to lead the resident to the office area, but she declined and indicated it was because of the people in the common area and stated she was embarrassed. The Administrator got a second chair and sat with the resident just inside the interior vestibule door where 1:1 conversation was provided as an intervention for approximately 45 minutes. During this time the resident attempted to share her concerns but her speech patterns were mostly incomplete thoughts and random words and topics. The resident pointed at the top of the wall and said that she could hear them making sounds and spoke to the wall behind her as if it were a person. She further indicated that other people in the cottage were making her upset but could not indicate any specific people present in the common area. When anyone would speak in a loud voice, she would flinch and repeatedly motioned for me to speak more quietly. This Administrator notified the nurse to see if she had any as needed medication available and she stated she did not. The Advanced Practice Registered Nurse (ARNP) was on site rounding and the Administrator asked her to come to see Resident #34 during this time. The ARNP stated Resident #34 was speaking word salad and she was unable to make any additional progress with the visit, but asked the Administrator to send progress notes about the incident and a current medication administration record (MAR) and she would review with the doctor. Timeline: The Director of Nursing (DON) reported that he reviewed the video footage of the elopement. Prior to the elopement Resident #34 occasionally leaned against the wall as she ambulated (walked) up and down the hallway. At 10:00 AM, the resident pushed on the back entrance door. At 10:13 AM, she opened another door that led to the employee entrance vestibule. The alarm triggered but the resident did not exit. Afterwards, the resident ambulated toward the direction of her room. At 10:14 AM, Staff N, CNA walked past Resident #34 to visually check the employee entrance door. At 10:20 AM, Staff N found Resident #34 in another resident's room and encouraged her to leave, the resident then ambulated towards the living area. At 10:21 AM, the resident again ambulated toward the employee entrance, opened the inside door, exited into the vestibule, and then pushed the outside door which activated the delayed egress alarm. Both the inside and outside doors sounded with the alarm. While Resident #34 was in the vestibule, Staff N attended to another resident in their room and Staff O, Dietary Aide was in the bathroom next to the employee entrance. While in the vestibule, the resident opened the employee entrance door to come back into the hall. Then, the exterior vestibule opened via delayed egress, which activated the automatic door opener. This seemed to have caught the resident's attention and she turned around, exited through the open egress door, and departed from the cottage. Immediately after the departure, Staff O can be seen exiting the bathroom. Staff O stopped and looked through the window of the employee entrance then continued to the kitchen. The DON reported approximately 1 minute later, two staff members outside on break spotted the resident and called for help. The DON's summary of the facility's investigation recorded at 10:20 AM revealed the DON noticed someone running outside. When he went outside to investigate, he noticed the resident was standing in the road beside cottage 128 with Staff P, CNA, Staff N, and the Registered Dietician (RD). Nobody was able to state how the resident got outside. Staff P stated when she was going outside, she noticed someone walking in the road. It wasn't until she got closer to the resident that she identified it was a resident from the facility. The nurse tried to unsuccessfully redirect the resident while the resident kept pushing and stated she needed to go this way, which was away from the facility. The nurse was able to direct the resident to the sidewalk out of the road and the resident then punched the nurse in the face and started hitting her with her cane. The nurse called the DON at 10:20 AM asking for some assistance. Redirecting the resident by foot was ineffective for both CNA's, the nurse, and the DON, so the CNA obtained a wheelchair. The nurse and the DON assisted the resident back to the cottage via wheelchair and the resident calmed down and then continued to wander. The DON checked all doors to make sure they were working properly, put the resident on 15 minute checks, and called the door service company, and left a voicemail asking them to call the facility. Staff O, Dietary Aide stated she was in the bathroom by the employee entrance around 10:20 am and heard someone pull on the bathroom door. When she came out, she looked over at the employee entrance and did not see anyone. At 10:26 am, Staff N was in another resident's room assisting with toilet use when she came out, threw away the trash, and asked after Resident #34, Just then, Staff O received a call from the RD stating that the resident was outside. Staff N left the cottage and saw Resident #34 standing in the half circle drive with Staff R, CNA, RD and Staff P. The RD was sitting outside of cottage 130 on the bench around 10:20 am when she looked up and saw Resident #34 walking down the sidewalk about to pass cottage 128. The RD ran to her calling her name to try to get her to turn around. The RD called 132 to inform them that Resident #34 was outside on the sidewalk by cottage 128. Staff P, CNA, stated that she was sitting on the bench outside cottage 128 when she saw someone walking across the half circle drive toward the sidewalk by the west side of cottage 128. Staff P stated that she and the RD reached Resident #34 at the same time. She also stated that Staff Q, Licensed Practical Nurse (LPN), came out of cottage 128 and arrived on scene. Staff R stated she was going on break and driving her car when she saw the resident with two women who appeared to be facility staff. Staff R stopped to assist with the resident by helping the other two CNAs get Resident #34 to the sidewalk and then she left. Staff N stated at 10:26 she came out of a resident's room, did not see the resident, and asked where she was. Right after that she was told by Staff O that she got a call from the RD to say Resident #34 was outside. CNA Staff N immediately left the cottage and stated that both she and Staff Q went toward the resident, Staff P, and the RD. After arriving, Staff N, Staff Q, Staff P, Staff R, and RD assisted Resident #34 to the sidewalk. The Director of Nursing, received a phone call from Staff Q at 10:28 am requesting assistance with Resident #34. I arrived on scene at 10:30 am finding the resident on the sidewalk next to cottage 128 with Staff Q, Staff P, Staff N, and Staff R. The DON directed Staff N to get a wheelchair and when it arrived, Staff Q and the DON assisted the resident to sit in it and they wheeled her to cottage 132. Once inside Resident #34 was assessed by Staff Q. Staff Q did state that Resident #34 refused to have her vital signs taken and refused most of the initial assessment. Later, the resident did allow Staff Q to complete a skin assessment. Family and Primary Care Physician (PCP) notified. Observation of the elopement videos on 12/30/21 at 5:15 revealed the DON's timeline accurately aligned with his summary report and timeline. In an interview on 12/28/22 at 7:30 AM, the DON presented Wandering, Elopement Risk Assessment and Door Security Educational slides that are given to new hires during orientation along with verbal education. The DON referred to his notes often as he reported details of the elopement. The interview coincided with the summary report. The DON described the prevention plan as the maintenance of the door and staff education. The DON reported that he gave immediate education about the alarm policy and expectations to the staff present during the elopement. The DON stated that he instructed staff that if you hear a door alarm and do not immediately see anyone enter or do not know who may have exited, you must investigate promptly. The DON explained that he also sent the same instructions via email to the entire staff along with the elopement policy. In an interview on 12/28/21 at 10:00 AM, the Maintenance Supervisor stated that he received a call from the Administrator immediately after the elopement. The Maintenance Supervisor tested the outside door immediately and found there was a spring stuck in the magnetic locking mechanism. The stuck spring caused the door to stay open for 30 seconds triggering the fire safety egress feature that unlocked the door. The DON stated he reviewed the video and the resident did not hold pressure on the door for a full 30 seconds. If the lock was functioning correctly, it would not have opened. The door security company (SCI) came to inspect the lock on the day of the incident. The DON stated the facility planned to add a check of the lock springs to the quarterly checks. These checks will be increased to monthly for the memory care cottages. They have also added the task of oiling the lock springs to the quarterly checks. In an interview on 12/28/21 at 10:43 AM, Staff P stated on 12/24/21 while on break at approximately 1:30 PM, she and the RD were sitting outside of cottage 128 when they noticed a resident crossing the parking lot. The resident crossed from the grass area within the parking lot to the sidewalk where Staff P and the RD were able to intervene. Staff Q and Staff N then came out of other cottages to help. Staff P reported Resident #34 punched Staff Q in the face while staff attempted to bring the resident inside. In an interview on 12/28/21 at 01:52 PM, the RD stated I was sitting outside of cottage 130 and I looked down the sidewalk and saw Resident #34 walking on the sidewalk by the road. I yelled and got her to stop. We got her in the building with the help of others. I called her cottage 132 to let them know. As far as I know they didn't know she was out. I did not hear alarms. Observation on 12/29/21 at 8:35 AM, in cottage 138 rev, Staff J held the door open to the outside that exited the back of the building and triggered the alarm. She held the door open as Staff S, RN, went down the hallway and past the dining area. Staff S acknowledged that the alarm could not be heard down the hallway. In an interview on 12/29/21 at 5:00 PM, Staff O stated in the morning Resident #34 wanders the halls but she never thinks anything of it. I was in the bathroom when I could hear her wiggle the door handle. I thought she went back to her room. I didn't hear the door alarm while I was in the bathroom. The alarm had been going off with family coming in and out all day. I thought I heard the alarm when I opened the bathroom door to leave. I peeked to look toward the door then down the hallway toward her room. I kept walking when I overheard the CNA ask where Resident #34 was, then the phone rang. It was my boss saying the resident was outside, and they needed help. In a follow up interview on 12/29/21 at 5:00 PM, Staff O stated after coming out of the bathroom I peeked out the door and didn't see Resident #34 and she wasn't down the hall, so I went back to the kitchen to cook lunch. During an interview on 12/29/21 at 5:26 PM, Staff N stated she did not hear the alarm while she was in the other resident's room when Resident #34 eloped. She had been pacing and agitated, so Staff N said she had been watching and keeping an eye on the resident since she was an elopement risk. When she finished and left the other resident's room, she asked where the resident was. According to [NAME] Iowa's city page, the temperature reached 42 Fahrenheit on 12/24/21, the day of the elopement. The Wandering and Elopement Policy and Procedure dated 8/2020, documented it is the responsibility of all staff to provide a safe environment for all residents. All team members will remain alert to the location of all residents. The purpose of this policy is to identify residents who are at risk for wandering and to provide interventions to prevent an elopement. In the event of an actual elopement, the enclosed procedure must be followed. The policy states In the event a resident attempts to leave the facility the team member should intervene by attempting to redirect the resident, call for assistance and notify the Charge Nurse. It is the responsibility of all team members, regardless of the department in which they work, to respond to activated door alarms and assist in redirection of residents. When a resident is determined to be missing, all areas of the building, grounds and neighboring streets and buildings are to be systematically searched. This facility uses the following preventative measures to prevent residents from elopement. Preventative measures include: a. Elopement Assessments and Care Plans b. Secured Doors including delayed egress - door codes updated routinely c. Alternative Delayed Egress Plan for Memory Support and Rehabilitation Cottages d. Safety Check at intervals of 15-30 minutes as needed e. Door alarms used as needed on the interior vestibule doors for Memory Support or as needed for residents in other facility cottages f. Diversionary Activities g. Other interventions as developed by the care teams. An environmental tour of both Memory Care Cottages on 12/29/21 at 6:30 PM, revealed cottage 132 and cottage 134 door alarms were noticeably louder. In cottage 132, Staff A reported she heard the alarm throughout the facility. Staff C reported that she heard the door alarms throughout cottage 134. In an interview on 12/29/21 at 6:57 PM, the Maintenance Supervisor related he will be checking the door alarm batteries on Tuesdays and Fridays to ensure they are functioning at the loudest level. All the door alarm batteries have already been changed. This process will be logged. When In an interview on 12/29/21 at 06:55 PM, Staff T, CNA, stated I would go see exactly why the door alarms were on. I would investigate and go out the second door if I don't see anyone, then if I don't still see anyone I'd do a room check. In an interview on 12/29/21 at 7:26 PM, Staff A was not aware of any new education and had not checked her email and said that she had not ' been at work for several days. Staff B looked through a communication binder that was on the table and found a copy of the email communication regarding alarm awareness. Staff U, CNA, said it was her first day at work and was not aware of the email sent regarding the alarm awareness. The DON then came in with a copy of the elopement education and a signature page for them to sign stating that they understood the instructions. In an interview on 12/29/21 at 7:36 PM, Staff C said she had not seen an email with any new instructions regarding alarms. Staff D stated she had not checked her email since coming to work and was not aware of any changes in the alarm system. During the interview the DON came into the cottage with a copy of the education and a sign-up sheet. He talked to Staff D and Staff C and had them sign to indicate they understood the instructions regarding following up with alarms. The facility was notified of the immediate jeopardy on December 29, 2021 at 6:08 PM. The immediate jeopardy was removed on December 29, 2021 at 7:28 PM and lowered from a scope and severity of J to a D when the facility took the following actions: The facility educated all staff currently working about the elopement policy and agreed to educate all staff before they worked another shift. The Maintenance Supervisor was also educated regarding the new plan of door and battery maintenance. Based on observation, record review, facility policy/procedure review, and staff interviews, the facility failed to ensure that each resident received adequate nursing supervision and assistive devices to prevent hazards for 2 of 7 residents reviewed (Residents #34 and Resident #56). On 12/24/21, Resident #34 eloped (when a resident exits the facility without staff knowledge or permission) from the facility. A short time later, facility staff noticed the resident walking in front of the facility near the road and brought her back to her cottage. Although the door alarm activated when Resident #34 left the facility, neither of the staff in the cottage responded to the alarm as soon as it activated because they were in rooms (a resident room and a bathroom) and could not hear it. When the staff person in the bathroom walked into the hallway, she heard and responded to the alarm, but failed to fully investigate the reason the alarm had sounded in accordance with facility policy. This resulted in an Immediate Jeopardy to resident health and safety. The facility reported a census of 61 residents. According to the Minimum Data Set (MDS) assessment tool dated 11/21/21, Resident #34 had diagnosis that included dementia with Lewy Bodies, anxiety disorder, and major depressive disorder. The MDS identified the resident scored 2 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which indicated she experienced severe cognitive impairment. The MDS documented the resident exhibited physical behaviors directed toward others such as hitting on 1 to 3 days of the 7-day look back period. The MDS also documented Resident #34 exhibited wandering behavior on a daily basis during the 7-day look back period. The Elopement Risk assessment dated [DATE] identified Resident #34 as at risk for elopement. Resident #34's Care Plan updated 11/118/21 described the resident as at risk for weight loss and revealed she wandered through the facility with a significant diagnosis of dementia. The facility failed to address the elopement risk identified on 11/16/2021 and also did not include elopement interventions in the resident's plan of care. The care plan informed staff the resident could become disruptive and directed them to provide comfort measures for basic needs. The care plan also informed staff of the resident's history of hallucinations, delusions, and paranoia. A Progress Note dated 12/23/2021 at 11:54 AM, documented Resident #34 approached Staff M, Certified Nursing Assistant (CNA), about the bruising she had noticed on her lower extremities. The nurse completed a full skin assessment and observed scattered, unmeasurable bruising on the right and left buttock area, a 4 cm x 3 cm area to the left inner knee and a dark purple/black area on the left, upper outer thigh that measured 16 cm x 13 cm. The nurse documented the resident denied pain and revealed she documented the bruising event and notified the Care Coordinator. The nurse added her intention to send a Situation, Background, Assessment, and Recommendation (SBAR) to the doctor and to notify power of attorney (POA). A Progress Note dated 12/18/2021 at 11:01 AM, documented CNA reported Resident #34 wandered into another resident's room at 630 AM and was hitting the occupant's bed with her cane. The CNA separated the residents and called the nurse, who attempted to calm the resident. However, the resident continued to wander through the house trying to leave through the exits while carrying an empty laundry basket with her. This nurse persuaded the resident to go to her room and she eventually lay in bed and stayed in the room. The nurse attempted to give resident PRN [MEDICATION(S)] but the resident would not take it, so the nurse dissolve pill in water and place [MEDICATION(S)] in OJ she drinks for breakfast. Will continue to monitor. No cough, sore throat, SOB, increased weakness or lethargy noted. No cyanosis noted around lips. A Progress Note dated 12/11/2021 at 04:06 AM, documented the CNA called and reported the resident wandered into another resident's room and started going through the other resident's closet. Both residents started becoming verbal and cursing at each other. CNA reported she got in the middle and Resident #34 hit her hand. After the resident was easily redirected out of the room. No other behaviors were noted on this shift. In a Progress Note dated 12/08/2021 at 4:48 PM, the facility Administrator documented the Care Coordinator notified her the resident was attempting to elope and staff in the cottage was having a hard time redirecting her. The Administrator arrived to find the Assistant of Resident Services Director sitting in a chair just inside the vestibule with Resident #34 standing inside the vestibule with tears in her eyes. The resident appeared distressed. The Administrator attempted to lead the resident to the office area, but she declined and indicated it was because of the people in the common area and stated she was embarrassed. The Administrator got a second chair and sat with the resident just inside the interior vestibule door where 1:1 conversation was provided as an intervention for approximately 45 minutes. During this time the resident attempted to share her concerns but her speech patterns were mostly incomplete thoughts and random words and topics. The resident pointed at the top of the wall and said that she could hear them making sounds and spoke to the wall behind her as if it were a person. She further indicated that other people in the cottage were making her upset but could not indicate any specific people present in the common area. When anyone would speak in a loud voice, she would flinch and repeatedly motioned for me to speak more quietly. This Administrator notified the nurse to see if she had any as needed medication available and she stated she did not. The Advanced Practice Registered Nurse (ARNP) was on site rounding and the Administrator asked her to come to see Resident #34 during this time. The ARNP stated Resident #34 was speaking word salad and she was unable to make any additional progress with the visit, but asked the Administrator to send progress notes about the incident and a current medication administration record (MAR) and she would review with the doctor. Timeline: The Director of Nursing (DON) reported that he reviewed the video footage of the elopement. Prior to the elopement Resident #34 occasionally leaned against the wall as she ambulated (walked) up and down the hallway. At 10:00 AM, the resident pushed on the back entrance door. At 10:13 AM, she opened another door that led to the employee entrance vestibule. The alarm triggered but the resident did not exit. Afterwards, the resident ambulated toward the direction of her room. At 10:14 AM, Staff N, CNA walked past Resident #34 to visually check the employee entrance door. At 10:20 AM, Staff N found Resident #34 in another resident's room and encouraged her to leave, the resident then ambulated towards the living area. At 10:21 AM, the resident again ambulated toward the employee entrance, opened the inside door, exited into the vestibule, and then pushed the outside door which activated the delayed egress alarm. Both the inside and outside doors sounded with the alarm. While Resident #34 was in the vestibule, Staff N attended to another resident in their room and Staff O, Dietary Aide was in the bathroom next to the employee entrance. While in the vestibule, the resident opened the employee entrance door to come back into the hall. Then, the exterior vestibule opened via delayed egress, which activated the automatic door opener. This seemed to have caught the resident's attention and she turned around, exited through the open egress door, and departed from the cottage. Immediately after the departure, Staff O can be seen exiting the bathroom. Staff O stopped and looked through the window of the employee entrance then continued to the kitchen. The DON reported approximately 1 minute later, two staff members outside on break spotted the resident and called for help. The DON's summary of the facility's investigation recorded at 10:20 AM revealed the DON noticed someone running outside. When he went outside to investigate, he noticed the resident was standing in the road beside cottage 128 with Staff P, CNA, Staff N, and the Registered Dietician. Nobody was able to state how the resident got outside. Staff P stated when she was going outside, she noticed someone walking in the road. It wasn't until she got closer to the resident that she identified it was a resident from the facility. The nurse tried to unsuccessfully redirect the resident while the resident kept pushing and stated she needed to go this way, which was away from the facility. The nurse was able to direct the resident to the sidewalk out of the road and the resident then punched the nurse in the face and started hitting her with her cane. The nurse called the DON at 10:20 AM asking for some assistance. Redirecting the resident by foot was ineffective for both CNA's, the nurse, and the DON, so the CNA obtained a wheelchair. The nurse and the DON assisted the resident back to the cottage via wheelchair and the resident calmed down and then continued to wander. The DON checked all doors to make sure they were working properly, put the resident on 15 minute checks, and called the door service company, and left a voicemail asking them to call the facility. Staff O, Dietary Aide stated she was in the bathroom by the employee entrance around 10:20 am and heard someone pull on the bathroom door. When she came out, she looked over at the employee entrance and did not see anyone. At 10:26 am, Staff N was in another resident's room assisting with toilet use when she came out, threw away the trash, and asked after Resident #34, Just then, Staff O received a call from the RD stating that the resident was outside. Staff N left the cottage and saw Resident #34 standing in the half circle drive with Staff R, CNA, RD and Staff P. The RD was sitting outside of cottage 130 on the bench around 10:20 am when she looked up and saw Resident #34 walking down the sidewalk about to pass cottage 128. The RD ran to her calling her name to try to get her to turn around. The RD called 132 to inform them that Resident #34 was outside on the sidewalk by cottage 128. Staff P, CNA, stated that she was sitting on the bench outside cottage 128 when she saw someone walking across the half circle drive toward the sidewalk by the west side of cottage 128. Staff P stated that she and the RD reached Resident #34 at the same time. She also stated that Staff Q, Licensed Practical Nurse (LPN), came out of cottage 128 and arrived on scene. Staff R stated she was going on break and driving her car when she saw the resident with two women who appeared to be facility staff. Staff R stopped to assist with the resident by helping the other two CNAs get Resident #34 to the sidewalk and then she left. Staff N stated at 10:26 she came out of a resident's room, did not see the resident, and asked where she was. Right after that she was told by Staff O that she got a call from the RD to say Resident #34 was outside. CNA Staff N immediately left the cottage and stated that both she and Staff Q went toward the resident, Staff P, [TRUNCATED]

Based on record review, staff and physician interviews the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and also failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 5 residents reviewed (Residents #1, #2, and #4). On [DATE], Resident #1's admission assessment documented the resident had multiple small red areas to her left hip and left back. On [DATE], the physician wrote an order for Duoderm to the open area on the resident's back and directed staff to change it every 48 to 72 hours. Facility staff failed to apply the Duoderm until [DATE], and then it was discontinued due to an allergy on [DATE]. On [DATE], staff identified some shearing abrasions on the resident's back, and on [DATE], an abrasion to her left lower back. The chart contained skin assessments for [DATE], [DATE], [DATE], [DATE] and [DATE], but no comprehensive skin assessment(s) after [DATE]. On [DATE], the physician saw the wounds and ordered a wound culture and a consult with the wound clinic. The facility cultured the wounds on the [DATE]. On [DATE], the physician assessed the resident's wounds, reviewed the labs and then ordered staff to transfer the resident to the hospital for intravenous antibiotics. The resident was subsequently admitted to the hospital for a pressure ulcer infection (pseudomonas and providencia). The resident's record contained no indication to show the facility made an attempt to refer the resident to the wound clinic per physician order between [DATE] and [DATE]. According to the physician, the resident died of sepsis related to the wound infection. These findings constitute an immediate jeopardy (IJ) to resident health and safety. The facility reported a census of 61 residents. Findings include: 1. The significant change in status Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 readmitted to the facility on [DATE]. The MDS documented the resident as at risk for pressure ulcers and had moisture associated skin damage but no pressure ulcers. The MDS also documented she required extensive assist of 2 staff for bed mobility, transfers and eating and was totally dependent on staff for locomotion, toilet use and hygiene. Resident #1's Face Sheet revealed the resident had diagnoses that included cerebral infarction, aphasia, dementia, and morbid (severe) obesity. The Clinical Admission assessment dated [DATE] documented the resident had multiple small red areas to her left hip and left back. The resident's Care Plan dated [DATE] documented a risk for pressure ulcers and directed staff to reposition the resident frequently to prevent pressure ulcers, however, it failed to include parameters or direct staff how frequently the resident should be assisted to reposition. The Care Plan also directed staff to assess the resident's skin weekly. Review of the Care Plan revealed it failed to contain any interventions for pressure relieving devices for the bed or chair, and lacked any documentation to show that the resident refused to refused to get out of bed or be assisted with repositioning. The Braden Scale form dated [DATE] assessed the resident as at a moderate risk for pressure related skin breakdown. The Progress Notes dated [DATE] revealed the physician made facility rounds and gave an order for Duoderm to the open area on the resident's back and directed staff to change it every 48 to 72 hours. Record review revealed an order dated [DATE] that directed staff to discontinue the Duoderm to resident's lower back due to an allergy and then start border gauze daily. The Treatment Administration Record (TAR) for February 2020 did not contain the Duoderm order. The order was included on the [DATE] TAR, but not signed off as applied until [DATE]. The [DATE] TAR also contained staff initials that signified they had completed the treatment on [DATE] and [DATE], which was after the physician had ordered staff to discontinue the Duoderm. An email from the Environmental Services Manager revealed the facility applied a low air loss mattress to the resident's bed on [DATE]. The Progress Notes dated [DATE] at 10:04 PM documented the resident had some shearing abrasions on her back from the brief and chux. The Progress Notes dated [DATE] at 4:34 PM documented the resident had a 0.2 cm by 0.1 cm abrasion to her left lower back. Record review revealed staff had completed skin assessments on [DATE], [DATE], [DATE], [DATE] and [DATE]. The chart lacked documentation that showed staff had done a comprehensive skin assessment after [DATE]. The Weekly Skin assessment dated [DATE] revealed Resident #1 had excoriations on her mid-back (with no open areas or skin breakdown); a knot on her right hip; an intact perineal area, and 3 red spots in a line across her right buttocks. The skin assessment form failed to contain any measurements. The Weekly Skin assessment dated [DATE] documented staff noted excoriated areas to the resident's backside, abdominal folds and groin. No other skin breakdown or measurements had been documented. The Weekly Skin assessment dated [DATE] revealed Resident #1 had excoriated areas to her backside, abdominal folds and groin with no other skin breakdown or measurements documented. The Weekly Skin assessment dated [DATE] documented the resident had excoriations and an open area on her back with lotion applied to the areas. No other skin breakdown or measurements had been documented. The Weekly Skin assessment dated [DATE] revealed Resident #1 had excoriations on her mid and lower back with no other skin breakdown or measurements documented. The Progress Notes dated [DATE] revealed the physician saw the resident and ordered a referral to the hospital wound care clinic, cultures to the wounds on her back, and labs (a complete blood count and comprehensive metabolic panel). The Progress Notes dated [DATE] revealed the facility obtained the wound culture and noted the wounds were tender with a yellowish center and a red edge. The chart failed to contain any documentation of the wounds from [DATE] to [DATE] with no referral to the wound care clinic found. The Progress Notes dated [DATE] revealed the physician assessed the resident's wounds and reviewed the cultures and labs in the facility, and then ordered staff to transfer the resident to the hospital for intravenous antibiotics. The resident was subsequently admitted to the hospital for a pressure ulcer infection (pseudomonas and providencia). The Skin Integrity and Wound/Pressure Injury Policy for the facility directed staff to monitor pressure ulcers daily measure all areas of impaired skin integrity weekly. It also specified that nurses were to update the care plan with the nursing interventions needed. During an interview with the resident's son on [DATE] at 1130 AM he stated his mom, Resident #1, was never the same after her stroke and it caused her to decline. When asked about her skin condition the son became tearful and reported the facility never told him about any open areas and he was not aware of the pressure ulcers until her physician sent her to the hospital on [DATE]. During an interview with the physician on [DATE] at 12:05 PM he stated Resident #1 admitted to the hospital due to a stroke and it was all downhill after that. The resident became depressed, stopped eating and became failure to thrive. The physician added the resident had been a bigger lady and all of sudden she wasn't able to move, so she developed the pressure areas. When asked about the cause of death he stated it was sepsis (pseudomonas) from the wound infections. The physician added he did not know about the pressure wounds until [DATE], and he then ordered wound cultures and a referral to a wound specialist and the resident was subsequently hospitalized on [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 12:20 PM, she stated staff are to complete a formal skin assessment weekly at a minimum for open areas and pressure ulcers are to be assessed daily. She reported the skin assessments she had provided through [DATE] were all the facility had for Resident #1. In a subsequent interview with the DON on [DATE] at 3:00 PM, she stated she expected the nurses to complete a full assessment of Resident #1's wounds per facility policy. During an interview with the Dietician on [DATE] at 12:32 PM, she stated she was aware Resident #1 had documentation of excoriation and shearing but did not know anything about pressure wounds. She reported that typically if a resident develops a pressure ulcer the facility should contact her within 48 hours for an intervention. During an interview on [DATE] at 11: 25 AM with a nurse that cared for the resident at the hospital, she stated Resident #1 was very ill when she was admitted . The nurse reported Resident #1 was septic and received many fluid boluses and intravenous antibiotics, and added it was obvious where the infection was coming from when they rolled her over for the skin assessment and found the wounds on her lower back and coccyx area. She reported she had been a nurse for eleven years and she had never seen anything so severe; the area was open and deep and when they rolled her it would crack open and bleed and drain purulent foul smelling drainage. She stated they were unable to stage the wound due to the amount of slough and purulent drainage present, and the resident would moan in pain with any repositioning or wound care. During an interview with the Administrator on [DATE] at 2:30 PM she stated she had found with auditing that staff had not been completing weekly skin assessments consistently for all residents. She reported when she became aware of the problem, the facility immediately began to put a plan in place so it would not happen again. The facility abated the Immediate Jeopardy on [DATE] by: a. Upon hire of the new care coordinators they were educated on their responsibilities in the Skin Integrity Management Programs to include a weekly assessment of any identified skin issue by the Care Coordinator documented in the 2020 Wound Tracking Form spreadsheet. This form was reimplemented effective week of [DATE]. b. Facility review notes dated [DATE] revealed wound counts looked higher but that was due additional wounds being identified and tracked following implementation. c. All nurses were re-educated regarding wounds in an inservice on [DATE]. d. Facility review notes dated [DATE] documented the facility continued to work on a Performance Improvement Plan for wounds and working on more effective documentation of the progression of the wound and healing. e. [DATE] Ongoing compliance with the 2020 Wound tracking form will be monitored by the DON or designee each week and wound trends are reviewed by Cottage at each monthly QAPI meeting. Any compliance concerns will be reported immediately to the Administrator and reviewed by the QAPI team. 42842 1. According to the MDS Resident #4 demonstrated intact cognition and was totally dependent on two staff for bed mobility, transfers and toilet. The MDS documented the resident was incontinent of urine and stool. The MDS revealed the resident had the following diagnoses: diabetes mellitus, multiple sclerosis, insomnia, diabetic neuropathy, vitamin d deficiency, restless leg syndrome, and tension type headaches. The recent MDS it documented the resident as at risk for developing skin injuries and had one or more unhealed pressure ulcers at a stage 3. Review of the resident's care plan revealed the resident was at risk for skin breakdown to impaired mobility and incontinence. The care plan identified the resident with a stage 3 pressure area on her left ischium with treatments per physician order. The care plan directed staff, in part, to: observe skin and any wounds for changes such as redness, tenderness, foul drainage, heat and notify the doctor if noted and conduct weekly skin checks per facility protocols. The Braden Scale documented the resident as at moderate risk for skin injury. Review of the resident's progress notes reported the resident's the resident's ulcer measured 0.4 cm x 0.6 cm on [DATE]. On [DATE], the resident's ulcer deteriorated with measurements of 1.8 cm x 2.0 cm x 0.1 cm. Review of the weekly skin assessments showed the staff failed to perform skin assessments weekly as ordered. The resident's record lacked weekly assessments from [DATE] to [DATE] and [DATE] to [DATE].

Based on record review and family, physician, and staff interviews, the facility failed to ensure residents were free from significant medication errors for 1 of 1 residents reviewed (Resident #1). On 9/4/20, the facility received Resident #1's hospital discharge orders which contained an order for apixaban (generic Eliquis, which is an anticoagulant medication used to treat and prevent blood clots and to prevent stroke). Resident #1 received the medication from 9/5/20 to 9/9/19, but then it was discontinued with no order found in the medical record to do so. On 10/8/20, the pharmacy faxed the physician to inform them the facility had not started the medication as ordered and asked if the physician wanted the facility to resume it. The physician faxed back on 10/9/20 with an order for the facility to give the medication. According to the Medication Administration records, the facility failed to restart the resident's Eliquis until 2/20/20. The progress notes showed on 2/16/20, the resident began exhibiting slurred speech and confusion; the facility notified the physician and obtained an order to send the resident to the emergency room and she was admitted to the hospital with a subacute infarct (stroke). Hospital records showed she failed the bedside swallowing study (a test to assess swallowing ability), was aphasic (language or speaking impairment), and weaker on the left side. Due to these findings, an immediate jeopardy (IJ) was identified to resident health and safety. The facility reported a census of 61 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #1 had clear speech, was able to make self understood and scored a 15/15 on her Brief Interview of Mental Status (BIMS). It revealed she required extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use; extensive assist of 1 person for personal hygiene; limited assist of one person for locomotion on the unit and was able to eat with supervision and set up help only. It revealed she had diagnosis to include anemia, hypertension, depression and chronic obstructive pulmonary disease. The MDS did not include a diagnosis of stroke or any swallowing disorders. Record review of Discharge Documents dated 9/4/19 for Resident #1 revealed orders for new medications to include apixaban 5 milligrams 1 tablet by mouth two times a day for 90 days and apixaban 5 milligrams 2 tablets by mouth two times a day. New Prescription Form dated 9/4/19 and noted 9/5/19 revealed a prescription for apixaban 5 milligrams 1 tablet by mouth twice a day for 90 days was faxed to the pharmacy. Faxes dated 10/8/19 and 10/9/19 documented the resident was not started on the apixaban and the facility sent a fax to the physician to clarify if they should follow the order or discontinue it. The physician documented continue with the order, apixaban 5 milligrams 1 tablet by mouth twice a day. The facility had sent Physician Orders with current orders as of December 1, 2019 and current orders as of February 1, 2019 to the physician for recertification, but the documents failed to list apixaban as a routine medication. The Medical Administration Record (MAR) dated September 2019 revealed Resident #1 received Eliquis (apixaban) 5 milligrams 2 tablets twice a day from 9/5 to 9/9/19, but then it was discontinued. Further review of the MARs revealed staff failed to resume the order for Eliquis until 2/20/20, however, clinical record lacked an order to discontinue the Eliquis. Record review of the Progress Notes dated 2/16/20 at 4:24 AM revealed Resident #1 exhibited slurred speech, threw her plate on the floor, yanked on her oxygen tubing and thought she was at a different place. The clinical record did not contain documentation of a full assessment or physician and family notification at that time. The Progress Notes dated 2/16/20 at 1:08 PM revealed the resident had shown increased confusion, garbled speech and an inability to make her needs known. Staff assessed the resident, notified the family and physician, and transferred the resident to the hospital via ambulance at 1:00 PM. The History and Physical (H & P) from the hospital dated 2/16/20 documented Resident #1 sent to the emergency room for altered mental status since the night before, but the nurse stated she had been told at 11:00 AM. The H & P revealed facility staff reported resident as normally alert and oriented, however the resident could not follow any commands or respond appropriately at that time. The head scans done at the hospital diagnosed Resident #1 with an acute to subacute left parietal and temporal infarct with an overall poor prognosis. Record review of the Hospital Progress Note dated 2/18/20 documented no anticoagulation listed on the residents nursing home MAR, she failed the beside swallow study, was aphasic, and weaker on the left side. The Hospital Progress Note dated 2/19/20 revealed the resident was supposed to be on anticoagulation both for recent pulmonary emboli as well as chronic atrial fibrillation, but was off of it for some time. The facility Progress Notes care facility dated 2/20/20 revealed Resident #1 returned to the facility with aphasia, an inability to speak except for yes/no questions, and could not grip with her left hand. The Progress Notes dated 2/22/20 documented the resident was staying in bed and required assistance to eat due to left side hemiparesis (weakness or paralysis on the left side). The note added the resident had been restarted on Eliquis. According to the significant change in status MDS dated [DATE], Resident #1 had diagnoses that included anemia, hyperlipidemia, depression, chronic obstructive pulmonary disease, and cerebral infarction. The MDS documented Resident #1 had unclear speech, was rarely/never understood, and demonstrated moderately impaired cognitive skills for daily decision making. The MDS also documented she required extensive assist of 2 staff for bed mobility, transfers, and eating and was totally dependent on 2 staff for locomotion on the unit, toilet use, and personal hygiene. The MDS revealed Resident #1 had swallowing disorders of coughing or choking during meals or when swallowing medications. During an interview with the resident's son on 6/15/20 at 1130 AM, he stated in September of 2019 the physician started his mother on Eliquis due to having blood clots. He reported he had assumed she had been on it the entire time she was at the facility, but staff had called him on 2/16/20 to report they were sending his mother to the hospital due to stroke symptoms, and he later found out that she hadn't been on the Eliquis at the facility. The son added that his mother was never the same after the stroke and it caused her decline. During an interview with the physician on 6/15/20 at 12:05 PM, he stated Resident #1's issues stemmed from having atrial fibrillation (quivering or irregular heartbeat). He stated the resident was on Eliquis and at one point the nurse coordinator and pharmacy asked if she needed to continue it. He told the nurse coordinator the resident needed to stay on the medication but it was either missed by the facility or pharmacy and she did not receive the medication. He stated the weeks went by, she was off the Eliquis and then staff notified him 2/16/10 of the resident's slurred speech. He stated that he expected staff to notify him as soon as they noted such a significant change (the slurred speech and confusion) The physician reported Resident #1 admitted to the hospital for a stroke and, It was all downhill after that. She became depressed, was not eating, and showed a failure to thrive. During a subsequent interview with the physician on 6/16/20 at 11:50 AM he was informed that Resident #1 went 5 months without her anticoagulant Eliquis and he stated that it didn't matter if she went a few weeks or a few without the blood thinner, it put her at a significantly higher risk for a stroke. During an interview with the Director of Nursing on 6/15/20 at 12:20 PM she stated that with a significant change such as slurred speech and confusion the nurse should notify the nurse coordinator, physician, and family right away. During an interview with the Community Care contact of the pharmacy, on 6/16/20 at 11:58 AM she stated the pharmacy received an order for Eliquis on 9/4/19 for 2 tabs twice a day which was dispensed to the pharmacy. The pharmacy faxed the physician on 10/8/19 to clarify the Eliquis order and got a verbal confirmation from the physician's nurse on 10/9/19 to continue 1 tab twice a day. They didn't dispense any more at that point because the order on 9/4/19 was for 90 days. She stated that was all the information she could provide. During an interview with Staff A LPN on 6/16/20 at 4:40 PM she stated all of the incoming orders are sent to the pharmacy and it is their responsibility to put them on the medication administration record (MAR). The nurse will then chart the orders in the progress notes and notify the family of any changes. Once the pharmacy inputs the orders into the MAR they are alerted to review and approve or reject the orders in the quickmar system. We then note the orders and give them to our nurse coordinator to review. When asked if she recalled why Resident #1 never received her anticoagulant for 5 months she stated that when the pharmacy was entering all the meds into the system they entered 2 medication orders. She stated that she rejected one of them but the pharmacy reported she accepted the discontinued order and rejected the active order so it never pulled through. During an interview with Staff B LPN on 6/16/20 at 9:42 PM she stated that when she gets an order at the facility she will send it to the pharmacy and they put it into the MAR. She will document it in the nurse notes, notify the family, and the order will go to her nurse coordinator for review. She reported the meds are in bubble packs and she personally checks the cart at the end of each med pass to make sure everything is given. She also stated that if the nurse doesn't give something then the box on the MAR in the system will stay blue which will alert you to give it. During an interview with the pharmacist responsible for the facility on 6/17/20 at 10:15 AM he stated he had been researching the med error and he found that on 9/4/19 Resident #1 readmitted back to the nursing home and they received all the discharge orders from the hospital. She had a new order for Eliquis 10 milligrams twice a day for 7 days with an ending date of 9/9/19. He stated that order was entered into the MAR and accepted by the nursing staff so the medication was dispensed to the facility. On 9/10/19 Eliquis 5 mg twice a day for 90 days was supposed to start. That order was entered into the MAR and accepted. He stated the pharmacy got a duplicate order faxed to them the next day. They reviewed it with the original and that it had looked like they had the end date wrong for the order. They wrote to discontinue the first order and put a second order in. The nurse at the facility accepted the discontinue order thinking it was the active order and rejected the active order. He stated that it showed up as active on their end so they never caught it but the nurse rejected it so it was never activated on the facility end of the order. He stated there was some liability on the pharmacy for the error but it was a miscommunication on the part of the facility as well. The facility abated the Immediate Jeopardy on 6/25/20 by implementing the following: a. On 6-24-20 the Physician Orders Process was reviewed and revised to include a required notation by each Care Coordinator going forward to document the review. The SBAR process was also reviewed and revised to ensure timely follow-up of an identified need for Physician communication. b. The re-education on the process was completed with all facility nurses on 6-25-20. All nurses unable to attend were educated via telephone 1:1. The nurses were provided the education materials in print upon arrival for their next shift.

Based on clinical record review, staff interviews and review of facility orientation guidelines and staffing education, the facility failed to prevent a fall for 1 of 2 residents reviewed for falls (Resident #54). The fall resulted in a fracture to the base of Resident #54's left second toe. The resident complained of dizziness right before staff assisted her to the commode, had a high risk for falls and was left unattended on the commode. The facility reported a census of 57 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #54 had a Brief Interview of Mental Status (BIMS) score of 13, indicating no cognitive or memory impairment. The MDS listed Resident #54 required the assistance of one staff for bed mobility, transfers, and toilet use and had occasional incontinence of urine and frequent incontinence of bowel. The MDS listed the following [DIAGNOSES REDACTED]. The recorded Resident #54 fell twice with non major injuries since admission or the previous assessment. Review of the care plan revealed Resident #54 required assistance with dressing/undressing of one person. The care plan recorded that at times she will not wait for assistance and transfer herself from the bed and/or wheelchair or vice versa making her a risk for falls. The care plan listed the following interventions: soft touch call light started on 9/11/18, commode height reviewed and updated as needed to suit resident's height started on 9/10/18, non-skid strips placed in front of bedside commode started on 9/10/18, keep her wheelchair next to her bed with the brakes locked started on 9/4/18, non-skid strips next to her bed started on 8/29/18, encourage the resident to use gripper socks or non-skid footwear when walking started on 8/26/18 and she is OK with supervision while in the bathroom started on 5/25/18. Resident #54 had a history of [REDACTED]. Review of fall risk assessment dated [DATE] revealed Resident #54 scored a 21; a score of 10 or higher represents a high risk for falls. A falls prevention program is listed as a referral for this resident. A nurse's note at the bottom of the form reads: fall risk assessment completed with a score of 21. She is at risk due to her immobility, incontinence, [MEDICAL CONDITION], and hypertension diagnoses. She is on a diuretic and on several medications for her hypertension. A review of the EHR revealed the following progress notes: a. 8/14/18 at 9:28 AM - Resident #54 continued to complain of dizziness and continued to state that the PRN (as needed medication, [MEDICATION NAME]) does nothing. The resident felt awful and when asked what exactly is wrong, she stated everything. b. 8/16/18 at 10:22 PM - Resident #54 stated she felt horrible. Staff addressed the resident's dizziness and pain with PRN medications on this shift; both medications were ineffective. c. 8/21/18 at 12:47 PM - Quarterly Review: she needs assistance of one with transfers and toilet use. There have been times when she took herself to the bathroom. She frequently complains of dizziness and currently received 3 different medications for hypertension. The resident has had a significant drop in her blood pressure before receiving medication up to an hour after. Her primary physician wanted for her to see a cardiologist, but the family does not think it is necessary. She could put her light on and ask for assistance. d. 8/21/18 at 10:23 PM - Resident #54 received PRN medication for complaints of dizziness (Ativert) and the medication was not effective. e. 8/23/18 at 9:58 PM - She continued to be dizzy constantly; medication not effective. f. 8/25/18 at 9:49 PM - Resident #54 got up for about 30 minutes before wanting to be laid back down in her bed. Her blood pressure measured 180/78, she complained of being unbearably dizzy. Staff administered a PRN medication and it was not effective. g. 8/26/18 at 10:23 PM - At 5:00 AM, a CNA (certified nursing assistant) paged for a nurse who noted Resident #54 sitting on the bathroom floor, with her knees bent and head and shoulder leaning against the wall. A CMA (certified medication aide) stated Resident #54 tripped over her walker and she lowered Resident #54 to the floor. h. 8/28/18 at 10:35 PM - Resident #54 ate her dessert for supper and wanted to be put back into her bed immediately; she would have no oral care completed or to use the bathroom. Staff administered a PRN medication for dizziness and two Tylenol for pain. i. 8/29/18 at 3:33 AM - Staff witnessed Resident #54 falling to the floor as she entered the room. Resident #54 landed on her right side and hit her head on the floor, resulting in a half-dollar sized bump on the side of her head. j. 8/29/18 at 9:19 AM - Resident #54 complained of dizziness per her normal; staff administered PRN [MEDICATION NAME] but is not effective. This had been discussed multiple times with family as well as physician. k. 9/1/18 at 12:35 AM - A CNA reported she observed Resident #54 on her knees with her head in the seat of her wheelchair and yelling for help. Staff noted no injuries. l. 9/4/18 at 10:08 PM Resident #54 would not put forth any effort in helping staff with transfers; she required total assistance from two with a gait belt. Two staff had difficulty transferring the resident into her wheelchair to be taken to the restroom or out to eat in the dining hall, because of her lack of any effort to help with transfers. m. 9/7/18 at 10:45 - While walking past the resident's room, staff heard a noise, looked inside and found Resident #54 on the floor with her head under the sink and feet at the toilet. She had her brief pulled up but her pants were still down. Resident #54 had been educated beforehand when placing her on the toilet, to hit the red button on her call light. When found, Resident #54 lay on the floor, holding her head and smiling. The resident stated 'I guess you didn't get here fast enough'. n. 9/8/18 at 5:24 AM - Staff H RN (Registered Nurse) and Staff G LPN (Licensed Practical Nurse) were called into Resident #54's room by Staff I CNA. Upon entering the room, staff witnessed Resident #54 lying on the floor on her back. Staff I stated that Resident #54 was sitting on the bedside commode, stood up and fell forward onto the floor and hitting her head. Resident #52 had a 4.5 centimeter (cm) in diameter hematoma to her left lateral forehead and a 4 cm skin tear to the back of her left hand. Staff applied a cold pack to her head, cleansed the skin tear and applied 6 steri-strips, [MEDICATION NAME] and Kerlix secured with tape. Resident #54 was awake and alert, with her pupils active and reactive to light and equal hand grasps, range of motion within normal limits and no abnormalities no rotation noted. All proper notifications made, intervention implemented: Education to CNA. o. 9/8/18 at 9:00 AM - Resident #54 complained of pain to her left foot with weight bearing. Staff noted swelling to her left foot, tender with inversion. Resident #54 could flex and dorisflex her foot without pain. Staff received an order for [REDACTED]. p. 9/8/18 at 11:30 AM - Staff re-assessed the resident's pain level. She denied pain and rested in bed. Staff noted decreased swelling in left foot and waited for the X-ray to be completed. q. 9/8/18 at 5:00 PM - X-ray results recorded a fracture base of left second metatarsal (the long bone to the top of foot). Staff received an order to transfer resident to the emergency room . r. 9/8/18 at 10:05 PM - Staff received a call from the emergency room nurse; they are sending her back to the facility. Resident #54 had a head CT scan that was negative. Resident #54 would return with a post-surgical boot to her left foot. She is minimal weight bearing and can transfer. Resident #54 should remain minimal weight bearing until follow up appointment. s. 9/8/18 at 10:45 PM - Resident #54 arrived back to facility around 9:20 PM. t. 9/12/18 at 10:09 AM - Resident #54 showed increased weakness and lethargy and her neurological assessment fell within normal limits. Resident #54 will verbally respond when she chooses to and complained of dizziness but this is per her normal. As needed (PRN) [MEDICATION NAME] is not effective when used and resident does not wish to have it at this time when asked. Staff assisted her using two person assist and a pivot transfer with use of a gait belt. The Radiology Report of 9/8/18 documented Resident #54 had a fracture involving the base of the left second metatarsal (the long bone on the top of a foot) with modest displacement. Review of Event Reports revealed the following falls for Resident #54: a. 8/26/18 at 5:00 AM - Staff found her on the bathroom floor without the proper footwear on. b. 8/29/18 at 11:55 PM - She fell in her room; the resident did not want to wait for assistance and did not wear gripper socks. c. 9/1/18 at 12:35 AM - Resident #54 did not use her call light to ask for help to the bathroom. d. 9/7/18 at 5:45 PM - She did not use her call light to ask for assistance. e. 9/8/18 at 4:00 AM - Resident #54 attempted to stand up from the commode and fell forward Video footage viewed on 9/8/18 with the Administrator and DON present revealed the following: a. 9/8/18 at 3:49 AM - Staff I entered Resident #54's room and left at 3:54 AM. b. 9/8/18 at 4:01 AM - Staff I entered Resident #54's room and left at 4:02 AM. c. 9/8/18 at 4:03 AM - Staff I entered Resident #54's room. d. 9/8/18 at 4:05 AM - Staff G and H entered Resident #54's room. During an interview on 9/11/18 at 2:30 PM, Staff I stated Resident #54's call light went off, she answered it and the resident stated she needed to go to the bathroom. With a gait belt, she transferred her to the commode. Staff I stated she heard another resident yell for help, so she told Resident #54 that she would be right back. When she returned Resident #54 was on the floor. Staff I stated Resident #54 wore a gait belt, secured under her breasts and outside of her shirt. Staff I stated Resident #54 has been having dizzy spells where she will grab right above her eyes and state she is light headed and dizzy. When asked if Resident #54 was dizzy the morning she fell , Staff I stated she said the resident stated she felt dizzy before Staff I got her on the commode. Staff I stated she was maybe out of the room for 2-3 minutes and the commode was positioned next to the bed so she could do a stand and pivot transfer with her. Staff I stated Resident #54 did not have care plan directions for supervision while on the commode. Staff I stated she found Resident #54 face down on the ground. Once she entered the room and found Resident #54 on the floor, she panicked then called for the nurses on her walkie talkie. When asked if there was anything she could have done different, she stated she should have called someone else to go help the other resident that yelled for help. During interview on 9/11/18 at 2:50 PM, Staff H RN stated she received a page about 4:00 AM to go downstairs. She walked into Resident #54's room and the resident lay on her back on the floor with a goose egg on the left side of her head. Staff H stated Resident #54 has a history of self-transferring. Staff H stated staff is to be in the room with Resident #54 if she is on the toilet or commode because she is at high risk for falls. Staff H stated Staff I told her that she went to help another resident calling out for help and when she returned she found Resident #54 on the floor. Staff H stated Resident #54 had a gait belt on. During interview on 9/11/18 at 3:50 PM, Staff G LPN stated she got a page from Staff I to come to Resident #54's room. When she arrived with Staff H, she noted Resident #54 on the floor on her back. When she looked, Resident #54 had a raised area on her left forehead and a skin tear on her left hand. During interview on 9/11/18 at 4:20 PM, when asked to see the fall prevention program listed on the incident (event) report sheet, the Director of Nursing (DON) stated they do not utilize that anymore. They would rather come up with individual interventions rather than utilize a program that gives generic interventions. During interview on 9/12/18 at 8:50 AM, Staff F LPN stated Resident #54 complained of dizziness for a long time. Her primary doctor knows about these dizzy episodes and had requested a cardiology consult but the family did not want to move forward. Staff F stated Resident #54 just started using the commode recently. When Staff F assists Resident #54 to the toilet, she always stays with her because of her frequent falls and complaints of being dizzy. During interview on 9/12/18 at 9:00 AM, when asked what the facility does for residents deemed at high risk for falls, the DON stated they make sure the slip strips are in place, Resident #54 has gripper socks, the wheelchair is kept next to her bed with the brakes locked and non-slip footwear is being utilized when ambulating. She stated after the fall they started to utilize a soft touch call light. When asked what interventions need to be in place due to Resident #54 not wanting to wait for help, she stated they are trying to keep the environment safe for her as staff cannot be in everyone's rooms when they are in the bathroom. When asked what she would do if a resident felt dizzy and on the toilet, she stated she can put on the care plan not to leave her but it would be unrealistic for staff to stay when there are other demented residents that need help. She stated this would be setting her staff up to not follow care plans. The DON was given a scenario of a resident complaining of being dizzy but needing to use the toilet and asked if she would put that resident on the toilet and leave, she diverted back to not wanting to put on the care plan for Resident #54 to be supervised while on the toilet. It was then reiterated that if a resident was dizzy and needed the bathroom, would she put them on the toilet and leave knowing they were dizzy? The DON stated she would not leave the resident alone and would call for assistance if she needed to leave the room. When asked of the education given to Staff I after Resident #54 fell , she stated Staff I received education on the use of the walkie talkies to get help when assisting another resident. During interview on 9/12/18 at 11:00 AM with Staff J CMA/CNA stated she always worked downstairs. When working with Resident #54 she stated she always stays in the room with her while she is on the toilet or commodes because she will self-transfer. Staff J stated Resident #54 likes her privacy so she will stay in the room and pull the privacy curtain or shut the bathroom door. Staff J stated Resident #54 will push her call light and if staff is not there within seconds, she will get up on her own. When asked what she would do if she was in the room with Resident #54 and another resident called out for help, she stated she would get on her walkie talkie and ask for assistance. Staff J stated Resident #54 complains about being dizzy a lot and has been for a while now. During interview on 9/12/18 at 2:34 PM, Staff L CNA stated about two weeks ago, Resident #54 required assistance of 2 staff and a gait belt for transfers. Staff L stated he stays in the room when Resident #54 sits on the toilet or commode. When asked why he stays in the room, he stated because she has a high risk for falls and a tendency to lean forward when sitting up and that is when she falls. During interview on 9/12/18 at 2:45 PM, Staff K LPN stated Resident #54 required 1-2 staff for transfers for the last 2 weeks and had to be within sight of staff while up on the toilet or commode. Staff K stated in (MONTH) she required 1 staff for transfers and that she used to complain of dizziness but not so much anymore. Review of education form with a date of 9/10/18 revealed the following: Education for fall and safety provided verbally on 9/10/18 via phone after interview regarding Resident #54's fall. In the future Staff I will contact a team member for assistance via walkie for another person to assist residents while assisting a person with a fall risk to the bathroom or the commode. Staff I agreed to this education via the phone and reported to the DON she would sign it on her next shift.

Based on clinical record review, facility record review and staff interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 10 residents reviewed (Resident 15). Record review revealed Resident #15 required staff assistance for transfers and toilet use. The facility call light log and staff's statements, revealed Resident #15 waited approximately 39 minutes on the toilet until staff responded to his/her call light and found the resident on the floor face down. Resident #15 sustained injuries including a cervical spine fracture. Staff E reported she knew Resident #15 had been on the toilet but went to assist another resident. Staff H reported nurses receive alerts on a pager if a call light had been on for over 10 minutes however, that day he could not find a pager. The facility reported a census of 63 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated [DATE] indicated Resident #15 had a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS listed the following [DIAGNOSES REDACTED]. The MDS indicated Resident #15 required extensive assistance of 1 staff for bed mobility, transfers and extensive assistance of 2 staff for toilet use. Review of Resident #15's care plan with a revision date of [DATE] revealed staff are to assist (1 staff) with activities of daily living and assist of 2 with sit to stand or use of walker, gait belt and assistance of 2 for transfers (per resident's preference). Staff is to check and change resident frequently as s/he is incontinent of urine. Record review of Resident #15's event report dated [DATE] at 11:18 a.m. identified on [DATE] at 8:00 a.m., Resident #15 fell in the bathroom. Staff documented Resident #15 had been alone/unattended at the time of the fall. Staff found Resident #15 on the floor with injuries to his/her head (laceration to forehead), extremities, trunk and left hand, however the resident denied neck pain. The resident rated his/her pain at 4 out of 10 (moderate pain distressing, miserable-verbalized by moaning). Resident #15's range of motion was limited/painful in upper extremity-could not lift arm for transfer, and staff observed no rotation/deformity/shortening noted. Resident #15 had no falls/fracture in the past and had been wearing gripper socks at the time of the incident. The report documented factor/s related to the fall, such as lost of strength /appeared to get weak and the resident had been sitting on the toilet prior to the fall. Review of contributing factors listed toileting status. The even report indicated following the fall, staff will supervise the resident in bathroom. Review of Resident #15's progress note in an event report documented : stat call to resident's room at approximately 8:14 a.m. by Certified Nursing Assistant. The writer was downstairs at the time and ran upstairs to respond to call. Another nurse was already present in room applying pressure to head wound. There was moderate amount of blood on floor under the resident's head (no other areas of blood noted). Resident was lying under the sink with head towards wall on top of walker, arms folded underneath and feet pointed towards the toilet. The walker was underneath resident and appeared right below his/her chest level. Resident #15 answered simple questions slowly (which is normal) and was alert. The report documented 911 called at approximately 8:18 a.m and arrived at 8:25 a.m. Resident repositioned in bathroom with use of blankets. Resident #15's walker removed from underneath and blanket used to remove resident from bathroom by sliding on floor. Resident transferred to backboard and c-collar applied by emergency medical team. Resident #15 was transferred to emergency room . Review of Resident #15's chart revealed a neurosurgeon consult with a date and time of [DATE] at 6:37 p.m. revealed a CT scan was reviewed and demonstrated a type II odontoid fracture (peg or dens fracture) without displacement. CT of the head was negative. Review of Resident #15's hospital history and physical with a date and time of [DATE] at 5:16 p.m. revealed the resident fell in the bathroom at the nursing home and struck his/her head on the sink during an unwitnessed fall. When the resident was brought to the emergency room upon arrival he/she was confused and unable to answer questions. The resident had a forehead laceration which was sutured. A computerized axial tomography (CAT) scan revealed a C2 fracture (cervical spine) through the base of the odontoid process. ( A peg of bone called the odontoid process (sometimes called the dens). The odontoid process sticks up from the front of C2 and fits into a groove in C1.) The resident received Diluadid and morphine to address his/her pain. The resident remained lethargic and was admitted to the hospital. According to the Certificate of Death, on [DATE] at 3:30 a.m., Resident #15 died at the hospital. Resident #15's manner of death was classified as an accident from a ground level fall. The immediate cause of death listed odontoid fracture with the date of injury on [DATE]. According to the call light log, given by Administrator revealed the bathroom call light for Resident #15 was cleared on [DATE] at 8:20:34 a.m. with a reset time of 39 minutes and 1 second. On [DATE] at 12:40 a.m. the Administration stated the time on the log, with the date, is when the call light was cleared. A written statement by Staff E documented on [DATE] around 7:30 to 7:40 a.m., she put Resident #15 on the toilet and the resident stated he/she wanted to sit on the toilet for a little bit so Staff E went to assist another resident. Staff E documented when she was done, she went back to Resident #15's room to shut off his/her call light and found him/her head first under the sink with blood all over the floor. During a staff interview on [DATE] at 6:04 p.m. Staff E stated she worked on [DATE], she split the hall with Staff F. Staff E stated she had gotten Resident #15 up to the toilet at about 7:45 a.m. and asked if Resident #15 wanted to sit and the resident said yes. So Staff E gave Resident #15 the call light then went to room 214 to assist the residents in there. After Staff E assisted those residents, she went in to Resident #15 room, room 213 and found the resident on the floor at about 8:05 a.m. but wasn't certain on the time. Staff E stated Resident #15 used a walker, gait belt, and 1 staff for transfers and never got up by themselves, would use the call light. Staff E stated residents can be left alone in the bathroom unless the care plan says not to. Staff E stated Resident #15's care plan never said someone had to be in the bathroom with him/her. When asked how she knew a call light was going off Staff E stated it pops up on a reader screen by the elevator and it shows up on the pagers. Staff E stated the pagers go off for bathroom and bedroom lights. Staff E stated only CNAs had pagers not the nurses that day. Staff E stated since the incident now everyone has a pager. If the call light is on, after 10 minutes the management/department heads will get a page. Staff E stated the staff will then ask nursing staff to shut off the call light. Staff E stated the Director of Nursing (DON) pulled up the video from the hall and said she saw her partner (Staff F) had walked by the room and never assisted Resident #15 and walked next door. Staff E stated the DON said Staff F should have turned the light off. During a staff interview on [DATE] at 2:15 p.m. Staff F CNA stated she was working the morning of Resident #15's fall on [DATE]. Staff F stated she and Staff E CNA split the hall that day; Staff F had North Hall and Staff E had South Hall. Staff F stated Resident #15 would call if assistance was needed. Staff F stated Resident #15 used to use an EZ-stand mechanical lift but worked with physical and occupational therapy and was using a walker, gait belt and staff assistance for transfers. Staff F stated Resident #15 had a riser on their toilet seat, but the resident's feet never touched the floor. When asked what happened on [DATE], Staff F stated Staff E had assisted Resident #15 on the toilet before breakfast (before 8:00 a.m.) and Staff G CNA was assisting Staff F with other getting other residents up. Staff F walked down the hall and saw Staff E walk out of Resident #15's room and said call nurse stat Resident #15 is on the floor. Staff F said this was roughly about 8:10 a.m. as Resident #15 was the only one left in their room. Staff F said she saw Resident #15 lying face down on the floor on top of their walker. When Staff F was asked if she was in Resident #15's adjoining room she indicated she was in there around 8:00 a.m. and saw Resident #15 on the toilet. Staff F stated she saw Resident #15's call light on a few times that morning. When Staff F was asked about when the pagers go off she stated they go off whenever a call light is turned on, even for the bathroom light. The pagers will go off until the light is shut off but if it's on passed 10 minutes the nurse's pagers will go off. Staff F stated residents can be left alone in their bathroom unless their care plan says otherwise. When asked if Staff E seemed distracted that day, she stated that Staff E talks too much about her personal life and her mind always seems elsewhere. Review of the facility's investigation for the incident on [DATE] revealed Staff F's statement as follows: Staff F was taking care of a resident with another CNA then came out and Staff D had her check on a resident in 211 bed. At 7:50 a.m. Staff F got a washcloth and noticed Resident #15 on the toilet and was fine. Staff F then left and checked on another resident, came out to the hall and Staff E said to call nurse stat that Resident #15 was on the floor. During a follow up staff interview on [DATE] at 1:50 p.m., Staff F was asked what she meant in her facility statement when she stated she noticed Resident #15 seated on the toilet and fine. Staff F stated when she saw Resident #15 s/he was fine, sitting on the toilet. During a staff interview on [DATE] at 12:00 p.m. Staff G CNA stated she worked on [DATE] but on a new hall. Staff G stated once her tasks were completed she went to the North/South to assist with other residents. Staff G stated she first helped Staff F and that's when Staff E ran out of room 211 and said to page for nurse stat. Staff G stated Staff F went in to the bathroom of room 211 to see what happened. Staff G stated after the incident more of the management team has pagers that go off if a call light is on passed 10 minutes. Staff G also stated that nurses are supposed to have the 10 minute pagers too. When asked if Staff E seemed distracted that day, Staff E stated you have to tell her what to do, like if a light was going off, you'd have to tell her to get it. During an interview on [DATE] at 1:00 p.m. the DON stated they could not save the video footage for the incident that took place on [DATE]. During a staff interview on [DATE] at 1:27 p.m. Staff D Licensed Practical Nurse (LPN) stated she did work on [DATE]. Staff D stated she had gone in Resident #15's bathroom before 8:00 a.m., between 7:30 a.m. and 7:40 a.m. to administer medications and resident had just transferred to the toilet. Staff E was still in the room and the call light was not on at that time. Staff D stated she gave Resident #15 their meds and left the room, but Staff E was still there. Staff D stated she heard the nurse stat call about 8:15 a.m. from downstairs then ran upstairs to assist. Staff D stated Staff H LPN was already in the bathroom applying pressure to the resident's head. Staff D stated she called 911. She was unsure if the call light was on. When asked who has the pagers, Staff D stated at the time of the incident she could not find a working pager, so she did not have one. She stated that if a call light is on for more than 10 minutes the nurses get paged and after the incident all department heads have pagers. During a staff interview on [DATE] at 2:15 p.m. Staff H stated he worked on [DATE] and was working on new Hall when he heard the nurse stat call around 8:00 a.m. Staff H stated when he arrived he found Resident #15 face down on top of the walker with a laceration to his/her head. Staff H stated all nurses and CNAs have pagers, but that day he could not find one. Staff H stated nurses receive pages if a call light has been on over 10 minutes. Since the fall he believes the facility has obtained more pagers. Review of the facility's investigation for the incident on [DATE] revealed Staff H's statement as follows: Approximately 8:12 a.m. responded to a nurse stat to room ,[DATE] bathroom. Resident #15 was witnessed to be face down on top of walker. Blood was coming from head, immediately applied pressure to wound. Told Staff D to call 911. Kept pressure on wound. Resident was conscious. Asked if she was hurting anywhere, stated his/her left hand hurt. Resident #15 became restless. Calmed him/her down and told him/her we can't move until the ambulance had arrived. During a staff interview on [DATE] at 12:15 p.m. the Administrator stated Resident #15 didn't try to get up on his/her own and was not an impulsive person. At the time of the incident it is the busiest time of day. The Administrator stated she watched the video and it showed Resident #16 turned on their call light right as staff walked out of the room. She's not sure what they could have done differently as she believes the resident passed out then fell on the floor.

Based on record review and physician, surgeon and staff interviews, the facility failed to assess a wound and implement interventions when an onset of adverse symptoms occurred (Resident #3). The sample consisted of 6 residents. Resident #3 had a surgical wound on the right upper thigh. The wound did not receive treatments as ordered. The wound dehisced (pulled apart) on 9/13/16 and the surgeon did not become aware of the dehisced wound until seen at the clinic on 9/15/16 and then admitted the resident into the hospital for proper treatment of [REDACTED]. The facility reported a census of 59 residents. Findings include: Resident #3 had a MDS (Minimum Data Set) with an assessment reference date (ARD) of 9/13/16. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS with a reference date of 9/8/16indicated the resident had no problems with cognition and scored a 14 on the BIMS (Brief Interview for Mental Status) test. A Clinical Admission assessment dated [DATE] identified additional [DIAGNOSES REDACTED]. The resident needed extensive assistance with bed mobility, transfers and toileting from staff members. The Care plan with a problem start date of 8/1/16, identified the resident had an admission to the facility for right femur fracture skilled care. The resident required the Hoyer lift (a mechanical device to lift and transfer), wore an immobilizer on the right leg with no weight bearing and a risk for skin breakdown due to being on bedrest. The interventions directed staff to provide two staff person assistance with a Hoyer lift with all transfers and the assistance of one staff person with cares including toileting as the resident incontinent of urine. Transition Orders and Information for the Continuation of Patient Care (Discharge orders) identified the resident had a hospitalization dated 9/1/16-9/7/16. Discharge orders included Wound care - Right thigh - change dressing every two days with 4 x (by) 4 gauze and [MEDICATION NAME] or Mediport tape. Keep incisions clean and dry and do not submerge in water. Remove sutures on right lateral thigh on 9/21/16. The Progress Notes dated 9/7/16 at 2:39 p.m. documented a skin assessment revealed the resident's right upper thing has an incision 4.5 inches long with a small amount of bloody drainage and the edges of the wound well approximated. Treatment Administration Records (TARs) for September 2016 identified the following: Origin date: 9/14/16 - Suspended: 9/16/16 - Wound care-change dressing every other day with 4 x 4 gauze and [MEDICATION NAME] or Mediport tape. No entries during this period were recorded. The assistant director of nursing (ADON), in a typed written statement, reported she contacted the pharmacy on 9/27/16 to see if they were notified on 9/7/16 of the wound care orders of the right upper thigh. The ADON reported the pharmacy had been notified on 9/7/16 of the resident's discharge orders, but did not have any explanation why the wound care treatments had not been added to the TAR. Wound care treatments were added to the resident's TAR on 9/14/16 when facility staff called the pharmacy inquiring why treatments had not been added to the TAR. Resident progress notes dated 9/8/16 at 12:04 a.m. noted the right thigh wound dressing intact with small to moderate amount of serous sanguineous drainage noted. The incision below the right knee was well approximated with no redness or drainage. The resident complained of pain at a 9 on a 1 to 9 scale. The Progress Notes dated 9/10/16 at 1:46 p.m. noted the resident stated he/she wanted to go home and attempted to get out of bed. Staff noted drainage to dressings on incision sites after the resident attempted to get out of bed. The resident became combative and refused cares. Staff called the resident's primary physician who gave an order to send the resident to a local hospital emergency room for a psychiatric evaluation. The resident refused to go to the hospital. Staff called the physician and gave an update to the resident's refusal at which time the physician gave an order for [REDACTED]. The Progress Notes dated 9/11/16 at 3:48 p.m. noted during a dressing change to the site (site unknown) due to dressing saturated from incontinence of urine. A fax dated 9/12/16 at 5:18 p.m. notified the resident's primary physician that the resident had loose, mucous a foul smelling stools. The facility requested and the physician ordered to check for [MEDICAL CONDITION] (an inflammation of the colon caused by bacteria). The Progress Notes dated 9/13/16 at 2:16 a.m. noted the wound dressing to the right thigh full of mainly serous fluid. The skin under the dressing had a cream color and appeared waterlogged. No foul order or redness noted. The Progress Notes dated 9/13/16 at 6:38 p.m. noted the right upper thigh had dehisced (a technical term meaning the wound opened) approximately 4 centimeters (cm). The wound had a moderate amount of thick white discharge and serosanguinous drainage. The nurse notified the assistant director nursing (ADON) of the resident's skin condition. The nurse attempted to contact the resident's surgeon but it was after hours and could not locate a fax number. The registered nurse documented she notified the oncoming nurse of the situation. The nurse covered the wound with an ABD (large, absorbent and thick) dressing. The Progress Notes dated 9/14/16 at 12:02 p.m. (recorded as a late entry on 9/16/16 at 12:10 p.m.) noted the ADON attempted to fax the resident's surgeon regarding the appearance of the right upper thigh wound. The ADON noted staff had left a completed fax form under her office door when she left on 9/13/16. Six (6) attempts to fax the surgeon resulted in error reports which indicated the fax had not been transmitted and came back as BUSY. Fax's record the attempts made on 9/14/16 at 8:35 a.m.-8:58 a.m. The original fax placed under the ADON's door confirmed the six attempts had been made. No other faxes were found in the resident's file. A fax dated 9/14/16 at 3:49 p.m. notified the resident's primary physician that the resident had increased mental confusion, delusional and paranoid thought after surgery and could the anesthesia be the cause. The Progress Notes dated 9/14/16 at 4:31 p.m. (recorded as a late entry on 9/15/16 at 4:36 p.m.) noted the resident allowed staff to do a dressing change to the right upper thigh with drainage noted, no foul smell and skin tan in color. Staff discussed seeing the surgeon as the wound needed to be seen. The resident stated no. The Progress Notes identified the following: On 9/14/16 at 6:41 p.m. the facility received an order (from the resident's primary physician) for a wound clinic that comes to the facility be notified to assess and treat the resident's wounds. The wound clinic reported they could not see the resident without an order from the resident's surgeon. The notes indicated the resident's surgeon had been notified regarding the wound. On 9/15/16 at 12:17 a.m. the note indicated the resident had a slight temperature of 99.1 degrees, had diarrhea and wanted to be taken to a local hospital emergency room for an evaluation. The resident complained of not seeing their physician that day. The facility completed wound care to the right thigh and noted the wound clean, dry and intact. On 9/15/16 at 4:24 p.m. the note indicated the staff took the resident to an appointment with the surgeon and while there, reported to staff the resident would be sent to the hospital emergency room for an evaluation and admission to the hospital. On 9/15/16 at 4:44 p.m. the facility received a call from the resident's surgeon office asking why the facility hadn't called and spoke with anyone about the resident's wound dehiscing and all they did was fax the office on 9/13/16 about the wound. The surgeon's office requested the resident be seen as soon as possible. On 9/21/16 at 1:17 p.m. a Medicare 5 day review revealed the resident had episodes of increased agitation and attempted to climb out of bed unassisted. It was noted on 9/13/16, the incision on the right thigh had dehisced and several attempts were made to contact the physician. On 9/15/15, the resident went to see the surgeon who then admitted the resident to the hospital. Hospital records dated 9/18/16 at 2:04 p.m. noted the surgeon saw the resident at the orthopedic clinic and discovered the incision completely dehisced. On 9/116/16 the resident had surgery and wound vac (vacuum-tube to remove wound drainage) placed. A 10 day course of antibiotic therapy initiated and cultures taken revealed a wound infection. During an interview dated 9/27/16 at 2:10 p.m. Staff A (licensed practical nurse) reported on 9/10/16, the resident became agitated and attempted to get out of bed as he/she wanted to leave the facility. In attempting to get out of bed, the staff noted drainage from the incision sites of the right thigh. The resident refused cares and became physically aggressive toward staff and local police were called. After things calmed down, she reported the resident allowed her to change her/his dressings. Staff A reported changing the dressing to the right thigh and noted the wound had opened slightly. No measurements were taken but no bleeding had been noted. Staff A stated she reported to the oncoming nurse of the resident's wound opening and of the soaked bandages. During an interview dated 9/27/16 at 9:02 a.m. Staff B, (licensed practical nurse) reported she received report from Staff A on 9/10/16 of the resident's wound to the right thigh had opened. Staff B reported she hadn't seen the wound because she didn't have any orders to provide wound care to the site. During an interview dated 9/26/16 at 4:20 p.m. Staff C (registered nurse) reported she couldn't find the surgeon's contact information in the resident's chart. She looked on the Internet and found a phone number which she called. She stated no one answered and she couldn't leave a message. She reported to the oncoming nurse of the resident's wound status and not finding contact information for the surgeon. During a follow up interview dated 9/27/16 at 8:13 a.m. Staff C, stated she completed an assessment of the resident's wound to the right thigh on 9/13/16 at 4:31 p.m. noting the wound had opened. She attempted to locate but could not find contact information for the surgeon. She stated she placed a prepared fax describing the resident's open wound under the assistant director of nursing door. During another interview dated 9/27/16 at 8:13 a.m. Staff D, LPN reported Staff C stayed late on 913/16 and reported she had changed the resident's wound dressings to the right thigh and thought the wound infected. Staff D asked if she had contacted the surgeon and Staff C reported she had. Staff C also reported the resident had not been acting like himself/herself. During an interview dated 9/26/16 at 3:51 p. m. Staff E, LPN and assistant director of nursing (ADON) stated Staff C had left a fax sheet under her door regarding the open wound on the right thigh. Staff C had reported she couldn't locate a fax or phone number for the surgeon. Staff E stated she found the fax number for the surgeon and attempted to fax the information to the surgeon but each of 6 faxes did not go through as the surgeon's fax number had been busy. She stated she had given the fax to the evening nurse on 9/14/16. During an interview dated 9/26/16 at 2:55 p.m., the Director of Nursing (DON) stated she had previously educated staff on documentation requirements on wound care and notification of the physician when necessary. The staff are to document the location, size, type of drainage if seen of the wound and the color and odor of the wound and document in the treatment administration records (TAR's). If a wound change occurs, staff are to complete a wound assessment and notify the physician directly by calling or fax. Staff are to continue calling and faxing the physician until they get a response. During an interview dated 9/27/16 at 2:55 p.m. the surgeon's nurse reported neither she nor the surgeon had been contacted by the facility until a fax had been received late in the day on 9/14/16. She stated she spoke for the surgeon and he expected the facility to call him immediately if the wound had opened. The contact information had been on the discharge orders (Transition orders noted above), which included the fax number and phone numbers. The clinic phone number to the clinic during office hours allows the caller to leave a message during normal business hours. An answering service is available after business hours. The case manager reported the measurement of the wound on 9/16/16 before surgery measured 12 centimeters (cm) in length, 8 cm in depth and 8 cm wide and infected. The resident received intravenous antibiotic therapy and remains in the hospital. During an interview dated 9/28/16 at 1:30 p.m. the resident's primary physician stated the facility called him on 9/14/16 at 9:34 a.m. requesting an order for [REDACTED]. During an interview dated 10/5/16 at 12:18 p.m., the resident's surgeon reported he expects to be notified immediately from the facility when a wound changes significantly, as it did with this resident. The facility did not notify him of the resident's wound opening except by fax and not when the wound opened. The resident's open wound required immediate hospitalization , surgery and intravenous therapy.

Based on record review, observation, staff interviews and review of the policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self or elements in the environment (Resident #3, #6, #7, #8 & #11). The sample consisted of 11 residents. The facility identified a census of 61 residents. Findings include: 1. Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 2/12/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 identified the resident with severe cognitive impairment. According to the MDS, the resident required extensive assistance with bed mobility, transfers and ambulation in the room and corridor. The MDS identified the resident used a wheel chair. The Care Plan dated 12/17/15, directed staff to ensure the resident had a Wander Guard (device to protect, signal and secure doors) on the wheelchair because the resident liked to move around the halls in the facility. The note indicated the resident liked moving around and did not feel as agitated or restless and enjoyed visiting with others. Review of the Elopement Risk assessment dated [DATE], identified the resident an elopement risk and needed a Wander Guard. Review of the Progress Notes dated 12/27/15 at approximately 9:00 PM revealed the resident brought back into the building from out in front of the building. The State Climatologist was interviewed on 4/20/16 at 1:25 p.m. and stated the temperature at 9:00 p.m. on 12/27/15 was 17 degrees with a wind chill of 5 degrees. The wind was at 10 miles per hour and clear sky. Review of a work order dated 12/28/15 indicated a repair need to replace the door alarm at the nurses ' station as soon as possible per the Administrator. Review of the documents titled Monthly Door Alarm Checklist identified the following dates the door alarms were checked and functioning: 9/23/15, 10/26/15, 11/23/15, 12/23/15, 1/25/16, 2/25/16 and 3/25/16 (approximately each month). Observation on 4/7/16 at 11:4 0 AM identified the side door at the nurses station open and the alarm sounded with sound of a door bell. The bell sounded 2 times and then stopped. The alarm sounded at the door only. During an interview with Staff A, LPN (licensed practical nurse) on 4/7/16 at 4:30 PM, he stated Staff L, CNA (certified nursing assistant) notified him the resident had wandered out into the parking lot and a visitor assisted him/her back into the facility. The resident had already been returned into the facility when he had been notified. He found the resident exited through the side door when he and the Administrator reviewed the cameras the next day. They saw him/her walk out the side door (at the nurses ' station). The visitor had left the facility through the front door and saw the resident. The visitor assisted the resident back through the side door. He further stated he did not hear a door alarm that night. Nursing staff did not open or check alarms on the doors following the resident ' s exit from the facility. The resident had a Wander Guard on that night, but no Wander Guard alarm had been on the side door. He stated he had heard the alarm sound in the past and it chirped like a bell alert when going into a store, and the magnet shuts the alarm off when the door closes. He then filled out an order for [REDACTED]. On 4/7/16 at 1:00 PM, the Maintenance Supervisor was interviewed and stated the current alarm on the side door had malfunctioned and had been set on chime instead of instant. The Maintenance Supervisor stated he glued the alarm every time to ensure it remained on instant. He further stated the staff removed the glue at times and change to chirp or off. He fixed the alarm. On 4/8/16 at 9:00 AM the Maintenance Supervisor stated he received a work order on 12/28/15 for the side door alarm. The alarm had not been working at all on 12/28/15 when he checked it. The supervisor stated he replaced the battery and it still did not work. He replaced the alarm. He further stated the alarms are hit and miss. Sometimes they only last 1 month and quit working. The facility checks the function of alarms by monthly checks or if someone opens a door and it does not work. They get right on it to place a new alarm or functional alarm. Currently they are looking for a new type of alarm. 2. Resident #7 had a MDS with an assessment date of 1/24/16. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMs score of 3. A score of 3 identified the resident as severely cognitively impaired. According to the MDS the resident required supervision with ambulation in the corridor and on and off the unit. The Care Plan dated 2/5/16 directed the staff to make sure a Wander Guard (bracelet) is on at all times and working. Review of the elopement risk assessment dated [DATE] indicated the resident had elopement attempts in the past that had been unsuccessful and elopement successes in the past. The assessment revealed the resident did not present an elopement risk, but did have a Wander Guard. Review of the Progress Notes dated 12/10/15 at 11:02 AM indicated the resident left the facility via the front door attempting to gain access to vehicles. The staff were able to redirect the resident back in to the facility. The resident wore a Wander Guard (bracelet) to alert staff if exiting the facility. On 4/15/16 at 12:00 PM, Staff S, certified nursing assistant, was interviewed and stated during her lunch break, she had been in her car located in the parking lot. She saw the front door open and the resident walked out. She went to the resident before he/she got to the parking lot. No staff followed the resident out and she had to page for staff to come and get the resident because she had not been on the clock. She further stated that she cannot remember hearing the Wander Guard alarm sound but may just not have heard it. She also could not remember the day the incident occurred or who the staff member had been that came to direct the resident back into the facility. During an interview with the Administrator on 4/21/16 at 11:50 am she stated she had not been made aware of a time when Resident #7 had exited the building. The State Climatologist was interviewed on 4/20/16 at 1:25 p.m. and stated on 12/10/15 at 11:00 a.m., the temperature outside was 54 degrees Fahrenheit with wind at 17-27 miles per hour and a clear sky for the Glenwood Area. Review of the Policy and Procedure titled Elopements/Glen Haven Home, dated December 2007 directed staff to do the following: a. Staff shall promptly report any resident who tries to leave the premises or is suspected of missing to the Charge Nurse or Director of Nursing. b. If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the departure in a courteous manner; Get help from other staff members in the immediate vicinity, if necessary; Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. Note: At the time of the complaint investigation, the complaint was coded at a J, serious and immediate jeopardy. By 4/13/16, the facility had implemented measures that adequatly addressed the jeopardy and the grid placement was lowered to the G level due to the harm issues identified with incidents of resident's falling (Residents #3, #8, #11). The facility placed a coded lock on the front door with the current Wander Guard alarm system. The door leading from the office (LV2) alarm was replaced on 4/7/16. As of the 4/28/16 exit conference, the facility continued to need to: · Continue to monitor the effectiveness of the door alarms in order to ensure the residents remained safe and without elopements. · Continue to monitor the facility policy/procedures for checking the door alarms. 3. Resident #3 had a MDS with a reference date of 11/29/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance of 1 person physical assistance for bed mobility and toilet use. The transfer and locomotion did not occur in the assessment period. Review of the Fall Risk assessment dated [DATE] indicated the resident had a total score of 8. A score of 10 or higher represented the resident to be at a high risk for falls. The Care Plan dated 10/9/15 indicated the resident had a pressure mattress and required a wheel chair for mobility. The Care Plan, updated on 12/21/15, directed staff to have 2 people present when repositioning the resident. Review of the facsimile to the physician dated 12/21/15 indicated the resident slid out of bed while being repositioned and bed sheets changed. The resident received a hematoma (bruise area) on the right lower shin that measured 5 cm (centimeters) by 6 cm initially. The area continued to swell. The staff applied cold water/ice and administered pain medication. The physician ordered the resident be sent to the hospital emergency room . The Fall Scene Investigation Report dated 7:44 AM indicated the resident slid out of bed during repositioning, with the bed elevated. The nurse intercepted the fall by holding onto the resident ' s arm and leg when the resident slid off the bed. The resident had been on his/her side for changing the bottom sheet and slid off the bed. The resident received a large hematoma on the right shin and bruised/swollen area on top of the right foot. The staff updated the Care Plan which directed 2 staff persons to assist with repositioning. Review of the Progress Notes dated 12/21/15 at 12:33 AM indicated the staff assisted the resident with changing the pad/bottom sheet and 1 person assistance. The resident began slipping from the bed and slid to the floor after attempting to keep in bed. The resident assisted back into bed with a Hoyer (mechanical) lift. The resident had a hematoma on the right lower shin and bruised/swollen area on top of the right foot. The nurse administered Oxycodone (narcotic analgesic) and placed ice/cold water on the hematoma. The resident still complained of significant pain from the hematoma. The nurse placed a call to the physician and waited for a response. The resident ' s vital signs were within normal limits for the resident. On 12/21/15 at 1:15 PM (late entry) the hematoma on the right shin now covering the entire shin/calf. The nurse telephoned the physician and received a verbal order to have the resident evaluated at the emergency room and to give additional oxycodone 10 mg (milligram) for continued pain. At 2:48 (late entry) the transport arrived and picked up the resident to transport to the emergency room . On 12/22/15 at 10:52 AM an update received and the resident was admitted for treatment of [REDACTED]. On 12/30/15 at 4:54 AM the document revealed the resident returned from the hospital with a wound vac (device to remove drainage from a wound) on the right lower leg wound. Observation on 4/13/16 at 8:20 AM indicated the resident's bed positioned approximately 5 feet from the wall. The side table and bedside table sat between the bed and the wall. During an interview with Staff E, RN on 4/112/16 at 5:00 PM, she stated she went to the resident's room to do the skin checks. She asked the resident if she/he could turn and the resident voiced though he/she could. Staff E stated she looked at the resident's skin and saw the sheets soiled and proceeded to change them. The bed had been up to waist level and away from the wall, the same position the bed currently sits. The opposite side of the bed had a small triangle shaped rail for positioning and he/she also had an air mattress. The residents legs where sliding off of the bed and then his/her body. The resident grabbed for the staff person ' s and she assisted the resident to slow the fall. Review of the Policy and Procedure titled Turning a Resident On His/her Side Away From You dated October 2010, directed staff to do the following: a. Slide both your arms under the resident's back to his/her far shoulder. b. Slide the resident's shoulders toward you on your arms. (Note: Keep your knees bent and you ' re back straight as you slide the resident toward you.) c. Slide both your arms (as far as you can) under the resident's buttocks. d. Slide the resident's buttocks toward you. e. Slide both arms under the resident's feet and ankles. f. Slide the resident's feet toward you. g. Cross the resident's arms over his/her chest. h. Cross the resident's leg nearest you over the leg farthest from you. i. Stand with your weight evenly distributed on both feet. j. Place 1 hand on the resident's shoulder nearest you. k. Place your second hand under the resident's buttocks. l. Gently turn the resident away from you. During an interview with Staff J, CMA (certified medication assistant) on 4/13/16 at 10:30 AM she stated the resident could be assisted by 1 staff but she would use 2 staff due to he/she likes the bed high. There also had been no rail on 1 side of the bed and to position for comfort, used 2 staff. During an interview with Staff W, CMA on 4/27/16 at 2:30 PM, he stated had always felt safer with 2 staff assisting the resident. The resident could help but not a lot. Staff W stated the resident could slide out of bed easily. 4. Resident #8 had a MDS with a reference date of 1/31/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMs score of 2. A score of 2 represented a severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers and toilet use. The MDS identified the resident frequently incontinent of bowel and bladder. According to the MDS the resident had 1 fall with no injury and 1 fall with injury since the prior assessment. The Care Plan dated 2/11/16 directed staff to provide a floor mat, use relaxation therapy such as back rub or use a soothing voice to help calm down when restless and when (the resident) in the wheelchair to be in the commons area to be monitored (by staff). Review of the Fall Risk assessment dated [DATE] identified the resident with a total score of 16. A score of 10 or higher represented a high risk for falls. Review of the pocket Care Plan (not dated) indicated the resident required a wheelchair and eye glasses and transferred with 2 assist with the EZ stand lift. The Care Plan also directed staff to anticipate needs such as toilet, hunger, thirst and pain. The Care Plan failed to direct staff to ensure the resident remained in the commons area when in the wheelchair. Observation on 4/20/16 at 1:30 PM identified the resident in the wheel chair in his/her room. The wheel chair was tilted back and the resident sat forward. No staff were in the room while the resident remained in the wheelchair. At 3:00 PM the resident sat in the wheelchair in his/her room alone. On 4/21/16 at 2:00 PM the resident sat in the wheelchair in his/her room alone. 5. Resident #11 had a MDS with a reference date of 4/8/16. The MDS identified [DIAGNOSES REDACTED]. The MDS identified the resident had a brief interview for mental status score of 10. A score of 10 identified the resident with moderate cognitive impairment. According to the MDS, the resident required supervision with bed mobility, transfers, ambulation and toilet use. The MDS identified the resident required the use of a walker for mobility device. The care plan dated 4/1/16 revealed the resident had a history of [REDACTED]. The care plan failed to identify the resident required assistance. Review of the Pocket care plan (not dated) revealed the resident transferred with use of a walker/cane. The pocket care plan failed to identify the resident required assistance. Review of the Fall Risk assessment dated [DATE] revealed the resident had a total score of 2. A score of 10 or higher represented a high risk for falls. Review of the Event Report dated 4/19/16 at 9:00 AM revealed the resident lost their balance in the hallway and fell to the floor. The gait assist device not in use. The injury included a fractured nose and fractured right knee cap. Review of the Emergency Department Encounter dated 4/19/16 identified the diagnostic results included a nondisplaced patellar (knee cap) fracture and depressed nasal (nose) fracture. Review of the Physical Therapy Report dated 4/14/16 indicated the resident required contact guard; 1 staff person assistance. During an interview with the Physical Therapist on 4/20/16 at 10:30 AM, he stated resident was seen on 4/15/16 and he spoke with nursing. He evaluated the resident and made no change. The resident continued to be independent in his/her room and required assistance out of the room. During an interview with Staff T, CNA on 4/20/16 at 11:30 AM, she stated the facility provides pocket care plans to identify assistance required for each resident. The Care Plan did not identify if the resident required assistance or had been independent. She further stated that she did not know the resident required assistance. She had been walking into the dining room and saw a female resident go into a male resident ' s room. She went down the hall and asked the resident if he/she had been confused. The resident stated he/she needed to use the restroom. Staff walked with the resident to the shower room to toilet. Staff turned away from the resident to unlock the shower room door and the resident fell . She yelled for help and assisted the resident due to his/her nose had been bleeding. The nurse came to assess and the resident was transferred to the hospital. She further stated she knew the resident required a walker but after the fall staff looked for it and could not find it anywhere. During an interview with Staff S, CNA on 4/20/16 at 12:00 PM she stated that the last she knew, the resident had been independent with a walker. No one told her any changes. During an interview with the Assistant Director of Nursing on 4/21/16 at 10:20 AM she stated the resident had been independent in the room and required 1 person staff assistance out of the room. The resident had ambulated by holding onto furniture prior to admission into the facility.

Based on record review, staff interviews and review of the facility policy/procedures, the facility failed to plan for and provide education and support regarding [MEDICAL CONDITION] care to ensure staff competence during an emergency situation for 1 of 1 resident reviewed. The facility reported a total census of 61 residents and had 1 resident with a [MEDICAL CONDITION]. Resident #5 was found in respiratory distress and the facility nurse did not follow the facility policy/procedures and failed to provide appropriate [MEDICAL CONDITION] care. Staff interviews identified the facility failed to ensure the nursing staff could provide services to a resident with a [MEDICAL CONDITION]. Findings include: 1. Resident #5 had a MDS (Minimum Data Set) assessment with a reference date of 12/10/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS the resident required total depended upon staff for bed mobility, transfers, eating, toilet use and personal hygiene. The MDS identified the resident had shortness of breath or trouble breathing when lying flat and had a condition that may result in a life expectancy of less than 6 months. The MDS indicated the resident received oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of the Physician's Orders dated 11/28/15 at 8:11 AM, directed the staff to do the following: a. Oxygen (O2) titrate O2 as needed to maintain levels at 90%. b. [MEDICAL CONDITION] every 4 hours, schedule: 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM & 10:00 PM. c. [MEDICAL CONDITION] needed for signs of respiratory distress. Review of the TAR (Treatment Administration Record) dated January 2016 identified the following treatments: a. [MEDICAL CONDITION] 4 hours and documented completed 2:00 AM to 4:00 AM. b. Titrate oxygen to maintain oxygen saturations at 90% or higher. Circled on 1/12/16 4:00 AM to 6:00 AM. Circle represents not done. c. [MEDICAL CONDITION] needed for signs of respiratory distress. (not documented completed) d. Oxygen titrate O2 as needed to maintain levels at 90%. (not documented completed) Review of the Progress Notes dated 1/12/16 at 5:10 AM, written by Staff Q, (Registered Nurse), indicated the resident on his/her side and foaming at the mouth. The resident's face purple. The inner cannula removed. The resident remained unresponsive. The nurse patted on the resident's chest and repositioned him/her several times. A new cannula inserted. At 5:20 AM the nurse obtained an O2 (oxygen) reading of 84% and a pulse on the pulse oximeter that varied from 66 to 212 (normal reading is 97-100 percent). The nurse noted the chest not rising. At 5:25 AM, no longer able to get a pulse or O2 reading on the pulse oximeter. The nurse called Hospice answering service at 5:43 AM. At 5:50 AM, received a call from the Hospice nurse stating she was on her way. During an interview with Staff Q, RN (Registered Nurse) on 4/13/16 at 5:00 PM, she stated she had suctioned the resident per the physician's order when in the room earlier in the shift. When she went into the room, she patted the resident on his/her back. She had also turned the resident on his/her side. She took the inner cannula out and saw mucus inside of the cannula. She placed a new inner cannula into the trach. She could see the resident got a little better after that. She stated that [MEDICAL CONDITION] been plugged and thinks if she would have suctioned it he/she would still be alive. She stated that the resident had [MEDICAL CONDITION] in the past. When she did suction the trach, she suctioned to the end of the trach, just until she met resistance. She did not deep suction. She stated that when the resident 1st came to the facility, the DON (Director of Nursing) gave her a quick run through of his/her trach. On 4/21/16 at 7:30 PM, she stated the resident had oxygen on per the order. Staff Q stated she did not increase the liter flow of oxygen for the resident. During an interview with Staff E, RN on 4/26/16 at 1:40 PM she stated that she did not have training on [MEDICAL CONDITION] care at the facility. Staff E stated she learned how to care for patients with tracheostomies in school (nurse ' s training) and did not have a resident [MEDICAL CONDITION] in her work experience prior to her current employment. During an interview with Staff M, RN on 4/26/16 at 5:35 PM she stated that she did not receive training on [MEDICAL CONDITION](how to care for a resident with [MEDICAL CONDITION]) at the facility. Staff M stated she had been familiar with the resident and the [MEDICAL CONDITION] from a previous facility. Staff suctioned just past the tip of [MEDICAL CONDITION] a small catheter and never used saline or an Ambu bag. They did not deep suction the resident. If the resident with [MEDICAL CONDITION] had distress or a low pulse oximeter reading, then staff are to clean the inner cannula/trach and increase the oxygen as needed. Review of the Policy and Procedure titled Suctioning the Lower Airway (Endo tracheal or [MEDICAL CONDITION]) dated October 2010 identified the purpose of the procedure is to remove secretions, maintain a patent airway and prevent infection of the lower respiratory tract: a. Remove oxygen or humidity delivery device using the nondominant hand. b. Hyper inflate and hyper oxygenate the resident using an Ambu bag connected to supplemental oxygen. c. Manually ventilate (bag) the resident 4 to 5 times, coordinating with natural breaths. Remove bag. d. Instruct the resident to inhale. e. Upon inhalation, insert the catheter into airway (ET tube [MEDICAL CONDITION]) without applying oxygen. Advance the catheter until resistance is met and/or resident coughs (at the carina). Pull back 1 to 2 cm. f. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than 10 seconds. g. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions. h. Rinse catheter and tubing with sterile saline or sterile water until clear. i. Assess cardio-pulmonary status. j. Repeat steps a through h, if necessary. Limit suction passes to a maximum of three. The Resident Progress Notes dated 1/12/2016 indicated Staff Q informed the Director of Nursing and the Administrator about the resident ' s passing. The Hospice nurse now at the facility. The Certificate of Death identified the immediate cause of death was listed as [MEDICAL CONDITION]. Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. By 4/22/16, the facilty had implemented measures that adequately addresssed the jeopardy and the grid placement was lowered to the D level. The facility provided in-services for the policy/procedures of [MEDICAL CONDITION] Suctioning to licensed nurses. As of the 4/28/16 exit conference, the facility continued to need to: · Continue to in-service nursing staff about [MEDICAL CONDITION] care, · Monitor nursing staff and ensure all nursing staff are competent to perform [MEDICAL CONDITION] care per the facility policy/procedures manual.

Based on observation, clinical record review and staff interview, the facility failed to initiate interventions after a fall and to provide planned safety interventions to reduce the risk of falls for 1 of 3 current residents identified with recent falls reviewed (Residents #1). The facility identified a census of 62 current residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented the [DIAGNOSES REDACTED]. The MDS further documented the resident scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. According to the MDS, the resident required limited assistance of 1 staff with transfer and walking in the room. The MDS documented the resident required extensive assistance of 1 person with toileting and personal hygiene. The MDS documented the resident's balance as not steady but able to stabilize without staff assistance during transitions and walking. A care plan dated 6/5/14 identified a problem with walking due to a fall risk and requiring assistance. The care plan documented the following falls: 9/5/13 (no injury) 9/22/13 (abrasion to left knee) 11/10/13 (no injury) 2/9/14 (no injury) 6/15/14 (no injury) 6/21/14 (right hip fracture) The care plan documented the resident as independent in his/her room with cues and supervision needed. The care plan documented the resident had a floor alarm beside the bed for use during the night and an alarm in the recliner, as well as walking with staff using a walker to meals. A handwritten entry dated 7/1/14 documented the resident as no longer independent and requires assistance with all activities of daily living (ADLs). Review of the progress notes dated 2/9/14 at 4:29 p.m. revealed the resident had a witnessed fall without injuries. The resident walked in the hall and stumbled over his/her own feet. Resident #1 landed on the left hip area but did not hit his/her head. Review of a physical therapy discharge summary with dates of service from 2/12/14-2/21/14 revealed that the physical therapist provided patient and caregiver training. The physical therapist completed staff education: regarding the need for the patient/resident to be CGA (caregiver assisted) with walk to dine in order prevent further falls. The physical therapist documented the patient/resident with slightly decreased dynamic balance associated with ambulation and would therefore benefit from CGA with ambulation. Staff states understanding, although poor carryover demonstrated by staff. The same physical therapy summary scored the resident 17/28 on the Tinetti Assessment (high risk for falls) at baseline, previous and on discharge from physical therapy. Review of progress notes dated 6/15/14 at 18:51 (6:51 PM) documented the resident observed on the floor by a certified nursing assistant (CNA) who notified the nurse. The nurse observed Resident #1 on the floor near the closet, had his/her shoes on, with the walker in the restroom. The resident asked the nurse to pull the covers up as though he/she were in bed. The staff explained to the resident that he/she was on the floor. The staff completed a nursing assessment with no injuries noted. Review of the care plan with a handwritten entry dated 6/15/14 documented that the physician advised no new orders when notified of the fall. The care plan failed to initiate any further nursing interventions at this time. An event report dated 6/15/14 at 18:23 (6:23 PM) documented a fall in the room with no care plan revisions documented. Review of progress notes dated 6/21/14 at 1:15 AM documented that a CNA was alerted to the resident room by an alarm sounding. The CNA found the resident lying on the floor next to the bed. The CNA called the nurses to the room for help. The progress note documented the resident as alert and oriented to self but did not know what he/she was doing or whether he/she had hit his/her head. The progress note documented no abrasion, laceration or bumps to the head. Observation revealed range of motion was limited to the lower right extremity with pain. The progress note documented the right foot rotated in and the resident was unable to bear weight. The staff moved the resident to the bed for assessment and the resident complained of pain in the right leg. The staff noted some shortening of the right leg. The facility staff notified the physician and sent the resident to the emergency room for evaluation of the hip. An event report dated 6/21/14 at 01:00 (1:00 AM) revealed a CNA was alerted to the room related to an alarm sounding. Review of a progress note dated 6/21/14 at 3:35 AM documented that the resident/S daughter called and informed the facility that the resident did have a fractured hip. Review of the care plan updated on 7/1/14 documented the resident now required staff assistance with bed mobility, transfers (Hoyer mechanical lift) eating, toileting, dressing, personal hygiene and locomotion in a wheelchair and with bathing. The approaches included a bed, floor and wheelchair alarms in place. Review of progress notes dated 7/3/14 at 14:36 (2:36 PM) revealed the resident found on the floor next to the bed by facility CNA and float pool CNA. The progress note documented the resident fully dressed with shoes on, nothing on the floor and the floor dry. The resident lay on top of the wheelchair footboard with the Hoyer sling under him/her. During an interview with Staff A, Licensed Practical Nurse (LPN) on 7/8/14 at 4:10 PM, she stated Resident #1 was on PT after the fall of 2/9/14 until 2/21/14. She stated that she was unaware if the alarm sounded during the fall on 6/15/14. She stated that the facility requested a Physical Therapy and Occupational Therapy (PT/OT) evaluation and treatment order from the physician who refused and no other interventions were initiated. During an interview with Staff B, LPN on 7/9/14 at 9:10 A.M., he stated he was present after the fall on 6/15/14. Staff B stated Resident #1 lay close to the closet on the floor and stated he couldn't reach his/her covers. Staff B thought the resident believed he/she was in bed. Staff B stated one of the CNAs found the resident and alerted him. Staff B assessed the resident. Staff B stated he didn't remember hearing an alarm sounding. Staff B stated regarding the fall on 7/3/14, he observed what looked like the resident slid out of the wheelchair and ended up in lying/sitting position on the footboard of the wheelchair. He stated he didn't hear an alarm and identified Staff C, CNA as the aide who alerted him to the fall. During an interview with Staff C, CNA on 7/9/14 at 9:25 A.M., he stated he walked into Resident #1's room on 7/3/14 because he was alerted by the resident's roommate that the resident was on the floor. Staff C observed the resident on the floor resting on the foot pedals of the wheelchair. Staff C stated it looked like the resident slid out of the wheelchair. Staff stated that the resident could propel himself/herself but was not sure how the resident got to the room. Staff B stated that no alarm was sounding. During an interview with Staff D, CNA on 7/9/14 at 1:35 P.M. she stated that she observed Resident #1 in the corner on the floor of the room during room to room checks at the beginning of her shift on 6/15/14. She stated the resident asked for blankets and acted like he/she wanted to take a nap. She stated the resident had been in the recliner prior to being found on the floor. Staff D stated no alarm sounded and the resident's wheelchair was outside the door of the room. Staff D stated that some alarms are faulty and have to have the batteries checked. Staff D stated Resident #1 asked everyday where his/her spouse was and every day they tell him/her that the spouse has passed away. Staff D stated resident #1 is very confused and doesn't remember anything. The facility failed to provide appropriate supervision and interventions to prevent falls resulting in the hip fracture for Resident #1.

Based on observation, record reviews, and interviews, the facility failed to ensure residents received adequate supervision to prevent hazards while being transported in the facility vehicle. On [DATE], staff transported Resident #25 in the facility vehicle without a lap belt to secure him/her in the wheelchair. When the vehicle came to an abrupt stop to avoid hitting another vehicle, Resident #25 only had a shoulder strap on, and slid out of his/her wheelchair and onto the floor. The resident fractured both his/her knees and his/her condition declined and he/she died three days after the incident. The onsite observation revealed Resident # 32 returned in the facility vehicle in his/her reclined wheelchair with the lap safety belt significantly loose (with ,[DATE] inches of space), not securing the resident in the wheelchair. Staff interview identify Resident #25 and Resident #32 had not been safely secured in their wheelchairs when transported. The findings constitute an immediate jeopardy to residents health and safety. Additionally, observations identified the facility failed to protect residents from hazards for Residents #30, #6, #28, #31, #19 and #2). The facility identified a census of 62 current residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated [DATE] revealed pertinent [DIAGNOSES REDACTED]. The same assessment revealed a BIMS score of 7 which indicated severely impaired cognition. The assessment revealed the resident required the assistance of two for transfers and using the toilet. The assessment identified the resident could not stabilize his/her balance without staff assistance when moving from surface to surface. Review of the resident Care Plan dated [DATE] revealed the resident at risk for falling and history of falls. The facility self-reported the following to the Department: At approximately 10:30 a.m., Staff Ee transported Resident #25 in the facility van. Resident #25 had been secured (with the shoulder strap) in his/her wheelchair in the back of the van. Staff Ee had to stop the vehicle immediately to avoid hitting other vehicle/s and Resident #25 slid under the (shoulder) strap to the floor. The resident sustained [REDACTED]. The Sheriff ' s office refused to take a report of the incident. The facility learned Resident #25 had fractured both femurs and later died on [DATE]. The Plan of Correction was for staff to take a different route on the Highway and the facility would be securing residents to their wheelchairs by adding a dycem to the wheelchair to prevent additional slipping. A tether belt had been bent from the incident and had now had been replaced. The facility identified they replaced all their other tethers belts. (Resident #35 had also been transported in the van, siting in the front passenger side of the van, and sustained no injuries.) A review of the employee file for Staff Ee identified he/she must use the safety restraints, seat belts & other safety devices as appropriate. The employee file showed no disciplinary actions documented. During Group Meeting with 15 alert residents, a resident reported he/she fearful of going out of the facility in the facility van while Staff Ee drives the van. The resident reported the staff had transferred him/her back to the facility and the resident stated they would not ride with that driver again. The resident stated, this driver had a history of [REDACTED]. The resident reported the staff uses their cell phone texting while driving, and she drives too close behind other vehicles. Review of the facilities transportation calendar revealed the facility provided transportation in two vans to approximately 10 to 15 residents that used wheelchairs. Review of the Vehicle Accident Report dated [DATE], written by the driver (Staff Ee) described an incident where she slammed on her brakes to avoid hitting the car in front of her. Resident #25 slid out of the wheelchair and onto the floor. Staff Ee called the facility then called 911. Staff Ee documented the road conditions were normal; it had been a clear day. The road was a paved highway with curves and hills. The incident occurred at approximately 10:30 AM. There had been no impact to other vehicles. The driver reported she had not been following too close or speeding; she just reacted to the situation in front of her. During interview on [DATE] at approximately 1:30 p.m., Staff Ee, Transportation driver for the facility stated she began working in transportation early this year. She stated she had a chauffeur ' s license and the facility trained her in how to strap the residents in the van for safety. She stated she used the 4 point tether system to secure the wheelchair and the shoulder belt for the resident. She stated did not have a lap belt on Resident #25 at that time. She stated after the shoulder strap had been tightened, there was space between the shoulder strap and the resident. She stated she transported Resident #25 and Resident # 35 in the facility van to a clinic visit and when she came to top of the hill, she saw a white sedan in front of her with the brakes on and a pickup truck in front of the white car turning around. Staff Ee stated she had been driving about 50 miles per hour in a 55 speed zone. She stated her van ended up in the oncoming lane when she stopped (there was no impact). She reported she heard a noise coming from Resident #25, and pulled out of the lane to the side of the road. She asked Resident #35 (seated in the front seat) if he/she was ok and the resident replied yes. She heard Resident #25 say " ouch, my ankle hurts " , and checked on him/her. Staff Ee reported Resident #25 ' s lower legs curled underneath his/her upper legs. She called the facility and told her Supervisor (Staff II), what happened. Staff Ee received instructions a couple minutes later called 911. Staff II arrived at the scene (approximately 5 minutes later) then the ambulance arrived about 5 minutes later. During interview and observation of the incident site on [DATE] at 10:30 AM, a witness to the incident described the incident where the Glen Haven van had to stop to suddenly. The witness reported the van swerved into the center of the road into the oncoming lane over the double yellow lines to avoid hitting the car. The witness stated the driver used her cell phone, then about 15 minutes later, another Glen Haven van pulled up and within 5 minutes the ambulance unit arrived. The hospital reported dated [DATE] identified Resident #25 had been brought in to the emergency room after the vehicle he/she was riding in stopped suddenly and he/she fell forward out of his/her wheelchair. The resident hit his/her knees and fractured both of his/her femurs. The resident underwent [REDACTED]. The resident's desire to eat diminished and he/she developed a respirator acidosis (impaired lung function) with CO2 retention (too little carbon dioxide is removed from the blood by the lung) and hypoxia (oxygen deprived). The resident's family made the decision that he/she needed comfort cares and during and episode of aspiration passed away on [DATE]. The facility provided a list of residents in wheelchairs which showed more than ten residents names listed. On [DATE] at 9:10 a.m., the surveyor observed Staff II securing a resident's wheelchair in the van. Staff II used the shoulder and waist/lap belt but the belt was fitted loosely. During interview on [DATE] at 3:45 PM, Staff II, Supervisor/driver stated she had just become supervisor of transportation services this year. Her responsibilities are to supervise the drivers, provide training and assure safety was always practiced when buckling residents in the vehicles. She stated the clip that fastens the shoulder strap to the floor broke during the incident that involved Resident #25. Staff II reported a new shoulder strap replaced the broken one after this incident. Staff II stated they also installed a new lap belt after the incident.(On [DATE], the vehicle did not have lap belts to secure resident's in their wheelchair, only shoulder strap.) She stated the shoulder strap had not been broken prior to this. Staff II reported Staff Ee had been discipline after this, but they determined she did nothing wrong. Observation on [DATE] at 4:15 PM, found the facility van returning from a doctor's visit and Resident #32's in a wheelchair fastened in the back of the van. The surveyor obtained a photograph showing Resident #32 found in a recliner wheelchair with nothing to keep the resident in the wheelchair if the vehicle suddenly stopped. The resident's feet was positioned elevated up (verse down) and the front seats and the shoulder strap fastened to the lap belt resulting in one strap across the resident, with ,[DATE] inches of space under the strap. The strap lay across the resident and over across the arm rests. The Administrator present at this time and observing, reported the lap belt was on and stated, "no it's not securing (the resident)". She reported she needed to look into the matter. The surveyors asked for a demonstration of how Resident #32 had been secured in his/her wheelchair with the seat belts. Staff II reported this was a problem. Review of the MDS assessment for Resident #32 dated [DATE] revealed poor memory, unable to make own decisions. The resident required total assistance for bed mobility, transfers, use of toilet and incontinent of bowel and bladder. The same assessment revealed pertinent [DIAGNOSES REDACTED]. Staff II reported on [DATE] at 2:30 p.m. the interventions added after this incident included purchasing a new lap belt from the company they purchased the van from. During an interview with the service manager (a non-facility member) on [DATE] at 11:40 a.m. he reported there is information that describes how to use the mini-vans original seat belts with an adaptor for securing an individual resident into the wheelchair prior to providing transportation. He stated the adapter helps account for the additional drop of the mini- van floor. He also reported staff should secure the wheelchair with a 4 point system and can also use the 3rd row seat belt that should be hanging inside the van. During interview & observation on [DATE] at 1:35 p.m. the facility Administrator stated until today, residents were not restrained in the wheelchair's correctly during transport. The Administrator reported what the facility had done to correct the problem. The surveyor observed Staff Ee secure the Administrator in the van. The lap strap was tight and the shoulder strap was tight and placed across the chest/torso. The shoulder strap was now snug and the Administrator could not flop backwards or forwards even when she tried to. The Administrator reported all the transportation aides and transport supervisors were present during this demonstration. The Administrator reported all the transportation aides and transportation supervisor were trained today and received competency test. Review of the facilities Driver Safety Program dated [DATE] revealed, number 10 under General Policies: Restraint-seatbelts systems shall be worn at all times by all occupants. Seatbelts should be worn by drivers and passengers at all times when operating a vehicle. The facility abated the IJ on [DATE] when they implemented the following: Obtained lap strap to secure residents in their wheelchair when transported. Secure Resident #25's wheelchair cushion to his/her wheelchair. Added dycem to the wheelchair to prevent additional slipping. Upgraded tethers with a stronger attachment. The facility did not have a written transportation policy until [DATE]. On [DATE] the facility developed a written Transportation Policy which included but is not limited to the following: All residents who are transported in a standard wheelchair or transport chair, or specialized wheelchair will be secured using a securement system (qstraint), shoulder and lap seat belts. All residents in specialized wheelchair will be measured and fitted of a chest harness/H harness prior to being transported. All residents in specialized wheelchairs will only be transported via facility vehicle using their personalized chest harness/ H harness. Transportation staff will be trained on initial hire and annual thereafter. All transportation aides and transportation supervisors were all trained and demonstrated competency of securing residents in wheelchairs. These actions lowered the deficiency from a scope and severity of J to a D, with the need for ongoing monitoring to ensure the provisions are being followed to ensure residents safety. References: Review of the National Highway Traffic Safety Administration Regulation 49 CFR Parts 571, 585, 586, 589, 590, 596, 597 documented, Occupant Crash Protection to require all designated seating positions in rear seats, other than side facing seats, be equipped with Type 2 integral lap/shoulder safety belts. This final rule responds to a Congressional mandate that the agency begin to phase-in requirements for lap/shoulder belts for all rear seating positions, wherever practicable, not later than [DATE]. Review of the National Mobility Equipment Dealers Association Guidelines (NMEDA), 2014 Edition, and Approved [DATE] revealed any strap components must not lie over the wheelchair arms. The wheelchair should have minimal motion once secured in position, no more than ? inch. All wheelchair seating positions shall be equipped with a shoulder and lap belt systems and shall be provided for wheelchair seating position when the seating position is adjacent to an exterior vehicle wall. All 2011 and newer vehicles require shoulder and lap belt systems in all seating positions. 2. The MDS assessment dated [DATE] for Resident #30 identified [DIAGNOSES REDACTED]. The MDS revealed the resident required total assistance of 2 for transfers, bathing, and locomotion on and off the unit. The assessment documented the resident utilized a wheelchair. The resident's care plan dated [DATE] identified the resident required staff to anticipate the resident's needs. The care plan directed staff to provide total assistance with Hoyer (mechanical lift) transfers, bathing, locomotion, and locomotion in a wheelchair. The fall risk assessment dated [DATE] documented a score of 13 which indicated the resident at a high risk for falls. Observation on [DATE] at 7:50 a.m. revealed Staff Oo, CNA, transported Resident #30 in a shower chair with his/her feet on the floor, not on the pedals/platform. The resident's heels caught and bounced off the floor several times during the transport. The total distance calculated approximately 51 feet; (based on ,[DATE] inch floor tiles and 33 short paces). 3. The MDS assessment dated [DATE] for Resident #6 identified [DIAGNOSES REDACTED]. The MDS revealed the resident required the assistance of 1 for transfers, ambulation in room, and locomotion on and off the unit. The assessment documented the resident utilized a wheelchair and impairment in range of motion present on one lower extremity. The resident's care plan with an edit date of [DATE] identified a need for assistance. The care plan directed staff to provide assistance with transfers, walking with a walker, and locomotion in a wheelchair. Observation on [DATE] at 7:55 a.m. revealed Staff Pp, CNA, transported Resident #6 in a wheelchair from his/her room to the elevator. Staff Pp transported the resident without placing his/her feet on the wheelchair pedals and the resident's feet brushed the floor the entire distance. The total distance calculated at approximately 19 feet (based on 9 - 12 inch floor tiles and 12 short paces). 4. The MDS assessment dated [DATE] for Resident #28 identified [DIAGNOSES REDACTED]. The MDS revealed the resident required the assistance of 2 for transfers and indicated the resident independent with locomotion on and off the unit. The assessment documented the resident utilized a wheelchair. The resident's care plan dated [DATE] identified a need for assistance.The care plan directed staff to provide assistance with transfers, walking, and locomotion in a wheelchair. Observation on [DATE] at 11:37 a.m. revealed the facility's MDS coordinator transported Resident #28 in a wheelchair from the dining room to the elevator with the resident holding his/her feet suspended in air from floor. Observation further revealed no wheelchair pedals present on the wheelchair. The total distance calculated at approximately 68 feet, (based on 68 - 12 inch floor tiles). The fall risk assessment dated [DATE] documented a score of 17 which indicated Resident #28 at a high risk for falls. 5. The MDS assessment dated [DATE] for Resident #31 identified [DIAGNOSES REDACTED]. The MDS documented the resident required the assistance of 1 for transfers and indicated the resident independent with locomotion on and off the unit. The assessment identified the resident utilized a wheelchair and impairment in range of motion present on both upper extremities. Observation on [DATE] at 9:10 a.m. revealed Staff Xx, certified medication aide (CMA), transported Resident #31 in a wheelchair from the facility main building outside across a wooden bridge to the activity center building. Staff Xx transported the resident with the resident holding his/her feet suspended in air off the ground. Observation further revealed no wheelchair pedals present on the wheelchair. The total distance approximated 130 feet. The fall risk assessment dated [DATE] documented a score of 17 which indicated the resident at a high risk for falls. 6. According to the MDS assessment dated [DATE] Resident #19 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility and transfers. The care plan dated [DATE] directed staff to asset the resident with bed mobility, transfers, tilting, dressing, personal hygiene and bathing. Review of the Observation Report dated [DATE] revalued the resident with calculated points of 17. A score of 10 or higher represented a high risk for falls. Observation on [DATE] at 12:00 PM revealed Staff FF, CNA pushed the resident through the dining room. The resident sat in the wheelchair and held his/her feet up with no wheelchair pedals on. Observation on [DATE] at 11:00 AM revealed the resident sat in the wheelchair. Staff FF pushed the resident out the door to the outdoor smoking area (approximately 100 feet). The resident's back area of the right shoe scuffed the ground going across the parking lot. Observation on [DATE] at 9:30 a.m., revealed Staff A5 pushed Resident #19 in his/her wheelchair without the foot pedals on his/her wheelchair. Resident #19 had been out for a cigarette and Staff A5 pushed Resident #19 back to the resident's room. During an interview with the DON, (Director of Nursing)on [DATE] at 6:25 PM she stated that staff not to push a resident in the wheelchair without wheelchair pedals. The DON reported staff needed more education. 7. Observation on [DATE] at 11:35 a.m., with Staff B present, revealed the downstairs South Haven exit door leading to a courtyard and wooden bridge to the activity center as not locked. The wooden gate by the activity center building accessed the parking lot and had an unlocked padlock on the gate. Staff B stated the facility did not alarm the South Haven exit door during the day as nursing staff transported residents to activity center building for therapy and restorative nursing. In an interview on [DATE] at 5:45 p.m. Staff B stated nursing staff were not responsible for checking whether the gate by the activity center building would be locked; only therapy staff used the activity center. On [DATE] at 9:15 a.m. Staff Jj, certified medication aide (CMA) stated the facility provided restorative nursing care to residents in the activity center when the weather is decent and she can transport residents outside. Staff Jj stated the wooden gate leading to the parking lot is to be locked at all times and the key for the padlock is kept in the box attached to the railing. Staff Jj further reported some as needed therapy staff leave the gate unlocked because they don't know it is to be locked at all times. Staff Jj stated she does not know who is responsible for monitoring the gate to ensure it is locked. On [DATE] at 9:35 a.m. the Administrator stated the Maintenance Supervisor is responsible for monitoring the outside gates and her expectation is the gates are to be locked at all times. On [DATE] at 9:45 a.m. the Maintenance Supervisor stated he is responsible for monitoring the wooden gate every other day and ensuring it is locked. He stated his expectation is the gate should be locked at all times. 8. According to the MDS assessment dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility and transfers. The care plan dated [DATE] directed staff to use a Hoyer lift for transfers due to weakness. The care plan identified the resident had falls on [DATE], [DATE], [DATE] and lowered to the floor on [DATE]. The Observation Report dated [DATE] revealed the total score of 15. A score of 10 or higher represented a high risk for falls. Observation on [DATE] at 4:00 PM revealed the resident in bed awake. The bed in a high position that measured 28 ,[DATE] inches above the floor. Staff B, LPN (Licensed Practical Nurse)concurred that the bed in a high position and lowered it for safety.

Based on clinical record reviews, facility policy review and interviews, the facility failed to provide provision of assessment and timely interventions regarding an acute change of condition for 1 of 6 discharged residents reviewed (Resident # 23). The facility identified a census of 62 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE], documented Resident #23 had [DIAGNOSES REDACTED]. The assessment documented the resident required the assistance of one staff for completion of transfer, bed mobility, dressing and toileting. The assessment revealed the resident had functional limitation in range of motion of one lower extremity and utilized a walker and/or a wheelchair for locomotion. The Care Plan dated [DATE] identified the resident admitted to the facility for skilled level of care after heart surgery and required assistance for completion of activities of daily living which included bed mobility, transfers, hygiene, toileting, bathing, locomotion in a wheelchair and/or assistance with ambulation. The Care Plan also identified the resident received [MEDICATION NAME] (a blood-thinning medication which slows the clotting of blood) and directed staff to assist with ADL's and for staff to monitor the resident for uncontrolled bleeding. The Resident Progress Notes entry completed by Staff B, licensed practical nurse (LPN) who is also the facility's Assistant Director of Nursing (ADON) on [DATE] at 9:26 AM documented the resident alert and oriented, no complaints of pain, heart with regular rate and rhythm, clear lung sounds and non-labored respirations, the resident's oxygen saturation level at 97 % on room air and a normal abdominal assessment. The entry also documented the resident continued to work with occupational therapy (OT) and physical therapy (PT) and independent with ambulation in his/her room. The Resident Progress Notes completed by Staff B on [DATE] at 13:12 (1:12 PM) documented the therapy department reported the resident dragging his/her right foot, leaning to the right, had difficulty with transfers and following one step directions, decreased concentration, unable to complete rapid alternating movements with the right hand and complained of left shoulder pain. Staff B documented the information faxed to the resident's physician who ordered the resident to be sent to the hospital for a computerized axial tomography (CT) scan to rule out a recent [MEDICAL CONDITION] (TIA) and the facility's transportation department had been advised of this order. The entry contained no assessment of resident. At 15:13 (3:13 PM), staff found the resident on the floor of his/her room with the right shoulder against the bathroom door. The resident reported he/she became weak after getting off the toilet, fell against the door and slid to the floor. The entry documented the resident's range of motion and vital signs measured within normal limits. Staff B documented he sent a fax to the resident's physician regarding this incident. The next entry at 17:07 (5:07 PM) documented the resident left the facility for the hospital. An entry completed by Staff B at 17:09 (5:09 PM) documented a message left for the resident's family member /responsible party. The hospital report dated [DATE] at 19:02 (7:02 PM) documented the following findings: 1. large frontoparietal subdural hematoma with adjacent mass effect and 8 millimeters (mm) of left to right herniation. 2. Diffuse brain volume loss, greatest with the cerebellum. The report identified there is a large left cerebral convexity subdural hematoma with mixed attenuation compatible with acute on chronic subdural hematoma. The hospitalization Course Update report dated [DATE] documented the resident underwent [REDACTED]. The resident expired on [DATE]. During interview on [DATE] at 10:10 AM Staff A11, physical therapy assistant (PTA) stated she assisted with Resident #23's therapy in conjunction with OT on [DATE]. She stated the resident's change in functional status was remarkable. She stated the resident did not have facial drooping but did have a weak right side and his/her movements were not equilateral. She stated a few days prior to this she observed the resident with some difficulty with moving the right leg during ambulation, but the resident had a normally shuffling gait; on [DATE] the changes were marked. Staff A11 stated she notified Staff B to come and observe the resident ambulate. She said Staff B stated the changes observed in the resident's gait had not been noted by him prior to this. Staff A11 told Staff B it would be difficult to detect unless Staff B had actually assisted the resident to ambulate. Staff A11 stated she worked with Resident #23 five days per week ,[DATE] minutes each time. She stated she and the OT noted changes from the beginning to the end of therapy on [DATE] and felt the resident could have been experiencing some type of neurological injury such as a stroke or a TIA so that is why she alerted Staff B, Licensed Practical Nurse(LPN) to check the resident. During interview on [DATE] at 2:40 p.m. Staff B, Licensed Practical Nurse (LPN) stated Staff A11 alerted him of the resident's adverse changes. He suspected the resident may had had a stroke so he faxed and called the resident's physician and received an order to transfer the resident to the hospital for a CT scan. Staff B stated the physician ordered to make an appointment to get a CT scan and the physician specifically stated the resident could be transferred to the hospital by non-emergency transport such as the facility van. Staff B stated he did not document the order for the okay for non-emergent transport in the resident's clinical record. Staff B stated he told the physician Staff A11 had reported to him the symptoms the resident experienced had been going on for several days but he did not document that in the resident record. Staff B then stated he notified Staff OO, transportation aide, and the transportation supervisor the resident needed to go to the hospital for a CT scan. An hour later Staff B questioned the transportation supervisor why the resident had not left for the hospital. The transportation supervisor stated she had called to get an appointment but the hospital required additional information such as what part of the body required a CT. Staff B did not call the hospital to check on what additional information had been needed as he stated it is the responsibility of the transportation supervisor to call and make these appointments. Staff B stated he really did not believe the transportation director had called the hospital but did not check on this himself. He said he and the former director of nursing (DON) discussed the resident's condition and did not feel it was emergent to get the resident to the hospital. Staff B stated he could not recall how much time had lapsed, but he went and spoke to the Administrator regarding the transportation issue. He stated the Administrator called the hospital and staff there just wanted to know when to expect the resident to arrive. Staff B stated he tried his best to get Resident #23 to the hospital earlier. He did acknowledge he could have called for an ambulance at any time to transport the resident. During interview on [DATE] at 4:45 p.m. the facility's former DON stated Staff B reported to her on [DATE] at about 4:30 p.m. that he and the transportation director had a disagreement over transportation of Resident #23 to the hospital. The former DON stated when she went to the office to speak with the Administrator about the issue, both the Administrator and the transportation director stated the facility would transport the resident to the hospital During interview on [DATE] at 5:00 p.m. the Administrator stated she called the hospital on [DATE] around 4:,[DATE]:45 PM. She stated the radiology department did not require any additional information but the resident would now have to be admitted through the emergency room as the routine radiology appointments closed at 5:00 PM. The Administrator stated she thought the resident transferred to the hospital by ambulance because the facility's established criteria would have deemed for him to go by emergent transport. The undated Glen Haven Transportation Guide directed the following signs/symptoms experienced by a resident as one of the criteria which requires staff call 911:... for suspected stroke (resident experiences numbness, loss of function of hand, arm or leg, slurred speech, facial droop or severe abrupt headache). During interview on [DATE] at 3:49 p.m. the transportation director stated Resident #23 left the facility late because both facility vans were in use on other calls. The transportation director stated a nurse (cannot recall which one) told her the resident had an order for [REDACTED]. The transportation director stated she told a nurse (again, cannot recall which one) about the need for additional information and that nurse told her to call the doctor's office for the information. The transportation director stated the hospital requested which part of the body required the CT and if it should be done with or without contrast (dye). She stated she cannot take an order from the doctor so she did not call the office for the information. The transportation director stated she waited "probably too long" before she told the Administrator about the problem/disagreement with the nurse. When asked how long is "too long " she replied "about 2 hours". She stated when she reported the situation to the Administrator she took care of it. During interview on [DATE] at 12:28 PM the resident's physician stated he ordered a CT scan for the resident because of the information he had in the office and what had been told to him by facility staff. The physician reviewed the resident's information in his office and could not find documentation the symptoms the resident had ever occurred before. He stated he consulted with his son (also a physician in his practice) and agreed to order a CT of the head. The physician could not recall if facility staff had related the resident symptoms had been observed over several days. When asked if he specifically ordered the resident to go to the hospital by non-emergent transport the physician stated "in my [AGE] years of practice I have never said or ordered that". He stated there should not have been a 4 hour delay in getting the resident to the hospital; the resident could have been transported at any time by ambulance without an order. The physician stated he could not say the resident's outcome would have been any different but sooner, rather than later, transportation to the hospital may have made it more feasible to treat the resident.

Based on observation, record review and interviews with staff and physician, the facility failed to assess and provide timely interventions to aid in the prevention of skin breakdown and promote healing for one of one resident (Resident #2). The facility reported a census of 62 residents. Findings include: Record review of the Minimum Data Set (MDS) assessment for Resident # 2, dated 2/17/12 revealed his/her [DIAGNOSES REDACTED]. The MDS documented the resident had short and long term memory loss and his/her cognitive skills for decision making were severely impaired. The MDS documented the resident had no present pressure ulcers. The assessment identified Resident #2 had a pressure reducing device for his/her chair and bed. Record review of the Care Plan, dated 2/23/12 revealed the resident at risk for impaired skin integrity related to fragile skin, impaired bed mobility and incontinence. The care plan reported the resident had an open area to the right lower leg on 6/10/11. The care plan directed staff to : a. Transfer the resident with 2 staff member for extra caution to prevent skin tears. b. (wear) elbow protectors, added on 2/8/11. c. Remind staff, the resident to wear leg protectors when out of bed. d. Use heel protectors to relieve pressure on the heels. The resident to wear float heels and use a body pillow positioning. The Care Plan did not address the need for repositioning while in bed and or when in wheelchair. The resident's care plan also identified a history of fatty cysts that developed in various places on his/her skin. The most recent had been behind the resident ' s ear and had been lanced on 2/9/12. Record review of the Monthly Skin Checks dated 4/12/12 revealed the resident's bilateral shins were discolored and the resident had no reddened areas or open areas noted. The skin check identified Resident #2 had intact skin on his/her lower back, coccyx, and spine. Record review of the Standard Nursing Home Orders dated 11/11/10 revealed: 28. May apply Allevyn, [MEDICATION NAME], clear dressing gauze dressing to pen or red areas, change every 3 days/ as needed. Observation on 5/1/12 at 6:00 A.M. revealed the resident in the lobby area in a wheelchair, sitting in the lobby area. Resident #2 had both heel and leg protectors on. At 6:30 A.M. the resident continued to sit in the wheelchair. At 7:00 A.M. the resident continued to sit in the wheelchair at a 30 degree angle. At 7:50 A.M. the resident continued to sit in the wheelchair in the lobby area. At 8:15 A.M. the resident continued to sit in the wheelchair, in the dining room eating breakfast. At 9:00 a.m. the resident continued to sit in the wheelchair. At 9:22 A.M. Staff I and Staff K transferred the resident to the resident's room and toileted the resident. Observation on 5/1/12 at 9:22 A.m. revealed Staff I Certified Nursing Assistant (CNA) and Staff K provided incontinence care to the resident and transferred the resident to the bed. The resident had a [MEDICATION NAME] to the upper coccyx area. On 5/1/12 at 11:37 A.M. the resident lay in bed. Staff N CNA and Staff R CNA checked the resident for incontinence and revealed the resident incontinent of urine and bowel movement (BM). Staff N cleansed the resident's perineal area front to back. She cleansed the groin areas and then turned the resident to his/her left side. The resident had a [MEDICATION NAME] to the upper coccyx area. Staff F Licensed Practical Nurse (LPN) entered the room with tray with dressings on it. She removed the [MEDICATION NAME]. The surveyor observed an open area on the resident's upper coccyx that measured approximately 2-3 centimeter's long and .5 -1 cm wide. Staff F cleansed the area with wound cleanser and measured the opened area. The area measured 2.5 centimeters (cm) long x 1 cm wide. Staff F applied an Allevyn over the opened area. The area had a pink-red area surrounding the open area. The center of the wound had a small amount of slough present in the center. Resident #2's clinical record showed Staff F complete the Skin condition assessment on 5/1/12 of the area on the resident's coccyx area. Resident #2's Skin condition record did not contain any prior documentation of this area to his/her coccyx. Observation on 5/2/12 at 5:45 A.M. revealed the resident sitting in a wheelchair, in the lobby area. At 6:30 A.M. the resident continued to sit in the wheelchair in the lobby area. At 6:45 a.m., the resident continued to sit in wheelchair, sleeping as the Activity Director attempted to wake the resident. The resident remained sleeping. At 7:15 A.M. the resident sat in the day room in the wheelchair listening to staff read the newspaper aloud. At 8:00 A.M. the resident continued to sit in the wheelchair. At 8:45 A.M. the resident continued to sit in the wheelchair, in the dining room. At 9:15 A.M. the resident went to the therapy room in his/her wheelchair. Record review of the Treatment Administration Record (TAR), dated May 2012 revealed an order or apply Allevyn to bilateral hips every other day. The TAR record also identified on 5/1/2012 to apply barrier cream to buttocks, peri area, and coccyx two times a day and with each incontinent episode. Staff signed off that treatment had been completed on 5/1/12 at 12:00 a.m. to 7:00 a.m. Record review of the Treatment Administration Record (TAR) dated 5/1/2012 revealed at 1:05 p.m., a treatment order to measured open area below coccyx weekly. The TAR showed the resident's used arm protectors, elbow pads, leg protectors, and heels protectors during April 2012 and May 2012. The TAR also noted on 5/2/12 Staff measured Resident #2's open area below the coccyx. Staff Interviews: Staff interview with Staff L CNA, on 5/2/12 at 1:05 PM revealed she worked the north hall where Resident # 2 is located. She found the new open area on the resident's coccyx area on Sunday night 4/28/12-4/29/12 and told the charge nurse (Staff O LPN). Staff L stated she saw Staff O place a [MEDICATION NAME] on the open area. Staff L stated she only reported to the charge nurse. Staff L stated she did not document the open area on paper. Staff interview with the Director of Nursing (DON) on 5/2/12 at 8:45 A.M. revealed staff made her aware of the resident's open area on Tuesday morning (5/1/12). She said through her investigation she talked to Staff L CNA and she told her she reported the new open area to the charge nurse, Staff O LPN, on Sunday night. She said she also saw Staff O place a [MEDICATION NAME] on the resident's upper coccyx area. She said she saw Staff O place the [MEDICATION NAME] on the resident at 5:45 A.M. The DON said Staff C CNA had a text message from Staff L stating the resident had a new open area to the coccyx area. The DON stated when she came to work on Monday (4/30/12) morning, there were no skin sheets documented related to Resident # 2 new open area. The progress notes did not contain documentation or measurements referencing the new open area and the physician or family had not been notified of the change of condition of the resident. She said staff notified the physician on 5/1/12 and received a treatment order for the pressure ulcer. She revealed they did not have a specific protocol for wound care but did have a change in condition/report to the physician protocol. The DON stated she would consider the new pressure ulcer a change of condition. Staff interview with Staff M LPN on 5/2/12 at 9:00 A.M. revealed Staff O did not report to her about a new open area to Resident # 2 coccyx area on 5/1/12. She said the protocol for a new open area is to check the area, measure the area, notify the physician for a treatment order and fill out a skin sheet. She stated the resident should be positioned off the area as much as possible. Staff interview with Staff O LPN, on 5/2/12 at 7:20 A.M. revealed she did not know about a new open area on Resident # 2. Staff O stated she did not become aware of an open area until 5/1/12 at 11:00 PM when she heard report. Staff O stated she did not hear about an open area from any staff related to Resident # 2. She denied placing a [MEDICATION NAME] dressing to the coccyx area of Resident # 2. She only knew about the new [MEDICATION NAME] cream order to the open area. Staff interview on 5/1/12 at 12:15 PM with Staff Q LPN revealed Staff F reported to her Staff O LPN reported to her Resident # 2 had a new open area and she should contact the physician and get a treatment order. Staff O reported the new open area to Staff F on 5/1/12. Staff O told Staff F she did not notify the physician or contact the family. Staff Q stated there were no skin sheets or progress notes documented related to the new open area for Resident # 2. Staff interview with Staff F LPN on 5/2/12 at 7:30 A.M. revealed Staff O LPN reported to her on 5/1/12 the resident had an open area on his/her bottom. Staff F stated Staff O had reported the new open area to her during the night of 5/1/12. Staff interview on 5/2/12 at 8:35 A.M. with Staff N CNA revealed she worked the Sunday evening and could not remember if Resident # 2 had a patch to the coccyx area or had an open area. Staff N stated the resident had dressing to the hips so she assumed if the resident had a dressing to the coccyx, it did not seem out of place. An interview with the resident's physician on 5/2/12 at 2:00 PM revealed facility staff notified him related to the new open area for Resident # 2 on Tuesday morning (5/1/12). The physician stated he assumed that's when the staff had found the open area and ordered a new treatment for [REDACTED]. Record review of the Progress Notes revealed no documentation related to a new open area found on the resident's coccyx area on 4/29/12 or 4/30/12. Record review of the Report Sheets dated 4/29/12 and 4/30/12 revealed no new changes involving Resident # 2. Record review of the Identifying Change in Resident Condition/ Proper Notification of Physician revealed: 5. Document in the nurse's progress notes: All attempts to contact the physician all attempts to notify family member/ significant other Physician's response physician's orders [REDACTED].

Relates to complaint # -C: Based on record review and staff interviews, the facility failed to provide nursing provisions with assessment and timely interventions for Resident #19 when he/she had an adverse change in condition; and failed to consistently document assessments for Resident #11. The facility reported a census of 76 residents. Findings include: 1. The Physician order [REDACTED].#19 documented [DIAGNOSES REDACTED]. The Care Plan dated 1/13/10 documented additional [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] documented short term memory loss, modified independence with decision-making, the resident verbal communications understood and understood others, no variation of mental function over the course of the day, required extensive assistance for completion of bed mobility, transfer, ambulation in the room and in the hall, toileting and hygiene. The Care Plan dated 1/13/10 identified the resident could have a problem with bleeding or bruising as the resident received [MEDICATION NAME] ( an anti-coagulant medication) and directed staff monitor the resident for uncontrolled bleeding. The same Care Plan also identified the resident required assistance with activities of daily living such as dressing, grooming, mobility, hygiene, toileting and bathing. The Physician order [REDACTED]. The Certified Nursing Assistant (CNA) Notes dated 12/8/10 by Staff B, CNA, documented the resident complained of a severe headache, the nurse gave medications and the resident began to dry heave and required assistance of 3 and a mechanical lift to transfer the resident from the wheelchair to the bed and the resident noted to be clammy. The CNA Notes entry also documented the nurse called the doctor and gave the resident a shot which seemed to help a bit. The Progress Notes dated 12/9/10 at 1:43 AM completed by Staff C, licensed practical nurse, (LPN), documented the resident complained of a headache for which the resident received Tylenol at 12:20 AM. This entry further documented the resident found seated on the toilet leaning to the left side against another staff member, very pale in color, unable to hold his/her weight and transferred back into bed with the use of a mechanical lift. After transfer to the bed the resident instantly wanted to vomit although no emesis occurred. The resident's vital signs documented at this time indicated the resident's temperature as 97.1 degrees, pulse 88 beats per minute, respirations 22 per minute and a blood pressure of 180/110. The progress note documented the physician notified of the situation and ordered for the nurse to administer [MEDICATION NAME] (an anti-nausea medication) 5 milligrams (mg) IM (per injection into a muscle) now. The Notes documented the resident received [MEDICATION NAME] 5 mg IM in the right thigh as the resident very hard to roll to the side to give in the gluteal (buttock) region and that staff would continue to monitor the resident. The clinical record contained no further documentation of assessment made by Staff C. The Progress Notes dated 12/9/10 at 8:25 AM completed by Staff F, LPN, documented she checked the resident's condition at 7:10 AM and found Resident #19 's skin pale and the resident unresponsive to sternal stimuli. The Notes documented Staff F called 911 and the resident transferred to the hospital by ambulance at 7:25 AM. During interview on 2/23/11 at 4:00 PM Staff B stated she completed the CNA Notes entry dated 12/8/10, the day she started her shift at 10:00 PM, but the events occurred in the early morning hours of 12/9/11. Staff B documented the resident leaning while on the toilet and requiring transfer with a mechanical lift as very unusual for Resident #19. She stated the resident felt clammy, complained his/her head hurt "really bad" and that she reported this to Staff C. Staff B stated that even after the resident received medication s/he still complained of a headache and Staff B again reported this to the Staff C. Staff B stated Resident #19 responded verbally to questions for a little bit after the IM injection administered but then became non-responsive and she reported this finding to Staff C. Staff B stated Resident #19 remained non-responsive at the end of her shift on 12/9/10 at 6:30 AM. The surveyor attempted to interview Staff C without success on: a. 2/23/11 at 5:22 PM, b. 2/24/11 at 9:17 AM c. 2/28/11 at 2:14 PM d. 3/3/11 at 4:11 PM e. 3/7/11 at 8:25 AM. During interview on 2/23/11 at 6:15 PM Staff F stated Staff C told her in report at the beginning of her shift that Resident #19 did not respond, so she immediately checked on the resident and confirmed this finding. Staff F stated she called the resident's physician and home and told him/her the resident needed to go to the hospital as the resident desired a full code status and had been non-responsive for an undetermined amount of time. The hospital Primary report dated 12/9/10 at 8:02 AM documented the resident had multiple medical problems, unresponsive at nursing home and full code with the time and the onset of the unresponsiveness unknown. The resident assessed with [REDACTED]. The report further documented the resident with [MEDICAL CONDITION] (slow heart rate) decreased respiratory rate, comatose and urgently intubated endotracheally (placed on a machine to support the resident's breathing). The resident's blood pressure upon admission to the hospital documented as 184/122, pulse 68 and oxygen saturation of 82%. The hospital report documented the chief complaint for admission as unresponsiveness and the resident there for an evaluation of mental status change with an unknown onset. The report documented the resident ' s level of consciousness as follows: responds only to reflex motor effects, totally unresponsive. The report identified the resident had no movement(s) in his/her arms or legs; and the resident had severe to total sensory loss, resident not aware of being touched on face, arms or legs. A Computerized axial tomography (CT) of the resident's head on 12/9/10 at 8:12 AM documented the following: 1. large hematoma (pooled blood) within the right cerebral hemisphere with regional mass effect 2. moderate amount of intraventricular hemorrhage (bleeding) 3. small right frontal and parietal subdural hematoma 4. mild amount of subarachnoid hemorrhage The Hospital Discharge Summary dated 12/9/10, completed by the resident's primary care physician, documented the discharge [DIAGNOSES REDACTED]. The report documented the resident admitted to the Intensive Care Unit, remained non-responsive and pronounced dead on 12/9/10 at 7:30 PM. During interview on 2/23/11 at 6:40 PM the Director of Nursing stated Staff C completed no follow-up assessment on Resident #19 by Staff C on 12/9/10 and she expects follow-up assessment to be completed and documented when a resident has an acute change of condition. During interview on 3/7/11 at 9:24 AM the resident's primary care physician stated s/he had reviewed the resident's clinical record Progress Notes entries of 12/9/10 and would have expected the facility to contact him if the resident's condition deteriorated after the initial contact. He further stated the resident could have been transferred to the hospital at any time and could have done so without a physician order [REDACTED].#19. 2. The MDS dated [DATE] documented [DIAGNOSES REDACTED].#11. The same MDS documented the resident required extensive assistance with transfer, bed mobility, ambulation, dressing and toileting. The Care Plan reviewed 11/22/10 identified the resident at risk for injury due to unsteady gait and [DIAGNOSES REDACTED]. The Progress Notes dated 2/13/11 at 8:45 AM documented the resident found face first on the floor with blood coming from a laceration on the head. The resident transferred to the hospital by ambulance. The Progress Notes dated 2/13/11 at 9:57 AM documented the hospital called and stated the resident received stitches in the forehead due to a 4.5 inch laceration.The Progress Notes dated 2/13/11 at 2:46 PM documented the resident returned to the facility at 11:30 AM. The Neurological Assessment Flowsheet documented assessment of the residents level of consciousness, pupil response, hand grasps, movement of all extremities, response to pain and vital signs, in order to detect possible head injury caused by the fall. The facility documented the Neurological Assessment on the following dates and times: a. On 2/13/11 at 11:30 AM (when the resident returned from the hospital) and 11:30 PM. b. On 2/14/11 at 4:00 AM, 7 AM-7 PM (no specific time documented). c. On 2/15/11 7 PM-7 AM 2 entries for this time frame (no specific time documented for either check). d. On 2/16/11 7:00 PM-7:00 AM 2 entries for this time frame (no specific time documented for either check), and 2/16/11 7 AM-7 PM (no specific time documented). The facility's undated Crani (Neurological)-Check Schedule posted at the nursing desk directed checks are to include level of consciousness, vital signs, pupil response and size, motor functions and pain response and what the resident had been doing at the time of the assessment. The form directed these checks be performed every 15 minutes for 1 hour, every thirty minutes for 2 hours and every hour for 2 hours and every shift for 48 hours (4 shifts). During interview on 2/23/11 at 4:14 PM the DON stated it is expected that all residents with actual of possible head injuries are to be assessed according to the Crani-Check schedule and the results documented on the Neurological Assessment Flowsheet.

Relates to complaint -C: Based on clinical record review, observation and staff interview, the facility failed to provide the necessary provisions to ensure Resident #11 received adequate supervision during transfers to ensure against hazard from self. Record review and staff interviews established the resident frequently turned off his/her alarm and the care plan lacked any updates to address this until the resident fell and sustained a head laceration. Concerns were identified for one of five residents with reported census of 76 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. The assessment documented s/he required extensive assistance with transfer, bed mobility, ambulation, dressing and toileting. The Care Plan reviewed on 11/22/10 identified the resident at risk for injury due to unsteady gait and [DIAGNOSES REDACTED].(Each of these interventions were added at different dates.) The Care Plan also documented the resident experienced increased bladder and bowel incontinence and instructed to provide physical assistance for toileting until s/he could toilet independently. The Progress Notes dated 2/13/11 at 8:45 AM documented the resident attempted to transfer him/her(self) from the wheelchair to the toilet and fell . The note documented the resident ' s alarms were on and in place however, the resident turned alarm off. The note documented staff found the resident face first on the floor with blood coming from his/her head. The resident had approximately 2.5 inch laceration on the left side of his/her head. The report documented the resident had a large amount of blood. The resident complained of the site (area) hurting, and staff administered Tylenol and ice pack to the area. The resident had been transferred to the hospital by ambulance. At 9:57 AM, the hospital called and stated the resident received stitches in the forehead due to a 4.5 inch laceration. The Event Report dated 2/13/11 at 8:45 AM also documented the same set of facts as the progress note from 2/13/11. Interview with Staff G (certified nursing assistant (CNA), on 2/23/11 at 2:00 PM, she reported she had assisted Resident #11 out of bed around 6:15 AM on 2/13/11. Staff G stated she and another CNA worked together to get all the residents up on the North/South Halls then both CNAs left this hall and went to New Hall to assist the other 2 CNAs on duty get residents up and ready for the day. Staff G stated no staff remained on North/South Hall but the charge nurse could listen for alarms and watch for call lights. Staff G stated her pager indicated Resident #11's call light went off after she left the hall so she left New Hall and responded to the call light. She found Resident #11 face down in the doorway of the bathroom with the resident's legs towards the toilet and pants down around the knees. Staff G stated the resident had a pressure alarm on the wheelchair and no alarms had sounded. Staff G stepped into the hallway and yelled for help but no staff responded. She stated she went across the hall to locate a gait belt and saw a housekeeper came down the hall and he summoned the nurse. Staff G stated approximately 5 minutes passed before anyone responded to her call for assistance. Staff G stated the resident attempted self transfer on a routine basis, mostly before or after meals, and the resident was able to turn off the alarm boxes. During interview on 2/23/11 at 11:45 AM Staff L, licensed practical nurse (LPN), stated he assessed the resident after the fall on 2/13/11. He stated the resident had a history of [REDACTED]. Staff L also stated the resident had one alarm on, the pressure pad in seat. During interview on 2/23/11 at 2:15 PM Staff K, CNA, stated awareness of Resident #11's ability to turn off alarm (pressure) box. Staff K stated she had found the resident on the toilet in his/her room and alarms had been shut off by resident. Staff K stated Resident #11 had a pressure alarm only in wheelchair until he/she fell on [DATE]. During interview on 2/23/11 at 2:30 PM Staff H, CNA, stated she worked with Resident #11 two-three (2-3) days per week and stated the resident could turn off the alarm (pressure) boxes. Staff H stated she had caught the resident turning off alarm box (pressure). Staff H stated she had reported this to the charge nurses (Staff I, LPN and Staff F, LPN) and to other CNAs. Resident #11 ' s care plan dated 11/22/10 identified he/she at risk for injury due to unsteady gait and osteoporosis. The care plan documented no intervention to address his/her ability to turn off his/her alarm(s) box(es) or any different approaches until 2/14/11 after the fall. The intervention added on 2/14/11 identified personal tab alarm had been added. Observation on 2/23/11 at 1:15 PM revealed the resident seated in a wheelchair in his/her room and opened the bathroom door and entered. The resident's touch-pad call light cord was wrapped around the call light outlet on the wall above the resident's bedside stand out of the resident's reach. Another observation at 1:17 the resident removed his/her shirt and Staff J, LPN asked why he/she had removed his/her new shirt. Resident #11 responded he/she took off shirt to stop the alarm from going off.