Every finding on record at Good Samaritan - Algona

Based on clinical record, facility policy, resident and staff interview, the facility failed to provide a restorative exercise program for 1 of 3 resident reviewed (Resident #24). The facility reported a census of 61 residents. Findings include: Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of Parkinson's Disease, pain in unspecified knee, and muscle weakness. The current Care Plan updated 5/22/25 directed the staff to provide passive range of motion (PROM) hand strengthening blue digi-flex, resistance 25 reps bilaterally for 2 sets 3-6 times per week, Active range of motion (AROM) to upper extremities for 8 minutes overhead pulleys against resistance no weights 3 times per week, and lower extremities supine exercises: ankle pumps, heel slides, (assisted), hip abduction, (assisted), Short Arc Quad (SAQ) exercises, Straight Leg Raises (SLR), quad sets to bilateral sides of body, 3-5 times a week. Further review showed the Care Plan identified Resident #24 at risk for pressure ulcer development related to limited mobility. Resident #24's restorative charting lacked documentation of the program being completed as ordered by therapy for the past 3 months. Resident #24's Progress Notes lacked documentation of refusal to complete the restorative program for the past 3 months. On 12/02/2025 at 4:00 PM the Administrator reported there is no documentation of restorative being offered or completed for Resident #24. He reported he expects the restorative programs for the residents to be completed. On 12/03/2025 at 10:55 AM Resident #24 reported staff do not offer restorative exercises but if they did, he would do them. The facility policy titled Rehab/Skilled and Long Term Care: Therapy and Rehab with a revised date of 7/7/25 directs staff how to document the restorative nursing but lacked direction to ensure completing the program.

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent elopement with a fall for 1 of 3 residents reviewed (Resident #67). The facility reported a census of 60 residents.Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #67 scored12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required substantial/maximal assistance with transfers and ambulation. The resident's diagnoses included stroke, non-Alzheimer's dementia, and disorientation.The Care Plan dated 10/14/22 identified Resident #67 had impaired cognitive function related to dementia and stroke. The resident thought people were stealing her snacks which she ate and offered other residents. The resident had a history of going in to other resident's rooms and rummaging through their belongings. Interventions included monitoring/documenting/reporting to the health care provider any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, or mental status. They posted the resident's name on her room door in the hallway with a yellow bow. When the resident was at home she was not sleeping at night, and thought people were coming into her home and stealing from her. The Care Plan dated 5/27/22 identified the resident had impaired visual function related to cataract. The interventions included the resident would maintain a safe environment due to vision loss. The Care Plan dated 5/27/22 identified the resident at high risk for falls related to vertigo and stroke like symptoms. The interventions included ensuring/providing a safe environment.The Progress Notes 8/7/25 at 10:37 a.m. documented when staff went to get resident for an activity, she had ripped her calendar off the door, her water pitcher upside down on her side table and her tv hanging by the cord about hitting the floor. She stated that she needed to get her stuff packed up because she heard on the overhead page that everyone needed to pack their stuff up to leave.The Progress Notes dated 9/19/25 at 11:35 a.m. documented during bus ride, the resident reached for things in the air and off the ground that were not there.The Progress Notes dated 9/20/25 at 11:36 a.m. documented staff went into Resident #67's room to get her for an activity. The resident had a white cream all over her face, hands, clothes, and beside table. A Certified Nursing Assistant (CNA) went in and cleaned her up. When staff went back in to get her, she tried drinking her pop that was not yet open.The Elopement Risk dated 10/9/25 indicated Resident #67 had not exhibited or experienced increased confusion and forgetfulness, and had not exhibited packing of belongings or verbalizing statements about leaving.The Progress Notes dated 10/20/25 at 6:50 p.m. documented the nurse summoned by another resident for help outside. Upon arrival Resident #67 found face down, off the curb at the front entrance of the facility. A CNA returning from break, present at resident's side. The resident had a small amount of bleeding from her left upper forehead, and under her right eye. The resident complained of left knee pain. The resident had a (high) blood pressure (BP) of 215/124. At 7 p.m. placed a call to the hospital. The on-call physician informed of the event, current blood pressure, and resident complaints of knee pain. Received the order to transport the resident to the Emergency Department.On 12/3/25 at 2:11 p.m. Staff A Registered Nurse (RN) stated she was on the eve that Resident #67 fell. She said another resident reported she had fallen outside. She did not know how she got out, if someone let her out or if she got out herself. Staff interviews about resident prior to falling outside: On 12/4/25 at 8:53 a.m. Staff B CNA stated Resident #67 always wanted to go home, and would talk to her son or some other distraction. She didn't normally go to the doors but if she did and it was nice outside, they would go out with her. Staff B stated Resident #67 was an elopement risk.On 12/4/25 at 8:57 a.m. Staff C Licensed Practical Nurse (LPN) stated the resident did talk about going home but not aware of attempt to elope. She said anyone without a wander guard (bracelet worn to alert if a resident attempting to go out) could go out the front door and there was no alarm. She said the resident had been failing.On 12/4/25 at 9 a.m. Staff D CNA stated the resident wanted to call her family member, a lot. She could not recall her trying to go out of the facility.On 12/4/25 at 9:05 a.m. Staff E CNA stated the resident would say she wanted to go home once in awhile. She didn't see her try to leave. She said the resident had been declining, needing more assistance with eating, transfers and walking. She hadn't been asking to call her son as much.On 12/4/25 at 9:08 a.m. Staff F CNA stated Resident #67 talked about going home and she knew she had gone through the 1st door but staff stopped her before she went through the 2nd door, to the outside. On 12/4/25 at 9:15 a.m. Staff H CNA stated Resident #67 did talk about leaving.On 12/4/25 at 9:43 a.m. Staff J CNA stated Resident #67 would say she needed to get out of here. On 12/4/25 at 10 a.m. Staff K CNA stated she worked the night Resident #67 got outside. She did not see when it happened. She just heard a staff member came back from break and heard her yelling. Prior to the incident the resident had been more confused. She had not witnessed her trying to leave, but she talked about it.On 12/4/25 at 10:08 a.m. Staff L CNA stated Resident #67 would say she wanted to go home. She had a hard time getting around.On 12/4/25 at 3:35 p.m. Staff M CNA stated she worked the shift when Resident #67 got outside. She had gone to break. When she came back she parked in the back lot, and could hear someone screaming. She went to the front lot and she saw the resident face down on the ground. She had rolled off the curb.On 12/4/25 at 8:14 a.m. the Administrator stated the front door had a wander guard, otherwise no other alarm sounded during the day. The door alarm automatically engaged at 10 p.m. and disengaged at 6 a.m. Between 10 and 6 a person would have to put the code in or the alarm would sound.The facility Elopement policy dated 4/7/25 defined elopement as a resident who needed supervision left the premises or safe areas without authorization and or necessary supervision to do so. When an elopement occurred they would notify other agencies as required by state and/or federal regulation.

Based on clinical record review, hospital clinical record review, staff interviews and policy review the facility failed to assure the resident with pressure ulcers received treatment and services, consistent with professional standards of practice to promote healing for 2 of 3 residents reviewed (Resident #1and #2) for pressure ulcers. The facility reported a census of 58 residents.Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #1 required substantial/maximal assistance with bed mobility and all transfers. Resident #1's MDS included diagnoses of cancer, anemia, end stage renal disease, diabetes mellitus, morbid obesity and chronic pain. The MDS documented Resident #1 was at risk for developing pressure ulcers/injuries. The MDS documented the following skin and ulcer/injury and treatments: pressure reducing device for chair/bed and application of nonsurgical dressing. The Care Plan with a revision date of [DATE] indicated Resident #1 had actual impairment to skin integrity related to abrasion to buttocks evidence by need for treatment. The care plan directed staff to monitor location, size and treatment of skin injury and to report abnormalities, failure to heal, signs/symptoms of infection, and maceration to the health care provider. In addition the care plan documented Resident #1 required enhanced barrier precaution related to open wounds to bilateral heels and left upper buttocks. The Care Plan lacked interventions related to pressure ulcer prevention and treatment such as repositioning, turning or keeping Resident #1's heels floated or elevated off of a surface to reduce the risk for pressure ulcers and promote healing. The Braden Scale for Predicting Pressure Sore Risk documented the following scores (a lower score indicates higher risk):[DATE]- 18- Mild Risk[DATE]- 17- Mild Risk The Progress Note dated [DATE] documented a Nurse to Nurse Hospital Report indicated Resident #1 had Mepilex (foam dressing) treatments to her coccyx, labia and buttocks. The admission Skin Assessments (Wound RN Assessment and Wound Data Collection) dated [DATE] revealed the following information:A. Right buttock abrasion- full thickness, traumatic wound- measured 4 cm (centimeters) (length) x 1.6 cm (width), 25% epithelialized tissue and 75% granulation tissue.B. Left buttock abrasion- full thickness, traumatic wound- measured 1.2 cm x 1 cm, 25% epithelialized tissue and 75% granulation tissue. The Skin Assessments dated [DATE] for the right and left buttocks documented a treatment order to clean the areas with wound cleanser, apply Aquacel AG (antimicrobial dressing) and bordered Mepilex. Review of the June, July and [DATE] Treatment Administration Records (TAR) lacked documentation of a treatment being completed to the left buttock abrasion. The Progress Note dated [DATE] documented a blister was noted to Resident #1's left heel, betadine applied and a blue boot in the room. The clinical record lacked documentation Resident #1's family was notified of the area. The Wound Data Collection assessment dated [DATE] revealed an intact blister to the left heel that measured 5.7 cm x 3.5 cm with the surrounding skin erythematous/reddened. The assessment documented the treatment to the left heel was to apply betadine to the blister twice a day (BID). The Wound RN assessment dated [DATE] for the right buttocks revealed two abrasions with full thickness loss that measured 1 cm x 1cm (lower wound) and 1.5 cm x 1 cm (upper wound). The assessment lacked documentation of the wound characteristics of the two areas. The clinical record lacked documentation the Physician or family was notified regarding an additional wound to the right buttocks. The Wound Data Collection assessment dated [DATE] for the right buttocks revealed Resident #1 had 3 open areas to the sacrum/coccyx area and one area on the right buttocks. The assessment lacked wound measurements, wound characteristics, and dressing/treatments applied. The clinical record lacked documentation that the Physician/family was notified of the new areas. Review of the clinical record lacked any additional skin assessments to the sacrum/coccyx area. The Progress Note dated [DATE] at 10 AM documented Resident #1 had difficulty with transfers requiring 3 staff to assist her from the bed to the beside commode. Resident #1 stated the blister on her left heel was causing her pain during the transfer and requested to be seen by a Physician regarding the blister. The Progress Note dated [DATE] at 12:04 PM documented Resident #1 had returned to the facility from a Physician appointment with new orders to wear foam boots, start Keflex (antibiotic) 500 mg (milligrams) three times a day (TID) for 10 days for left heel blister infection. Review of the July and [DATE] TAR lacked documentation regarding the foam boots. The Wound RN assessment dated [DATE] for the left buttocks abrasion with partial thickness loss measured 0.5 cm x 1.5 cm. The wound assessment lacked documentation of wound characteristics. Review of the skin assessments for the left buttocks revealed the wound had not been measured since admission [DATE]. The Wound Data Collection assessment dated [DATE] documented the left buttocks presented with eschar (dead, nonviable tissue) and Resident #1 voice complaints of discomfort rating the pain a 9 out of 10. The assessment lacked documentation regarding measurements and wound characteristics regarding the amount of eschar and the color of the eschar. The clinical record lacked documentation the family or Physician was notified regarding the change in the wound. The Wound RN assessment dated [DATE] identified a stage 2 pressure ulcer to the left heel with 100% epithelization. The assessment documented the wound was assessed by an outside wound nurse and recommendations were sent to the Physician for review. Review of the skin assessments revealed the left heel pressure wound had not been measured since [DATE]. The Wound Evaluation Assessment completed by the outside wound nurse dated [DATE] documented stage 2 pressure ulcer to the left heel that measured 5.0 cm x 4.0 cm with the wound bed 100% epithelialized tissue. The wound nurse recommendations were to clean the wound with a cleanser of choice, apply moistened gauze with betadine (squeeze out excess) and secure with roll gauze and tape. The Wound Evaluation Assessment completed by the outside wound nurse dated [DATE] documented a non open area to the left calf that measured 0.3 cm x 10 cm that was dark red/purple in color and 100% epithelialized tissue. The wound nurse recommended applying skin prep to the area BID. The Wound RN assessment dated [DATE] documented a scab to the left lower calf that measured 0.3 cm x 10 cm. The assessment documented the area was observed by the wound nurse and wound recommendations were sent to the Physician for review. Review of the clinical record lacked any additional skin assessments to the left calf wound. The Progress Note dated [DATE] documented Resident #1 complained her bottom hurt from sitting in the wheelchair and Tylenol was given. The Wound RN assessment dated [DATE] for the right buttocks revealed the full thickness abrasion measured 1 cm x 5.8 cm. The assessment lacked any documentation regarding wound characteristics. Review of the skin assessments revealed the right buttocks had not been measured since [DATE]. The Progress Note dated [DATE] documented Resident #1 complained of pain to her bottom and Tylenol was given. The Progress Note dated [DATE] documented Resident #1 complained that her bottom hurt and Tylenol was given. The Progress Note dated [DATE] at 10:24 AM documented a call was placed to the Physician to report Resident #1 was having increased pain and did not want to get out of bed to see the Physician. The note documented Resident #1's wound on buttocks are noted to be worse and there was a new wound to the left groin and right heel. The Progress Note lacked any documentation regarding what the buttocks, left groin wound or right heel wound looked like. The Progress Note dated [DATE] at 4:44 PM documented Resident #1's son reported his mom had called him the night prior reporting she was having an increased amount of pain and worried about the sores she had. The Progress Note dated [DATE] at 5:51 PM documented a new order was received for Norco (pain medication) 5/325mg every 6 hours for pain as needed was reported to the son. There were no changes made to the treatment order for the buttocks. The clinical record lacked any formal skin assessments completed on [DATE] for the right and left buttocks. The Skin Assessments (Wound RN Assessment and Wound Data Collection) dated [DATE] documented an unstageable pressure area to the right heel that measured 5.5 cm x 3.5 cm with 100% eschar. The assessment indicated to continue with the current plan of treatment. The Skin Assessments (Wound RN Assessment and Wound Data Collection) dated [DATE] documented a non-pressure wound, partial thickness to the left posterior upper hip that measured 3.5 cm x 8.5 cm. The assessment documented the surrounding skin was reddened and tender. The wound had 25% epithelialized tissue and 75 % granulation tissue. The assessment documented staff would cleanse the area with wound cleanse and apply Mepilex light per Physician order. The Progress Notes lacked documentation of the new area, Physician or family notification. The clinical record lacked skin assessments or treatments for the wound to the left groin. The [DATE] TAR lacked documentation of a treatment to the right heel and posterior upper left hip. The Wound Data Collection dated [DATE] for the right buttocks documented a presence of possible complication, increasing area of ulceration or skin infection evidenced by increased redness, tenderness and pain with the wound. The assessment documented a minimum amount of serosanguinous (clear, watery fluid and red blood cells) drainage with foul odor. The assessment lacked documentation of measurements and wound characteristics. The Wound Data Collection dated [DATE] labeled 49 Right Heel documented the wounds on the right and left buttocks had increased blackened areas with pain and drainage present. The assessment lacked documentation regarding measurements or wound characteristics regarding amount of blackened areas, drainage amount and type. The Skin Assessments (Wound RN Assessment and Wound Data Collection) dated [DATE] documented unstageable pressure ulcer to the left heel that measured 4.6 cm x 10.6 cm. The skin assessments revealed the last time the left heel was measured was on [DATE] and measured 5 cm x 4 cm. The assessment lacked documentation regarding wound characteristics. The Skin Assessments (Wound RN Assessment and Wound Data Collection) dated [DATE] documented unstageable pressure ulcer to the right heel that measured 6.1 cm x 7 cm. The assessment lacked documentation regarding wound characteristics. The Wound RN Assessment for [DATE] for the left posterior upper hip documented the area measured 11.3 cm x 5.5cm. The assessment lacked documentation of wound characteristics. A facility fax form sent to the Physician on [DATE] documented the wound to the right buttocks had worsened and was draining. The form documented a request to cleanse the area and apply Aquacel with Mepilex lite BID. The Physician responded ok to do Aquacel and Mepilex BID on [DATE]. The fax form did not address declines to the right heel, left heel, left posterior upper hip or left buttocks. The Progress Notes lacked documentation regarding the declines to Resident #1's right/left buttocks wounds, right/left heel wounds and left posterior upper hip. The Progress Notes lacked documentation that the Physician and family were notified of the declines. The Progress Note dated [DATE] at 2:30 PM documented Resident #1 was sent out by Emergency Medical Services (EMS) to the local hospital due to hypoglycemic episodes (low blood sugar). The Progress Noted dated [DATE] at 6 PM documented the facility was informed by the hospital, Resident #1 was transferred to a different hospital and was admitted to Intensive Care Unit (ICU) due to septic shock (a life threatening condition that occurs when infection spreads throughout the body and causes a severe drop in blood pressure). The Hospital Critical Care Unit Progress Note dated [DATE] documented Resident #1 presented to the emergency room department with significant decubitus ulcer burden (necrotic sacral and bilateral heel ulcers), hypoglycemia (blood sugar 37), generalized weakness and signs of sepsis. The note documented Resident #1 had a history of poor oral intake and reported inability to reposition herself for several days. She was found to be in septic shock and admitted to ICU on [DATE] for vasopressor support. A wound consult identified extensive calciphylaxis (rare, life threatening syndrome that involves calcium build up in skin and fat tissue's small blood vessels), Kennedy ulcers (a type of skin ulcer that develops in the final stages of life) and dry eschar across sacrum, buttocks, thighs and bilateral heels. A CT scan (computed tomography) of the abdomen/pelvis/lower extremities revealed a moderate subcutaneous emphysema (serious condition where air get trapped under the skin) in the subcutaneous fat of the left gluteal region suggesting open wound and/or necrotizing infection and an erosive/osteolytic changes involving the left iliac wing and posterior aspect of the coccyx, concerning for possible osteomyelitis (serious bone infection). The acute assessment revealed septic shock secondary to suspected osteomyelitis from chronic sacral and bilateral heel/decubitus ulcers, metabolic encephalopathy, and multiple chronic pressure ulcers. The Wound Care Consult Dated [DATE] documented reason for consult was large necrotic smelling wound encompassing left and right hip into lower back, inner thigh wound, and bilateral pressure ulcers on heel. The note documented Resident #1 had malodorous wounds noted throughout the entire room. Resident #1 moaned in pain. Resident #1 had necrotic areas to her bilateral heels, bilateral hips, sacral coccyx and bilateral thighs. The wound consult assessment and wound images revealed the following:-Sacral/Buttocks: Necrotic, dry eschar with foul odor, consistent with Kennedy ulcer and skin failure, measuring 15 x 6 cm (left sacrum) and 5 x 6 cm (left buttock). -Bilateral Heels: Unstageable ulcers with dry, stable eschar, complicated by calciphylaxis. Left heel measuring 5.5 x 5.5 cm, 25 % blood filled blister and 75 % dry eschar. Right heel measuring 5 x 8.4 cm with 100% eschar. -Bilateral Thighs, Hips, Iliac Crests: Scattered linear purple, non-blanching areas, consistent with skin failure.-Calciphylaxis lesions noted on posterior lower extremities bilaterally. The State of Iowa Certificate of Death with time of death on [DATE] at 3:51 PM documented the immediate cause of death was end stage renal disease due to or as a consequence of acute on chronic renal failure due to or as a consequence of acute hypoxic respiratory failure and underlying cause severe sepsis. On [DATE] at 10:35 AM, the Administrator acknowledged concerns with the facility wound documentation. He said he knew Resident #1's record lacked documentation regarding weekly wound assessments/measurements, family/physician notifications and the care plan did not reflect skin prevention interventions. On [DATE] at 2:03 PM, the Administrator verified a treatment for the right heel pressure ulcer was not on the TAR and he could not locate a Physician order for treatment of the right heel. He said he did see on the wound data collection forms staff were documenting they were applying betadine to the area. On [DATE] at 2:20 PM, the Administrator reported they could not find treatment documented on the TARs for the left buttocks. The Administrator acknowledged the lack of documentation regarding Physician and family notification for the increase in measurements for the bilateral heel ulcers and posterior left thigh. He said he knew there were issues with documentation and notifications. On [DATE] at 1:11 PM, the facility Medical Director reported Resident #1 had chronic wounds related to multiple comorbidities. He said Resident #1 was unhealthy. He said Resident #1's wounds became infected and she became septic. He said the wounds were end stage and presented as Kennedy ulcers. He agreed that the wounds were unavoidable due to her condition and reported he thought the wounds led to her death. He said Resident #1 was quite sick and the wounds looked more significant in the hospital than what they had been due to her organs shutting down. He said the family wanted a higher level of care so he sent her to another hospital. On [DATE] at 3:40 PM, Staff A, Certified Nursing Assistant (CNA) reported Resident #1 would be repositioned every 1-2 hours. She said she would try to check on her frequently as Resident #1 would pull the pillow out and go back to her back. She acknowledged Resident #1 had an alternating air mattress and had boots to her feet. She said Resident #1 would refuse to wear the boots often. She said Resident #1 would complain that the boots hurt and were uncomfortable. She said she would stack a couple of pillows to elevate her heels. She said Resident #1 would kick out the pillows at times but it was better than nothing. She said Resident #1 would refuse positioning a couple of times a day as she did not want to be touched. She said she would have to reproach 10-15 minutes later for care/repositioning. On [DATE] at 4:05 PM, the Nurse Consultant said she expected the CNAs to monitor skin with every care. She said skin observations were to be completed every week by the licensed nurse. She said any surgical wound and any type of ulcer was to be looked at daily and documented on the wound data collection form. The Nurse Consultant said she expected skins were to be measured weekly with complete/thorough assessments which included documenting the characteristics of the wound. She said if the wound showed no improvement within 14 days, she expected the family and Physician to be notified. She said if the wound declined/worsened, she would expect the family and Physician to be notified right away. She reported she expected the Unit Manager to have oversight of the wounds daily (Monday through Friday) and update the care plan as needed. She said any resident at risk for pressure ulcers should have interventions in place to prevent development of a pressure ulcer. She said if the wound was not improving, alternative interventions should be attempted. The Nurse Consultant reported she expected treatments to be obtained and completed for any pressure ulcer identified. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation dated [DATE] documented the purpose of the policy was the following:-To systematically assess residents regarding risk of skin breakdown.-To accurately document observations and assessments of residents.-To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcer.The policy documented the following procedures:1. A systematic skin inspection would be made daily by the nursing assistants assigned to those residents at risk for skin breakdown. The nursing assistant would report any abnormal findings or signs of skin impairment to the licensed nurse.2. Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to reposition themselves and based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. The positioning schedule should be communicated to the nursing assistants using the Kardex in the medical record. Any resident at risk would be placed on a pressure redistribution surface as determined appropriate. 3. If a pressure ulcer was identified, the registered nurse should record the type of wound and the degree of tissue damage on the Wound RN Assessment UDA. The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics on the Wound Data Collection UDA. 4. Staff to notify the Physician/Practitioner of the ulcer and the resident's condition to obtain orders for a treatment. 5. Staff to notify the resident and/or family/representative of the pressure ulcer, orders and planned interventions. 6. The interdisciplinary team should determine any modifications that are necessary to the resident's plan of care. Interventions should focus on physical, mental and psychosocial aspects that may be impacted. Treatment and Interventions should be consistent with the resident's goals. 7. The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment UDA. Observations of the ulcer characteristics may be documented by a licensed nurse and should include at least the following:-Measurements: length, width, depth-Characteristics of the ulcer including wound bed, undermining/tunneling, exudate, surrounding skin, ect.-Presence of pain-Current treatments 2. Resident #2's MDS dated [DATE] assessment identified a BIMS score of 9, indicating moderately impaired cognition. The MDS identified Resident #2 was independent with bed mobility and transfers. Resident #2's MDS included diagnoses of renal disease, Non-Alzheimer's dementia, hypertension and edema. The MDS documented Resident #2 was not at risk for developing pressure ulcers/injuries. The Care Plan with a revision date of [DATE] indicated Resident #2 had actual skin breakdown related to pressure area to the left outer ankle, dementia, hypertension, incontinence, history of CVA evidenced by need for pull up and assistance with activities of daily living as needed. The care plan directed the following interventions:-Staff to monitor location, size and treatment of skin injury. Staff to report abnormalities, failure to heal, sign/symptoms of infection, maceration, to the health care provider- Revised: [DATE]-Keep skin clean and dry. Use lotion on dry skin. Do not apply on site of injury. Blue boots at night- Revised on: [DATE]-Restorative Nursing referral-Date Initiated: [DATE]-Weekly skin observation by a licensed nurse.-Date Initiated: [DATE]-Resident uses incontinence products pull ups- Date Initiated: [DATE] The Progress Note dated [DATE] at 1:06 AM revealed Resident #2 pulled her call light to summon a nurse to the room. Upon the nurse arrival, Resident #2 was noted to be teary and complaining of left outer ankle pain. Upon inspection, the nurse noted Resident #2 had a Mepilex dressing on the lateral left ankle. The note indicated a yellow open area that measured 1 mm (millimeter) was identified. The surrounding tissue was red and warm to touch. Resident #2 reported pain was localized to the left outer ankle and rated the pain 5 out of 10. The note documented Tylenol was given. The clinical record lacked documentation regarding when and why the Mepilex dressing was applied to Resident #2's left outer ankle. The Progress Note dated [DATE] at 1:23 AM documented the nurse contacted Resident #2's Physician regarding the new skin area. Resident #2's Physician directed to administer pain medication as needed and continue to monitor. The Physician reported she would be at the facility the next morning and would examine Resident #2 at that time. The Physician Progress Note dated [DATE] documented Resident #2 was seen due to some redness around her left ankle. The note documented the lateral malleolus on the left ankle was tender, red and had a very tiny superficial ulceration. The Progress Note documented the diagnosis was cellulitis. The Physician ordered Doxycycline (antibiotic) 100 mg BID for 10 days and topical wound care that consisted of Aquacel AG and foam border with baths and as needed. Resident #2's [NAME] hose were put on hold. The Progress Note on [DATE] revealed Resident #2 did not want to wear the bootie to her left foot. The left foot was elevated with a pillow. The Progress Note on [DATE] revealed Resident #2 refused to utilize the offloading boot at HS (bedtime). The note lacked any alternative intervention to elevate her left foot. The Skin Assessments (Wound RN Assessment and Wound Data Collection) for the left ankle pressure wound revealed the following information:[DATE]- left outer ankle- measured .10 cm x 1.0 cm- The assessment documented the area was covered with slough (moist nonviable tissue). [DATE]- left lateral ankle- unstageable pressure injury. Area measured 0.8 cm x 1.2 cm x 0.1 cm. The assessment documented wound consultation was completed by an outside wound nurse. The assessment documented treatment recommendations were received from the wound nurse and would be faxed to the Physician to be reviewed. [DATE]- left outer ankle- measured 0.2 cm x 0.2 cm- The assessments lacked documentation regarding wound characteristics. The ET Services Patient Wound/Skin Assessment Form dated [DATE] documented a wound assessment to the left lateral ankle that consisted of a pressure injury measuring 0.8 cm x 1.2 cm x 0.1 cm. The wound base was yellow, pink, dry, with a scant amount of serous (clear, watery) drainage. The assessment documented the peri wound was intact. The wound was tender to touch. The assessment documented a recommendation to alter topical care to add moisture. The wound nurse recommendations included the following:1- Hold compression at this time2- Pressure offloading boots at HS (hour of sleep)- off in AM (morning) and with ambulation.3- Continue antibiotics per Primary Care Physician recommendations4- Staff to complete topical care to left lateral ankle on bath days and PRN: cleanse wound with wound cleanser and dry with gauze, apply mupirocin 2% ointment to wound base and secure with Mepilex or similar foam border dressing.5- 4 oz (ounces) house supplement BID6- High protein diet7- Wound care follow up. Review of the clinic record revealed the recommendations from the outside wound nurse were not implemented. The clinical record lacked documentation the Physician or Dietician received/reviewed the wound nurse recommendations and provided any orders or directions. The clinical record lacked documentation that the staff followed up with the Physician regarding the fax. On [DATE] at 9:45 AM, observation of the left ankle wound revealed the area was closed with a dry, scaly scab and a small amount of pinkness around the wound. The DON reported she did not think the current treatment of Aquacel remained appropriate and would follow up with the Physician. The DON reported Resident #2 did not like to wear the heel lift boot. Review of the Care Plan and CNA Kardex lacked documentation of an alternative intervention when Resident #2 refused to wear the heel lift boot to her left foot. On [DATE] at 11:05 PM, the Director of Nursing (DON) reported she had talked with Staff B, Licensed Practical Nurse (LPN). She reported Staff B applied the Mepilex dressing to the left ankle right before shift change on [DATE]. She said Staff B applied the Mepilex dressing to reduce rubbing under the [NAME] hose as it was bothering Resident #2. The DON said Staff B reported she had passed it on to the night nurse. The DON acknowledged Mepilex dressing was a treatment and she reported she would expect the nurse to obtain a physician order for it. On [DATE] at 12:13 PM, the DON reported she faxed the wound nurse recommendations to the clinic late in the afternoon on [DATE]. The DON said she had been told there had been no changes to the original orders. She said she called the clinic and the clinic did not have any record of the fax or any new orders related to the fax. She said she would expect the nurses to follow up on a fax sent out to ensure a response was received. On [DATE] at 2:33 PM, Staff B, LPN reported on [DATE], Resident #2 complained that her [NAME] hose was bothering her left ankle. She said her thoughts were to put padding on the area for protection. She said she applied the Mepilex dressing and thought she would follow up on it the next day. She said once she applied the Mepilex dressing and put the [NAME] hose back on, Resident #2 reported it felt better. Staff B reported the left ankle bone was slightly red but not open. She said she did not document that she had put the Mepilex on the ankle in the clinical record as it was later in the day. When asked if she should have documented it, she said more than likely. She said she passed it on to the night nurse. When asked if Mepilex dressing was a treatment that could be initiated without a Dr's order, she said no. Staff B said she should have padded the area with something different or notified the physician to obtain an order. She said she could have left the [NAME] hose off since it was later in the day. She reported she did not have any concerns with cellulitis when she looked at the left ankle. Staff B reported she worked on [DATE] and was aware that a fax was sent out on 10/7 regarding wound nurse recommendations. She said she did not see the fax come back. She said they usually give the clinic a day or two to respond. She said she did not call or follow up with the clinic regarding the fax. She said the faxes that go out are put on the nurses clipboard while waiting for a response. She said as the faxes come back they get rid of the fax on the clipboard. Staff B reported she did not know if the fax was on the clipboard or not. She said she was not the one who sent the fax out.

Based on clinical record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 1 residents (Resident #61) reviewed from personal degradation. The facility reported a census of 63 residents. The facility completed Social Media and HIPPA training on 10/22/24 prior to surveyors entering the facility on 11/18/24. The deficiency F600 sited at a D will be considered past non compliance. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #61 showed the Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS documented diagnoses of Non-Alzheimer ' s Disease, hypertension (high blood pressure), arthritis, hyperlipidemia (a condition where there are high levels of fats or lipids in the blood), and gastroesophageal reflux disease. Review of the facility self report revealed the facility was made aware on 10/22/24 at 11:30 AM, by Staff A, Dietary Manager, reported a video via social media of Staff B, Certified Nursing Assistant (CNA), having a conversation with Resident #61 while she was sitting in her wheelchair in her room. The video was sent to another dietary aid, who reported it to Staff A. Review of the facility investigation self-report incident occurring on 10/22/24 at approximately 9:30 AM - 4:00 PM revealed the following: Interview conducted with Staff A, Dietary Manager, according to her interview and written statement, Staff A stated that Staff C reported to her another staff member was posting videos on social media of herself with a resident. Staff A reported she received the videos through social media, where Staff B was talking to a resident and getting the resident in the video. Staff B was talking about being her friend, pulling her pants up and sitting on her lap. Staff A stated you can clearly see and hear the Resident in the video. I reported the videos to our Administrator. Interview conducted with Staff B, CNA according to her interview and written statement, Staff B denied the incident repeatedly and said nothing of this has ever occurred. Staff B was not able to state if anyone else was present in the room. Staff B stated that she is well aware of the social media and Health Insurance Portability and Accountability Act (HIPAA) policies and that staff are not allowed to take videos or pictures without written permission. Interview conducted with Staff C, Dietary Aide, according to her interview and written statement, Staff C stated that she received the video over the weekend. Staff C stated that she sent it to Staff A to report the concern and denies sending it to anyone else. Staff C confirmed that she is aware of the HIPAA and social media policy and that videos and pictures cannot be taken or distributed without written permission of the resident or family. Interview on 11/19/24 at 9:30 AM with Staff A, Dietary Manager, reported to the Administrator on 10/22/24 that Staff C, dietary aide, received a video via social media of Resident #61. Staff A reported that she has the video. Staff A reported she saw the video on 10/22/24 and took it to the Administrator that day. Staff A stated she knows the CNA in the video but doesn't know the person's name. Staff A stated that this had never happened before and she along with all of the staff received education regarding phone use and HIPPA. Staff A reported she doesn't remember if this was reported to her before 10/22/24. Interview on 11/19/24 at 12:18 PM with Staff C, Dietary Aide, stated that she received from a friend who was a previous employee of the facility, a couple of videos. Staff C stated she received two videos/pictures on 10/18/24 and the third picture on 10/24/24. Staff C stated that the video on 10/18/24 were of Resident #61 and the picture was of a resident's feet. Staff C stated when asked if Staff B told her who's feet they were and she stated yes. The other picture Staff C received was one of a catheter bag and stated she didn't know which resident this was. Staff C stated she reported these to Staff D, Cook. Staff C revealed she couldn't remember if she sent them or showed them to Staff D. Staff C stated I went to report these to Staff A. Staff A then showed them to the Administrator. Staff C stated I talked to the Administrator in his office and explained how I received them. Staff C reported that she didn't show the video's to the Administrator. Staff C stated reported them on 10/18/24 to Staff D. Staff A stated they needed proof. Staff C reported that when she received the video and pictures she took them to Staff A. Staff C stated that she didn't report it to the Administrator because she didn't have his number and didn't know how to get in touch with him. Interview on 11/19/24 at 1:53 PM with Staff D, Dietary Cook, reported that Staff C, texted her and told her that Staff B had taken pictures of the residents. Staff D stated that she has not seen the pictures or the videos. Staff D reported she can't remember when Staff C texted her. Staff D stated she thinks it had been over a month ago or month and a half ago that Staff D texted her. Staff D reported she told Staff C needed to report these to Staff A. Staff D reported this to Staff A. Staff D stated she thinks there was a second picture that this CNA posted, but she has never seen any of the pictures. Staff D reported I think Staff C reported it to me because I am a night cook and that I would immediately let Staff A know. Staff D reported that she does not have the text saved. Interview on 11/21/24 at 12:30 PM with Staff B, CNA, reported that she was in Resident #6' s room waiting for another staff member to come assist her in putting Resident #61 to bed. Staff B stated that Resident #61 was in her wheelchair and dressed. Staff B stated that no one else was in the room with them. Staff B stated that they were having a conversation and thought Resident #61 was being funny and Staff B started recording their conversation. Staff B stated that while she was holding onto her phone she bent down to do something and she didn't realize her phone turned towards Resident #61's face. Staff B stated she didn't realize her face was in the video and didn't think to go back and look at the video before she sent it. Staff B stated she couldn't remember the conversation that went on between her and the Resident. Staff B stated she was just talking with Resident #61 and didn't think she said anything to her. Staff B stated that she was just joking around with her and that they have a close relationship with her and it is normal to talk to her that way. Staff B stated she does not remember the date she took the video and she has not sent any previous videos or pictures. Staff B did admit to sending this video. Staff B stated that she sent this to a previous employee, this previous employee does not know Resident #61. Staff B stated she thought Resident #61 was being funny and this friend had worked at the facility previously and was a CNA. Staff B stated that she did not realize it was a HIPPA violation to record their conversation. Review of the facility provided policy titled Abuse and Neglect-Rehab/Skilled, Therapy and Rehab Policy dated 7/6/23 revealed the following information: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. To ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location. To ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect, exploitation and abuse of residents and misappropriation of their property. To ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals. To ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. To ensure a complete review of existing incidents by the investigation team to identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation

Based on clinical record review, staff interviews, and facility record review, the facility failed to report an allegation of abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 1 of 1 residents reviewed for abuse due to a staff member sending a video via social media with (Resident #61). The staff member was made aware of the allegations of possible abuse on 10/18/24, the Administrator was not made aware until 10/22/24. The staff member reported she did not know how to get a hold of the Administrator to report it. The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #61 showed the Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS documented diagnoses of Non-Alzheimer's Disease, hypertension (high blood pressure), arthritis, hyperlipidemia (a condition where there are high levels of fats or lipids in the blood), and gastroesophageal reflux disease (a chronic condition that occurs when stomach contents leak back into the esophagus, the tube that carries food from the mouth to the stomach). The Care Plan dated 8/27/24 revealed Resident #61 required a stand pivot for transfers, needed assistance with ambulation, bathing, bed mobility, dressing, grooming and toilet use. The facility self reported on 10/22/24 to DIAL an allegation of abuse involving Resident #61. Interview on 11/19/24 at 9:30 AM with Staff A, Dietary Manager, stated reported to the administrator on 10/22/24 that Staff C, Dietary Aide, received a video via social media of Resident #61. Staff A reported she saw the video on 10/22/24 and took it to the Administrator that day. Staff A stated she knows the Certified Nursing Assistant (CNA) in the video but doesn't know the CNA's name. Staff A stated that this had never happened before. Staff A reported she doesn't remember if this was reported to her before 10/22/24. Interview on 11/19/24 at 12:18 PM with Staff C, Dietary Aide, stated that she received a couple of videos from a friend who was a previous employee of the facility. Staff C stated she received a video and picture on 10/18/24 at 11:32 PM and the third picture on 10/24/24 at 7:21 PM. Staff C stated that the video on 10/18/24 were of Resident #61 and the picture of a resident's feet with a comment across the picture stating this man is literally dying. Staff C stated that she asked the previous employee if Staff B told her who's feet they were and she stated yes. The other picture Staff C received was one of a catheter bag with a comment the color a resident's piss and stated she didn't know which resident this was. Staff C stated she reported these to Staff D, Cook. Staff C revealed she couldn't remember if she sent them or showed them to Staff D. Staff C stated she went to report these to Staff A. Staff A then showed them to the Administrator. Staff C stated she talked to the Administrator in his office and explained how she received them. Staff C reported that she didn't show the videos to the Administrator. Staff C reported them on 10/18/24 to Staff D. Staff A stated they needed proof. Staff C reported that when she received the video and pictures she took them to Staff A. Staff C stated that she didn't report it to the Administrator because she didn't have his number and didn't know how to get in touch with him. Interview on 11/19/24 at 1:53 PM with Staff D, Dietary Cook, reported that Staff C texted her and told her that Staff B, CNA, had taken pictures of the residents. Staff D stated that she has not seen the pictures or the videos. Staff D reported she can't remember the dates Staff C texted her. Staff D stated she thinks it had been over a month ago or month and a half ago that Staff D texted her. Staff D reported she told Staff C needed to report these to Staff A. Staff D reported this to Staff A. Staff D stated she thinks there was a second picture that this CNA posted, but she has never seen any of the pictures. Staff D reported I think Staff C reported it to me because I am a night cook and that I would immediately let Staff A know. Staff D reported that she does not have the text saved. Interview on 11/21/24 at 12:30 PM with Staff B, CNA, reported that she was in Resident #61's room waiting for another staff member to come assist her in putting Resident #61 to bed. Staff B stated that Resident #61 was in her wheelchair and dressed. Staff B stated that no one else was in the room with them. Staff B stated that they were having a conversation and thought Resident #61 was being funny and Staff B started recording their conversation. Staff B stated that while she was holding onto her phone she bent down to do something and she didn't realize her phone turned towards Resident #61's face. Staff B stated she didn't realize her face was in the video and didn't think to go back and look at the video before she sent it. Staff B stated she couldn't remember the conversation that went on between her and the Resident. Staff B stated she was just talking with Resident #61 and didn't think she said anything to her. Staff B stated that she was just joking around with her and that they have a close relationship with her and it is normal to talk to her that way. Staff B stated she does not remember the date she took the video and she has not sent any previous videos or pictures. Staff B did admit to sending this video. Staff B stated that she sent this to a previous employee, this previous employee does not know Resident #61. Staff B stated she thought Resident #61 was being funny and this friend had worked at the facility previously and was a CNA. Staff B stated that she did not realize it was a HIPPA violation to record their conversation. Interview on 11/25/24 at 11:43 AM with the Administrator stated that he was not aware of the incident before 10/22/24 and his expectation would be to have the staff bring it to him or their supervisor so they can get it reported in a timely manner, in that 2 hour window. Interview on 11/25/24 at 4:09 PM with Staff A revealed that she did tell Staff D that they would need proof of the video/pictures. Staff A revealed she didn't remember the exact date this was reported to her, but knows it was a couple of days before 10/22/24 when she went to the Administrator. Review of the facility provided policy titled Abuse and Neglect-Rehab/Skilled, Therapy and Rehab Policy dated 7/6/23 revealed the following information: Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. These designated individuals are delegated the authority by the administrator to: 1. Intervene in any situation in order to protect residents. 2. Remove any individual from the location necessary for the protection of residents or employees, including but not limited to employees, visitors, contractors or family members. 3. Call local law enforcement for assistance with interventions necessary for the protection of residents or employees. 4. Call 911 for any type of emergency assistance. The location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency within five working days of the incident, or sooner as designated by state law. If the alleged or suspected violation is verified, appropriate corrective action will be taken.

Based on clinical record review, policy review, and staff interview, the facility failed to immediately report an allegation of abuse to the Department of Inspection and Appeals and Licensing (DIAL) for personal degradation, and failed to separate the staff member from the resident after the incident for 1 of 1 residents reviewed for an allegation of abuse (Resident #61). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #61 showed the Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS documented diagnoses of Non-Alzheimer ' s Disease, hypertension (high blood pressure), arthritis, hyperlipidemia (a condition where there are high levels of fats or lipids in the blood), and gastroesophageal reflux disease (a chronic condition that occurs when stomach contents leak back into the esophagus, the tube that carries food from the mouth to the stomach). The Care Plan dated 8/27/24 revealed Resident #61 required a stand pivot for transfers, needed assistance with ambulation, bathing, bed mobility, dressing, grooming and toilet use. Interview on 11/19/24 at 9:30 AM with Staff A, Dietary Manager, stated reported to the administrator on 10/22/24 that Staff C, dietary aide, received a video via social media of Resident #61. Staff A reported that she has the video. Staff A reported she saw the video on 10/22/24 and took it to the administrator that day. Staff A stated she knows the Certified Nursing Assistant (CNA) in the video but doesn't know the person's name. Staff A stated that this had never happened before. Staff A reported she doesn't remember if this was reported to her before 10/22/24. Interview on 11/19/24 at 12:18 PM with Staff C, Dietary Aide, stated that she received a couple of videos from a friend who was a previous employee of the facility. Staff C stated she received two videos/pictures on 10/18/24 and the third picture on 10/24/24. Staff C stated that the videos on 10/18/24 were of Resident #61 and the picture was of a resident's feet with a comment across the picture stating this man is literally dying. Staff C stated that she asked the previous employee if Staff B told her who's feet they were and she stated yes. The other picture Staff C received was one of a catheter bag with a comment the color a resident's pissand stated she didn't know which resident this was. Staff C stated she reported these to Staff D, Cook. Staff C revealed she couldn't remember if she sent them or showed them to Staff D. Staff C stated she reported these to Staff A. Staff A then showed them to the Administrator. Staff C stated she talked to the Administrator in his office and explained how she received them. Staff C reported that she didn't show the videos to the Administrator. Staff C reported them on 10/18/24 to Staff D. Staff A stated they needed proof. Staff C reported that when she received the video and pictures she took them to Staff A. Staff C stated that she didn't report it to the Administrator because she didn't have his number and didn't know how to get in touch with him. Interview on 11/19/24 at 1:53 PM with Staff D, Dietary Cook, reported that Staff C texted her and told her that Staff B, Certified Nursing Assistant (CNA), had taken pictures of the residents. Staff D stated that she has not seen the pictures or the videos. Staff D reported she can't remember when Staff C texted her. Staff D stated she thinks it had been over a month ago or month and a half ago that Staff D texted her. Staff D reported she told Staff C she needed to report these to Staff A. Staff D reported this to Staff A. Staff D stated she thinks there was a second picture that the CNA posted, but she has never seen any of the pictures or video. Staff D reported I think Staff C reported it to me because I am a night cook and that I would immediately let Staff A know. Staff D reported that she does not have the text saved. Interview on 11/21/24 at 12:30 PM with Staff B, CNA, reported that she was in Resident #61's room waiting for another staff member to come assist her in putting Resident #61 to bed. Staff B stated that Resident #61 was in her wheelchair and dressed. Staff B stated that no one else was in the room with them. Staff B stated that they were having a conversation and thought Resident #61 was being funny and Staff B started recording their conversation. Staff B stated that while she was holding onto her phone she bent down to do something and she didn't realize her phone turned towards Resident #61's face. Staff B stated she didn't realize her face was in the video and didn't think to go back and look at the video before she sent it. Staff B stated she couldn't remember the conversation that went on between her and the Resident. Staff B stated she was just talking with Resident #61 and didn't think she said anything to her. Staff B stated that she was just joking around with her and that they have a close relationship with her and it is normal to talk to her that way. Staff B stated she does not remember the date she took the video and she has not sent any previous videos or pictures. Staff B did admit to sending this video. Staff B stated that she sent this to a previous employee, this previous employee does not know Resident #61. Staff B stated she thought Resident #61 was being funny and this friend had worked at the facility previously and was a CNA. Staff B stated that she did not realize it was a Health Insurance Portability and Accountability Act (HIPPA) violation to record their conversation. Interview on 11/25/24 at 4:09 PM with Staff A revealed that she did tell Staff D that they would need proof of the video/pictures. Staff A revealed she didn't remember the exact date this was reported to her, but knows it was a couple of days before 10/22/24 when she went to the Administrator. Interview on 11/25/24 at 11:43 AM with the Administrator stated that he was not aware of the incident before 10/22/24 and his expectation would be to have the staff bring it to him or their supervisor so they can get it reported in a timely manner, in that 2 hour window. Review of Staff B's time sheet revealed the following information: On 10/20/24 punch in at 3:57 PM and punch out 10/20/24 at 9:38 PM. On 10/21/24 punch in at 4:05 PM and out for lunch punch 5:50 PM and in punch at 6:22 PM and out on 10/21/24 at 10:04 PM. Review of the facility provided policy titled Abuse and Neglect-Rehab/Skilled, Therapy and Rehab Policy dated 7/6/23 revealed the following information: 1. If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident property or witnesses suspected abuse, neglect or misappropriation of resident property, the employee will take measures to protect the resident, provided the safety of the employee is not jeopardized. The employee will then report the allegation to a supervisor. 2. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions: a. If this is an allegation of employee to resident abuse, the employee will be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation. Another employee will be assigned to complete the care of the resident. 3. A designated individual will complete the documentation. 4. Notification procedures: a. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. b. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker,). If the alleged perpetrator is one's supervisor or department manager, notify his or her supervisor. Document this notification in the electronic health record. c. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. If applicable, Adult Protective Services will be notified where state law provides for jurisdiction in long-term care centers. i. If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later then two hours after the allegation is made. ii. If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported not later than 24 hours after the allegation is made. d. If the designated agency(ies) requests a written report, notify the social worker and administrator. e. Employees will exercise caution when handling evidence that could be used in a criminal investigation. Do not tamper with or destroy anything that may be evidence. Notify law enforcement of the alleged crime and protect the crime scene to prevent the destruction or contamination of evidence. Secure the scene until law enforcement arrives. f. Disclosure of the resident's protected health information may need to be recorded for compliance with the HIPAA Privacy Rule. Contact the privacy point of contact for assistance with logging the disclosure. g. Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or an injury of unknown origin, inform them that an investigation is in progress. Record this notification. h. Immediately contact regional leadership when there is alleged/verified abuse (sexual, physical, neglect) to a resident that requires outside medical treatment, hospitalization or results in death or causes physical harm, pain or mental anguish. 5. After the initial documentation of the incident, if there is a need for additional documentation, this will be completed. 6. The investigation team (social worker, administrator and director of nursing services) will review all incidents no later than the next working day following the incident.

Based on clinical record review, observations, staff interviews and facility policy review the facility failed to assure that a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to prevent pressure ulcers from developing and to promote healing of a pressure ulcer for 1 of 1 resident reviewed (Resident #38). The facility reported a census of 50. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging consideration include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #38's MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderately impaired cognition. The MDS identified Resident #38 required extensive assistance of one person with bed mobility and two persons with toileting use. The MDS identified Resident #38 required limited assistance of one person with transfers. The MDS included diagnoses of cerebrovascular accident (stroke), aphasia (difficulty with language), arthritis and overactive bladder. The MDS identified Resident #38 was at risk for developing pressure ulcers and did not have any pressure ulcers on assessment. The MDS documented Resident #38 had a pressure reducing device for the chair. Resident's 38's Care Plan dated 9/14/23 documented the resident has a self-care performance deficit related to a history of a stroke. The care plan directed staff that she was able to move herself in bed but required assist by staff to get in and out bed, and required one staff assist for ambulation, toileting and transfers. A Wound RN assessment dated [DATE] revealed Resident #38 had a new stage 2 pressure ulcer to the right buttocks. The Progress Notes on 11/25/23 lacked documentation regarding a new stage 2 pressure ulcer to the right buttocks. The Care Plan dated 11/29/23 documented the resident has a stage 2 pressure ulcer to her right buttock related to immobility. The care plan directed staff to: -Monitor/remind/assist to turn and reposition at least every 2 hours. Reposition with repositioning wedge in bed. -Assess/record/monitor wound healing daily. Report improvements and declines to the healthcare provider. -Provide an air mattress on the bed and a roho cushion to chair/wheelchair. -Notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. The Care Plan lacked information regarding applying a treatment to the wound, nutrition and/or hydration interventions to promote healing. The Care Plan prior to 11/29/23 did not identify Resident #38 was at risk for skin impairments and/or developing pressure ulcers. The care plan lacked focus areas, goals and interventions/tasks to manage, treat and prevent skin impairments and pressure ulcers. The Braden Scale assessments (tool used to evaluate risk of development of a pressure ulcer) documented a score of 10-12 indicated that the resident had a high risk for pressure sore development, 13-14 meant the resident had a moderate risk, and 15-18 meant the resident had a risk for pressure ulcer development. The review of the Braden Scale assessments completed for Resident #38 from 9/23 to 10/23 documented scores on the following dates: 1. 9/14/23= 16 2. 9/25/223=14 3. 10/2/2=16 4. 10/9/23= 15 Resident #38's clinical records lacked a Braden Scale assessment after the development of the stage 2 pressure ulcer. On 11/30/23 at 7:34 AM, The DON (Director of Nursing ) reported the facility had no straight policy for completing the Braden Scale. The DON stated the facility does the Braden Scale on Admission, Quarterly, and with Significant changes. The facility policy titled Pressure Ulcer Treatment revised 2/7/23 instructed once a pressure ulcer had been identified, licensed personnel will complete a Braden Scale and implement additional interventions as appropriate. Resident 38's wound evaluation form revealed the following information: -11/25/23: Stage 2 pressure area to right buttocks that measured (Length x Width x Depth) 0.5cm x 1cm x 0cm. Wound bed not assessed. No drainage. Peri wound indurated. Comments on form stated: Will apply foam and tape to the area, apply air mattress to bed and roho cushion to wheelchair and also encourage Resident #38 to lay in bed between meals. - 11/26/23: Stage 2 pressure area to right buttocks- Wound measurements and wound bed not assessed. Dressing present and intact. Resident #38 reported pain during assessment. No drainage. Peri wound intact and pink. Continue with current treatment. -11/27/23: Stage 2 pressure area to right buttocks- Wound measurements and wound bed not assessed. Dressing present, clean, dry and intact. Minimum serosanguinous drainage. Peri wound indurated. Wound cleaned, foam and tape applied. -11/28/23: Stage 2 pressure area to right buttocks- Wound measurements and wound bed not assessed. Dressing present and intact. No drainage. Peri wound indurated. No undermining or tunneling. Wound cleaned, foam and tape applied. -11/29/23: Stage 2 pressure area to right buttocks that measured 1cm x 2cm x 0.1cm. Wound bed 25% epithelial and 75% granulation tissue. No slough or eschar. Dressing present and intact. No drainage. Peri wound intact and was pink in color. No undermining or tunneling. Applied foam and tape per Physician order. -11/30/23 1st Assessment: Stage 2 pressure ulcer right buttocks that measured 1.8cm x 1.2cm x 0cm with redness and peeling skin surrounding the pressure ulcer with a total measurement of 3cm x 3cm. No dressing present. Center of the ulcer appeared dry. Wound bed 50% granulation and 50% eschar. Minimum amount of serous drainage with no odor. Peri ulcer denuded. Treatment changed per Physician order to clean with wound cleanser, apply Aquacel AG (silver impregnated dressing), foam and tape. -11/30/23 2nd Assessment: Unstageable pressure ulcer to right buttocks that measured 3cm x 3cm x 0cm. The center of the wound bed was dark in color and measured 1.8cm x 1.2cm and unable to see the base of the wound. No dressing present. Center of the ulcer appeared dry. Wound bed 50% granulation and 50% eschar. Minimum amount of serous drainage with no odor. Peri ulcer denuded and reddened. Treatment changed per Physician order to clean with wound cleanser, apply Aquacel AG, foam and tape. The Clinical Record lacked documentation from 11/25/23 to 11/27/23 regarding family and physician notification of the pressure ulcer to the right buttocks. The facility was not able to provide an incident report. The Physician Order dated 11/28/23 directed staff to clean and apply foam/tape to wound on the right lower buttocks twice daily. The Clinical Record lacked a physician order for the treatment of foam and tape to the pressure ulcer to the right buttocks until 11/28/23. On 11/29/23 at 3:20 PM, the DON reported she did not have an incident report for the pressure ulcer identified on 11/25/23. The DON stated she was not aware of the pressure ulcer until the afternoon of 11/27/23. On 11/29/23 at 3:17 PM observed Resident #38 sitting in a recliner with feet elevated in her room with no cushion present in the recliner. Resident #38's wheelchair was in the hallway across from the room with the roho cushion in the wheelchair. On 11/29/23 at 3:30 PM, Staff B, Nurse Manager reported she had communicated the pressure ulcer to the Dietary Manager on 11/28/23 so the Dietician could review Resident 38's nutritional status next time at the facility. On 11/30/23 at 8:45 AM, the DON acknowledged and verified there was no skin care plan prior to the development of the pressure ulcer on 11/25/23 and no documented skin intervention in place to prevent the development of a pressure ulcer. The DON verified the physician was not notified until 11/27/23 of the pressure ulcer and the family was notified on 11/28/23. The DON reported she expected the Dr and family to be notified on the day the pressure ulcer was identified. The DON verified and acknowledged a treatment order was not obtained until 11/28/23. She stated she expected the facility to request a treatment order on the day the pressure ulcer was observed. A Physician Order dated 11/30/23 directed staff to cleanse the right lower buttocks wounds with wound cleanser, add Aquacel AG, cover with foam and tape daily and as needed. On 11/30/23 at 11:52 AM observed Staff E, LPN (Licensed Practical Nurse) complete dressing change to right buttocks. Staff E reported she had looked at the wound earlier in the morning and had a nurse manager look at it also. Staff E stated she called the Physician to get the wound treatment changed as she knew the foam treatment was not going to cut it. Staff E placed a barrier on the bedside table and did not clean or sanitize the table prior. Staff E placed dressing items on top of the barrier (wound cleanser bottle, package of Aquacel AG, foam, scissors). Staff E cleansed her hands with hand sanitizer from the wall unit in the room and then put on a pair of gloves that were in her uniform pocket. Staff E proceeded to unfastened Resident #38's brief and assisted with rolling her on her left side. Staff E removed the old dressing from Resident #38's right buttocks and threw it in the garbage can next to the resident's bed. Staff E reported the old dressing contained a small amount of sanguineous drainage. Staff E then picked up the wound cleanser and sprayed the cleanser onto a piece of gauze and cleansed the wound. Staff E reported she did not stage the wound but felt the wound bed had slough in it. Observed wound edges to be red and irritated. Staff E then cut a piece of Aquacel AG and placed it on the wound on the right buttocks. Staff E then cut a piece of foam and Mepilex tape (soft silicon tape) and placed it over the Aquacel AG. Staff E did not label or date the dressing. Staff E did not change her gloves or sanitize her hand between cleansing the wound and applying a new dressing. Staff E verified and acknowledged she wore one pair of gloves through the entire dressing change and did not change her gloves or sanitize her hands between dirty and clean. Staff E acknowledged she touched the Aquacel AG, foam, and Mepilex tape with contaminated gloves. Staff E acknowledged she did not date or initial the dressing. On 11/30/23 at 12:05 PM, Staff H, Nurse Manager reported she had looked at Resident #38's pressure wound that morning per request of Staff E. Staff H reported she felt the wound needed some sliver to help it heal as it had some drainage. Staff H stated she does not stage wounds. She stated another nurse manager does the wound measurements and staging so one person was doing the assessments consistently. Staff H verified she felt the pressure wound bed had slough present. She also verified the wound edges were red and irritated. On 11/30/23 at 12:35 PM, the DON reported her expectation was for staff to change gloves and clean their hands between dirty and clean tasks. She stated she would prefer staff not to keep gloves in their pockets. The DON stated the expected staff to date and initial dressing changes. On 11/30/23 at 2:35 PM, the DON reported if there was eschar documented in the wound bed then she would not consider the pressure ulcer a stage 2 and agreed the assessment was not accurate. The DON reported if the pressure ulcer was getting worse, then the facility would need to send Resident #38 to the clinic to be seen. The DON reported there was a wound nurse at the clinic that could see the wound. On 11/30/23 at 2:45 PM, Staff B acknowledged she had coded 50% eschar and staged the wound a stage 2 pressure ulcer on Resident #38's wound assessment. Staff B acknowledged a stage 2 pressure ulcer does not have eschar present in the wound bed. Staff B stated she was not sure what to stage the wound but thought it might be unstageable due to the center of the wound bed was not being visible under the hard tissue. Staff B reported she was not sure how much of the wound bed had to be not visible to be coded unstageable. Staff B reported that she needed to have more training in wound care and that she was not an expert in wounds. On 11/30/23 at 3:12 PM, Staff B completed an updated wound assessment and coded the pressure ulcer on right buttocks as unstageable. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/23 documented the purpose of the policy are the following: -To systematically assess residents regarding risk of skin breakdown -To accurately document observations and assessments of residents -To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. The policy directed staff to do the following: a. If a pressure ulcer is identified, cleanse the area prior to observation being made to allow the wound bed and depth to be more accurately observed. The registered nurse should record the type of wound and the degree of tissue damage on the wound assessment. b. Notify the physician of the ulcer and the resident's condition to obtain orders for a treatment. c. Notify the resident and/or family of the pressure ulcer, orders and planned interventions. d. The interdisciplinary team should determine any modifications that are necessary to the resident's plan of care. Interventions should focus on physical, mental and psychosocial aspects that may be impacted. Treatments and interventions should be consistent with the resident's goals. Education should be provided to the resident and/or family.

Based on clinical record review, observation, facility record review, staff and resident interviews, the facility failed to ensure resident's environment remained free from accidents and hazards for 2 out of 5 residents reviewed (Residents #8, and #54) for falls/incidents. The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS also documented that Resident #8 needed extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and was limited to only walking once or twice. The MDS further documented diagnoses of diabetes, anemia, heart failure, anxiety, depression, and morbid obesity. Resident #8's Care Plan dated 8/14/23 revealed that the resident was ambulatory with staff assistance as she desired. In an interview with Resident #8 at 4:27 PM on 11/27/23, she stated that in September she broke her ankle by catching it on the edge of her recliner. She stated that Staff G, Licensed Practical Nurse (LPN) was walking with her from her commode across the room to her recliner when she told her she wasn't going to make it and needed to sit down. She stated Staff G kept saying that she could make it. She stated that when she caught her foot on the recliner, she heard and felt a pop and told Staff G that she broke her ankle. In an interview with Staff G at 9:10 AM on 11/29/23, she stated that Resident #8 had been complaining to staff that she came into the facility walking and no one ever had the time to walk with her now. She stated the resident said this again to her after lunch and she told her that she had time to walk with her now. Staff G stated she assisted the resident to ambulate with a walker and gait belt all the way around the dining room and that she did wonderful. She stated that later that day the resident was on the commode and wanted to go to her recliner. She stated she assisted the resident up, and they started walking across her room to the recliner, (approximately. 15 ft), when the resident's walker bumped the recliner. Staff G stated the resident started freaking out saying I'm gonna fall, get me a chair, I'm gonna fall, I'm gonna go down. She stated she reassured the resident that she wasn't going to let her fall, and Staff G stated I had my knee up her butt, she wasn't going anywhere. Staff G stated that she called for help on her walkie, but she didn't have access to a chair and she knew the resident could do it. She stated the resident lost all confidence in herself after bumping the recliner. She stated as she was helping the resident to sit down in the chair, the resident caught her foot underneath the edge of the recliner and the resident screamed at her you broke my ankle! Staff G stated she did hear a pop, but she personally had rolled her ankle before and heard it pop. She stated the resident did complain of some pain and she gave her ice and Tylenol. At supper time, she stated the resident stood to transfer and did not complain of pain at that time. She stated she let the night nurse know what happened and that she would need to schedule an X-ray for her ankle on Monday since it was the beginning of the weekend. The next day the night nurse reported to her that the resident did not complain of pain or request medication during the night. The facility Investigation documented the incident occurred on 9/22/23 at 1:00 PM and was reported on 9/25/23 at 1:20 PM. The report documented the level of injury at the time to be a moderate injury (resulted in hospitalization /outside medical treatment). The report documented the resident reported she was ambulating with staff on 9/22/23 at 1:00 PM when her foot got caught on her recliner and she heard a pop. The resident stated she had pain all weekend (9/23 and 9/24/23) and ice was provided. Review of Resident #8's clinical record Progress Notes revealed documentation that the resident was scheduled to have an X-ray of her right ankle on 9/25/23 at 1:15 PM, and follow up with the physician at 1:45 PM. The Progress Notes also revealed that on 9/25/23 at 1:12 PM, the facility was notified that the resident had a nondisplaced medial malleolus fracture. The Progress Notes lacked any documentation of the incident on 9/22/23 prior to 9/25/23. The Care Plan for Resident #8 initiated on 10/2/23 documented an actual fall with no injury. The care plan lacked any documentation of an incident with injury or interventions on 9/22/23. 2. The MDS dated [DATE] for Resident #54 documented a BIMS score of 13 out of 15, which indicated intact cognition. The MDS also documented that Resident #54 needed partial to moderate assistance with toileting, applying lower body clothing, shoes, and personal hygiene. It also documented partial to moderate assistance for transfers and ambulation. The MDS further documented diagnoses of stroke, traumatic brain injury, nontraumatic intracranial hemorrhage, irritable bowel syndrome, atrial fibrillation, cataracts, difficulty walking, and muscle weakness. The MDS documented the resident had two or more falls with no injury since the last assessment. Resident #54's Care Plan with a revision date of 11/24/23 revealed that the resident had a Focus Area of falls related to intracranial hemorrhage, making poor choices, and confusion. The care plan directed staff with the following fall interventions: On 7/6/23: Educate resident/family about safety reminders and what to do if a fall occurs. On 11/2/23 revised: Grip strips to bathroom floor. On 8/28/23: Make sure wearing rubber sole shoes. On 10/30/23: Monitor for significant changes in gait, mobility, balance and joint function. Ortho-static blood pressures every shift x 3 days and report to physician due to incident. On 11/24/23 revised: When resident sitting in her recliner in her room, place walker to her right and within reach. On 10/9/23 revised: Ensure/provide a safe environment with bed in low position. Frequently transfers self without calling for assist. Observation on 11/27/23 at 2:20 PM, revealed that the resident did not respond to a knock on her door which was partially opened. The surveyor stepped just inside the resident's door and called out the resident's name which elicited no response from the resident. At 2:25 PM, Staff K, Restorative Nurse Aide entered the resident's room and looked in the bathroom, finding the resident laying on the floor. Staff K called out from the resident's doorway down the hallway saying Get the nurse, we got one down. Review of Resident #54's Progress Notes revealed the resident had falls on 7/20, 7/21, 8/8, 8/9, 8/10, 8/13, 8/26, 9/11, 9/13, 9/23, 10/1, 10/29, 11/2, 11/24, and 11/27/23. The Progress Notes for the resident documented the following: On 9/11/23 at 6:49 PM during report heard residents alarms sounding. Nurse went in room and resident sitting on the floor between her recliner and restroom with walker behind her and toothbrush with basin on the floor next to her. Right side of back with 2 abrasions. Resident stated she was trying to put her toothbrush away in the restroom. Staff reminded not to leave her while doing oral cares. On 9/13/23 at 7:45 PM entered resident room and resident lying on her right side on top of her walker. Blood from under the right temple. Foley catheter intact and out of body laying on the bed. Resident stated it happened last night. Skin tear noted to right arm also. Order to send to the emergency room (ER) for stitches. Motion sensor was not on. On 9/13/23 at 10:42 AM call from the ER who stated the resident will be admitted . On 9/14/23 at 10:07 AM resident will return this morning. On antibiotic for urinary tract infection. Stitches to laceration on head and splint on her arm for a fracture. The facility policy Fall Prevention and Management revised date of 3/29/23 documented the Purpose of the policy: -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To prevent further injury. -To provide guidance for documentation. The facility policy Procedure included the following: 1. Do not move the resident. 2. Remain calm and reassure and comfort the resident. 3. Stay with the resident and summon the nurse or other help. If able, observed the fall scene. 4. For a fall without injury, skip to Step 6. 5. For a fall with injury, do the following: a. If the resident is bleeding, locate the injured area and apply continuous, firm pressure to the area. b. Do not remove any blood soaked dressings or clothing. c. Cover the resident and have her lay quiet until help arrives. 6. A nurse must observe the resident and perform a full body exam to determine if there may be suspected injury and direct whether to move the resident. a. Obtain vitals. b. If the fall was not witnessed, neurological checks are required. c. Continue to monitor the resident's condition; communicate updates as needed. d. Review medications for recent changes or medication that could have contributed to the fall. e. Notify the physician and resident representative of the incident. 9. Document the physician's comments in the medical record. 17. Update the care plan with any changes/new interventions. 19. Continue to monitor condition and effectiveness of the interventions. In an interview with the Administrator on 11/30/23 at 4:00 PM regarding the concerns, he stated that he had no questions and that everything was pretty black and white.

Based on observation, clinical record review, resident, family, and staff interviews, and review of the Resident Council Meeting minutes, the facility failed to answer call lights in a timely manner for 4 of 7 residents reviewed (Resident #34, #29, #2, and #41). The facility reported a census of 50 residents. Findings Include: 1.Resident #34 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During an interview on 11/28/23 Resident #34 reported that she sometimes has to wait 45 minutes or longer for assistance and once ended up wetting herself due to waiting so long. She reported she felt stupid and embarrassed when she wet herself but just couldn't hold it any longer. She reported it is all shifts that the call lights go a long time without being answered. An observation on 11/29/23 of Resident #34 call light oserved it on at 7:42 AM and not answered until 8:27 AM. 2. Resident #29 MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During an interview on 11/29/23 at 8:35 AM Resident #29's daughter reported that the facility is short staffed frequently and that her dad waits a long time for his call light to be answered. She reported her dad didn't tell the other surveyor the truth when she interviewed due to being worried of backlash from staff. 3. Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During an interview on 11/27/23 at 1:51 PM Resident #2 reported sometimes she waits a long time for her call light to be answered. She reported sometimes she has waited up to 30 minutes for it to be answered. An observation on 11/29/23, observed Resident #2's call light on at 7:32 AM and answered at 7:55 AM. 4. Resident #41 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. An interview on 11/27/23 Resident #4 reported she sometimes waits up to an hour for help when she puts her call light on. A Review of the Resident Council Meeting Minutes revealed the following: a. 0n 9/11/23- concern of call lights not being answered, long wait times and staff turning them off and not returning was a large part of the discussion for the meeting. b. 0n 10/9/23- residents reporting they have to wait up to 45 minutes or longer for call light to be answered. Residents report they spend a lot of time in the bathroom waiting for help and aids turn off the lights and say they will be back but don't come back. c. On 11/6/23- Residents report the call lights are not improving. They reported the wait is still up to 45 minutes or longer. One resident report they wait so long that their roommate finally will get up on their own and they are not to be walking alone. During an interview on 11/28/23 at 3:00 PM the Social worker reported she let the Administrator and DON know about call light concerns from resident council meetings. She reported the Administrator and DON were doing call light audits. On 11/29/23 at 8:07 AM the Administrator emailed they do manual audits of call lights but didn't recall any recent audits for this.

Based on observations, staff interviews and facility policy review, the facility failed to ensure food was labeled with dates after opening, discarded after product recommended date, record temperatures of freezers/refrigerators to ensure safe food storage, record food temps prior to serving and complete test strips and temperatures on the dishwasher and with manual washing to ensure proper sanitation of dishes. The facility identified a census of 50 residents. Findings include: 1. An initial kitchen tour conducted on [DATE] at 10:10 AM, of the kitchen revealed the following items were stored in the upper level kitchen's refrigerator ready for service: a. Tartar Sauce- two squeeze bottles- one labeled ,d+[DATE] and one not labeled/dated. b. Squeeze bottle with white substance- not labeled or dated. c. Squeeze bottle with dark red substance- not labeled or dated. d. Squeeze bottle with red substance- not labeled or dated. The following item was stored in the lower level refrigerator ready for service: a. Chocolate Milk- expiration date [DATE]. Review of Refrigerator/Freezer Temperature logs for the upper level refrigerator, store room freezer, walk in fridge/freezer, dining room refrigerator and lower level refrigerator revealed temperatures were not recorded consistently during the month of [DATE]. The log did not provide any directions or how often to check the refrigerator temperatures. [DATE] upper level refrigerator temperatures were not recorded on the following dates and times: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. The other days of the month the temperatures were recorded daily. [DATE] store room freezer temperatures were not recorded on the following dates and times: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. The other days of the month the temperatures were recorded daily. [DATE] walk-in refrigerator/freezer temperatures were not recorded on the following dates and times: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. The other days of the month the temperatures were recorded daily. [DATE] dining room refrigerator temperatures were not recorded on the following dates and times: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. The other days of the month the temperatures were recorded daily. [DATE] lower level refrigerator temperatures were not recorded on the following dates and times: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. The other days of the month the temperatures were recorded daily. On [DATE] at 10:30 AM, Staff I, Cook reported she tried to do the temperature checks each day she worked but she does not work every day. Review of Dish Machine Temperature/Chemical log revealed temperatures and testing strips were not recorded consistently during the month of [DATE] for the upper level dishwasher. The log directed staff to record temperatures and testing strips three times a day (morning, noon and evening). [DATE] upper level dish machine temperatures and test strips were not recorded on the following dates and times: ,d+[DATE] to ,d+[DATE]- evening ,d+[DATE]- morning, noon and evening ,d+[DATE]- morning, noon and evening ,d+[DATE]- noon and evening ,d+[DATE]- morning, noon and evening ,d+[DATE]- morning and evening ,d+[DATE]- morning and evening ,d+[DATE]- morning, noon and evening ,d+[DATE]- noon and evening ,d+[DATE]-morning, noon and evening ,d+[DATE] through ,d+[DATE]- morning, noon and evening ,d+[DATE]- morning, noon and evening Review of high temp dish machine temperature log revealed temperatures were not recorded consistently during the month of [DATE] for the lower level dishwasher. The log directed staff to record temperatures three times a day (breakfast, lunch and supper). [DATE] lower level high temp dish machine temperatures were not recorded on the following dates and times: ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- breakfast, lunch and supper ,d+[DATE]- lunch ,d+[DATE]- breakfast and lunch ,d+[DATE]- lunch and supper ,d+[DATE]- breakfast ,d+[DATE]- breakfast and lunch ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- breakfast and lunch ,d+[DATE]- breakfast, lunch and supper Review of manual ware washing/chemical log for pot and pan sink revealed temperatures and testing strips were not recorded consistently during the month of [DATE]. The log directed staff to record temperatures and testing strips three times a day (morning, noon and evening). [DATE] manual ware washing temperatures and test strips for the pot and pan sink were not recorded on the following dates and times: ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening ,d+[DATE]- evening On [DATE] at 11:00 AM observed the chlorine test strips for the dishwasher had an expiration date of [DATE]. Staff I, Cook acknowledged and verified the test strips were expired. Staff I reported she could not locate a new bottle of test strips. Staff I reported it was an expectation to record temperatures and test strips three times a day. She acknowledged and verified the temps and sanitizing checks were not completed as expected. On [DATE] 9:30 AM, Staff I, Cook reported she was unable to locate new test strips for the dishwasher. She stated the batch of test strips that were located were all expired. Reviewed food temperature logs for the past 30 days revealed multiple temperatures missing from the logs. ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- breakfast, lunch and supper ,d+[DATE]- lunch, supper ,d+[DATE]- lunch ,d+[DATE]- supper ,d+[DATE]- supper ,d+[DATE]- breakfast, lunch ,d+[DATE]- breakfast, lunch, and supper On [DATE] at 11:30 AM, Staff I, Cook reported there were no food temperature logs for the lower level serving area. Staff I stated food temperatures are taken when the food comes out of the oven and not before serving. Staff I stated the food comes out of the oven and then goes into the steam tables. On [DATE] at 11:35 AM, Staff I obtained food temperatures and then started serving the resident. No hand hygiene was observed prior to taking food temperatures or serving. On [DATE] at 12:00 PM, Staff I did not perform hand hygiene prior to serving the upper level dining room. Observed Staff I touched multiple surfaces prior to serving as she had pushed the refrigerated cart from the lower level in the elevator, had taken chicken out of the oven, and touched several dishes/pans preparing to serve. On [DATE] at 12:05 PM, Staff I left the dining room to check on where the aides were at and when she returned she did not complete hand hygiene prior to serving. On [DATE] at 12:20 PM, Staff I left the dining room to check on where two residents were and when she returned she did not complete hand hygiene prior to continuing to serve. She prepared a plate for a resident who had not come to the dining room to eat and placed it in the refrigerator for later. On [DATE] at 8:30 AM, Staff J, Regional Food and Nutrition Consultant reported she would expect food to be labeled and dated and expired food items to be discarded. She would expect food temperatures to be taken at a cook temp and prior to serving. She would expect handwashing to be completed in between tasks and prior to serving. On [DATE] at 10:45 AM, Staff J reported she would expect manual washing sanitation to be completed when water is visibly dirty or depleted. She reported basically before doing the dishes. Staff J stated she would expect sanitation checks to be completed on the dishwashers three times a day and refrigerator/freezer temps to be taken at BID. The facility policy titled Food-Supply Storage revised [DATE] documented internal temperatures of all refrigerators and freezers in the food and nutrition department, dining room and nourishment areas are recorded twice daily on the refrigerator/freezer temperature log. The facility policy titled Warewashing-Mechanical and Manual revised [DATE] documented the purpose of the policy is to promote good practice ware washing regarding prevention of foodborne illness. a. The Mechanical Ware Washing Operation portion of the policy directed staff to record temperatures and chemical concentrations on the Dish Machine Temperature Log. The policy further directed to check compliance for wash and rinse cycles at each meal service. b. The Manual Ware Washing portion of the policy directed temperature and chemical concentration to be recorded on a Chemical Sanitizing Log or a Pot/Pan Hot Water Sanitizing log. The policy documented proper test strips and thermometers to be available for frequent measuring of the washing and sanitizing water temperature. The facility policy titled Food Temperature Monitoring revised [DATE] documented the following: a. Food is cooked, reheated or cooled to ensure proper holding temperatures before each meal service. b. Food temperatures are taken and recorded before each meal service. Periodically, temperatures are taken at other times during or at the end of the meal service to ensure temperatures are held within acceptable ranges. c. Food is served at proper serving temperatures. The policy directed staff before meal service, the cook or designee to take the cook-to and serve temperatures of all menu items and record on the Weekly Food Temperature Record. The policy titled Hand Washing and Glove Us- Food Nutrition Services revised [DATE] documented the purpose of the policy was to provide guidelines regarding hand hygiene and glove use, to reduce risk of cross-contamination when serving highly susceptible populations. The policy directed staff to wash hands before handling food, after handling raw meat, when switching tasks, and performing any activity that could contaminate hands. The further directed staff involved in food preparation, distribution and serving must consistently utilize good hygienic practices and techniques.

Based on clinical record review, staff interviews, Center for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the pneumococcal immunization for 3 of 5 residents reviewed (Resident #1, #38 and #41). The facility reported a census of 50 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of clinical records for immunizations lacked documentation Resident #1 received Prevnar 13 (PCV13) on 10/2/2015 and Pneumovax 23 (PPSV23) on 11/23/2016 but lacked documentation of being offered, educated or consent for or refusal of the Prevnar 20 (PCV20). 2. Resident #38's MDS assessment dated [DATE] identified a BIMS score of 10 out of 15, indicating moderately impaired cognition. Review of clinical records for immunizations lacked documentation Resident #38 received PCV13 on 10/10/2010 and PPSV23 on 11/28/2016 but lacked documentation of being offered, educated or consent for or refusal of the PCV20. 3. Resident #41's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15, indicating intact cognition. Review of clinical records for immunizations lacked documentation Resident #41 received PPSV23 on 06/21/2007 and PCV13 on 10/26/2016 but lacked documentation of being offered, educated or consent for or refusal of the PCV20. During an interview on 11/29/23 at 2:58 PM Staff B, Registered Nurse (RN) reported they have not offered residents the PCV20 vaccine at this time. On 11/29/23 at 4:25 PM the DON reported the facility has not offered PCV20 at this time. She was unaware Resident #1, #38 and #41 were able to take the PCV20 if they wish to. She reported she was not aware of the guidelines with the vaccine. Review of the Centers for Disease Control and Prevention (CDC) document titled, Pneumococcal Vaccine Timing for Adults, dated 09/22/2023 revealed adults older than [AGE] years of age are recommended to have both Prevnar (PCV) 13 or 20 and Pneumovax (PPSV) 23 given at least 1 year apart or Prevnar (PCV) 20 alone. Prevnar (PCV) 20 given at least 5 years after PCV13 and PPSV23. A review of the facility policy titled Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19 documented residents will be reviewed for vaccine eligibility on an ongoing basis as immunization recommendations change. Education, consent and screening are done for vaccine.

Based on clinical record review, staff interviews and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the Coronavirus booster vaccine to 5 of 5 residents reviewed (Resident #1, #15, #38, #41, and #51). The facility reported a census of 50 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #1's Immunization Record listed that she received her first dose of COVID-19 vaccine on 03/10/21 and second dose on 04/7/21. The Immunization Record documentation she received her first booster on 10/25/2021 and second booster on 06/7/23 but lacked documentation of any further boosters offered. 2. Resident #15's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15, indicating intact cognition. Resident #15's Immunization Record listed that she received her first dose of COVID-19 vaccine on 01/13/21 and the second dose on 02/11/21. The Immunization Record documented she received her first booster on 6/07/22 but refused the further boosters. The clinical record lacked documentation of education provided for the refusal of the boosters. 3. Resident #38's MDS assessment dated [DATE] identified a BIMS score of 10 out of 15, indicating moderately impaired cognition. Resident #38's Immunization Record listed that she received her first dose of COVID-19 vaccine on 03/11/21 and second dose on 04/7/21. The Immunization Record documentation she received her first booster on 03/01/2022 but lacked documentation of any further boosters offered. 4. Resident #41's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15, indicating intact cognition. Resident #41's Immunization Record listed that she received her first dose of COVID-19 vaccine on 01/13/21 and second dose on 02/11/21. The Immunization Record documentation she received her first booster on 11/11/2021 and second booster on 04/21/22 but lacked documentation of any further boosters offered. 5. Resident #51's MDS assessment dated [DATE] identified a BIMS score of 10 out of 15, indicating moderately impaired cognition. Resident #51's Immunization Record listed that he refused the vaccine. The progress notes documented resident refused the vaccine but lacked documentation of education regarding the vaccine. During an interview on 11/29/23 2:58 PM Staff B, Registered Nurse (RN) reported they have not offered residents the PCV20 vaccine at this time. On 11/29/23 at 4:25 PM the Director of Nursing reported the facility has not offered PCV20 at this time. She was unaware Resident #1, #38 and #41 were able to take the PCV20 if they wish to. She reported she was not aware of the guidelines with the vaccine. A review of the facility policy titled Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19 documented residents will be reviewed for vaccine eligibility on an ongoing basis as immunization recommendations change. Education, consent and screening are done for vaccine.

Based on resident and staff interviews and clinical record review, the facility failed to notify the physician or family for 1 of 1 residents reviewed (Resident #8), who suffered a fractured ankle during a transfer. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS also documented that Resident #8 needed extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and was limited to only walking once or twice. The MDS further documented diagnoses of diabetes, anemia, heart failure, anxiety, depression, and morbid obesity. Resident #8's Care Plan dated 8/14/23 revealed that the resident was ambulatory with staff assistance as she desired. In an interview with Resident #8 at 4:27 PM on 11/27/23, she stated that in September she broke her ankle by catching it on the edge of her recliner. She stated that Staff G, Licensed Practical Nurse (LPN) was walking with her from her commode across the room to her recliner when she told her she wasn't going to make it and needed to sit down. She stated Staff G kept saying that she could make it. She stated that when she caught her foot on the recliner, she heard and felt a pop and told Staff G that she broke her ankle. In an interview with Staff G at 9:10 AM on 11/29/23, she stated that Resident #8 had been complaining to staff that she came into the facility walking and no one ever had the time to walk with her now. She stated the resident said this again to her after lunch and she told her that she had time to walk with her now. Staff G stated she assisted the resident to ambulate with a walker and gait belt all the way around the dining room and that she did wonderful. She stated that later that day the resident was on the commode and wanted to go to her recliner. She stated she assisted the resident up, and they started walking across her room to the recliner, (approximately. 15 ft), when the resident's walker bumped the recliner. Staff G stated the resident started freaking out saying I'm gonna fall, get me a chair, I'm gonna fall, I'm gonna go down. She stated she reassured the resident that she wasn't going to let her fall, and Staff G stated I had my knee up her butt, she wasn't going anywhere. Staff G stated that she called for help on her walkie, but she didn't have access to a chair and she knew the resident could do it. She stated the resident lost all confidence in herself after bumping the recliner. She stated as she was helping the resident to sit down in the chair, the resident caught her foot underneath the edge of the recliner and the resident screamed at her you broke my ankle! Staff G stated she did hear a pop, but she personally had rolled her ankle before and heard it pop. She stated the resident did complain of some pain and she gave her ice and Tylenol. At supper time, she stated the resident stood to transfer and did not complain of pain at that time. She stated she let the night nurse know what happened and that she would need to schedule an X-ray for her ankle on Monday since it was the beginning of the weekend. The next day the night nurse reported to her that the resident did not complain of pain or request medication during the night. The faciity Investigation documented the incident occured on 9/22/23 at 1:00 PM and was reported on 9/25/23 at 1:20 PM. The report documented the level of injury at the time to be a moderate injury (resulted in hospitalization /outside medical treatment). The report documented the resident reported she was ambulating with staff on 9/22/23 at 1:00 PM when her foot got caught on her recliner and she heard a pop. The resident stated she had pain all weekend (9/23 and 9/24/23) and ice was provided. Review of Resident #8's clinical record Progress Notes revealed documentation that the resident was scheduled to have an X-ray of her right ankle on 9/25/23 at 1:15 PM, and follow up with the physician at 1:45 PM. The Progress Notes also revealed that on 9/25/23 at 1:12 PM, the facility was notified that the resident had a nondisplaced medial malleolus fracture. The Progress Notes lacked documentation of physician or family notification of the incident which occurred on 9/22/23 at approximately 3:00 PM. The Incident Report dated 9/25/23 documented the resident's family and physician were not notified timely of the injury. The Incident Report revealed they were notified on 9/25/23 at 1:43 PM. The facility policy Fall Prevention and Management revised date of 3/29/23 documented the Purpose of the policy: -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To prevent further injury. -To provide guidance for documentation. The facility policy Procedure included the following: 6. A nurse must observe the resident and perform a full body exam to determine if there may be suspected injury and direct whether to move the resident. e. Notify the physician and resident representative of the incident. In an interview with the Administrator on 11/30/23 at 4:00 PM regarding the concerns, he stated that he had no questions and that everything was pretty black and white.

Based on clinical record review, staff and resident interview, the facility failed to perform a caregiver background check for 1 of 1 resident reviewed (Resident #8). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS also documented that Resident #8 needed extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and was limited to only walking once or twice. The MDS further documented diagnoses of diabetes, anemia, heart failure, anxiety, depression, and morbid obesity. Resident #8's Care Plan dated 8/14/23 revealed a Focus that the resident had an ADL self care performance deficit related to decreased mobility and range of motion. Interventions documented in the Care Plan included the following: -Personal Caregiver assists the resident with showers. Resident requires assist of one. -Personal Caregivers may come in at times to assist residents with morning and bedtime care/dressing. In an interview with Resident #8 on 11/27/23 at 4:30 PM, she stated that she had a private caregiver that came into the facility several days a week to assist her with care. She stated the caregiver had been with her at home for [AGE] years before she came into the facility and she couldn't just let her go. In an email to the Administrator on 11/29/23 at 1:14 PM, regarding whether or not the facility performed a background check on Resident #8's personal caregiver, he responded that they did not as the caregiver was not their employee or a volunteer.

Based on clinical record view and staff interview, the facility failed to transmit 1 of 3 Minimum Data Set (MDS) assessments for the facility within the required timeframe. The facility reported a census of 50 residents. Findings include: The review of Resident #16's MDS assessment dated [DATE] lacked a transmission date. On 11/30/23 at 2:34 PM, the Administrator emailed a copy of the transmission logs for October and November 2023 which documented Resident #16's MDS was rejected. On 11/30/23 at 3:00 PM, Staff C, Registered Nurse (RN) and Health Information Director reported she opens and submits the MDS but that is all she does for the MDS. During an interview on 11/30/23 at 3:05 PM, Staff B, RN reported she gets a report if a MDS is rejected. She reported she was unaware of Resident #16's MDS from 10/17/23 was rejected and will look into why it was rejected. An email from the Administrator on 12/4/23 at 9:53 AM reported there was a glitch in the system that week. It was resubmitted and accepted.

Based on clinical record review and staff interviews the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) Assessment for 1 of 3 residents reviewed (Resident #58). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #58 discharging to an acute hospital. Review of the progress notes from 9/5/23 documented Resident #58 discharged to home with her husband. During an interview on 11/29/23 at 4:40 PM the DON reported the MDS must have been marked in error because the resident discharged to home and not the hospital.

Based on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 3 out of 16 residents (Residents #38, #52, #8) reviewed for comprehensive care plans. The facility reported a census of 50 residents. Findings include: 1. Resident #38's MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderately impaired cognition. The MDS identified Resident #38 required extensive assistance of one person with bed mobility and two persons with toileting use. The MDS identified Resident #38 required limited assistance of one person with transfers. The MDS included diagnoses of cerebrovascular accident (stroke), aphasia (difficulty with language), arthritis and overactive bladder. The MDS identified Resident #38 was at risk for developing pressure ulcers. The MDS documented Resident #38 had a pressure reducing device for the chair. A Wound RN assessment dated [DATE] revealed Resident #38 had a new stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising) to the right buttocks. A Wound Data Collection assessment dated [DATE] revealed Resident #38's pressure ulcer to the right buttocks deteriorated and was documented as an unstageable pressure ulcer (full thickness tissue loss where the depth of the wound bed is obscured by eschar). The assessment documented the wound bed of the unstageable pressure ulcer with 50% eschar (necrotic, nonviable tissue) and 50% granulation (healthy) tissue. The Care Plan with a target date 1/3/24 did not identify Resident #38 was at risk for skin impairments and/or developing pressure ulcers. The care plan lacked focus areas, goals and interventions/tasks to manage, treat and prevent skin impairments and pressure ulcers. The care plan was updated on 11/29/23 to reflect Resident #38 had a stage 2 pressure ulcer to the right buttocks related to immobility. On 11/29/23 3:30 PM, Staff B, Nurse Manager acknowledge and verified a comprehensive skin/pressure ulcer care plan was not completed until after Resident #38 developed a pressure ulcer. Staff B acknowledged Resident #38 was at risk for developing pressure ulcers before the ulcer developed. The facility policy titled Care Plan revised 11/1/23 documented residents will receive and be provided the necessary care and services to attain or maintain the highest practical well-being in accordance with the comprehensive assessment. The policy further documented the care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. The care plan will address the relationship of items or services required and facility responsibility for providing these services. 2. The MDS assessment for Resident #52 dated 8/26/23 identified a BIMS score of 14 out of 15, which indicated intact cognition. The MDS included diagnoses of anemia, heart failure (inability for the heart to pump enough blood), chronic kidney disease, hypoxemia (low level of oxygen in the blood) coronary artery disease, pulmonary emboli (blood clot in the artery of the lung) and chronic obstructive pulmonary disease. The MDS documented Resident #52 received an anticoagulant medication 4 days during the assessment period (last 7 days). A Physician order dated 4/7/23 directed staff to administer Apixaban (Eliquis) (anticoagulant) 5 mg (milligrams) by mouth twice a day for pulmonary embolism. Review of Resident #52's care plan revised 9/19/23 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 11/29/23 at 11:05 AM, Staff B, Nurse Manager verified and acknowledged the anticoagulant medication was not addressed on the care plan. Staff B stated she would update the care plan. 47261 3. The MDS dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The MDS also documented diagnoses of diabetes, anemia, heart failure, anxiety, depression, and morbid obesity. Review of Resident #8 ' s clinical record Orders revealed that resident had been receiving insulin daily as needed since 5/1/23. Review of Resident #8 ' s Care Plan with a revision date of 11/28/23 revealed lack of Focus, Goal, or Intervention for the resident having diabetes. The only documentation of Resident #8 ' s diabetes was listed as a diagnosis. In an interview with the Administrator on 11/30/23 at 4:00 PM regarding the concerns, he stated that he had no questions and that everything was pretty black and white.

Based on clinical record review, staff interview, and facility policy review, the facility failed to update the care plan for 1 of 1 resident reviewed (Resident #52) who was receiving an anticoagulant. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #52 dated 8/26/23 identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS included diagnoses of anemia, heart failure (inability for the heart to pump enough blood), chronic kidney disease, hypoxemia (low level of oxygen in the blood) coronary artery disease, pulmonary emboli (blood clot in the artery of the lung), chronic obstructive pulmonary disease, anxiety and depression. The MDS documented Resident #52 received an antidepressant and diuretic medication 3 days during the assessment period (last 7 days). A Physician order dated 4/7/2023 directed staff to administer Lexapro (antidepressant) 10 mg (milligrams) two tablets by mouth once a day for depression and anxiety. A Physician order dated 5/5/2023 directed staff to administer Wellbutrin SR Extended Release (antidepressant) 150 mg one tablet by mouth once a day for depression. A Physician order dated 8/23/2023 directed staff to administer Lasix (diuretic) 40 mg one tablet by mouth once a day for acute congestive heart failure. Review of Resident #52's care plan revised 9/19/2023 revealed potential side effects and what to monitor for while taking diuretic medication and antidepressant medications were not addressed on the comprehensive care plan. On 11/29/23 at 11:05 AM, Staff B, Nurse Manager verified and acknowledged side effects for the antidepressant and diuretic medications were not addressed on the care plan or CNA (Certified Nurse Assistant) kardex. Staff B stated she would update the care plan. The facility policy titled Care Plan revised 11/1/23 documented residents will receive and be provided the necessary care and services to attain or maintain the highest practical well-being in accordance with the comprehensive assessment. The policy further documented the plan of care will be modified to reflect the care currently required/provided for the resident.

Based on observations, staff interviews, and facility policy review, the facility failed to provide supervision with medication administration according to accepted standards of clinical practice for 1 of 7 residents reviewed (Residents #40). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #40 dated 9/7/23 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. On 11/29/23 at 8:00 AM observed Staff D, CMA (Certified Medication Aide) walk to the dining room with a pill cup in her hand. Staff D sat the pill cup on the table next to Resident #40 and returned to the medication cart without watching Resident #40 take her medications. Staff D acknowledged and verified she did not watch the resident take her medications. Staff D stated she knew Resident #40 would take them. Staff E, LPN (Licensed Practical Nurse) was present in the dining room, sat down next to Resident #40 and told the resident she needed to watch her take her medications. The November 2023 Medication Administration Record (MAR) revealed Resident #40's morning (AM) medications on 11/29/23 were signed off by Staff D indicating she administered the medications. The Clinical Record lacked documentation that Resident #40 could self-administer medications or had a physician order to do so. On 11/29/23 at 10:38 AM, Staff D verified and acknowledged she signed off Resident #40's AM medications. Staff D reported that Staff E provided her education that she needed to stay with the resident while taking their medications to make sure the resident does not choke. On 11/29/23 at 10:42 AM, Staff E reported the facility expectation was for nurses and CMAs to stay with the resident while they are taking their pills. On 11/19/23 at 10:50 AM, the DON (Director of Nursing ) reported her expectation was for the nurses and CMAs to stay with the resident while they are taking their medications. The facility policy titled Medication Administration including Scheduling and Medication Aides revised 3/29/23 instructed staff to do the following: a. Administer only those medications that you prepared. Do not ask anyone else to administer medication that you prepared. Do not administer medications prepared by anyone else. b. Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. If the resident has not been assessed for safety for self-administration and there is not a physician order to leave the medication with the resident, stay with the resident until the medication is taken and you observe the resident swallow.

Based on observations, clinical record review and staff interviews, the facility failed to follow physician's orders for 1 of 8 residents reviewed (Resident #49). The facility reported a census of 50. Findings include: The Minimum Data Set (MDS) assessment for Resident #49 documented a Brief Interview for Mental Status (BIMS) Score of 15 out of 15, indicating intact cognition. The MDS documented the resident had diagnosis of hypertension, chronic kidney disease stage 3, diabetes, chronic venous insufficiency and cellutitis. The Care Plan documented Resident #49 to have ted hose on in AM and off at HS. Review of the clinical records documented an order for ted hose on in AM and off at HS which started on 8/25/23. Further review documented a Clinic Referral document for the ted hose with a physician's signature on 8/25/23. During an observation on 11/27/23 at 4:26 PM Resident #49's left lower leg wrapped with ace wraps and nothing on right lower leg. During an observation on 11/28/23 at 9:00 AM Resident #49's left lower leg wrapped with ace wraps and nothing on right lower leg. During an interview on 11/29/23 at 4:35 PM the Director of Nursing (DON) reported she could not find documentation of resident refusing ted hose or that the order was discontinued. She didn't know why staff were not following the physician's orders.

Based on observation, record review and staff interviews, the facility failed to ensure residents are free from abuse for 3 of 7 residents reviewed and living in the Memory Care Unit (Resident #2, #3, #7). The facility identified a census of 80 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment form with a reference date of 7/19/16. The MDS identified the resident had [DIAGNOSES REDACTED]. A score of 3 identified the resident with severe cognitive impairment. The MDS indicated the resident did not have behaviors. The MDS indicated the resident required supervision when walking in his/her room and in the unit. The Care Plan, with a revision, dated 8/2/16, documented the resident had an impaired cognitive function related to dementia, [MEDICAL CONDITION] and intellectual disability as evidenced by sleeps frequently throughout the day, a history of raising up his fist like he would hit someone when upset, a history of yelling out I shi (Expletive) my pants which disrupts others and became easily annoyed with others. The resident put his/her arm up another ' s shirt and touched the bra. 2. Resident #2 had a MDS assessment form with a reference date of 5/3/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The Care Plan, with a revision dated 5/16/16, documented the resident had an impaired thought process related to Alzheimer ' s disease evidenced by resistive, hit out and yelled during cares, easily annoyed by others, wandered in her wheel chair and ran into other residents and furniture at times. The MDS indicated the resident struck out at other residents and cried frequently. An Incident Report form dated 7/3/16 at 3:45 p.m., identified the following documentation: Staff passed linens on the Memory Care Unit when they heard a cry. When they entered the room of Resident #1, they noted Resident #2 in her wheel chair between the bed and window and Resident #1's hand up her/his shirt with bra exposed and hand on her breast. Resident #2 had her/his hand on wrist which appeared like she/he tried to push the hand away. On 8/17/16 at 3:37 p.m., Staff D, CNA was interviewed and stated she walked into the room of Resident #1 and observed Resident #2 positioned in his/her wheel chair between the wall and the bed of Resident #1. Staff D stated she saw Resident #1 positioned in his/her bed with hand up the shirt of Resident #2, exposing the bra and his/her hand on breast above the bra. Resident #2 cried and looked upset. Resident #2 had her/his hand on top of Resident #1 ' s hand as if trying to remove the hand from the breast. The staff member separated the 2 residents and reported the incident to the nurse. On 8/17/16 at 3:33 p.m., Staff D, was interviewed and stated she sat with another resident in the dining room. Resident #3 held a baby in his/her arms and Resident #4 walked up to the resident, who did not like it and told Resident #4 to go away. Resident #4 then used a fist and hit Resident #3 on the left arm who reacted unphased . Resident #4 then walked away and the staff member reported the incident to the charge nurse who assessed the area. 3. Resident #4 had a MDS assessment form with a reference date of 6/9/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The Care Plan with a revision dated 8/5/16, documented the resident had an impaired though process related to dementia as evidenced by he/she wandered and at risk for leaving the facility, carried and talked to stuffed animals, resistive, hit and kicked at staff and a history of hitting his/her spouse in the shoulder when he/she did not want to do something. An Incident Report form dated 7/16/16 at 8:35 a.m., identified the following documentation: A CNA followed the resident into the room of Resident #2. When the CNA entered the room, she observed Resident #4 slapping Resident #2 in the face. The CNA immediately intervened and separated the residents. The incident report reflected the resident seemed startled by the altercation but had no injuries. On 8/17/16 at 9:36 a.m., Staff B, CNA was interviewed and stated she assisted Resident #4 with morning cares and then out for breakfast. Staff B stated the resident refused to eat and kicked and hit at her and refused medications from the medication aide. Staff B stated she tried to redirect the resident but he/she refused to go back to his/her room. Staff B stated she no sooner turned her back and the resident went to the room of Resident #2, who had been asleep in bed and slapped the resident across the face. Resident #2 arose and stated what the fuc(Expletive). Staff B stated she again redirected and Resident #4 hit and kicked at her. Staff B redirected and able to get Resident #4 out of Resident #2 ' s room. Staff B stated she informed the nurse who came to assess Resident #2. Resident #2 had a reddened face after the slap but no other marking or bruising. During an interview 8/17/16 at 11:52 a.m., Staff C, Licensed Practical Nurse (LPN) confirmed that when she arrived in the room of Resident #2 he/she had been in bed with a slightly reddened right cheek but denied pain. 4. Resident #3 had a MDS assessment form with a reference date of 6/21/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The Care Plan with a revision dated 7/27/16, documented the resident had an impaired cognitive function related to dementia and depression evidenced by the resident became agitated in the afternoon into the evening, resisted cares when redirected when he/she wanted to leave, talked to his/her shadow in the window or children in his/her room, at risk for leaving the facility and resided in the Memory Care Unit. An Incident Report dated 7/23/16 at 8:22 p.m., indicated the following documentation: As Resident #3 sat at the table in the dining room, Resident #4 walked up to Resident #3, put his/her arm around the resident and visited. A CNA walked towards the residents and Resident #4 walked away. The CNA turned away to return to CNA ' s duties and at that time Resident #4 walked back and hit Resident #3 on the left arm. The CNA intervened immediately. The assessment identified Resident #3 had no injury or pain. 5. Resident #7 had a MDS assessment with a reference date of 7/19/16. The MDS identified the resident had a [DIAGNOSES REDACTED]. A Care Plan with a revision dated 2/1/16, documented the resident had an impaired cognitive function related to [MEDICAL CONDITION] and depression, evidenced by he/she awoke in the morning on own to prevent him/her from having been resistive to cares, varying moods from happy and cheerful to crying, anxious, wandering and rummaging through others belongings. An Incident Report dated 8/14/16 at 12:15 p.m., identified the following documentation: A CNA called the nurse to the Memory Care Unit and reported the resident hit another resident in the left arm with a closed fist because he/she thought the bed the resident ambulated past had been his/her bed. As the other resident ambulated past this resident, that ' s when he/she struck out at him/her despite the CNA having tried before the resident entered the room to remove the aggressive resident from the room. The resident yelled at him/her and also struck out. No injuries noted on the other resident upon inspection. The staff removed the resident to another part of the Memory Care Unit. When asked Resident #4 why he/she hit the other resident, he/she replied, because I wanted it (in reference to the bed of Resident #7). On 8/17/16 at 12:19 p.m., Staff E, CNA was interviewed and stated he assisted Resident #7 to his/her room and he knew Resident #4 had been in the resident's room so he went into the room first to redirect Resident #4 without success. Resident #7 arrived and Resident #4 had been mad and yelling. As Resident #7 walked past Resident #4, Resident #7 touched his/her shoulder which made Resident #4 angry. Staff E stated Resident #4 made a closed fist and angrily hit the upper left arm of Resident #7 which caused the resident to cry. The staff member redirected Resident #4 from the room and reported the incident to the charge nurse who assessed the resident.

Based on record review and staff interviews, the facility failed to perform an ongoing thorough assessment and timely interventions for a resident with an onset of adverse symptoms (Resident #2). Staff documented Resident #2 exhibited significant physical changes. The staff failed to thoroughly assess the resident at regular intervals and failed to notify a physician timely of the resident ' s change in condition. The facility reported a census of 80 residents. Findings included: 1. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date of 10/4/16. The MDS indicated the resident's [DIAGNOSES REDACTED]. The MDS identified the resident as severely cognitively impaired and had problems with short and long term memory. The resident displayed physical behaviors such as hitting, kicking, pushing, scratching, grabbing and verbal behaviors such as threatening others, screaming at others or cursing at others, once during the 3 day assessment period. The MDS identified the resident needed extensive assistance of 2 staff persons for bed mobility, transfers, toilet use, personal hygiene and walking in the room. The MDS indicated the resident ' s balance as not steady but able to stabilize with staff assistance when moved from a seated to a standing position, walking, turning around and transfer between a bed and chair or wheelchair. The resident used a walker and wheelchair. A Discharge Summaries report dated 9/28/16, completed by a Psychiatric Medical Provider, indicated the resident required an in-patient stay at a hospital related to behavioral disturbances between the dates of 9/15/16 - 9/28/16. The discharge report included [MEDICAL CONDITION] medication orders (used to treat psychiatric conditions) for: [MEDICATION NAME] - 0.5 milligrams (mg) every 4 hours as needed for anxiety and 2 mg injections every 4 hours as needed for agitation and anxiety. [MEDICATION NAME] - (anti-psychotic medication), 0.5 mg every evening [MEDICATION NAME] - (anti-depressant medication) 75 mg, every day Trazadone - (anti-depressant medication) 74 mg, every evening [MEDICATION NAME] 5 mg (anti-psychotic medication) 1 tablet every 4 hours as needed for agitation and [MEDICATION NAME] injection 1 milliliter every 4 hours as needed for agitation but no more than 2 doses in 24 hours. A hospital Care Plan recommendations form dated 9/28/16, included the following instructions for facility staff at the time of the resident's transfer from the hospital back to the facility: If the patient becomes sedated or lethargic to the point you feel they are having difficulty functioning, it is important to contact the hospital for medication assessments and or adjustments. Review of the nursing Progress Notes included the following notes from staff documentation: On 9/28/16 at 3:48 P.M. - the resident returned to the facility following hospitalization . On 9/29/16 at 4:06 A.M. - the resident as wide awake and made attempts to hit out at staff. On 9/29/16 at 4:14 A.M. - the resident told staff he/she needed to use the bathroom, had attempted to get into another resident's bed and opened the curtains. On 10/1/16 at 12:30 P.M. the resident ambulated steadily with limited assistance from 1 staff member. On 10/8/16 at 8:52 A.M. - the resident pounded on a table. On 10/13/16 at 10:58 A.M. - the resident lethargic, unable to arouse the resident and will not accept any food or liquids. The nurse notified the resident's physician at 11:00 A.M. and made an appointment for 1:45 p.m. According to an Office Clinic Note dated 10/13/16, a physician examined the resident. The Physician documented the resident probably had excess sedation from interactions of some of his/her medications and reduced the resident's Trazadone and [MEDICATION NAME] medications. The physician documented the facility staff needed to keep the physician apprised (to inform) his/her response to the medication changes. The urinalysis was normal. A vital summary report form revealed staff documented the resident's pulse as follows: 9/28/16 at 4:15 P.M.- 72 beats per minute (bpm) and regular rate 9/29/16 at 4:12 P.M. - 70 bpm and regular rate 9/30/16 at 11:30 A.M. - 80 bpm and regular rate 10/13/16 at 12:45 P.M. - 126 bpm and regular rate 10/15/16 at 12:23 A.M. - 100 bpm and regular rate 10/16/16 at 5:20 A.M. - 120 bpm and irregular rate 10/16/16 at 8:24 A.M. - 104 bpm and regular rate 10/16/16 at 9:15 P.M. - 110 bpm and irregular rate 10/17/16 at 2:06 A.M. - 125 bpm and irregular rate (Note: The American Heart Association reports a normal pulse for Adults as 60 -100 bpm. Even though the resident's pulse increased and staff documented a change in the rate from regular to irregular, record review identified the staff did not notify the resident's physician of the change in his/her pulse, until a facsimile was sent to the physician's office on 10/17/16 at 5:17 A.M.) Further review of the nursing Progress Notes included the following: On 10/15/16 at 12:33 A.M. the nurse documented the resident's neck as hyper-extended, altered mental status, non-responsive to the staff member ' s voice, pupils slow to react and had a fixed gaze. The note lacked physician notification of the change in condition. On 10/15/16 at 2:49 A.M. the resident had dizziness, drowsiness, sedation and ataxia (loss of control of body movements). The record lacked documentation of vital signs or further assessment or description of the resident. On 10/16/16 at 5:23 A.M. a discussion with the resident's son/daughter was made. The nurse informed the son/daughter of the resident's low vital signs but didn't feel (the resident) was going to come out of it. (Note: even though staff informed the resident's family member of low vital signs, the vital summary report as noted above revealed staff documented the resident's pulse rate as elevated on 10/16/16 at 5:20 A.M. at 120 bpm and irregular. Review of a vital summary report form for BP readings on 10/16/16 at 5:20 A.M. identified the resident's BP as 55/45. The American Heart Association reports a normal BP as 120/80). The record lacked any further assessment of the resident and/or physician notification. On 10/16/16 at 6:15 A.M. the resident's son/daughter arrived to the facility and the resident had not responded to the family member ' s voice or touch. The note lacked any further assessment of the resident and/or physician notification. On 10/16/16 at 9:08 A.M the resident's blood pressure read 90/60, pulse ox low 90 ' s (normal 96-100), the resident responded to verbal and tactile (touch) stimuli and passive range of motion of the resident's neck appeared to cause the resident discomfort. On 10/17/16 at 3:09 A.M. the resident's condition as sedated and ataxic (the vital summary report form on 10/17/16 at 2:06 A.M., revealed a pulse of 125 bpm and irregular rate and a BP of 110/70). On 10/17/16 at 3:11 A.M. - staff documented the resident as unresponsive to touch and voice and his/her neck hyperextended to the side. Staff documented the resident as afebrile (without fever). On 10/17/16 at 5:33 A.M. the nurse sent a fax to a physician (at 5:17 A.M.) in regards to the resident's change in condition, greater than 48 hours after the first noted change. (Note: staff advised the physician of the resident's change in condition via fax, at 5:17 A.M., even though no physician would be available at a physician's office at 5:17 A.M.). On 10/17/16 at 12:22 P.M. the resident's physician responded to the fax sent on 10/17/16 at 5:17 A.M. The physician wrote to have the patient seen if the family desires and the nurse feels it is needed. At this time the resident appears comfortable and the son is ok (alright) with comfort care and for the resident to remain in the facility. On 10/19/16 at 4:35 P.M., Staff A, Registered Nurse (RN), stated if she assessed a resident with a change in condition such as a hyperextended neck, fixed gaze and non-responsive to verbal stimuli, she needed to notify an emergency room physician. A telephone interview on 10/19/16 at 4:45 P.M. with the resident ' s primary physician ' s office nurse stated she spoke to the resident's physician and the physician stated he expected to be notified and/or updated with a resident's change in condition as described on 10/15/16 at 12:33 A.M. During an interview on 10/19/16 at 5:00 P.M. Staff B, Licensed Practical Nurse (LPN) stated if she assessed a resident with a hyperextended neck, fixed gaze and non-responsive to verbal stimuli, she needed to notify a physician to see if the resident needed to be examined by the physician. A telephone interview on 10/19/16 at 5:30 P.M., with Staff C, RN, confirmed she had worked and completed the documentation on 10/15/16 at 12:33 A.M. and 2:49 A.M., and 10/16/16 at 5:23 A.M. Staff C stated typically she would notify a physician with symptoms similar to Resident #2's on 10/15/16 at 12:33 A.M., but she had not notified a physician at that time, as the resident had been seen by a physician on 10/13/16 for the same symptoms. Staff C stated on 10/16/16 at 5:20 A.M., in hind sight and based on the resident's symptoms, she should have had the resident seen by a physician. Staff C stated on 10/17/16 at the time she informed the resident's physician via fax (at 5:17 A.M.) of the change in condition, she knew no one would be available at the physician's office at that time of day and had not thought about contacting an emergency room physician. On 10/20/16 at 7:50 A.M. the facility Director of Nursing (DON) confirmed he expected nurses to contact a physician with a change in condition such as Resident #2's. During an interview on 10/20/16 at 9:50 A.M., the DON confirmed he expected nurses to re-assess a resident, at some point during the shift, with a pulse greater than 100 bpm and/or a BP of 55/45 and further assessment overall.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and assistive devices to ensure against hazards from self and other and failed to develop a Care Plan for resident to resident incidents for 5 of 7 residents reviewed. Resident #7 fell and received a subdural hematoma and expired. The resident laid in bed for 1 hour and 26 minutes (12:17 p.m. to 1:43 p.m.). Staff did not check on the resident from 1:06 p.m. until 1:43 p.m. (37 minutes). CCDI (chronic confusion and dementing illness) unit protocol directed the staff to check residents every 15 minutes. Following a previous fall, the Care Plan directed staff to lay the resident in bed for shorter periods which the Director of Nursing (DON) identified as one hour. Resident #1 fell and following the falls, the facility failed to implement new interventions. The facility listed interventions already in place as new interventions. Resident #4, Resident #7, Resident #12 and Resident #13 were involved in resident to resident incidents. Only one incident was documented. Care plans did not identify concerns with resident to resident incidents. The facility reported a census of 80 residents. Findings include: 1. Resident #7 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The assessment identified the resident had a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 referenced the resident as severely cognitively impaired. The resident required extensive staff assistance with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. The resident used a walker and wheelchair for mobility. A balance during transitions and walking test indicated the resident as not steady and only able to stabilize with staff assistance. The resident was occasionally incontinent of urine and bowel. The resident had [DIAGNOSES REDACTED]. The MDS identified one fall with injury since the prior assessment. The resident resided in the CCDI unit. Falls: [DATE] An incident report (IR) dated [DATE] at 2:05 p.m. and documented by Staff A LPN (licensed practical nurse) revealed an unwitnessed fall in the resident's room. Observation revealed the resident laying on the floor at the foot of the bed on the right side with tears in his/her eyes. The resident hit his/her head when the fall occurred. Staff assessed the resident and the resident complained of pain when staff palpated the resident's hips. The resident also complained of shoulder pain. A positioning wedge was in place on the left side of the bed and the wedge on the right side of the bed was not in sight. It was not around the bed or on the floor by the bed. The magnet from the resident's personal alarm lay on the bed and the blue clip remained clipped together. The Incident Report indicated the alarm did not activate when the fall occurred. The resident was transported to the hospital emergency room for examination. A Care Plan dated [DATE] revealed the resident at risk for falls related to dementia, anxiety, restless leg syndrome and spinal stenosis as evidenced by unsteady gait, confusion and agitation at times. The care plan directed staff to apply grip strips to the left side of the bed and in front of the closet, bathroom door, toilet and sink, ensure the resident wore appropriate footwear and gripper socks at bedtime, a concave mattress and a personal alarm in the chair. The care plan did not contain information that the resident used the alarm in bed or that the resident removed alarms or used wedge cushions on the bed. A Care Plan history form identified the resident began using the personal alarm in bed on [DATE]. The facility discontinued the personal alarm on [DATE] after the [DATE] fall. The DON (director of nursing) documented on the care plan history form that they discontinued the alarm due to the alarm not preventing falls and the facility going alarm free. A Care Plan history form indicated the facility used a concave mattress and positioning wedges PRN (as needed) for positioning since [DATE]. An entry on the Care Plan history form dated [DATE] directed staff to use a concave mattress and wedges for positioning at all times. (No longer PRN) On [DATE] at 2:53 p.m. Staff A, LPN stated she did not think the alarm sounded when the fall occurred. The resident's wedge was not in place on the right side of the bed. The left side did contain a wedge. Staff A stated the CCDI unit policy is for staff to check residents every 15 minutes. Staff A stated it was an unwritten policy. Prior to the [DATE] fall, Staff A stated the resident was known to remove the alarm. The resident would take off his/her clothes with the alarm remaining intact and would get up without the alarm sounding. On [DATE] at 10:10 a.m. Staff I CNA stated the resident did climb over the bed wedges to get out of bed. Staff I stated she found the resident on the floor on [DATE]. She stated the resident was known to manipulate and remove clothing so the alarm would not sound. A [DATE] clinic referral form revealed staff toileted the resident at 1:45 p.m. and then laid the resident down in bed. At 2 p.m. staff passed by the resident's room and observed the resident in bed. The resident wore a personal alarm and had a history of [REDACTED]. Staff found the resident laying in his/her right shoulder with his/her head by the foot of the bed. The resident's right side of the neck and jaw appeared swollen. The resident became lethargic. A CT (computerized tomography) was negative. The resident stood and bore weight without pain in the ER (emergency room ). The physician directed staff to apply a heat pack to the bilateral hips, legs, arms and shoulders for 20 minutes every 4 hours as needed and ambulate as tolerated. An investigation form, dated [DATE] revealed the corrective action taken to prevent reoccurrence of falls as referral to ER for physician review. Results of the investigation were returned ,[DATE] from ER. All tests negative. Warm moist packs ordered and continue normal activity. No major injury. [DATE] An IR dated [DATE] at 3:40 p.m. and documented by Staff B LPN revealed an unwitnessed fall in the resident's room. Staff observed the resident on the floor on his/her back between the bed and the window. The resident did not know what happened. Staff stated they thought the resident was at activities and didn't think much of it when they observed the resident's bed was empty. The IR documented that there was only one staff in the CCDI unit at the time. The resident denied hitting his/her head. Assessment showed no injury. Two staff assisted the resident up. Staff held a falls huddle after the fall and concluded staff should lay the resident down for a shorter period in the afternoon and conduct 15 minute checks when the resident lay in bed. On [DATE] at 12:10 p.m. the DON stated lay the resident down for a shorter period meant to leave the resident in bed about an hour and then bring the resident out of his/her room. On [DATE] at 3:11 p.m. Staff B LPN identified the positioning wedges as in place when the fall occurred. Staff B stated the resident must have crawled out of the bed and the wedges went out of the bed with the resident. She stated the resident did not have gripper socks in place. The resident wore normal socks. When asked what may have prevented the incident, Staff B stated maybe if another staff was present on the unit. When asked about 15 minute checks, Staff B stated she did not think everyone did the checks. 15 minute checks are general policy but in the afternoons staff is so scattered that the checks are not always done. [DATE] An IR dated [DATE] at 8:32 p.m. revealed an unwitnessed fall in the resident's room. Documentation revealed staff observed the resident lying on the floor with his/her feet out in front of the resident. Staff observed another resident sitting on the spare bed in the resident's room. Staff did not observe injury when they assessed the resident. Ten minutes earlier staff saw the resident resting in bed. The resident did have gripper socks on when the incident occurred. The action following the incident was: pull the resident's privacy curtain when the resident lay in bed because the resident did not like anyone sitting on the spare bed in the resident's room. An investigation dated [DATE] did not identify if the wedge cushions were present on the resident's bed. Video review of the incident showed at 8:23 p.m., Staff C CNA (certified nurse aide) walked down the hall past the resident's room. At 8:35 p.m. one staff walked by the room. At 8:45 p.m. Resident #12 and another resident went in Resident #7's room. At 8:46 p.m. Resident #12 left Resident #7's room but the other resident stayed in the room. Also at that time, two staff walked up the hall past the resident's room At 8:47 p.m. one staff left the CCDI unit. At 8:53 p.m., 6 minutes after the staff left the unit, the video showed Staff C running up the hall and additional staff entered the CCDI to assist in the resident's room. On [DATE] at 3:55 p.m. Staff C CNA stated she assisted another resident to the bathroom and following that, observed the resident on the floor with another resident seated on the bed in the resident's room. Staff C stated she just did a hall check and when she checked she did not see the other resident in the room. She observed Resident #7 on the bed with wedges on place. After the fall, one wedge was under the bed on the side the resident fell out of and the other wedge was in place on the side that the resident did not fall from. Staff C stated the resident did try and climb over the wedges. Staff places the wedges under the fitted sheet. Staff C stated 15 minute checks have been in place for the past 2 years. When staff does 15 minute checks, they are to look in the room and make sure the resident is OK. [DATE] An IR dated [DATE] at 1:40 p.m. and documented by Staff D LPN revealed an unwitnessed fall in the resident's room. Staff informed Staff D that the resident had previously been in bed asleep and when staff checked, staff found the resident on the floor with a wedge under the bed and Resident #12 attempting to assist the resident off the floor. Assessment showed a hematoma on the back right side of the resident's head. On [DATE] at 3:30 p.m. Staff D stated she was not in the CCDI unit when the fall occurred. Staff got her and said the resident was on the floor. When Staff D arrived at the room, staff assisted Resident #12 out of Resident #7's room. Staff D assessed the resident and observed a hematoma to the back of the head. They got the resident up from the floor by using a total sling lift. After they got the resident up, the resident started acting weird and started to vomit. She notified the physician and the resident went to the ER for examination. Staff D stated Resident #12 liked to push other residents in wheelchairs but she never saw him/her try to transfer anyone. Staff D stated if residents are lying down in their room ' s general policy in the CCDI is to check on the residents every 15 minutes checks. Staff D stated the policy was in place when she started 6 months ago. Video view of the incident, showed staff took the resident to the resident's room at 12:17 p.m. At 12:43 p.m. Staff E CNA, walked in and out of the room. On [DATE] at 1 p.m. Staff E stated she probably checked on the resident at 12:43 p.m. She stated she didn't ask the resident anything because the resident was asleep in bed. At 12:59 p.m. Staff F CNA walked in and out of the resident's room. On [DATE] at 2:10 p.m. Staff F stated she probably just checked on the resident at that time and didn't ask her anything. At 1:06 p.m. a staff person went to the resident's doorway without entering and left. At 1:35 p.m. Resident #12 went in Resident #7's room. At 1:43 p.m. Staff E went to the resident's room and discovered the resident fell . She then spoke with Staff F. At 1:44 p.m. Resident #12 left the resident's room and went back in at 1:45 p.m. At 1:46 p.m. Staff D LPN arrived and Resident #12 went into his/her room. Video showed no one checked the resident from 1:06 p.m. to 1:43 p.m. In summary the resident laid in bed for 1 hour and 26 minutes (12:17 p.m. to 1:43 p.m.). Staff did not check on the resident from 1:06 p.m. until 1:43 p.m. (37 minutes) On [DATE] at 12:15 p.m. Staff E stated she checked on the resident before she left the CCDI unit. Before she left the CCDI unit, she informed Staff F that everyone was asleep. Staff E stated she left the CCDI to go to the laundry and then go outside with the garbage. She stated Resident #7 ate lunch and then staff laid the resident down and the resident slept. Staff E stated she estimated she was gone about 15 minutes and then returned. When she returned, she stopped at the clean laundry room to put a new bag in the cart and put it away. At that time she heard yelling. She observed Resident #12 come out of Resident #7's room and Resident #7 was on the floor. Staff E stated Resident #12 will push and pull residents in wheelchairs and also cover and uncover residents. Neither resident could report any information following the incident. Staff E did not think Resident #12 ever pushed anyone down. After Staff D LPN checked the resident, staff got the resident up. The resident had 2 wedges in the bed, one under each side of the fitted sheet. The wedges were still in place. Staff E stated the resident would have had to have gone over them to get out of bed. When Staff E clocked out at 2 p.m. the resident was going to the ER. Staff E stated the resident would try and get up by self. There were grip strips by the bed. The privacy curtain was half pulled. Staff checks residents every 15 minutes. They used to chart it over a year ago but they don't now. On [DATE] at 10:55 a.m. Staff F CNA stated she was in the CCDI dining room when the incident occurred. She stated Staff E left the unit and came back about 15 minutes later. Resident #12 walked out of Resident #7's room and then staff discovered the resident on the floor. Staff F stated neither resident could tell staff what occurred following the incident. They notified Staff D LPN who checked the resident. Staff then got the Hoyer lift (mechanical lift) and they got the resident up with the lift and into bed. Staff F left at 2 p.m. Staff F heard later that the resident vomited and went to ER. The resident then stayed at the hospital. She stated the resident didn't seem any different until around 2 p.m. The resident fell in the past and they took his/her alarm away. She stated staff conducts 15 minute checks but they do not document them. She couldn't think of anything else in place for the resident to prevent falls. On [DATE] at 11:50 a.m. Staff F stated maintenance was painting in the dining room at the time of the incident. Staff F stated she helped maintenance paint because the 2 residents in the dining room slept and she could not leave the dining room with residents in there. At 2:10 p.m. of the same date, Staff F stated the resident had both wedges on the bed when the incident occurred. The resident would climb over the wedges. On [DATE] at 4:25 p.m., the DON stated there was no evaluation for safety regarding the resident's use of the wedges. The Care Plan identified as in place when the incident occurred and undated, contained an addendum dated [DATE] that directed staff to assist the resident to the recliner for short periods of rest after meals. On the day of the [DATE] fall, staff did not assist the resident to a recliner. They laid the resident in bed in his/her room. Staff Interviews: On [DATE] at 10:50 a.m. Staff E CNA stated she had seen the resident try to climb over the bed wedges. She stated the resident either went over the wedges or crossed them when he/she had falls. On [DATE] at 10:51 a.m. Staff G CNA stated the resident would try and climb over the wedges. On [DATE] at 10:55 a.m. Staff H CNA stated the resident would try and climb over the wedges and the resident would also try and stand up by self. Staff H stated the wedges did not work and she did not think they were safe. She stated she observed Resident #12 try and assist a resident up from bed in the past and she reported it to the nurse. On [DATE] at 10:56 a.m. Staff F stated she observed the resident try to climb over the wedges and she did not think they were safe. She stated Resident #12 pushed other resident's wheelchairs and tried to assist them. On [DATE] at 3:55 p.m. Staff C CNA stated Resident #12 tried to transfer residents out of bed and wheelchairs. She stated the nurses have been told and they all know about it. A MDS with assessment reference date of [DATE] assessed Resident #12 with impaired short and long term memory and severely impaired decision making skills. The resident was independent with transfers and ambulation. The resident had daily physical, verbal and other behaviors directed towards others, daily rejection of care and daily wandering. Review of resident progress notes from [DATE] to present did not reveal any documentation regarding resident altercations or assisting other residents. On [DATE] at 5:40 p.m. observation identified Resident #12 tried to get into a locked medication room. At 6 p.m. the resident walked up and down the halls. On [DATE] at 4:56 p.m. the DON stated staff needs to do hall checks every 15 minutes if a resident is in their room. On [DATE] at 9:30 a.m. the DON stated there was no policy for the 15 minute checks. On [DATE] at 10:33 a.m. the DON stated staff is expected to check residents frequently. Staff should check every 15 to 30 minutes. The time frame is not specific or set in stone. There is no policy and the staff does not document the checks. He stated if a staff person leaves the CCDI unit they need to have someone come in and cover for them before they leave. Hospital Information: Hospital admission notes dated [DATE] revealed the resident fell at the nursing home earlier that day and had a goose egg on the back of the head and some vomiting. The resident complained of a headache. The assessment showed a 5 centimeter edematous area on the right head occiput (back portion of head). The physician diagnosed the resident with a subdural hematoma (collection of blood outside the brain). The physician discussed the prognosis with the durable power of attorney. The prognosis was poor and the resident was not a surgical candidate. The plan was to keep the resident comfortable. Diagnostic results showed a small to moderate right hemispheric subdural hematoma, very small left frontal anterior parafalcine subdural hematoma and small subarachnoid hemorrhage at the left lower temporal occipital junction. A progress note dated [DATE] identified the resident on comfort care for subdural hematoma after trauma fall and hitting his/her head. The resident continued to be minimally responsive and not taking anything orally. The resident remained on comfort care because the family did not want anything else done. Death Certificate: A death certificate filed on [DATE] revealed the resident died on [DATE] at 11:08 p.m. The immediate cause of death was subdural hematoma due to or as a consequence of fall. Resident to Resident incident: A progress note dated [DATE] at 3:54 p.m. and documented by Staff B LPN revealed Resident #4 exhibited agitation most of the shift and while Resident #7 sat in the dining room the other resident lashed out and knocked Resident #7's glasses off. Staff intervened and directed the other resident away. On [DATE] at 3:11 p.m. Staff B stated Resident #4 has random moments where he/she hits out. Resident #7 just happened to be there. The resident was not injured. Video view of the incident on [DATE] at 11:30 a.m. showed Resident #4 wheeled up to Resident #7 and with an open hand swiped at the face of Resident #7. The surveyor could not tell if the glasses came off. At that time, the Administrator stated he did not think the glasses came off. 2. A MDS with assessment reference date of [DATE] assessed Resident #4 with long and short term memory impairments and severely impaired decision making skills. The resident had the following indicators of delirium: inattention and disorganized thinking. The MDS identified the resident with verbal and physical behaviors directed towards others, other behavior symptoms directed towards others, rejection of care and wandering. All of the behaviors occurred daily. The resident required extensive staff assistance with transfers, ambulation, dressing, eating, toileting and personal hygiene. The resident had [DIAGNOSES REDACTED]. On [DATE] at 3:55 p.m. Staff C CNA stated she observed Resident #4 lash out at Resident #7 and Resident #7's glasses flew off. Staff C also stated about 1 to 2 months ago, Resident #4 slapped Resident #13 across the face unprovoked. She stated she told Staff B about it. On [DATE] at 1:40 p.m. Staff B stated she did not recall being told the information. She stated if she was told, she would have informed the social worker and the DON. On [DATE] at 2 p.m. the social worker denied knowledge of the incident. On [DATE] at 10:33 a.m. the DON stated he did not know of the incident. On [DATE] at 11:50 a.m. the surveyor asked Staff C if she was sure Resident #7's glasses came off during the incident. She said she thought they did come off. On [DATE] at 10:10 a.m. Staff I CNA stated about 6 months ago Resident #12 made Resident #4 mad so Resident #4 backhanded Resident #12 and said leave me alone . Staff I stated the staff tells the nurses when behaviors occur. A Care Plan dated [DATE] identified Resident #4 with impaired thought processes related to Alzheimer's disease as evidenced by resistive, hits out and yells during cares, easily annoyed by others, wanders in wheelchair and cries frequently. The Care Plan did not identify a concern with resident to resident incidents. On [DATE] at 10:15 a.m. observation identified Resident #4 wheeling self in wheelchair and propelling the chair with his/her feet. Review of Resident #4, Resident #12 and Resident #13's progress notes indicated the staff only documented the [DATE] incident between Resident #4 and Resident #7. Progress notes dated [DATE] at 10:33 a.m. identified the resident attempted to hit other residents. Staff intervened and kept the resident away from others. A MDS with assessment reference date of [DATE] identified Resident #13 with a BIMS score of 4 (severe cognitive impairment). The resident had daily verbal behaviors directed towards others, daily rejection of care and daily wandering. The resident required extensive staff assistance with transfers and supervision with ambulation. 3. Resident #1 had a MDS assessment with a reference date of [DATE]. The MDS assessed Resident #1 with a BIMS score of 8 (moderate cognitive impairment). The resident required extensive staff assistance with transfers, bed mobility, dressing and toileting. The resident did not ambulate. The resident used a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The current undated Care Plan identified the resident at risk for falls related to benign positional vertigo, schizophrenia, osteoarthritis, osteoporosis, pulmonary fibrosis and chronic obstructive pulmonary disease as evidenced by dyspnea with exertion and limited physical mobility with a slow dragging gait. An edit intervention sheet indicated after the resident returned from the hospital ([DATE]) the resident began using a concave mattress with positioning wedge in bed and a soft touch call light. Falls: An Incident Report dated [DATE] at 1:40 a.m. indicated an unwitnessed fall in the resident's room. The nurse heard a loud noise and found the resident sitting on the floor in front of his/her bed. The resident slipped in feces, present on the floor. The resident stated he/she got up to the bathroom and slipped down to the floor. The resident denied hitting his/her head. The action taken after incident was: grip strips applied to the front of the bed frame and replaced the grip strips that were not close to the bed. An Incident Report dated [DATE] at 4:05 p.m. revealed an unwitnessed fall in the hallway. Staff found the resident laying on his/her back with head to the back door of the unit and feet to the front door. Staff observed shortening and external rotation to the left lower extremity. The facility notified the physician of the incident and transported to the hospital. The resident sustained [REDACTED]. A progress note entry dated [DATE] at 9:26 a.m. indicated prior to the fracture of the left hip, the resident was independent with transfers/ambulation. An Incident Report dated [DATE] at 5:05 a.m. indicated an unwitnessed fall in the resident's room. Staff found the resident sitting with her feet straight out and back against the bed frame. The resident denied hitting his/her head. The resident did not sustain injury. The action after the incident was: toilet the resident at 5 a.m. per resident request. An Incident Report dated [DATE] at 7:55 a.m. revealed an unwitnessed fall in the resident room. Staff stated they walked by the resident room and saw the resident on the floor beside the bed with back against bed frame and legs extended outward. The resident stated he/she tried to turn the oxygen off. The resident denied hitting his/her head and did not sustain injury. The action after the incident was: apply grip strips on the floor beside the bed and recliner. Staff also educated the resident to use the call light. On [DATE] at 9:33 a.m. the surveyor asked Staff J (unit manager) why they needed to reapply grip strips by the bed when grip strips by the bed were listed as the intervention following the [DATE] fall. Staff J stated staff may have arranged the room again and did not replaced the grip strips. An Incident Report dated [DATE] at 8:29 p.m. indicated an unwitnessed fall in the resident's room. Staff found the resident sitting on the floor next to the bed. The resident stated he/she tried to turn the oxygen off. An investigation form dated [DATE] identified the intervention following the incident was: rearrange room. An Incident Report dated [DATE] at 7 a.m. indicated an unwitnessed fall in the resident's room. Staff found the resident on the floor between the bed and recliner. The resident stated he/she fell trying to turn the oxygen off. The resident denied hitting his/her head and did not sustain an injury. An investigation form dated [DATE] revealed following the incident, the facility changed the oxygen administration to PRN (as needed) and put carpet under the oxygen concentrator. An Incident Report dated [DATE] at 5:41 a.m. indicated an unwitnessed fall in the resident's room. Staff noted the resident sitting on the floor with his/her legs straight out in front of the resident. Staff did not identify injury and the resident denied hitting his/her head. The resident stated he/she attempted to scoot to the bathroom on his/her bottom. The report identified the staff just toileted the resident via bed pan and the resident did not void. An investigation dated [DATE] indicated the intervention following the incident was: grip strips by bed, wedge in bed and gripper socks in bed. According to previous documentation, staff already applied grip strips [DATE] and [DATE]. An edit intervention sheet indicated the resident began using a wedge in bed [DATE] (already in place). The Care Plan already contained the gripper socks intervention dated [DATE]. An Incident Report dated [DATE] at 4:53 a.m. indicated an unwitnessed fall in the resident ' s room. Staff found the resident sitting on the floor by the bed with a wedge behind his/her back. The resident denied hitting his/her head and denied injury. The resident stated he/she slid to the floor trying to go to the bathroom. An investigation form dated [DATE] revealed the intervention following the incident was: soft touch call light. An edit intervention sheet revealed, the resident already used a soft touch call light since [DATE]. On [DATE] at 9:30 a.m., the DON confirmed the facility initiated a wedge, concave mattress and soft touch call light on [DATE]. On [DATE] at 3:08 p.m. observation identified the resident asleep in bed with a wedge to the right side of the bed under the fitted sheet, grip strips by the bed and soft touch call light in hand.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision when transferring 1 of 8 residents to prevent accidents (Resident #9). The facility reported a census of 83 residents. Findings include: The facility procedure for Gait Belt Transfers (revised on October 2013) comprised of the intended purpose to safely transfer or ambulate a resident or to aid a resident in maintaining their balance. The procedure noted the gait belt transfers would lessen injury to both the resident and the staff member. Gait belts were used unless medically contraindicated. According to the Minimum Data Set (MD'S) assessment, dated 06/19/14, Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS) cognitive test, indicating no cognitive impairment. Resident #9 required two staff assistance for bed mobility, toilet use, and transfers; and one staff for walking in/out of his/her room. Resident #9 was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and during surface to surface transfer. Resident #1's [DIAGNOSES REDACTED].#9 received scheduled pain medication regimen and experienced no pain over the assessment period. The MDS noted a zero (0) to ten (10) pain scale with zero being no pain; and 10 being the worst pain imaginable. An Incident Details report dated 01/04/14 at 6:45 p.m. documented staff lowered Resident #9 to the floor in the bathroom when his/her legs gave out. The new intervention put in place to prevent the incident from happening again; to use 2 staff to transfer when Resident #9 felt weak. The Interdisciplinary Progress Notes dated 01/04/14 at 6:45 p.m. documented when transferring Resident #9 from the bathroom with the walker, his/her knees gave out and staff transferred him/her to the floor with a gait belt. An assessment showed no injuries. A Falls Data Collection Tool dated 06/30/14 scored Resident #9 at 21, with a score of 12 or more indicating a high risk for falls. The Care Plan dated 07/01/14 identified Resident #9 had limited physical mobility related to Parkinson's disease, and generalized weakness with a secondary gait disturbance. The care plan documented Resident #9 had a history of [REDACTED]. a. Resident #9 used a walker and staff assistance of 1 or 2 and a gait belt for transfers. An Incident Details report dated 08/31/14 at 9:30 p.m. documented Resident #9 slipped when staff assisted to transfer him/her from the wheelchair to the bed. A Certified Nursing Assistant transferred Resident #9 without a gait belt and eased him/her to the floor. The incident details revealed the resident's walker had not been used. The immediate intervention included to re-educate staff to always use a gait belt. An x-ray report dated 09/02/14 documented the reason for the exam was a fall over the weekend with pain on the lateral ankle and inability to bear weight. Resident #9 had an acute fracture of the distal tibia extending in to the tibiotalar joint, and a possible small avulsion fracture from the lateral malleolus with adjacent soft tissue swelling. The findings also identified the resident's bones were osteopenic in appearance (low bone mass/or bone density). The Progress Notes documented the following: a. On 08/31/14 at 9:30 p.m. documented a Certified Nursing Assistant (CNA) summoned the nurse to Resident #9's room. Resident #9 was noted on his/her knees next to the bed.The CNA reported while transferring Resident #9 from the wheelchair to the bed without a gait belt she eased him/her to the floor. Three staff assisted Resident #9 to bed with a gait belt. Resident #9 complained of bilateral knee, and left ankle pain. Staff administered routine pain medication and offered to send Resident #9 to the emergency room . Resident #9 rated the pain at 7 out of 10 (0 being no pain and 10 the worst pain imaginable). b. On 09/01/14 at 4:22 a.m. documented Resident #9 awake after bed check and stated he/she thought he/she would feel better by then and that it hurt across his/her right leg again. Resident #9 acknowledged the need for pain medication. c. On 09/01/14 at 11:37 a.m. Resident #9 complained of pain to his/her right ankle, and it appeared slightly swollen. Staff notified the physician and received new orders for Ibuprofen 600 mg every 8 hours as needed (prn) for 7 days. At 11:54 p.m. Resident #9 received medication for left ankle pain that had been rated an 8 out of 10. d. On 09/02/14 9:59 a.m. Resident #9 going for an x-ray in the afternoon. At 10:16 a.m. staff educated to use the gait belt with transfers and ambulation at all times. e. On 09/03/14 at 9:16 a.m. staff received a call from the physician's office. Resident #9 had a distal tibia fracture and Resident #9 to wear a walking boot when up. f. On 09/04/14 at 1:34 p.m. staff updated Resident #9's care plan to reflect recent changes in condition due to a right distal tibia fracture sustained after staff lowered Resident #9 to the floor during a transfer from his/her wheelchair to his/her bed. Resident #9 no longer ambulated and required staff assistance of 2 for transfers. Resident #9's active range of motion and walking restorative programs put on hold until injury improved. g. On 09/04/14 at 11:39 p.m. Resident #9 complained of ankle pain of 5 out of 10. h. On 09/05/14 at 11:27 p.m. Resident #9 complained of ankle pain of 8 out of 10. i. On 09/08/14 at 9:40 p.m. Resident #9 complained of pain to ankle rated at 6 out of 10. j. On 09/10/14 at 4:38 a.m. Resident #9 asked for something for right leg and foot and usually slept at this time of day. At 5:52 a.m. Resident #9 cried with pain. Staff offered a position change and cool/warm therapy. Resident #9 refused stating it would get better. k. On 09/10/14 at 11:26 p.m. Resident #9 complained of ankle pain at 8 out of 10. During an interview on 10/13/14 at 1:15 p.m. Resident #9 stated the evening he/she fell she walked from the recliner to the his/her bed, and he/she didn't get his/her foot turned, and it caused him/her to go down. Resident #9 stated the leg was still pretty sore. During an observation on 10/14/14 at 9:25 a.m. staff had Resident #9 set up for the EZ stand (mechanical lift). Resident #9 assisted to the commode by 2 staff. At 9:33 a.m. staff assisted Resident #9 to the recliner (via the mechanical lift). During an interview on 10/14/14 at 5:38 p.m. Staff F Certified Nursing Assistant (CNA) stated the evening of the incident she transferred Resident #9 from his/her wheelchair to his/her bed. Staff F helped Resident #9 stand and went to pivot him/her. Resident #9 was very weak and acted like he/she was going to sit back down. Staff F told Resident #9 to turn with her, but he/she went down. Resident #9 got hung up partially on the chair and then went down to his/her knees on the floor. Staff F couldn't remember if she used the walker. Staff F had transferred Resident #9 from his/her chair to the bed before, without a gait belt, and he/she had never been weak like this before. Staff F did not use the gait belt when the incident occurred. Staff F stated she normally used the gait belt if she walked with Resident #9, but thought she could transfer him/her without it. During an interview on 10/13/14 at 2:51 p.m. Staff C Licensed Practical Nurse (LPN) stated she heard Staff F Certified Nursing Assistant (CNA) radio for someone to help with a transfer. Staff C was busy with treatments. Staff C then heard Staff F page for someone to help get Resident #9 off the floor. When Staff C walked in the room Resident #9 was on his/her knees with his/her feet behind him/her. The CNA stated she transferred Resident #9 and he/she gave out, and went down. Staff F said she did not use a gait belt. Staff C told Staff F she had to use a gait belt with transfers. During an interview on 10/14/14 at 2:17 p.m. Staff B Certified Nursing Assistant (CNA) stated she heard the call over the walkie that Resident #9 was going down. When Staff B went to the room Resident #9 was on his/her knees with his/her feet awkward under him/her. Resident #9 did not have a gait belt on. Staff B stated they were to do all resident transfers with a gait belt. Staff B stated it absolutely would not be safe to transfer Resident #9 without a gait belt prior to the fracture. During an interview on 10/13/14 at 4:53 p.m. Staff D CNA stated she had transferred and ambulated with Resident #9. Staff D would put the gait belt on Resident #9. He/she could be assist of 1 and used a walker. Resident #9 should always have a gait belt on, he/she was not steady without assistance. Staff D stated the evening of the incident, Staff F called for assistance getting Resident #9 off the floor. Staff D told Staff F she should have a gait belt on Resident #9. Staff F told Staff D she never used a gait belt on Resident #9 he/she just tried to pivot transfer him/her. During an interview on 10/14/14 at 5:22 p.m. Staff E, CNA stated when she worked with Resident #9 prior to the fracture she normally got a 2nd person to assist. The times she did assist Resident #9 with 1, she had him/her use the walker and the gait belt. Resident #9 was not steady at all, and not safe to transfer without the gait belt. During an interview on 10/14/14 at 3:50 p.m. the Unit Manager stated staff were to use a gait belt with all assisted transfers and ambulation. A Quality Audit Report dated 09/18/14 (after the incident with Resident #9) documented CNA's were observed transferring 12 dependent residents on days and 12 dependent residents on evenings. The audit documented 23 of 24 transfers were done in accordance with the care plan. The negative findings or areas of concern documented to ensure all staff were aware of the importance of using a gait belt with any dependent transfer. The immediate fix put in place included re-education to the appropriate times to use a gait belt, and spoke with the staff member immediately.