Every finding on record at Good Samaritan - Davenport

Based on observations, staff and resident interview and facility policy review the facility failed to use Enhanced Barrier Precautions (EBP) and failed to completed hand hygiene for 2 out of 4 residents reviewed (Resident#2 and #92) and failed to transport clean laundry covered for 2 out of 2 days. The facility reported a census of 98 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #92, dated 11/28/25, list of diagnoses included anemia (lack of red blood cells), Parkinson's disease, and diabetes mellitus (DM). The MDS identified Resident#92 Brief Interview for Mental Status (BIMS) as 12 out of 15, which indicated moderately impaired cognition. The MDS indicated Resident#92 required a wheelchair for mobility, dependent on staff for toileting hygiene, lower body dressing and chair to chair transfer. The Care Plan for Resident #92, dated 5/20/25 revealed Resident #92 required EBP related to urine culture that held Extended-Spectrum Beta-Lactamases (ESBL) (enzymes from bacteria that make them resistant to standard antibiotics). The Care Plan directed staff to put on gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene, changing lining, repositioning checking and changing, device care and/or wound care. Review of a Provider's Progress Note, dated 1/25/26, revealed the resident had a positive urine culture showed ESBL. During an observation on 01/27/2026 at 8:04 AM, Resident #92 sat in the wheelchair (w/c) in her room. The resident stated she needed to use the bathroom, she said she's on antibiotic for a UTI. A sign indicating the need for EBP noted on the resident's door, and with EBP (gown and gloves) supplies available. During on observation on 01/29/2026 starting at 8:50 AM Staff A, Certified Nursing Assistant (CNA) reported Resident #92 goes to the shower room to use the commode. Staff A completed hand hygiene and applied gloves before he placed the gait belt on Resident#92. Staff L, CNA completed hand hygiene and put gloves on, both CNAs stood Resident#92 up to the shower wall, lowered her pants and moved the commode behind her. Resident#92 sat on the commode and emptied her bladder. Staff A reported her brief appeared dry. Both CNAs removed their gloves, completed hand hygiene and applied new gloves. At 9:04 AM, Staff A, CNA and Staff L, CNA stood Resident #92 up, Staff A used wipes to clean her, Staff L pulled her pants up and assisted her back in to the w/c. Neither Staff A and Staff L wore a gown during this observation. During an interview on 01/29/2026 at 9:07 AM, Staff L, CNA reported the EBP sign on Resident #92's room door is for her roommate, and she is not sure why. During an interview 01/29/2026 at 9:09 AM, Staff A, CNA reported the EBP is for Resident #92. He stated they needed to wear the EBP for her cares. Staff A stated Resident #92's urine is why the EBP is needed. During an interview on 01/29/2026 at 1:11 PM, the facility Infection Preventionist (IP) reported she expected the staff to use EBP as directed on the wall sign, she said the staff needed to completed hand hygiene when they enter and when they leave the room before and after cares. 2. Review of the Resident #2's MDS assessment, dated 12/19/25, revealed a BIMS score of 15 out 15 which indicated intact cognition. The assessment identified diagnoses cerebral vascular accident (stroke), diabetes, and hemiplegia. The resident received nutrition both through a gastric feeding tube (g-tube) and a mechanically altered diet. Review of the Care Plan, last revised 12/22/25, revealed, in part, the resident required enhanced barrier precautions (EBP) related to her g-tube. An Intervention directed staff to don gown and gloves for high contact care activities including device care and/or use, and to doff gown and gloves inside the room and perform hand hygiene. Review of Clinical Physician Orders in the electronic health record (EHR), revealed a. An order, dated 9/20/24, to check and record residual amounts every shift and PRN (as needed) four times per day. b. An order, dated 6/18/25, for Isosource 1.5 Cal oral liquid, give 200 milliliters (ml) via g-tube four times per day for meals bolus feeding. c. An order, dated 9/24/24, for Calcium 600 milligrams (mg) one tablet every day via g-tube. d. An order, dated 4/11/25, for DuoNeb solution 0.5-2.5 mg/3 ml (Ipratropium/Albuterol) one inhalation four times per day. During an observation on 1/26/26 starting at 12:53 PM, the outside of the room door for Resident #2 revealed a sign that instructed staff to follow EBP when providing cares to the residents in the room. At 12:45 PM, Staff B, Licensed Practical Nurse (LPN), revealed Staff B was pushing Resident #2 in her wheelchair down the hallway into the resident's room, moved the resident's bedside table, and repositioned the wheelchair by the bedside table. Staff B stated that she had washed her hands prior to getting the resident. Staff B then donned gloves got a syringe out the resident's supplies, attached the syringe to the resident's g-tube and pulled back on the plunger of the syringe to check for residual. Staff B then removed the syringe, washed the syringe out, removed her gloves, left the room and used the alcohol-based hand sanitizer outside of the resident's room. Staff B did not wear a gown during the g-tube residual check. At 12:50 PM, Staff B, LPN, prepared a Calcium 600 mg tablet for administration. A pharmaceutical medication supplier approached Staff B and dropped off medications for another resident. Staff B took the new medication supply along with Resident #2's crushed Calcium, opened the medication room door near her cart with a key, and placed the supplies in the medication room. Without completing hand hygiene, Staff B exited the room, got on her computer, made a slurry mix with the calcium tablet, and then locked her medication cart. Staff B walked down the hallway to the resident's room and entered the resident's room. Without completing hand hygiene, or donning gloves and a gown Staff B poured water into a graduated cylinder, drew up the water with a syringe, got a wash cloth and put it on the resident's lap, connected the syringe to the g-tube port and flushed the g-tube with 30 cc of water. Staff B administered the calcium slurry via the g-tube. Staff B then washed the syringe and her hands in the bathroom sink, and put the syringe back in the residents' supplies. Staff B exited the room, and returned with the g tube feeding. Without performing hand hygiene, donning gloves or a gown, Staff B poured the Isosource in a graduated cylinder, removed the plunger from the syringe, connected the syringe to the g-tube port and slowly poured the Isosource into the syringe. Staff B then flushed the g-tube with water through the syringe. Staff B removed the syringe, rinsed the syringe and cylinder in the resident's sink and washed her hands. At 1:14 PM, Staff B, LPN, left the resident's room and returned to her medication cart to prepare the resident's Ipratropium Bromide and Albuterol sulfate 0.5-2.5 mg/3 ml solution treatment. Without completing hand hygiene, donning gloves or a gown, Staff B entered the room moved the resident's nebulizer machine and set the machine up. Staff B got resident's mask, connected the tubing to the machine, put the medication in the reservoir below the mask, and put the mask on the resident without performing hand hygiene or donning gloves. Staff B set a timer on her phone, moved to the hallway outside of the resident's room, put her phone back in her pocket, and then sanitized her hands after handling her phone. At 1:24 PM, Staff B, LPN, after removing Resident #2's mask off the resident, turned off the nebulizer machine and returned it to the resident' night stand, took the mask into the bathroom and rinsed the mask and reservoir with soap and water, put the mask on a paper towel to dry, and then removed her gloves. Without performing hand hygiene, Staff B moved the resident's bedside table and pushed Resident #2 in her wheelchair to the activity room. During an interview on 1/28/26 at 4:02 PM, Staff B, LPN, reported she knew Resident #2 was on EBP and she knew that she had messed up by not wearing gloves or a gown while handling the resident's g-tube. She reported she was having an off day the previous day (1/27/26). During an interview on 1/29/26 at 11:11 AM, Staff J, LPN, reported staff needed to wear a gown and gloves for residents with EBP. Staff J reported staff should perform hand hygiene before starting cares, before gloving, between glove changes, and at the end of providing cares to a resident. During an interview on 1/29/26 at 11:43 AM, the Director of Nursing (DON), reported she had already provided education to Staff B on enteral feeding and PPE use. 3. During an observation on 01/28/2026 11:57 AM Staff K, Housekeeping/Laundry, pulled the open hanging laundry cart from the 3100 hall around the center hub down the hall 3300 hall. Staff K parked the cart in the hall and left the cart uncovered as she delivered clothes. During an observation on 01/29/2026 starting at 12:35 PM, Staff K, pushed the opened cart into the laundry from the station 2300 hall. At 12:43 PM, during an interview, Staff K reported she needed to cover the clean laundry cart when moving from one hall to the next. Staff K, stated she kept the cart uncovered as she delivered the clothes on the hall. Staff K reported the laundry delivery procedure is in her head. During an interview on 01/29/2026 at 1:11 PM The Infection Preventionist (IP) reported the laundry needed covered during transportation in the hall and while the cart sat in the hall. Review of the facility's policy, titled Hand Hygiene, dated 11/13/25, revealed, in part, .hand hygiene: a general term that applies to either handwashing or applying hand sanitizer. Handwashing includes washing hands with soap and water. Hand sanitizer involves using a waterless antiseptic agent .All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene. 1. Entering room [ROOM NUMBER]. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting room [ROOM NUMBER]. Zones: Patient zone and Health-care zones. The facility provided a policy titled Standard, Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions, All Service Lines- Enterprise dated 7/7/25 identified the purpose: To prevent the spread of infection and communicable diseases to residents/patients, employees, and visitors through infection prevention and control practices. Enhanced Barrier Precautions (EBP)(Rehab/Skilled Only) Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Enhanced barrier precautions are used for residents who are infected or colonized with a CDC-targeted MDRO, or an epidemiologically important MDRO (per facility discretion), when contact precautions do not otherwise apply. See Multidrug- Resistant Organism policy. Enhanced barrier precautions are also used for residents with chronic wounds (i.e.,pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers) and residents with indwelling medical devices (i.e., central lines, hemodialysis catheters, indwelling urinary catheters, feeding tubes, and tracheostomies), even if the resident is not known to be infected or colonized with an MDRO. High-contact resident care activities include transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with resident in therapy gym (specifically when anticipating close physical contact while assisting with transfers and mobility), changing linens, indwelling medical device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care. Enhanced barrier precautions are intended to be used for the duration of a resident's stay. For residents on enhanced barrier precautions for a wound or indwelling medical device only, precautions can be discontinued if the wound resolves or the device is removed. Procedure Post clear signage indicating the type of precautions and required PPE (i.e., gown and gloves). Signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Gowns and gloves should be readily available. Ensure access to alcohol-based hand rub. The facility provided a policy titled Laundry, Resource Packet dated 8/21/25 Transporting Clean Laundry/Laundry Passes. Package, transport and store clean clothes and linens to ensure their cleanliness and to reasonably protect them from dust and soil. Clean linen carts are to be covered at all times including during storage and distribution.

Based on observations, resident and staff interviews and facility policy review the facility failed to serve a palatable meal for 2 out of 2 meals observed and four out of four residents reviewed (Resident#14, 3, 43 and 6). The facility reported a census of 98 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident#14, dated 10/18/25, list of diagnoses included heart failure and malnutrition (insufficient intake of calories and/or protein). The Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicated the resident with intact cognition. The Care Plan for Resident#14 dated 10/28/25, directed educate resident not to skip meals. During an interview on 01/26/2026 at 2:05 PM, Resident #14 reported she did not like the food, and explained it is not hot and the taste is bad. 2. The kitchen staff provided the lunch menu for 1/27/26 which consisted of beef and broccoli, fried rice, peas, and egg roll. On 01/27/2026 at 12:20 PM, the State Agency received a test tray. The beef looked an unattractive dark color, the broccoli appeared pale with little green color, and tasted salty. The rice and peas tasted bland and were gummy in texture. The egg roll had a soggy texture, and the beef juice/gravy had an unsavory taste. 3. Review of the MDS assessment for Resident #3, dated 12/17/25, revealed a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnoses included heart failure and diabetes. During an interview on 1/27/26 at 9:09 AM, Resident #3 reported the food did not taste good. Resident #3 explained the food had no flavor and did not look appetizing. During an observation on 1/28/26 starting at 12:34 PM, Resident #3's door was partially shut, and a dietary food cart was sitting outside of the resident's room door. Staff I, Certified Nursing Assistant (CNA) called out she was providing cares when the surveyor knocked on the door. At 12:38 PM, Staff I, CNA exited Resident #3's room. Resident #3 observed to be sitting up in bed with her lunch on the bedside table positioned over the bed. Resident #3 had baked rosemary chicken, roasted red potatoes, cauliflower au gratin (covered in cheese) and a pumpkin cake. At 1:05 PM, Resident #3 reported the chicken was too tough to eat. The resident's plate had 50 percent of her meal left, with the majority of her chicken still on the plate. 4. Review of the MDS assessment for Resident #43, dated 11/19/25, revealed a BIMS score of 14 out of 15, which indicated intact cognition. The list of diagnoses included diabetes, high blood pressure, seizures and gastroesophageal reflux disease (GERD). During an interview on 1/26/26 at 12:59 PM, Resident #43 reported the food was either over or undercooked. The resident the food got soggy as it sat on the steam table. During an observation on 1/28/26 at 11:30 AM, Resident #43 served rosemary baked chicken, cauliflower au gratin, roasted potatoes, and a roll. At 11:44 AM, the resident had eaten the chicken and potatoes, but the majority of the cauliflower was still on the resident's plate. The resident requested and received another serving of roasted potatoes. Resident #43 reported the cauliflower was too tough to eat. 5. Review of the MDS assessment for Resident #6, dated 12/3/25, revealed a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnosis included high blood pressure and right hip fracture. During an interview on 1/26/26 at 11:15 AM, Resident #6 reported the food was not good. Resident #6 explained that when the menu had French dip, it didn't have the dip, and when the menu had Philly cheesesteak, there was no cheese. The resident reported the food was dry and missing flavor. On 1/28/26 at 12:00 PM, observation revealed Resident #6 received a room tray for lunch. The resident had ordered the rosemary baked chicken and nothing else. At 12:03 PM, observation revealed Resident #6 was eating the baked chicken. Resident #6 reported the chicken was dry and then stated, the chicken was always dry. 6. During an interview on 01/28/2026 at 12:26 PM, the kitchen staff provided a lunch meal tray that included baked rosemary chicken and cauliflower au gratin. The rosemary baked chicken taste was dry and bland. The cauliflower au gratin was a mixture of mushy texture little pieces and tough texture, large pieces. The cauliflower large pieces did not cut with a knife. During an interview on 1/29/26 at 11:36 AM, the Manager of Nutritional and Food Services reported she encouraged cooks to taste the food, and she ate at facility almost every day. The Manager of Nutritional and Food Services reported staff followed a Meal Service policy, and that she ran the resident food council meetings. Review of the Food Counsel meeting minutes, dated 1/12/26, revealed residents had complaints of kitchen staff serving cold lasagna, not serving breadsticks, French dip without dip, meatball and cheese sub sandwich served without cheese, and the spaghetti and meat sauce was dry. Review of the facility policy titled Food Preparation- Food and Nutrition dated 3/14/25 directed employees routinely sample the food before it's served to ensure good taste, texture and quality. The policy identified the plates should have an attractive appearance and be free of spillovers.

Based on clinical record review, observation, review of facility policy, resident and staff interview, the facility failed to ensure a safe environment free from potential hazards for 3 of 7 sampled residents (Residents #6, #11 and #43). The facility reported a census of 98 residents.Findings include:1. Review Resident #43's Minimum Data Set (MDS) assessment, dated 12/19/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated intact cognitive function. The MDS indicated Resident #43 utilized a walker and wheelchair for mobility, and required substantial/maximum staff assistance with activities of daily living related to toilet transfer and toilet/personal hygiene. The list of diagnoses included diabetes, hemiplegia (paralysis on one side of body), cerebral infarct (stroke), seizures and right shoulder pain. Review of Resident #43's Care Plan, last revised 11/26/25, revealed, in part, the resident an ADL self-care performance deficit related to left-sided hemiplegia and required 1:1 (assist of 1 staff) with the commode at shower wall or in the bathroom.During an interview on 1/26/26 at 12:59 PM, Resident #43 reported there had been a commode in the shower room on his hall (East 300 hall) with a faulty left leg. Resident #43 reported on a Saturday in December [2025], Staff G, Certified Nursing Assistant (CNA), assisted the resident to the commode in the shower room on his hall. The resident stated after he was safely seated the staff left and when he leaned to the left, the leg on the commode broke and he fell. The resident stated he landed on his left shoulder and hit his head. He stated he requested to go to the emergency room to be evaluated and returned later that night. The resident explained the leg on the commode had been faulty for about 2 weeks prior to the leg giving out on him, and he had informed staff of the faulty leg. Review of the facility's incident report, titled Resident Event, dated 12/6/25, revealed, in part, at 7:15 AM: Resident was being transferred to commode in shower room by staff. When resident sat on commode the leg buckled and resident fell to the floor. Call out to On-call doctor and received new order to send resident, per his request, to ED for eval and treat. Resident had no visible injuries. Complaints of pain to his right shoulder and left hip. Resident stated he had called his wife and updated her and requested this nurse not call his family and stated he would call them himself. Resident was given PRN pain med.Review of the progress note, titled Health Status, dated 12/6/25 at 11:55 AM, revealed Staff B, LPN documented the following: Res returned from the ED (emergency department) with no new orders. Scans done at ED were negative, no new injuries.During an interview on 1/28/26 at 8:05 AM, Staff D, CNA, reported being aware one of the legs being bent on the commode located in the 3300 hall (East 300 hall) shower room prior to Resident #43's fall. Staff D, CNA, reported the leg on the commode had been bent for some time before it was replaced but was unsure for how long. Staff D explained they had put commode in the maintenance book for repair. Staff D reported other residents had used the commode, as well. Staff D reported any of the residents on the East 300 hall would have used the commode when they were in the shower room. During an interview on 1/29/26 at 9:51 AM, the Maintenance Director reported they received information on items that needed repair through the written paper log maintained in each nursing station, through an electronic system, or through verbal requests made by staff. The Maintenance Director reported maintenance staff completed monthly checks on resident rooms and shower rooms to determine if repairs were needed. The Maintenance Director reported being unaware until yesterday (1/28/26) that there had been a problem with a commode chair in the East 300 hall shower room. During an interview on 1/29/26 at 11:03 AM, the Administrator reported staff replaced the commode the day of the accident happened. They had another commode available and did not have to order one.Review of the undated facility policy, titled Preventative Maintenance, revealed maintenance staff were to inspect and fix problems as they emerged, and repairs were to be fully documented.2. Review of Resident #6's MDS assessment, dated 12/3/25, revealed the resident had a BIMS score of 15 out of 15 which was indicative of intact cognitive function with minimal to no cognitive impairment. The MDS assessment identified the resident required substantial/maximum assistance for bed repositioning, was dependent on staff for transfers and independent in mobility with manual wheelchair use. The list of diagnoses included morbid obesity, right femur (upper leg bone) fracture, lymphedema (fluid buildup in the legs), muscle weakness and demyelinating disease of the central nervous system (disease that caused numbness, weakness and fatigue). Review Resident #6's Care Plan, last revised 12/10/25, revealed, in part, the resident used tobacco products. The Care Plan identified the resident used tobacco products independently and the resident was to smoke in the designated area: the courtyard.Review of the form, titled Tobacco Use Evaluation, dated 9/2/25, revealed the resident smoked/vaped 5 to 10 times per day, morning afternoon and evening. The form assessed the resident did not have any physical limitations that would interfere with her ability to get outside and get back in independently. The resident received education regarding smoking/vaping in designated area and acknowledged understanding. During an interview on 1/26/26 at 11:15 AM, Resident #6 reported being in bed all day for the last two weeks due to knee pain, swelling and cellulitis in the right leg. Resident #6 explained prior to the last two weeks, she had been out of bed all the time doing activities. During an interview on 1/27/26 at 10:00 AM, Resident #6 reported she both smoked cigarettes and vaped. Resident #6 explained when she vaped, she vaped in her room. She reported she had been just vaping the last couple weeks due to not being able to go out and smoke. Resident #6 reported she vaped in her room and staff were aware that she was vaping in her room.3. Review of Resident #11's MDS assessment, dated 12/24/25, revealed a BIMS score of 10 out of 15 which indicated a moderate cognitive impairment. The resident required substantial/maximum staff assistance for toileting, hygiene, transfers and upper body dressing. The resident was dependent on staff for lower body dressing. The resident was independent for mobility with manual wheelchair use. Diagnoses included stroke, dementia and schizophrenia (disorder that affects thinking, emotions and behaviors and characterized by delusions, hallucinations and cognitive difficulties). Review of Resident #11's Care Plan, last revised 12/30/25, revealed, in part, the resident had impaired cognitive function/dementia or impaired thought process, and poor recall. The Care Plan identified the resident had an ADL self-care performance deficit related to impaired mobility and cognition. The Care Plan identified the resident vaped inside in recliner, not in the designated smoking area and included interventions to educate and offer to take resident outside to the designated area; negotiate a time for vaping/smoking and return at the agreed upon time. Review of the form, titled Tobacco Use Evaluation, 12/22/25, revealed, in part, the resident currently used tobacco, there was no previous assessment, the resident smoked/vaped 5 to 10 times per day, morning, afternoon, evening, and night. The form assessed the resident did not have any physical limitations that would interfere with her ability to get outside and get back in independently. The form identified the resident was able to safely operate the e-cigarette device. The resident received education regarding smoking/vaping in designated area and acknowledged understanding. A review of the electronic health record revealed the following Progress Notes:a. A Communication with Resident/Family noted, dated 12/24/25, documented, in part social services staff spoke with the resident and her family regarding moving the resident. The resident's current roommate was complaining about the smoke from the vape.b. A Care Plan Review note, dated 12/24/25, documented, in part the resident would go outside to smoke every so often, but mainly stayed in her room vaping.During an interview on 1/26/26 at 11:05 AM, Resident #11 reported she could smoke any time she wanted and she could smoke by herself without staff. Resident #11 reported she was allowed to vape in her room. Resident #11 picked up her vape machine which had been sitting on her bedside table.During an interview on 1/28/26 at 7:46 AM, Staff B, LPN, reported she had not seen, but had heard that both Resident #6 and Resident #11 vaped in their room. Staff B reported if she caught them vaping in their room, she would redirect them to smoke outside. During an interview on 1/28/26 at 8:05 AM, Staff D, CNA reported she had witnessed both Resident #11 and Resident #6 vaping in their room. When asked if Staff D was supposed to do anything when resident seen vaping in their room, Staff D said no and that she had done nothing when she had witnessed the residents vaping. During an interview on 1/28/26 at 11:10 AM, the Director of Nursing (DON) explained that Resident #11 had a history of vaping, and needed to go outside if staff caught her smoking in her room. The DON reported the facility did not allow residents to smoke or vape in their room, because it was a fire safety hazard. The DON reported Resident #6 was not supposed to be vaping in the room either. If staff caught her, they were supposed to offer to take her outside or cue and remind her to take the vape outside to use. The DON reported both Resident #6 and Resident #11 were independent while smoking. During an interview on 1/29/26 at 9:35 AM, the Administrator reported residents who smoked/vaped had been educated today (1/29/26) on using vapes/cigarettes in the appropriate area. She had not done any staff education related to making sure staff redirected residents to smoke/vape outside, but planned to do education with staff. Review of the policy, titled Smoking and Tobacco Use, dated 12/15/25, revealed, in part, that smoking inside the building was not permitted .The electronic cigarette or e-cigarette is a battery-operated product that is intended as an alternative to cigarette smoking. This product may or may not deliver nicotine substances to the user in the form of a vapor. The vapor dissipates quickly; however regulators and health experts have not concluded this vapor is harmless when ingested or with skin contact. The facility will follow manufacturing guidelines for storage of the device and batteries. Although these devices are not considered smoking devices, they will not be permitted inside (facility-owned) buildings.

Based on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure dependent residents received assistance with personal care (showers and nail care) to maintain adequate personal hygiene for 3 of 3 residents (Resident #34, Resident #51, and Resident #84) reviewed for activities of daily living. The facility reported a census of 98 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #34 dated 11/16/25 documented diagnoses of depression, diabetes mellitus, and rheumatoid arthritis. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The MDS indicated Resident #34 used a walker and a wheelchair for mobility, and required substantial/maximal assistance for bathing.The Care Plan for the resident with an admission date of 4/22/22 indicated the resident was a fall risk, had the potential for pressure ulcer development, and had a self-care performance deficit with limited range of motion and activity intolerance.Review of an electronic health record (EHR) report titled Documentation Survey Report v2 revealed Resident #34 scheduled to receive showers during the evening shift (2:15 PM to 10:15 PM) on January 3, 7, 10, 14, 17, 21, 24, 28, and 31. As of 1/27/26 at 1:20 PM the EHR indicated the resident did not receive showers on January 14, 17, 21, or 24. The facility was unable to provide additional documentation these showers occurred.During an observation on 1/26/26 at 2:27 PM, Resident #34's hair flat to her head on one side and clumped in raised [NAME] on the other side. Resident #34 stated she was supposed to get a shower Saturday and did not get it. She reported staff did not offer a bed bath or an alternate time for a shower and said she still hadn't had a shower or a bed bath 2 days later but wanted one. She stated she spoke to a staff about it that day but did not know if they were day or evening staff. 2. The MDS for Resident #51 dated 11/23/25 documented diagnoses of cerebrovascular accident (stroke), diabetes mellitus, and depression. The BIMS score of score of 99. A score of 99 is used to indicated a severe cognitive impairment. The MDS indicated Resident #51 used a wheelchair for mobility and required substantial/maximal assistance for bathing.The Care Plan for the resident with an admission date of 8/13/21 indicated the resident had impaired cognitive function, was incontinent, was a fall risk, and had a self-care performance deficit related to a fall with a subdural hematoma.Review of the EHR Documentation Survey Report v2 revealed Resident #51 scheduled to receive showers during the evening shift (2:15 PM to 10:15 PM) on January 2, 6, 9, 13, 16, 20, 23, 27, and 30. As of 1/28/26 at 2:21 PM the EHR indicated the resident did not receive showers on January 2, 6, 13, 20, or 27. The facility was unable to provide additional documentation these showers occurred.During an observation on 01/26/2026 at 2:00 PM, Resident #51 lay in his room in bed, with his right hand resting on the top of a blanket. The fingernails on the resident's hand noted to be about a quarter of an inch in length past the tip of his finger. The resident's fingertips were caked with a brown substance which also noted to be present under the fingernail. During a follow up observation on 1/28/26 at 2:36 PM Resident #51's fingernails noted to be long on his right and left hand with a brown and yellow substance under the nails on each hand. 3. The MDS for Resident #84 dated 11/13/25 documented diagnoses of cancer, non-Alzheimer's dementia, and cognitive communication deficit. The BIMS score of 99 indicated a severe cognitive impairment. The MDS indicated Resident #84 was not rejecting care, used a wheelchair for mobility, and required substantial/maximal assistance for bathing.The Care Plan for the resident with an admission date of 8/13/25 indicated the resident had impaired cognitive function, was non-complaint with cares, was a risk for pain and pressure sores, and had a self-care performance deficit related to a stroke with left sided hemiplegia (paralysis) and dementia.Review of the EHR report titled Bath/Shower revealed Resident #84 received a shower 1/10/26, a bed bath 1/17/26, and refused a shower on 1/3/26. As of 11:44 AM on 1/28/26 the facility was unable to provide additional documentation showers occurred, or were offered at alternate times/days due to non-compliance, to cover January 3, 7, 14, 21, or 24.During an observation 01/27/2026 at 10:06 AM, Resident #84 noted to have long and jagged nails with a brown, pasty substance present under the nail.During an observation on 01/28/2026 at 11:16 AM, Resident #84 fingernails remained long and jagged, different lengths, and with brown and yellow substances underneath. His right index fingernail also contained a brownish red oval that appeared to be a small scab. During an observation on 01/28/2026 at 11:45 AM, Staff E, Certified Nurse's Aide (CNA) served Resident #84 a food tray. The CNS did not offer to wash his hands before he ate the meal. During an interview at 11:47 AM, Staff E, CNA stated she did not offer to assist Resident #84 with washing his hands prior to eating his meal. Staff E stated she should have asked the resident. CNAs should help with washing hands before meals. She confirmed she did not do that when serving Resident #84.During an interview on 1/29/26 at 9:54 AM Staff E, CNA stated CNA's received a list at the start of their shift with residents who needed bathing. She explained showers were scheduled 2 times a week for residents and if a resident refused or was not available, they should be approached later. Staff E reported showers were supposed to be documented in the resident's electronic health record and on a paper document to sign off that the shower was completed.During an interview on 1/29/26 at 10:04 AM, the Director of Nursing (DON) stated a resident who did not get a bath or shower as scheduled could be reassigned to a different day or be assigned to Sunday to make sure they were bathed at least twice a week. She confirmed bathing should be documented in the EHR system and on paper. The DON stated the CNAs were responsible for this documentation but ultimately, she was responsible when it wasn't done. Review of the facility policy titled Bathing - R/S, LTC dated 12/22/25 indicated the policy was in place to promote cleanliness and hygiene, to stimulate circulation, promote comfort and wellbeing, observe a resident's condition, assist residents with personal care, and promote safety while bathing. It included tub/shower bathing, bed baths, and noted that bathing should be documented in the EHR system.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure nursing staff followed physician orders to flush a feeding tube before/after an enteral feeding and after the administration of medications for 1 of 2 residents (Resident #2) reviewed with feeding tubes. The facility reported a census of 98.Findings include: Review of Resident #2's Minimum Data Set (MDS) assessment, dated 12/19/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated intact cognition. The list of diagnoses included cerebral vascular accident (stroke), diabetes, and hemiplegia. The MDS indicated Resident #2 received nutrition both through a gastric feeding tube (g-tube) and a mechanically altered diet. Review of Clinical Physician Orders in the electronic health record (EHR), revealed the following:a. An order, dated 6/18/25, for Isosource 1.5 Cal oral liquid, give 200 milliliters (ml) via g-tube four times per day for meals bolus feeding. Flush with 70 ml before and after each feeding. b. An order, dated 9/24/24, for Calcium 600 milligrams (mg) one tablet every day via g-tube. c. An order, dated 12/21/23, flush medication administration: Flush with 30 cc (cubic centimeters, 1 cc equal to 1 ml) patency of water before medications, may slurry and mix medications and give at at one mix, or utilize 5 cc water between medications administration with 30 cc after all medications given. During an observation on 1/27/26 at 12:50 PM, Staff B, Licensed Practical Nurse (LPN), crushed a Calcium 600 mg tablet and mixed in a medication cup with water making a slurry mix. Staff B took the medication to the bedside, and drew up 30 cc of water with a syringe from a graduated cylinder filled with water. Staff B flushed the G-tube with the 30 cc of water. Staff B then used a syringe to draw up the calcium slurry mix. Staff B inserted the syringe tip into the g-tube port and pushed the medication in. Without flushing the g tube after administering the slurry mix, Staff B washed the syringe and put the syringe back in the resident's supplies. Staff B left the room and then returned with Isosource 1.5 Cal oral liquid, 250 ml container. Staff B poured the Isosource into a graduated cylinder, removed the plunger from a syringe, connected the syringe to the g-tube feeding port, slowly poured 200 ml of the Isosource into the syringe, and then flushed with 70 cc of water after the feeding. Staff B did not flush the g-tube with 70 cc of water prior to the enteral feeding. During an interview on 1/29/26 at 11:11 AM, Staff J, LPN, reported that Resident #2 required the g-tube to be flushed with 30 cc of water flushed before and after medication administration and 70 cc of water before and after g-tube feeding. Staff J explained the importance of flushing with water before and after medication administration and enteral feeding was to keep the g-tube line from clogging. During an interview on 1/29/26 at 11:43 AM, the Director of Nursing (DON) reported the nurse managers reviewed orders for accuracy, completed clinical rounding on nursing staff and audits for quality assurance and compliance.Review of the facility policy, titled Medication: Tube Administration, dated 3/4/25, revealed, in part, . Water may be required for reconstitution of an enteral formula as well as to dilute medications, provide flushes and maintain hydration . Flush tube with 30 ml (cc) of water before and after administering each medication pass.

Based on clinical record review, policy review and staff interviews the facility failed to accurate mental health diagnoses are indicated on the Preadmission Screening and Resident Review (PASARR) for 2 of 2 residents reviewed (Resident #80 and Resident #84). The facility reported a census of 86 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], documented Resident #80 diagnoses included: bipolar disorder, stroke, hemiplegia (paralysis or weakness on one side) affecting right side, and aphasia (difficulty speaking). The Brief Interview for Mental Status (BIMS) assessment not completed. The electronic health record titled Medical Diagnosis, dated 1/15/25 included the diagnosis of manic episode, unspecified with a diagnosis date of 8/2/24. A review of the PASARR dated 5/29/24 lacked diagnosis of manic episode, unspecified and bipolar disorder. During an interview on 1/15/2025 at 9:28 AM. the Social Worker stated she is responsible for reviewing and completing the resident's PASARR. She explained she is sent a potential resident's PASARR information for review to determine if the facility can meet the resident's needs. If there are new mental health diagnosis or if they are coming from the community she will initiate the PASARR. The Social Worker stated she was not aware Resident #80 had any mental health diagnosis. During an interview on 1/15/2025 at 9:58 AM, the Social Worker stated she had reviewed the resident's documentation as well as the Level I PASARR that was completed prior to admission. The Social Worker stated Resident #80 admitted to the facility with a mental health diagnosis and a new PASARR should have been submitted. During an interview on 01/15/2025 at 11:27 AM, the Director of Nursing (DON) stated the facility should have caught that a Level II PASARR needed to be submitted upon admission or at least by the first care conference. The DON stated she would expect every resident's PASARR to reflect current mental health diagnoses. She stated a PASARR will be submitted for Resident #80. 2. The MDS dated [DATE] for Resident #84 documented a BIMS score of 15 out of of 15 which indicated intact cognition. The MDS listed diagnoses include psychotic disorder. A review of the PASARR, dated 10/16/24, completed for Resident #84 PASARR revealed a diagnosis of anxiety disorder. The PASARR failed to identify the diagnosis of psychotic disorder. During an interview on 1/15/25 at 9:28 AM, the Social Worker stated the diagnosis of Psychotic Disorder should have been on a PASARR from Resident #84's readmission in October 2024. During an interview on 01/15/25 at 11:19 AM, the DON stated the physician orders for Resident # 84 have listed a diagnoses of encephalopathy and delusions & hallucinations and he was on antipyschotic for his hallucinations when he came back from the hospital in October 2024. The DON stated that is when Resident #84 should have the PASARR resubmitted or at the least with his next assessment date. The DON stated staff should submit for new PASARR when there is change in mental health diagnosis. The facility policy revised on 12/30/24, titled Pre-Admission Screening and Resident Review indicated the Purpose of the policy is: a. To ensure each resident is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission. b. To ensure that individuals with MD or ID receive the care and services they need in the most appropriate setting. The policy directed staff Before Admission to: 3. The admissions coordinator, social services, or designated individual will ensure the PASARR Level I screening has been completed before admission and a copy has been received at the time of admission 4. The Level I screening will be reviewed to determine whether a Level II screening in required. The policy directed staff During the Stay to: 1. If the resident is diagnosed with a mental disorder while in the location, social services, or the designated individual will contact the designated state agency for a Level II screening.

Based on observation, clinical record review, and resident, resident family member and staff interviews, the facility failed to respond to activated call lights within in 15 minutes for 4 of 6 (Resident's #3, #4, #6, and #2) residents reviewed for call lights. The facility reported a census of 89 residents. Findings include: 1. The 8/29/24 Minimum Data Set (MDS) Assessment tool revealed Resident #3 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The MDS assessed the resident required substantial staff assistance to reposition in bed, transfer to and from bed or chair, for bathing, dressing and use of the toilet. The assessment revealed Resident #3 frequently incontinent of urine. During an interview on 10/17/24 at 10:36 a.m., Resident #3 stated she used the call light several times a day, completely dependent on staff for assistance when she was in bed, it usually took staff 45 minutes to an hour to answer her call light, rarely 30 minutes or less and she had been incontinent as a result of having to wait that long for staff response to her call light when she had to go to the bathroom. The resident stated it was an ongoing problem, she had discussed it with management staff and there had not been any improvement. 2. The 7/18/24 MDS Assessment tool revealed Resident #4 scored 14 out of 15 on the BIMS, indicating intact cognition. The MDS assessed the resident required substantial staff assistance for transfers to and from bed and chair, for dressing, use of the toilet and bathing. The assessment revealed Resident #4 always incontinent of bowel and frequently incontinent of urine. During an interview on 10/17/24 at 9:54 a.m., Resident #4 stated he was dependent on staff for assistance with care and used his call light several times daily. The resident stated it usually took 20 to 30 minutes for staff to respond to the call light, it was occasionally under 15 minutes, but usually longer and had experienced that nearly daily. The resident stated he used the call light when he needed to go to the bathroom and had been incontinent at least 4 or 5 times when staff didn't respond to the call light timely. 3. The 9/26/24 MDS Assessment tool revealed Resident #5 scored 15 out of 15 points on the BIMS, indicating intact cognition. The MDS assessed the resident required substantial staff assistance to transfer to and from bed and chair, for bathing, dressing use of the toilet. The assessment revealed Resident #5 occasionally incontinent of bowel and frequently incontinent of urine. During an interview on 10/17/24 at 10:25 a.m., Resident #5 stated he was dependent on staff for assistance with transfers, used his call light if he needed to use the bathroom after he was out of bed, or for any assistance when he was in bed, and it usually took 20 minutes for staff to respond to the call light, sometimes longer, it didn't matter what day it was or time of the day, other than they were always busy around the meal times and took longer for staff to respond then. 4. The 9/4/24 MDS Assessment tool revealed Resident #2 scored 15 out of 15 points on the BIMS, indicating intact cognition. The MDS assessed the resident required substantial staff assistance to reposition in bed, transfer to and from bed or chair, for bathing, dressing and use of the toilet. The assessment revealed Resident #2 always incontinent of bowel, and a urinary catheter in place. During an interview on 10/17/24 at 10:01 a.m., Resident #2 stated she used her call light several times a day, dependent on staff for care assistance, and her call light was usually answered in 15 to 20 minutes. There were times when it was longer, up to 25 minutes, and times it was less, around 10 minutes, but usually 15 to 20 minutes and it didn't matter what time of day it was or what day of the week it was. During an interview on 10/16/24 at 5:56 p.m., a family member and responsible party for a resident on Home #2 stated they visited the facility daily. They stated they had observed call lights on for several minutes at a time when staff were in the Nurse's Station area and not engaged in answering the call lights. The family member stated their family member [resident] had been incontinent as a result of the call light not being answered. The responsible party stated they had addressed the matter more than once with the Director of Nursing and the Administrator. The family member stated during a visit on the afternoon of 10/13/24, there were three call lights on in the hallway, including their family members. They stated there were several staff inside the Nurse's Station on their cell phones. The family member stated after 10 minutes they went to get help for the resident. One of the nurses that came out of the Nurse's Station said they couldn't answer the call light because they were on their way home. The family member stated it took 10 more minutes for staff to respond after they specifically asked for assistance for the resident. During an observation on 10/9/24 at 1:51 p.m., a resident call light in the 200 Hall activated. The light illuminated on the wall in the hall outside a resident's room, with no audible signal in the hallway. The electronic call light monitor in the Nurse's Station activated with identification of the resident room, and an audible alert. The Nurse's Station is a room with a door, with a glass window that encases the upper half of the station on 2 walls that face the entry family room area and hallway that lead to the Dining room. The audible sound from the call light monitor device was not heard when in the family room area with the door to the Nurse's Station closed. During an interview on 10/17/24 at 2:56 p.m., Staff B, Certified Nursing Assistant (CNA) stated she thought resident call lights were on for longer than 15 minutes at least 10 times a week, especially if a resident required 2 staff for care and both staff were in the resident's room for the care, there weren't other staff assigned to the hall that looked for activated call lights. During an interview on 10/17/24 at 3:01 p.m., Staff C, CNA stated she thought resident call lights were on for longer than 15 minutes maybe 3 times a week. Staff can't hear that a call light was on unless they were inside the Nurse's Station, the only other way to know a call light was on was to see the call light on by the resident's room, and if they were in another resident's room or not in the hallway they wouldn't know a call light was on until they saw it. During an interview on 10/17/24 at 3:04 p.m., Staff D, Licensed Practical Nursing (LPN) stated she thought resident call lights were on for longer than 15 minutes maybe twice a week, and occurred when the CNA's were on break and when they hadn't communicated about their assigned resident's care needs. During an interview on 10/17/24 at 3:09 p.m., Staff E, Registered Nurse (RN) stated she thought it was rare for a resident's call light to go unanswered for over 15 minutes, and occurred when all the aides were in a resident's room for care, or if 1 of the aides had called off and they were working short. When that happened the nurses had to help out, they had to help check on the residents and answer the call lights. During an interview on 10/17/24 at 2:25 p.m., the Administrator stated she attended the monthly Resident Council meetings and there had not been any concerns raised about call lights at the last 2 Resident Council meetings, and she expected staff to answer activated call lights timely, when they were aware of the resident's call for assistance.

Based on observation, record review, and staff interviews, the facility failed to follow appropriate Enhanced Barrier Precautions for 1 of 10 residents reviewed for urinary catheter care. The facility reported a census of 89 residents. Findings include: The 7/24/24 Minimum Data Set (MDS) Assessment tool revealed Resident #6 scored 10 out of 15 points possible on the Brief Interview for Mental Status (BIMS), indicating a moderate cognitive impairment. The MDS listed diagnoses included: cerebral palsy, obstructive uropathy (blockage of urine flow), and benign prosthetic hyperplasia (enlarged prostate). The MDS assessed the resident required substantial staff assistance for transfers to and from bed and chair, for dressing, bathing and use of the toilet. The assessment revealed a urinary catheter used for elimination. The Care Plan, initiated on 5/16/19 with revision on 1/31/24, included a Focus area to address The resident has an indwelling catheter R/T (related to) urethral strictures (narrowing), DX (diagnosis) Obstructive Uropathy. Interventions included, in part: a. Catheter care: Provide every shift and PRN (as needed). The Care Plan, initiated on 4/4/24 with revision on 5/6/24, included a Focus area to address The resident requires Enhanced Barrier Precautions (EBP) R/T (related to) indwelling catheter. Interventions included, in part: a. [NAME] (put on) gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use and wound care. b. Doff (take off) gown and gloves inside resident room. Perform hand hygiene. During an observation on 0/17/24 at 1:05 p.m, revealed a sign Resident #6 door indicating Enhanced Barrier Precautions. The sign directed staff to wear gown and gloves when high-contact resident care provided that included catheter care. A three drawer dresser outside of the door contained an adequate supply of disposable gowns, gloves and other Personal Protective Equipment (PPE) required for care. While Resident #6 sat on the toilet, Staff A, Certified Nursing Assistant (CNA) stated she would cleanse the resident's catheter. Staff A, donned gloves and with disposable wipes cleansed around the urinary catheter, and around the tip of the penis. Staff A cleansed away from the insertion point, and used one disposable wipe for one swipe. Staff A completed cleaning the catheter without wearing a gown. During an interview on 10/17/24 at 3:58 p.m., Staff A, CNA, stated she knew she was supposed to wear a gown when she provided the catheter care, she simply forgot to apply it prior to the care. During an interview on 10/17/24 at 1:25 p.m., Staff F, Registered Nurse (RN), Clinical Care Leader stated when resident's have EBP, staff are to wear gown and gloves at a minimum, potentially other PPE depending on the specific care. She stated staff should wear gown and gloves when catheter care provided. During an interview on 10/17/24 at 1:34 p.m., Staff G, RN and Infection Preventionist stated staff were educated on EBP when the standard came out. She stated staff should wear gown and gloves when urinary catheter care provided. Staff G stated the facility was getting more of the isolation door hangers that are applied to the outside of a resident's door and contain the PPE required, phasing out the 3 drawer dressers for isolation PPE, but the supply was on back-order so they continued to use the dressers until they could obtain more of the door hangers. Staff G stated staff would be re-educated on the expectation and they would put monitors in place to ensure staff were compliant with the isolation requirements. The facility policy, dated 4.2.24, titled Standard and Transmission-Based Precautions directed staff: 1. Enhanced Barrier Precautions (EBP) expand the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO's) to staff hands and clothing. 2. EBP are needed for residents with with indwelling medical devices (such as central lines, indwelling urinary catheters and feeding tubes). 3. EBP are intended to be used for the duration of a resident's stay. 4. High-contact resident care activities include: transfers, dressing, changing briefs, changing linens, wound care and device care that included urinary catheter, feeding tube and central line. 5. Post clear signage that indicated the type of Precautions and required PPE: gown and gloves. 6. Signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 7. Gowns and gloves should be readily available immediately outside of the resident room. 8. Ensure access to alcohol-based hand rub. 9. Position a trash and laundry receptacle can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room. 10. Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.

Based on observation, clinical record review, bathing records and staff interview, the facility failed to ensure residents are provided adequate personal hygiene services to include at least two bathing opportunities per week for 4 of 4 residents reviewed and failed to provide incontinency care at a frequency necessary to maintain adequate personal hygiene for a resident unable to carry out the activity independently. (Residents #1, #3, #4. #5) The facility reported census was 87. Findings include: 1. According to the Minimum Data Set (MDS) with an assessment reference date of 3/17/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 2, indicating a severely impaired cognitive status. Resident #1 required total dependence to maximal assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnoses included Non-Alzheimer ' s dementia, cerebrovascular accident (stroke), hemiplegia, peripheral vascular disease and atrial fibrillation. Resident #1 was always incontinent of bladder and frequently incontinent of bowel. According to bathing records, Resident #1 was scheduled for bathing opportunities on Mondays and Thursdays. Bathing records indicate all Monday opportunities since admission, resulted in a shower, however Resident #1 did not receive a shower opportunity 4 of 7 Thursdays (3/14, 3/28, 4/4 and 4/11). During observations on 4/25/24 at 6:51 a.m. Resident #1 was in bed as Staff A and Staff B entered her room to provide care and get her up for the morning. Staff A provided incontinence care appropriately and barrier cream was placed on Resident #1's coccyx wounds and excoriation in her peri area. Resident #1 remained in her broda chair throughout the morning, without any further attempt by staff to provide incontinence care until 12:50 p.m., six hours from the initial time incontinence care was first provided that morning. 2. According to the Minimum Sata set (MDS) with an assessment reference date of 4/18/24, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #3 required maximal to moderate assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnosis included atrial fibrillation and arthritis. According to bathing records, Resident #3 was scheduled for bathing opportunities on Saturdays and Wednesdays. Bathing records indicate both Wednesday opportunities since admission, resulted in a shower, however Resident #3 did not receive a shower opportunity on either Saturday (4/13, 4/20). 3. According to the Minimum Data Set (MDS) with an assessment reference date of 3/4/24, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9 indicating a moderately impaired cognitive status. Resident #4 required maximal assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnosis included congestive heart failure and cancer. According to bathing records, Resident #4 was scheduled for bathing opportunities on Mondays and Thursdays. Bathing records reviewed for April, found all bathing opportunities resulted in a shower except for one (4/8). 4. According to the Minimum Data Set (MDS) with an assessment reference date of 12/8/23, Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10 indicating a minimally impaired cognitive status. Resident #5 required supervision to moderate assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnosis included renal insufficiency. According to bathing records, Resident #5 was scheduled for bathing opportunities on Tuesdays and Fridays. Bathing records reviewed during her stay in November and December 2023, found three Tuesday opportunities (11/14, 11/21, 11/28) and three Friday opportunities (11/3, 11/17, 11/24) which did not result in a shower.

Based on observation, clinical record review and staff interview the facility failed to provide an activities program based on a resident's individual interests for 1 of 2 residents reviewed. (Resident #1) The facility reported census was 87. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of 3/17/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 2, indicating a severely impaired cognitive status. Resident #1 required total dependence to maximal assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnosis included Non-Alzheimer ' s dementia, cerebrovascular accident (stroke), hemiplegia, peripheral vascular disease and atrial fibrillation. Resident #1 was always incontinent of bladder and frequently incontinent of bowel. According to Resident #1's Plan of Care with focus on maintaining activity interest and interventions which include TV, comedy, non-aggressive shows, jazz,, contemporary, quit or calm music and to provide opportunities to engage in meaningful conversation and activities with others. In an interview on 4/25/24 at 3:20 p.m. Staff F, Activities Supervisor, stated Resident #1 can come to any group activities scheduled, but notes there were no individual activities planned. Clinical record review noted only one documented activity related to watching TV on 4/23/24 since her admission on 3/11/24.

Based on observation, policy review, and staff interview the facility failed to serve meals under sanitary conditions. The facility reported a census of 82 residents. Findings include: During an observation of the noon meal on 3/11/24 from 11:30 AM to 12:30 PM Staff A, Certified Nursing Assistant (CNA) and Staff B, Licensed Practical Nurse (LPN) served 7 glasses to 4 residents in the Home 2 dining area handling the cups with fingers on the drinking rim surface of the glasses. On 3/13/24 at 12:40 PM, the Culinary Supervisor reported she expected staff to keep their hands off the eating surfaces of dishes. She stated they are expected to use the handles on the cups or the side of the glass. The dietary team is taught the expectations of meal service. The facility policy titled Dining Service Standards- Food and Nutrition Services revised 7/21/23, directed staff to follow procedures for prevention of foodborne illness when serving meals (e.g. never touch ready-to-eat foods with bare hands; never touch the eating surface of utensils and dishware). The facility policy titled General Sanitation-Food and Nutrition revised 3/08/23, directed staff to touch silverware on the handles, plates and bowls on the outside rim, glasses at the base of the cup, and mugs on the handle or base.

Based on observations, clinical record review, facility policy review and staff interviews the facility failed to position an indwelling catheter bag and tubing in a manner to keep them off the floor for 3 of 3 residents reviewed (Resident #20, #3, and #46). Findings Include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/7/24, listed diagnosis for Resident #20 to include cerebral palsy, benign prostatic hyperplasia (enlarged prostate), and intellectual disabilities. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicating intact cognition. The Care Plan, dated 1/31/24, included a focus area for an indwelling catheter. A review of the clinical record revealed a Physician Order, dated 10/23/23, for monthly catheter change using an indwelling catheter 16 fr (French - related to size) with 10 ml (milliliters) of sterile water and replacing the catheter bag. A continuous observation on 3/11/24 for Resident #20 revealed the following: At 10:53 AM, Resident #20 sat in his wheelchair with the catheter cover bag and tubing resting on the bedroom floor. At 11:02 AM the Director of Nursing (DON) walked past Resident #20 and stopped to look at his catheter. At 11:03 AM, Staff C, Certified Nursing Aid (CNA) asked Resident #20 to wheel himself further into his room, and looked at his catheter. The CNA informed the resident she would come back to change the cover bag and position it off the floor. At 11:18 AM, the Staff C did not return to change the cover bag. At 11:19 AM, Resident #20 self propelled himself to the dining room, with the catheter cover bag and tubing dragging on the floor. 2. The MDS assessment tool, dated 2/7/24, listed diagnosis for Resident #3 to include type 2 diabetes, neurogenic bladder (loss of bladder control due to nerve issue), and anxiety disorder. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The Care Plan, dated 1/17/24, included a focus area for an indwelling catheter related to a neurogenic bladder. The plan included an intervention to report unusual observations/conditions to a nurse. During an observation on 3/11/24 at 1:47 PM, while resting in bed, Resident #3's catheter drainage bag and tubing rested on the bedroom floor. During an observation on 3/12/24 at 9:25 AM, while sitting in her wheelchair, the resident's catheter cover bag and tubing rested on the floor. 3. The MDS assessment tool, dated 1/31/24, listed diagnosis for Resident #46 included dementia, neurogenic bladder, and depression. The MDS listed the resident 's BIMS score as 00, indicating a severe cognitive impairment. A Physician Order, dated 2/18/24, revealed an order for an indwelling catheter with a change being completed monthly. During an observation on 3/11/24 at 1:33 PM, while resting in bed, Resident #46 catheter drainage bag and tubing rested on the bedroom floor. A Physician Order, dated 3/12/24, revealed an order to start a post void (completed after removal of the indwelling catheter) bladder scan every 4 hours. During an interview on 3/14/24 at 11:17 AM, the DON stated she expects all catheter drainage bags to be in a cover bag. She stated the bag and tubing need to be placed in a manner so they are off the floor. She stated she would expect staff to readjust any catheter bag and tubing observed resting on the floor. The DON stated she would not expect the catheter bag to be replaced or the tubing cleaned after repositioning. She stated that is not the facility's practice. The facility policy, dated 2/10/23, titled Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen directed staff to change catheter cover bags when visibly soiled. And the catheter tubing should never be allowed to touch the floor.

Based on clinical record review, facility policy and staff interviews the facility failed to notify the Ombudsman of resident transfers to the hospital for 3 of 4 residents reviewed (Resident #46, Resident #52, and Resident #60). The faculty reported a census of 82 residents. Findings include: 1. Clinical record review revealed a hospitalization for Resident #46. A Transfer to Hospital note dated, 11/10/23 at 11:10 PM, revealed the resident transferred to the hospital after a fall. An Admission/Readmission note, dated 11/16/23 at 2:27 PM revealed the resident returned to the facility from the hospital. A review of the clinical record lacked documentation of Ombudsman notification for the transfer to and from the hospitalization . 2. A clinical record review revealed a hospitalization for Resident #52. A Transfer to Hospital note dated, 2/15/24 at 1:35 PM, revealed the resident transferred to the hospital after being found unresponsive. An Admission/Readmission note, dated 2/19/24 at 6:52 PM, revealed the resident returned to the facility from the hospital. A review of the clinical record lacked documentation of Ombudsman notification for the transfer to and from the hospitalization . 3. A clinical record review revealed a hospitalization for Resident #60. A Transfer to Hospital note, dated 11/28/23 at 2:46 PM, revealed the resident transferred to the hospital due to a respiratory infection. An Admission/Readmission note, dated 12/22/23 at 1:35 PM, revealed the resident returned to the facility from the hospital. A review of the clinical record lacked documentation of Ombudsman notification for the transfer to and from the hospitalization . During an interview on 3/13/24 at 3:00 PM, the Administrator stated she completed Ombudsman notifications prior to hiring a Social Services staff, and missed sending the notifications. The Administrator stated the Ombudsman should be notified of all resident transfers. The facility policy, dated 12/6/23, titled Ombudsman lacked staff direction regarding address notification for transfers to and from the hospital.

Based on clinical record review, facility policy and staff interviews the facility failed to report alleged resident abuse within the required two hours time frame for 1 of 1 residents reviewed (Resident #46). The facility reported a census of 82 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 1/31/24, listed diagnosis for Resident #46 to include dementia, neurogenic bladder (loss of bladder control due to nerve issue), and depression. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 00, indicating a severe cognitive impairment. A clinical record review revealed a 1/6/24 Health Status note documenting on 1/5/24 at 2200 (10:00 PM) the resident found sitting on the edge of the bed without clothing and confused. The resident stated someone touched and raped her. During an interview on 3/13/24 at 8:31 AM, the Administrator stated the facility reported the alleged abuse on 1/12/24. The Administrator stated the 1/6/24 Health Status note documenting the alleged abuse was found on 1/12/24. The Administrator stated the facility immediately called 911, and notified the resident's family and physician. The Administrator stated the residents family believed her to be confused and did not want her to be examined in the emergency room . A review of the Facility Self Reports sent to the State Agency revealed a report made on 1/12/24 for Resident #46. A review of the Facility Investigation revealed a staff inservice training completed on 1/12/24. During an interview on 3/14/24 at 11:01 AM, Staff D, Certified Nursing Assistant stated she completes Abuse and Neglect training annually. Staff D stated if a resident made an allegation of assault she would immediately notify a nurse, or administration if a nurse not immediately available. Staff D stated the incident needs to be reported within 30 minutes of discovery. During an interview on 3/14/24 at 11:12 AM, Staff E, Licensed Practical Nurse stated she completes Abuse and Neglect training annually. Staff E stated if she discovered, or a staff informed her of an abuse allegation she would immediately inform the Director of Nursing (DON) or Administration. Staff E stated the incident needs to be reported to the State Agency within two hours of discovery. During an interview on 3/14/24 at 11:24 AM, the DON stated the 1/6/24 Health Status note did not get seen until 1/12/24 due to the type of documentation audit report ran. The DON stated this problem has since been corrected. The DON stated Abuse and Neglect training, including reporting timelines, is completed upon staff hire, annually, and as needed. The DON stated the facility held an Abuse and Neglect training on 1/12/24 after discovery of the allegation. The DON stated she expects staff to immediately inform herself or the Administrator of an abuse allegation. The DON stated the allegation should be reported within two hours of discovery. The facility policy, dated 7/6/2023, titled Abuse and Neglect, The policy directed staff to immediately report alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin to the Administrator.

Based on clinical record review, staff interview, and policy review the facility failed to have the minimum required members of the Quality Assessment and Assurance (QAA) committee present to identify issues for which Quality Assessment and Assurance activities are necessary. The facility reported a census of 82. Findings include: Review of the facility QAA sign in sheets dated 4/17/23 and 9/18/23 revealed the Director of Nursing (DON) failed to attend the quarterly meetings. In an interview on 3/14/24 at 12:30 PM, the Administrator explained that the core members of the QAA Committee included the Medical Director, RN Supervisors, DON, Infection Preventionist, Social Worker, and Dietary. She failed to know the facility lacked DON attendance at two quarterly meetings. Review of the policy titled Quality Assurance and Performance Improvement- QAPI revised 10/09/23 instructed the QAPI Committee to meet quarterly at a minimum. The Committee must consist of the DON, Infection Preventionist, Medical Director, and at least three other members to include the Administrator or other leadership.

Based on clinical record review, staff interview, and policy review the facility failed to provide the required Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice form (CMS 10055) at the completion of the skilled services for 1 of 3 residents reviewed (Resident #68). The facility reported a census of 82. Findings include: The Minimum Data Set assessment dated [DATE] for Resident #68 documented diagnoses that included: spastic hemiplegia affecting left nondominant side (inability to move the left side of the body), cancer, and Cerebral Palsy (a group of diseases affecting movement of the body). The Brief Interview for Mental Status (BIMS) score was 15/15 indicating no cognitive impairment. Review of Resident #68's record revealed the resident received skilled services in the facility from 9/15/2023 through 10/05/2023. At the completion of skilled services, Resident #68 remained in the facility. The record lacked the notification by the facility of form CMS 10055 as required to indicate the need to pay privately to remain in the facility and options to privately pay for skilled therapies. During an interview on 3/12/24 at 3:24 PM, the Business Office Manager confirmed the facility failed to provide the CMS 10055 form to Resident #68. On 3/13/24 at 10:52 AM the Administrator explained she expected the Business Office to provide the Notice of Medicare Noncoverage and CMS 10055 forms to acknowledge skilled services are ending when nearing completion of skilled therapies. The office must explain the costs to stay and to continue therapy private-pay. The facility policy titled Discharge and Transfer- Rehab/Skilled, Therapy & Rehab revised 1/03/24 instructed staff to notify the resident and representative of the transfer or discharge and the reason for the move in writing. The state-required forms serve as the written notice.

Based on observations, clinical record review, policy review, resident and staff interviews the facility failed to complete self medication assessments, and obtain a physician order to self medicate for 4 of 6 residents in the sample (Resident #11, Resident #10, Resident #5, and Resident #7.) The facility reported a census of 90 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 6/7/23, listed diagnoses for Resident #11 that included: Diabetes mellitus; anxiety disorder, and depression disorder. The MDS assessed the resident required extensive assistance of one staff for personal hygiene tasks. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A review of the clinical record revealed a physician order, dated 3/29/23, for Tums 500 mg chewable 1 tab by mouth daily for heartburn. During an observation on 9/14/23 at 7:36 AM, Staff A, Registered Nurse, administered Resident #11 morning medications. After the resident took the medications, Staff A placed a Tums 500 mg chewable tab in a medication cup and handed the cup to the resident. Staff A stated the resident takes the Tums after she finishes her breakfast. Resident #11 wheeled herself to the dining room and placed the medication cup on the dining room table. During a continuous observation from 7:44 AM to 8:34 AM, Resident #11 ate breakfast in the dining room with two other residents at the table. The Tums tablet sat on the table in a medication cup. The resident placed the Tums in her mouth at 8:34 AM. A record review revealed a lack of a self medication assessment or physician order for Resident #11 to self administer Tums. During a interview on 9/14/23 at 9:59 AM, Staff A stated it is common for Resident #11 to take the Tums to the dining room table and take when she is done with breakfast. Staff A stated the resident does not have a physician's order to self administer her medications. Staff A stated the resident should not be given medications to take later without a nurse present. 2. The Minimum Data Set (MDS) assessment tool, dated 6/1/23, listed diagnoses for Resident #10 that included: Chronic respiratory failure with hypoxia (low blood oxygen level), atrial fibrillation (irregular heart beat), heart failure, and diabetes mellitus. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an observation on 9/14/23 at 7:24 AM, Resident #11 stated to Staff B, Licensed Practical Nurse I suppose I need to take my pills now while someone is watching. Staff B agreed to take the medication out of the room and return when the resident received his breakfast tray. The clinical record revealed physician orders for the following medications at 8:00 AM: a. Amiodarone HCL 200 mg (milligrams)1 tab by mouth daily b. Magnesium 400 mg 1 tab by mouth daily c. Metolazone 2.5 mg 1 tab by mouth daily d. Metoprolol 25 mg 1 tab by mouth daily e. Prednisone 1 mg 2 tabs by mouth daily f. Prednisone 5 mg 1 tab by mouth daily g. Vitamin D3 50 mcg (micrograms) 1 tab twice daily h. Apixaban 5 mg 1 tab by mouth daily i. Doxycycline hyclate 100 mg 1 tab by mouth twice daily j. Mucinex ER (extended release) 12 hour 600 mg 1 tab by mouth twice daily k. Potassium chloride crystals ER 10 mEq (milliequivalents) give 40 mEq by mouth twice daily l. Senna-docusate sodium 8.6-50 mg 2 tabs by mouth twice daily m. Torsemide 20 mg 2 tabs by mouth twice daily n. Hydrocodone-Acetaminophen 5-325 mg 1 tab by mouth three times a day o. Zoloft 50 mg 1 tab by mouth daily During an interview on 9/14/23 at 9:29 AM, Resident #11 stated nurses give him his morning medications in a med cup and then leave the room. The resident stated he needs to take the medications while he is eating breakfast to avoid his stomach becoming upset. The resident stated the nurses do not wait in the room while he takes his medications. A record review revealed a lack of a self administration assessment or physician's order for the resident to self administer medication. 3. The Minimum Data Set (MDS) assessment tool, dated 6/1/23, listed diagnoses for Resident #7 that included: Alzheimer's disease, anxiety disorder, and hypertension. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating a moderate cognitive impairment. The clinical record revealed physician orders for the following medications: a. Amlodipine 10 mg 1 tab by mouth daily b. Aricept 5 mg 1 tab by mouth daily c. Escitalopram oxalate 10 mg 1 tab by mouth daily d. Lisinopril 40 mg 1 tab by mouth daily e. Metoprolol tartrate 100 mg 1 tab by mouth twice daily f. Vitamin D3 2000 units 1 tab mouth daily During an interview on 9/14/23 at 8:44 AM, a family member stated they found medications in a medication cup in the residents room on three different occasions, most recently on 9/9/23. The family member stated they have found the medications on the bedside table, and in a drawer of the residents night stand. A review of the clinical record revealed a Health Status note dated 9/9/23 documenting a family member notifying a facility nurse they found pills in the residents room. A record review revealed a lack of a self administration assessment or physician's order for the resident to self administer medication. 4. The Minimum Data Set (MDS) assessment tool, dated 6/1/23, listed diagnoses for Resident #5 that included: Parkinson's disease, fibromyalgia (widespread muscle pain and tenderness), and depression. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an interview on 9/13/23 at 10:34 AM, Resident #5 stated there are two nurses who will leave medications on the dinner table for her to take with her meal. The resident stated the nurses do not stay until she takes the medication. She stated these nurses do this because they know her and trust she will take them. A record review revealed a lack of a self administration assessment or physician's order for the resident to self administer medication. During an interview on 9/14/23 at 1:10 PM, the Director of Nursing (DON) stated she is unaware of any residents in the facility who are able to self administer medications. The DON stated if a resident is able to self administer medications they would have a Resident Self Administration Assessment completed in the electronic health record, and a physician's order for each specific medication they can self administer. The DON also stated the resident would have the ability to self administer medications added to their Care Plan, including a plan of where the medications are stored. The DON stated if a resident is not assessed as able to self administer a medication with the required physician's order, she would expect a nurse to stay in the room and observe a resident take and swallow all medications before leaving. A facility policy, dated 10/21/22, titled Resident Self-Administration of Medication listed six steps should be completed before obtaining a physician's order for a resident to self medicate. These steps include: 1. Complete Resident Self Administration Assessment 2. Interdisciplinary team (IDT) determines specific educational needs the resident may require 3. The IDT determines where medications will be stored 4. The IDT determines the location of where the medication will be self administered 5. The IDT determines who will document the medication administration 6. The IDT determination that the resident can safely self administer medications must be documented in the Resident Self Administration of Medication UDA (User-Defined Assessments).

Based on kitchen observations and staff interviews, the facility failed to prepare and serve food under sanitary conditions. The facility reported a census of 90 residents. Findings Include: The initial kitchen observations for the Main Kitchen on 4/03/23 with the Dietary Manager (DM) at 11:15 AM, revealed contaminated equipment. During the initial kitchen observation the following noted: a. Prior to entering the kitchen a drink dispensing area outside of the main kitchen noted with a refrigerator. A temperature log for the month of April 2023 affixed to the outside of the refrigerator, with 4/1/23 to 4/3/23 blank indicating no refrigerator temperature checks completed those days. b. Once inside the main kitchen the Dietary Manager stated a vendor had been called to look at the sink where resident dishes rinsed prior to being placed within the dishwasher. The DM stated the water sprayer nozzle needed maintenance as the nozzle not turning completely to off. The DM stated the vendor on site in the last week. c. A commercial brand, Star Max Grill noted next to a commercial gas burner range, with visible build-up of black substance on the grate. The grill set on wheeled casters with visible black hair and gray substance on all four casters. d. A Southbend commercial brand six gas burner range with a griddle set next to the grill, noting the gas burners with a build-up of black substance. e. Located behind the aforementioned two pieces of equipment was a divider wall approximately four feet in high and approximately twelve inches wide. The counter top (12-inch wide) had a layer of visible grime with fingerprint marks. f. Behind the divider noted two [NAME] commercial ovens stacked with double vertical opening doors with a buildup of dried grease and grime on the oven glass and the stainless steel above and below the oven glass doors. The substance buildup blocked viewing inside the oven and the oven windows had visible vertical streaks. The back of the ovens contained an exposed vent system and the horizontal vents observed with a gray substance hanging from the vents. g. Adjacent to the kitchen in the separate dry goods storage room noted the four ceiling heating, ventilation, and air conditioning (HVAC) vents approximately three feet by 2 feet in size, with visible gray substance on the vents and the surrounding ceiling. h. The floors throughout the kitchen noted with spotty dried substance and sticky to the bottom of shoes. g. All freezers and refrigerators with April 2023 temperature logs affixed to the front of them however the logs not filled out 4/01/23 to 4/03/23. On 4/04/23 at 9:32 AM, another observation took place in the main kitchen with the following noted: a. The floor in front of the pureed area sticky. b. The Southbend gas burner stove noted with brown dried substance on the front approximately four inches in length. c. Above the Southbend gas burner, pipes noted with a gray substance approximately three inches in length dangling from the pipes. d. All wheeled casters located on the bottom of equipment noted with a dried brown material on the casters and gray substances attached and dangling. On 4/04/23 at 12:00 PM, an initial observation completed of Kitchen #3, with the following noted:. a. A Scotsman Prodigy ice machine located outside of the kitchen, observed the top left side of the ice machine had a horizontal vent area with a gray substance buildup and some substance dangling from the horizontal vent. The top left outside of the gray ice machine with white streaks down the side of the machine. The ice machine had a plastic material shelf above the lid with white buildup and below the lid located on the left side, noted a white substance running down the left side and also the right side of machine noted with white streaks running down the side. The top right side of machine had a gray substance blowing out from the top. b. Located directly across from the Kitchen #3 ice machine, a hand washing sink and counter area observed and in front of the handwashing sink noted small brown ants. The cabinet door below the sink opened and observed evidence of rodent excrement. c. Kitchen #3's commercial brand Traulsen side by side refrigerator with an April 2023 temperature log noted, however no documentation seen on the log. When the right-side door of the refrigerator opened, observed evidence of a dried white substance on the inside wall near a milk area. When the left side door opened observed a pink color dried substance on the inside wall near the back. d. A blank April 2023 temperature log attached to a refrigerator prior to entering Kitchen #3 noted. e. A tabletop Adcraft griddle placed on a stainless-steel table noted on the left side with a buildup of brown and black substance on the outside of it. f. Directly above the serving steam table a minimum of ten ceiling tiles and an HVAC vent contained a heavy visible gray and brown substance, with some of the gray substance floating in the air at times. g. Racks of drinking glasses stacked on a clean glass rack, with white residue of some type on the inside and outside of the glasses. h. The Kitchen #3 Floor sticky and observed back and gray substances in spots. i. Observed a counter to have plastic grocery bags with individual snacks lying on top of them and no dates provided on the outside of the packages. In an interview with the DM on 4/4/23 at 12:30 PM, the question of the clean glass racks appearance discussed. The DM stated each kitchen had a separate water softener and even though the softener had been relatively new there had to be a part ordered for the Kitchen #3 softener. The DM further stated having to check with the facility Maintenance Director to see if the softener part had been ordered. The DM unable to state what the visible residue was when asked. On 4/04/23 at 12:38 PM, the DM shown the small brown ants located in front of the handwashing sink and the inside of the cupboard located below the sink and asked what the substance was. The DM stated the substance appeared to be from mouse droppings, however the DM stated unaware there had been any recently. The DM was asked if the facility maintained an Extermination Service and if a policy in place. The DM stated the Extermination Service provided monthly and could be provided more frequently when needed.

Based on kitchen observations and staff interviews the facility failed to maintain a clean kitchen free of rodents and other insects. The facility reported a census of 90 residents. Findings Include: On 4/04/23 at 12:00 PM, an initial observation of Kitchen #3 completed finding a handwashing sink and counter area. In front of the handwashing sink noted small brown ants. When the cabinet door below the sink opened observed evidence of rodent excrement. On 4/04/23 at 12:38 PM, the Dietary Manager (DM) shown the small brown ants located in front of the handwashing sink and the inside of the cupboard located below the sink and asked what the substance was. The DM stated the substance appeared to be from mouse droppings, however the DM stated unaware there had been any recently. The DM was asked if the facility maintained an Extermination Service and if a policy in place. The DM stated the Extermination Service provided monthly and could be provided more frequently when needed. During an interview on 4/6/23 at 3:00 PM, when asking the Director of Nursing (DON) for a policy on Facility Extermination Maintenance the facility Administrator joined the conversation and asked, have you seen anything else? The Administrator continued, stating the facility had taken care of the squirrel issue by putting plywood in place now. The DON then stated, the mice issue had been a hygiene cleanliness issue as we haven't seen any mice since November 2022 and the Exterminator had come and sprayed for ants the date you saw them. No Extermination policy presented at this time.

Based on record review, observation, staff interviews and facility policy review, the facility failed to address Advance Directives (Legal documents that provide instructions for medical care when a person is unable to communicate their wishes) on admission for 1 of 24 residents reviewed for Advanced Directives (Resident #292). The facility reported a census of 90. Findings include: The Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #292 not completed. The Medical Diagnoses dated [DATE] for Resident #292 were the following: a. COVID-19. b. Chronic Atrial Fibrillation, unspecified. c. Chronic Kidney Disease- Stage 4. d. Transient cerebral ischemic attack, unspecified. The resident admitted to the facility on [DATE]. Record Review on [DATE] at 12:13 PM, Resident #292's Electronic Medical Record (EMR) lacked documentation of the resident's Advanced Directives. The EMR also lacked documentation for an Advance Directive order. During an interview on [DATE] at 2:35 PM, queried Staff C, Licensed Practical Nurse (LPN) where the Advanced Directives were found and she stated here in the binder (binder at the Nurse's Station). Staff C asked if Advanced Directives were addressed on admission and she stated yes, usually. Staff C queried what Resident #292's Advanced Directives were and she stated she usually looked on the Face Sheet of the EMR and the resident's Iowa Physician Orders for Scope of Treatment (IPOST) placed in the binder if they had one on file. Staff C queried if a resident stopped breathing and Advanced Directives couldn't be found what interventions would be done and she stated start Cardiopulmonary Resuscitation (CPR). During an observation on [DATE] at 2:38 PM, Staff C reviewed the EMR for resident #292 and did not locate his Advanced Directives and she reviewed the IPOST binder and did not locate an IPOST for Resident #292. On [DATE] at 2:53 PM, reviewed the entire IPOST binder and an IPOST for Resident #292 not found. During an interview on [DATE] at 1:32 PM, the Interim Director of Nursing (DON) queried where Advanced Directives were located and she stated the IPOST are in the Social Services office and the IPOST should be scanned in and orders entered in the chart. The DON asked the expectation of Advance Directives being addressed and she stated upon admission they got a copy of them and if the resident didn't have one they asked the resident or family member to fill out an IPOST and if they didn't want one filled out, they would have an order for Code Status and when they wouldn't give an answer they would be a Full Code. The DON queried who addressed Advanced Directives and she stated Social Services. She stated if Advanced Directives not addressed the resident would be a Full Code until the Advanced Directives were addressed. The Facility Policy Advance Care Planning for Rehab Services and Long Term Care dated [DATE] revealed the following: a. At the time of admission or readmission, Social Services or designated staff member would inform resident/healthcare decision-maker of the right to consent to or refuse medical treatment and provided copies of this policy and appropriate state statue, regulations, and regulations and information regarding Advanced Directives to resident/families. b. The Social Worker asked the resident/healthcare decision-maker whether he or she had prepared an Advanced Directives such as a Living Will, Durable Power of Attorney for healthcare decisions, guardianship, portable and enduring order form, etc. If Advance Directives had been formulated, a copy would be scanned into the Medical Record.

Based on observation, record review, and staff interviews, the facility failed to implement appropriate Pressure Sore prevention interventions, complete regular skin assessments and document the assessments, which resulted in an unstageable Pressure Sore and subsequent Pressure Sore developments for 1 of 3 residents reviewed identified with Pressure Sores (Resident #1). The facility reported a census of 98 residents. Findings Include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). May be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. The 10/17/21 Admission Minimum Data Set (MDS) Assessment revealed Resident #1 admitted to the facility 10/11/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Area Assessment (CAA) Summary on the MDS identified the resident at risk for Pressure Sores, and interventions that addressed Pressure Sore prevention implemented on the nursing care plan. Hospital Physician Discharge orders dated 10/11/21 directed the resident's admission to the facility with non weight-bearing to right leg, full-length right leg immobilizer brace on while out of bed, gentle Range of Motion (ROM) exercises to knee appropriate, and Physical, Occupational and Speech Therapy Services to evaluate and treat the resident and provide any necessary equipment. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Assessment completed by Staff A, Registered Nurse (RN), identified as the facility's Wound Nurse, identified the resident had a surgical incision with applied dressing on the right upper leg, open wounds less than 0.5 centimeters (cm) around on either side of bottom jaw, and no other skin concerns recorded. Braden Scale Skin Assessment tools that identifies a person's risk for pressure sore development completed 10/12/21 identified a risk score of 14.0, at moderate risk for development of Pressure Sores. A potential for Pressure Sore development related to immobility problem initiated 10/11/21 on the Nursing Care Plan directed staff: a. Remind/Assist to turn/reposition at least every 2-3 hours. b. Provide pressure relieving/reducing device on bed. c. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. The facility's Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy dated as last revised 4/26/22, directed staff: a. Use Braden Scale for Predicting Pressure Sore Risk Assessment on admission and weekly for the first 4 weeks following admission. b. A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant will report any abnormal findings or signs of impairment to the nurse. c. Residents unable to reposition themselves independently should be repositioned as often as directed by the care plan. d. If a pressure ulcer is identified, the Registered Nurse (RN) should record the type of wound and degree of tissue damage on the Wound RN Assessment form. e. Record the location of the area, measurements and characteristics on the Wound Data Collection form. f. Notify the physician/practitioner to obtain orders for treatment, and notify the resident and/or family of the pressure ulcer and planned interventions. g. Dietary is notified by an alert from the Wound Data collection form. h. The interdisciplinary team should determine any modifications that are necessary to the resident's plan of care. i. The Pressure Sore should be assessed weekly and documented on the Wound RN Assessment form. A Nursing Progress Note entry on 12/6/21 by Staff A stated resident has unstageable Pressure Sore of right knee - appears related to knee immobilizer. Area cleansed with Normal Saline (NS) and dressing applied. Verbally notified Advanced Registered Nurse Practitioner (ARNP) and obtained orders. Review of all nursing documentation between 10/11/21 and 12/6/21 revealed no documentation of any abnormal skin assessments or concerns other than that described here: a. A Skin Assessment V-2 form completed by Staff A on 12/6/21 described a 4.5 centimeter (cm) by 2.5 cm area of eschar on the right knee, an unstageable Pressure Sore, with minimal serous drainage, surrounding tissue pink, physician notified and orders to cleanse the area with NS, apply Xeroform gauze and bordered foam dressings to area daily, and a non-bordered foam dressing placed between the brace and skin to prevent further breakdown. b. A Wound RN Assessment Form completed by Staff A on 12/6/21 described the leg immobilizer brace caused the unstageable Pressure Sore on the right knee. An unstageable Pressure Sore/ulcer is an ulcer having full thickness tissue loss, in which the base of the ulcer cannot be observed, usually because the wound bed is covered by slough or eschar tissue. Eschar tissue is dead tissue that sheds or falls off from the skin, is typically tan, brown, or black, and may be crusty. Slough tissue is yellow devitalized tissue, that can be stringy or thick and adherent on the wound bed. Additional Pressure Sore documentation completed by Staff A revealed: a. On 12/13/21 - 4.0 cm by 2.0 cm by 0 cm, wound bed 100 percent slough tissue, minimal serous (yellow liquid) drainage. b. On 12/20/21 - 1.5 cm by 1.2 cm by 0.2 cm, wound bed 50 percent slough and 50 percent granulation tissues, minimal serous drainage., c. On 12/22/21 - 2.1 cm by 1.2 cm by 0.1 cm, wound bed 90 percent slough tissue, moderate serosanguinous drainage (yellow mixed with red blood liquid), wound care orders changed to apply [MEDICATION(S)] to wound bed, cover with silver alginate dry dressing daily. d. On 1/5/22 - 3.5 cm by 1.5 cm by 0.2 cm, increased granulation tissue, moderate serous drainage. e. On 1/26/22 - 2.1 cm by 0.9 cm by 0.1 cm, moderate serous drainage. f. On 2/18/22 - 1.8 cm by 1.1 cm by 0.1 cm, moderate serous drainage. As of 2/23/22, the facility had not identified any other Pressure Sores or skin abnormalities. The resident was hospitalized [DATE] , where hospital staff noted the following Pressure Sores upon admission: a. Posterior Sacrum Deep Tissue Injury Pressure Sore that measured 4.0 cm by 5.0 cm by 0.1 cm, wound color purple, non-blanchable slough tissue, with serosanguinous drainage and macerated, defined wound edges. b. Right Posterior Ischium Deep Tissue Pressure Sore that measured 1.5 cm by 1.5 cm by 0.1 cm, wound color purple, non-blanchable, with serosanguinous drainage, the surrounding tissue erythemic (bright red) more than 2 cm surrounded the wound. c. Right Posterior Heel Deep Tissue Injury Pressure Sore that measured 2.2 cm by 2.2 cm, wound color purple, non blanchable, without drainage. d. Left Posterior Heel Deep Tissue Injury that measured 2.0 cm by 3.0 cm, wound color purple, non blanchable, without drainage. e. Right Shin/Knee (the pre-existing Pressure Sore) that measured 2.0 cm by 1.5 cm by 0.1 cm, slough wound tissue with serosanguinous drainage. The resident returned to the facility on [DATE]. As of 7/12/22, the resident continued to require treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Recent assessment documents revealed: a. On 6/11/22, area measured 3.0 cm by 1.0 cm by 0.1 cm, wound bed 90 percent granulation tissue, 10 percent slough tissue, and dressing changes twice daily with Dakin's Solution (an antiseptic) soaked gauze applied to the wound, covered by a dry dressing. b. On 7/7/22, the assessment revealed 100 percent granulation tissue at wound bed, no recorded measurements, with moderate serous drainage, and daily dressing changes with Dakin's solution soaked gauze applied to the wound, covered with a large gauze dressing and secured with rolled gauze. Staff interviews revealed: a. On 7/7/22 at 10:10 a.m., Staff A, RN and Wound Nurse stated she was notified by Nursing Staff of a skin concern on 12/6/21, she thought the staff had not removed the immobilizer and had showered the resident with it on, it presented as a full-thickness unstageabe Pressure Sore. b. On 7/11/22 at 3:08 p.m., Staff A reviewed photos included in the resident's 3/7/22 hospital discharge documents and indicated the Right Shin/Knee Pressure Sore was what the resident developed on 12/6/21, stated the area was under a Velcro strap closure on the full length leg immobilizer (that caused the pressure injury), and Nursing Staff should always assess a resident's skin conditions, circulation, motion and sensation of any body part when a cast or restrictive device such as an immobilizer is used, at least every shift.

Based on observation, record review, staff, physician, Pharmacist and family member interviews, the facility failed to provide a medication regimen free from unnecessary [CONDITION(S)] medications, administered [CONDITION(S)] medications without assessment and documentation of the need for the medication, which resulted in the resident's confusion, physical decline, repeated falls, and inability to participate in physician ordered skilled Physical and Occupational Therapy services for strengthening and return to independence for 1 of 9 resident records reviewed (Resident #3). The facility reported a census of 102 residents. Findings include: The 9/7/21 Minimum Data Set (MDS) Assessment Tool revealed Resident #3 with diagnoses that included [CONDITION(S)] (a stroke), diabetes, non-traumatic subdural hemorrhage (bleeding on the brain), depression and generalized muscle weakness, scored 10 out of 15 possible points on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, without symptoms of [CONDITION(S)] or any behavioral symptoms. Resident #3 identified received physical therapy treatment 194 minutes, occupational therapy treatment 190 minutes and 80 minutes of co-therapy treatment by Physical and Occupational Therapists on 4 of 7 days that preceded the assessment. The MDS indicated the resident required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed or chair, ambulation, dressing, eating, bathing, personal hygiene and toileting. Resident #3 documented able to make self-understood and understood others, had occasional pain rated at 10 on a 0 to 10 pain scale, with 10 rated as the worst pain on the 5 days that preceded the assessment, the pain didn't effect sleep but limited his day-to-day activities. The resident had 2 or more falls without injury since admission to the facility 9/1/21. The assessment revealed both the resident and direct care staff believed the resident was capable of increased independence in at least some activities of daily living (ADL's), an active discharge plan under development, and the resident and family expected discharge to the community at the conclusion of care. 9/1/21 Physician Orders directed the resident's admission to a skilled care facility, to wear a Miami J cervical neck brace collar all times when out of bed, receive Physical and Occupational Therapy services to evaluate and treat the resident, advance activity level as tolerated, follow-up appointment with the physician on 9/27/21 and medication orders that included: a. [MEDICATION(S)] 2 milligram (mg) tablet, administer 1 or 2 tablets (2 mg or 4 mg doses) oral (po) every 4 hours as needed (prn) for pain. [MEDICATION(S)] is a very strong opioid narcotic [MEDICATION(S)]. b. [MEDICATION(S)] 25 mg administered po every 4 hours prn for anxiety. [MEDICATION(S)] is an antihistamine medication that caused drowsiness. c. [MEDICATION(S)] 5 mg tablet administered po daily at hour of sleep (HS). [MEDICATION(S)] is a strong antipsychotic medication, normally prescribed for treatment of [CONDITION(S)] and psychotic disorders. d. [MEDICATION(S)] 25 mg administered po HS prn to treat a subdural hemorrhage. [MEDICATION(S)] is an antidepressant with common side effects that included drowsiness and tiredness, per website https://www.drugs.com/[MEDICATION(S)].html. e. Buproprion 150 mg extended release tablet administered po daily (antidepressant medication) . f. [MEDICATION(S)] 20 mg administered oral daily. [MEDICATION(S)], trademark name [MEDICATION(S)], is an SSRI antidepressant medication (Selective Serotonin Reuptake Inhibitor). g. [MEDICATION(S)], a natural human hormone that caused sleep, 5 mg administered po daily at HS. The [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Buproprion and [MEDICATION(S)] medication orders were flagged with Black Box warnings in the electronic record; A Black Box warning alerts the provider and staff of potentially serious adverse reactions that could lead to hospitalization and death. A black box warning also explained how reactions could be worse in certain groups of people, such as women who are pregnant or the elderly. The Opioid Black Box warning stated the concurrent use of opioids and benzodiazepines increased the risk of fatal overdose, per website https://medlineplus.gov/druginfo/meds/a 3.html. The [MEDICATION(S)] Black Box warning described increased death and heart-related side effects in seniors with dementia-related [CONDITION(S)], and [MEDICATION(S)] not approved for treatment of dementia related [CONDITION(S)], per website https://pi.lilly.com/us/[MEDICATION(S)]-pi.pdf. The [MEDICATION(S)] Black Box warning described increased suicidal thoughts and behaviors in children, adolescents and young adults, per website https://www.drugwatch.com/ssri/[MEDICATION(S)]/. An automated alert in the resident's electronic record at 5:27 p.m. on 9/1/21 notified the physician of severe drug to drug interactions that included: a. Severe increased risk for Serotonin Syndrome from [MEDICATION(S)] and [MEDICATION(S)] administration. b. Moderate risk for Serotonin Syndrome from [MEDICATION(S)] and [MEDICATION(S)] administration. c. Moderate risk for Neuroleptic Malignant Syndrome from [MEDICATION(S)] and [MEDICATION(S)] administration. The website https://www.webmd.com/depression/guide/serotonin-syndrome described Serotonin Syndrome as too much Serotonin, a chemical in the body, usually because of medication or combinations of medications, often began hours after a new medication that affected Serotonin levels were administered or after current drug dosage increased, and symptoms of Serotonin Syndrome included, but not limited to: a. Confusion. b. Agitation or restlessness. c. Headache. d. Changes in blood pressure and/or temperature. e. Tremor. f. Loss of muscle control or twitching muscles. The website https://www.webmd.com/[CONDITION(S)]/guide/what-is-neuroleptic-malignant-syndrome described Neuroleptic Malignant Syndrome (NMS) as a rare reaction to antipsychotic drugs that affect the nervous system and can cause symptoms within 2 weeks after medication initiated, or dosage changed, that include, but not limited to: a. High fever (102 to 104 degrees Fahrenheit). b. Muscle stiffness. c. Profuse sweating. d. Anxiety or other changes in mental state. e. Fast or abnormal heartbeat. NMS can damage muscles and cause very high or low blood pressure, if untreated, more serious conditions could result that required immediate medical treatment and included: a. Kidney failure. b. Heart and lung failure. c. Lack of oxygen in the body. d. Infection in the lungs caused by breathing in fluid (aspiration pneumonia). Other Physician Orders changed the medication regimen as follows: a. On 9/9/21 discontinue prn [MEDICATION(S)]. Start [MEDICATION(S)] 25 mg administered po daily at HS. b. On 9/14/21 [MEDICATION(S)] 1500 mg administered po 3 times daily through 9/30/21, then decreased to 1000 mg administered po 3 times a day from 10/1/21 through 10/21/21. [MEDICATION(S)] is a strong skeletal muscle relaxer with common side effects that included drowsiness, confusion, memory problems, loss of balance or coordination, light-headedness and dizziness, per website https://www.rxlist.com/[MEDICATION(S)]-side-effects-drug-center.htm. c. On 9/19/21 discontinue [MEDICATION(S)] ordered daily at HS. Start [MEDICATION(S)] 5 mg po twice daily. d. On 9/27/21 [MEDICATION(S)] discontinued. e. On 9/27/21 [MEDICATION(S)] 0.25 mg administered po every 8 hours prn for anxiety. [MEDICATION(S)] is a strong Benzodiazepine anti-anxiety medication, a Schedule IV controlled narcotic with a Black Box warning that stated taking benzodiazepines at the same time as opioids can lead to extreme sedation, slow and ineffective breathing, [NAME], and even death, per website https://www.center4research.org/fda-updates-black-box-warning-for-benzodiazepines/. e. On 10/4/21 discontinue [MEDICATION(S)]. f. On 10/6/21 discontinue [MEDICATION(S)]. g. On 10/9/21 discontinue [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. h. On 10/9/21 [MEDICATION(S)] decreased from po twice daily to once daily at HS. Medication Administration Records (MAR's) and narcotic inventory control sheets revealed the following medications administered to the resident: [MEDICATION(S)] 2 mg Discontinued 10/6/21, stock on hand destroyed: a. On 9/4/21 at 6:10 a.m. by Staff A, Licensed Practical Nurse (LPN). b. On 9/7/21 at 8:45 p.m. by Staff B, Registered Nurse (RN). c. On 9/12/21 at 3:45 p.m. by Staff C, RN. d. On 9/13/21 at 11:55 p.m. by Staff A, LPN. e. On 9/23/21 at 5:45 a.m. by Staff A, LPN. f. On 9/24/21 at 8:10 p.m. by Staff D, RN. g. On 9/29/21 at 8:00 p.m. by Staff E, Certified Medication Aide (CMA), not recorded on MAR. h. On 10/2/21 at 8:48 p.m. by Staff D, RN. [MEDICATION(S)] 4 mg Discontinued 10/6/21, stock on hand destroyed: a. On 9/1/21 at 9:10 p.m. by Staff D, RN. b. On 9/3/21 at 9:30 a.m. by Staff F, CMA. c. On 9/4/21 at 12:00 p.m. by Staff F, CMA. d. On 9/4/21 at 8:00 p.m. by Staff E, CMA. e. On 9/5/21 at 6:21 p.m. by Staff G, LPN. f. On 9/8/21 at 9:30 a.m. by Staff E, CMA. g. On 9/8/21 at 8:00 p.m. by Staff E, CMA. h. On 9/9/21 time and signature not recorded, assigned to Staff A, LPN, not recorded on MAR. i. On 9/9/21 at 9:00 p.m. by Staff F, CMA. j. On 9/12/21 at 8:00 p.m. by Staff H, LPN, not recorded on MAR. k. On 9/14/21 at 8:00 p.m. by Staff H, LPN. l. On 9/15/21 at 8:00 p.m. by Staff G, LPN. m. On 9/16/21 at 8:00 p.m. by Staff H LPN, not recorded on MAR. n. On 9/30/21 at 8:00 p.m. by Staff E, CMA. o. On 10/5/21 at 2:45 p.m. by Staff H, LPN, not recorded on MAR. p. On 10/5/21 at 8:00 p.m. by Staff H, LPN, not recorded on MAR. [MEDICATION(S)] 25 mg every 4 hours as needed (prn) discontinued 9/27/21: a. On 9/1/21 at 7:48 p.m. by Staff I, LPN. b. On 9/8/21 at 10:38 a.m. by Staff E, CMA. c. On 9/12/21 at 3:42 p.m. by Staff C, LPN. d. On 9/25/21 at 5:29 p.m. by Staff C, LPN. [MEDICATION(S)] 0.25 mg every 8 hours prn started 9/27/21, discounted 10/9/21, stock on hand destroyed: a. On 9/27/21 at 7:10 p.m. by Staff B, RN. b. On 9/29/21 at 6:00 p.m. by Staff E, CMA. c. On 9/30/21 at 8:00 p.m. by Staff E, CMA. d. On 10/2/21 at 8:48 p.m. by Staff D, RN. e. On 10/4/21 at 8:00 p.m. by Staff J, LPN. f. On 10/5/21 at 8:00 p.m. by Staff H, LPN, not recorded on MAR. [MEDICATION(S)] 25 mg as needed at HS, discontinued 9/9/21, changed to HS daily: a. On 9/1/21 at 8:10 p.m. by Staff D, RN. b. On 9/4/21 at 7:28 p.m. by Staff E, CMA. c. On 9/5/21 at 8:01 p.m. by Staff G, LPN. d. 9/7/21 at 8:51 p.m. by Staff B, RN. e. On 9/8/21 at 10:38 a.m. by Staff E, CMA (a medication error the facility was not aware of until the investigation). Pharmacy invoices revealed the following account of [MEDICATION(S)]: a. 14 doses [MEDICATION(S)] 25 mg tablets dispensed 9/1/21. b. 14 doses [MEDICATION(S)] 25 mg tablets dispensed 9/9/21. c. 14 doses [MEDICATION(S)] 25 mg tablets dispensed 9/23/21. d. 7 doses [MEDICATION(S)] 25 mg tablets dispensed 9/30/21. e. 9 doses [MEDICATION(S)] 25 mg tablets dispensed 10/6/21. f. A total of 58 doses received. g. A total of 34 documented doses recorded on the MAR. h. A total of 7 doses returned to the pharmacy after 10/9/21 discontinuation order. g. A total of 17 doses were not recorded and unaccounted for as of 10/19/21. Pharmacy invoices revealed the following account of [MEDICATION(S)]: a. 15 [MEDICATION(S)] 25 mg tablets dispensed 9/1/21. b. 15 [MEDICATION(S)] 25 mg tablets dispensed 9/23/21. c. A total of 30 doses received. d. A total of 4 documented doses recorded on the MAR. e. A total of 21 doses returned to the pharmacy after 9/27/21 discontinuation order. 5 [MEDICATION(S)] doses were not recorded and not accounted for as of 10/19/21. Nursing Progress Notes in the resident's record did not describe behaviors or indications of anxiety at times when [MEDICATION(S)] or [MEDICATION(S)] were administered. The computer software used for medication administration documentation placed an automated notation in the Nursing Progress Notes when staff administered a prn medication that stated the order, i.e. [MEDICATION(S)] 25 mg administered oral every 4 hours as needed for anxiety, appeared in the Progress Note, but without any description of the resident's anxiety or why the resident required the medication. A Hospital ER Progress Note dated 9/28/21 at 8:15 p.m., revealed the resident seen for altered mental status, confusion, falls, worsened mental status and motor function. Upon presentation to the hospital was unable to ambulate, speech mumbled and spoke in broken sentences. A CT (computed tomography) scan of head negative for changes, chest X-ray and lab work negative for findings, diagnosed that symptoms were possibly secondary to polypharmacy from new medications prescribed at facility, and resident discharged to the facility with recommendation for close follow-up with primary care provider. The resident returned to facility 9/29/21 at 1:45 a.m. A [CONDITION(S)] Medication Use related to depression and behavioral outburst problem, initiated on the Nursing Care Plan 9/1/21, with an 11/1/21 goal the resident would be free from discomfort or adverse reactions related to antidepressant therapy (implementation date in parenthesis at end of goal), directed staff on the following: a. Educate resident/family about risks, benefits, side effects and toxic symptoms of medication (9/1/21). b. Report confusion, mood charge, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideation, withdrawal, decline in ability to help with/do activities of daily living (ADL's), cognitive function, shuffled gait, difficulty ambulating, balance problems, falls, fatigue, [CONDITION(S)], appetite loss, weight loss to the nurse (9/1/21). c. Discuss with health care provider, family ongoing need for use of medication (9/1/21). d. Consult with pharmacy, health care providers to consider dosage reduction when clinically appropriate (9/1/21). A Risk for Fall problem, initiated on the Nursing Care Plan 8/13/21, with an 11/1/21 goal the resident would not sustain serious injury from a fall, directed staff on the following: a. Educate resident/family/staff as to causes of fall (8/13/21). b. Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (8/13/21) c. Place fall mat next to bed when in bed. Keep bed in low position. Keep bed remote out of reach of resident due to cognitive deficit impairing safety judgement. Bolsters/Body pillows to edge of bed for boundary identification (9/5/21). d. Review resident's medical record for medications or combinations of medications that could predispose to falls/increase fall risk (10/2/21) e. Check and change resident for incontinence at shift change (9/13/21). f. Contact therapy for consult for strength and mobility (8/13/21). Review of Incident Reports described the following falls: a. On 9/4/21 at 8:25 p.m., bed in lowest position, 2 falls from self-transfers from bed, sustained an abrasion to left knee, resident placed in wheel chair and kept by the nurse. b. On 9/5/21 at 9:45 a.m. found on floor on buttocks, no identified injury, sent to the hospital emergency room (ER), computed tomography (CT) scan of head completed without identified injury, returned at 5:37 p.m., 15 minute checks initiated and fall mats placed in room. c. On 9/18/21 at 5:25 a.m. found on fall mat next to bed on stomach, bed in low position, last seen 15 minutes prior, no identified injury, resident stated his bed was uncomfortable. Assisted off floor via mechanical lift and 2 staff, 15 minute checks initiated for 72 hours. d. On 9/21/21 at 5:40 a.m. found face down on fall mat next to bed, bed in low position, last seen 20 minutes prior in bed, awake and alert, call light within reach but not activated. Staff continued 15 minute checks and requested therapy staff to assess if they could provide other interventions to improve resident safety. e. On 10/2/21 at 5:15 a.m. found on floor on stomach, bed in low position, body pillow in place prior to fall, floor mat present, no injury identified, assisted back to bed with mechanical lift and 2 staff. Medication review completed, [MEDICATION(S)] dose recently decreased. f. On 10/4/21 at 10:46 p.m. found on back on floor fall mat, bed in low position, no injury identified. Resident lifted from floor with mechanical lift and 2 staff, placed in wheel chair and brought to the Nurse's Station. Facility made referrals to 2 facilities with behavioral units for resident transfer, awaited screening assessment results. A Physical Therapist assessment dated [DATE] revealed the following on the resident: a. Required substantial/maximal assistance to roll left and right. b. Substantial/maximal assistance required to transition from sitting to lying. c. Substantial/maximal assistance required to transition from lying to sitting. d. Dependent on helper, or 2 or more helpers, for all effort to transition from sit to stand position, resident did not participate in the effort. e. Dependent on helper, or 2 or more helpers, for all effort to transfer from chair to bed or bed to chair, resident did not participate in the effort. f. Ambulation not attempted due to medical condition or safety concerns. A Physical Therapy Plan of Care dated 9/2/21 listed 9/16/21 goals: a. Resident will be able to transfer from bed or chair with front wheeled walker (fww) with moderate assistance of 2 staff, and verbal, tactile and visual instruction cues. b. Resident will ambulate 5 feet on level surfaces with parallel bars with maximum assistance, and verbal instructions/cues to improve posture and sequencing to reduce burden of care. And 9/29/21 goals: a. Resident will ambulate 200 feet on level surfaces with fww and contact guard assist, and verbal instruction/cues to prepare for discharge home. b. Resident will ascend/descend 6 steps/stairs with contact guard assist, 2 hand rails and verbal instruction/cues to prepare for discharge to next site of care. c. Resident will perform sit to stand for transfers to and from bed or chair with fww with contact guard assist and verbal instructions/cues to prepare for a discharge home. A 9/15/21 Physical Therapist Assessment, completed after 10 therapy sessions detailed progress that included: a. Ambulated length of parallel bars (approximately 12 feet) with moderate assistance for weight shifting, with verbal instructions/cues for sequencing, step length, foot clearance and hand placement. b. Performed supine (laid on back) to and from sitting position with minimal assistance, and visual and verbal instructions/cues. c. Transferred to and from bed and chair with 100 percent assist, and verbal instructions/cues with sit to stand mechanical lift used. Review of Physical Therapist Notes revealed: a. On 9/20/21 ambulated 4 steps twice in parallel bars with maximum assist of 1 and minimum to moderate assist of a second person, demonstrated poor ability to follow cues to correct flexed posture and right lateral lean with maximum assist for weight shifting to offload and allow for advancing lower extremities with swing phase (to move leg forward with ambulation). At times lifted right foot, but did not follow cues to step forward. b. On 9/27/21 co-treat with occupational therapy secondary to need for 2 to 1 assistance required for ambulation in parallel bars, required maximum 2 to 1 assistance with significant posterior lean and no initiation to correct with verbal and tactile cues as well as visual demonstration. Completed 5 steps and 3 steps with verbal and tactile cues for advancing each lower extremity, maximum 2 to 1 assistance for weight shifting secondary to poor understanding of task. c. On 9/30/21 co-treat with occupational therapy secondary to 2 to 1 assist required for transfers. Resident did not lean forward when seated to prepare for sit to stand transfer despite verbal and tactile cues. Attempted ambulation in parallel bars, but resident unable to offload either foot enough to take a step. d. On 10/4/21 attempted to complete seated exercises, resident too lethargic to participate. When resident in bed, attempted active assisted range of motion (AAROM) and active range of motion (AROM) exercises, resident resistive and unable to follow directions. The 10/4/21 Physical Therapy Discharge Summary stated the resident had not made progress in the last several days due to inconsistent alertness levels and fatigue, limited ability to follow commands, and discharged from Part A skilled Medicare services. The resident was to continue therapy under Part B Medicare, not skilled level of care (less aggressive therapy treatment, shortened therapy sessions, provided fewer times per week) to maximize independence and minimize burden of care. Resident observations revealed: a. On 9/30/21 at 7:48 a.m., resident positioned recumbent in recliner chair with foot rest elevated in room, asleep, snored with mouth open, fall mat placed in front of the chair/under the foot rest, room dark, over-bed table positioned next to the chair, call light looped over the top of the table. b. On 9/30/21 at 8:01 a.m., Staff K, LPN, entered the resident's room, came out of the room at 8:02 a.m. with glucometer in hand, stated he was sound asleep and did not wake up when she lanced his finger for a blood sample. c. On 9/30/21 at 11:20 a.m. in therapy room, 2 therapists held a gait belt applied to the resident's chest area with both hands, held the resident upright between the parallel bars, both stated their maximal effort was required to hold the resident up. The resident's waist was bent slightly, hand were positioned on the rails, his chest/upper torso leaned to the right, near the bar on that side of his body, unable to move his feet or stand in a more erect posture despite multiple cues and physical guides provided by the staff, unable to ambulate and returned to the wheel chair. The resident did not speak or answer the therapist's questions, but pointed at the therapist when she asked him who spilled his soda. d. On 9/30/21 at 8:12 p.m. seated in a wheel chair in the hall, awake and appeared more alert than earlier in the day. Staff L, certified nursing assistant (CNA) and Staff E, CMA, instructed and assisted the resident to hold the handles of the Tolleo mechanical stand lift, applied the required belt, raised the resident to an upright position and transferred him to the bed. Staff E supported the resident's back to maintain a seated position as Staff L removed the belt, moved the lift away and then lifted his legs to the bed as they laid the resident down. The resident could not maintain a seated position without the staff's support. e. On 10/5/21 at 5:54 a.m. seated in wheel chair somewhat reclined in the hall by the nurses station, asleep, with food crumbs on chest area of shirt. At that time, Staff G, LPN, stated he'd fallen earlier in the night and awake for much of the night shift, the resident had fed himself snacks provided that included cookies, pudding and juice, and calmer when in the hall near staff. f. On 10/6/21 at 3:52 p.m. seated in wheel chair in lobby area, held his Miami J collar that he'd removed himself, awake and said hi when greeted. g. On 10/7/21 at 4:41 p.m. seated in recliner chair in his room, yelled hey as surveyor passed, held the television remote control in right hand, the cover for the battery compartment in his left hand and said I need a battery for this. Upon inspection 1 of the 2 batteries was in the device, staff found the other battery in the resident's chair. The resident then changed the television channel with the remote held in his left hand. h. On 10/13/21 at 10:20 a.m. stood between parallel bars in the therapy room, 1 staff stood in front of the resident, held the gait belt applied to chest area with light grip, provided verbal cues to move his hands forward on the bars, sometimes let go of the gait belt and physically assisted the resident to move his hand forward on the rails, resident maintained an upright position and ambulated forward several steps as she continued verbal cues. Another therapy staff member followed closely behind the resident with a wheel chair, but did not physically assist or support the resident's ambulation. i. On 10/18/21 at 4:22 p.m. seated in wheel chair in lobby area, asked for help to go to his room, stated his room number and said he had to call his wife. Staff M, CNA, assisted resident to his room. Physician interviews revealed: a. On 10/13/21 at 8:42 a.m., Staff N, Neurosurgeon, stated at the time of 9/1/21 hospital discharge, the resident's prognosis for return to independence was good with continued Physical Therapy services for strengthening. The prescriptions for [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] were implemented by the Hospital Nurse Practitioner (NP) and likely to treat sleeplessness, restlessness or anxiety during the hospitalization . The Neurosurgeon reported had not been consulted about the medications, did not believe the symptoms were serious or indicative of further treatment required because they would have been consulted and had to have consulted with Psychiatry if so, and not aware of any concern for possible dementia or [CONDITION(S)]. The physician stated the resident remained under their care with a scheduled follow-up appointment, and the facility should have consulted with them in reference to his falls, anxiety or behaviors of concern and implementation of additional sedative medication, so they could have assisted or opined to address the issues as they were likely related to the resident's subdural hemorrhage. b. On 10/18/21 at 2:40 p.m., the facility's Medical Director and resident's physician stated she didn't think facility staff had notified her of the 9/28/21 ER findings, the staff probably would have notified the NP, and noted the NP was off duty on 9/29/21 and 9/30/21, so may not have received a notification until 10/4/21 when back on duty. Staff interviews revealed the following: a. On 10/6/21 at 1:11 p.m. Staff E, CMA, stated she was directed by the nurse to administer [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] at the same time to the resident, she didn't make those decisions on her own, Staff D, RN, didn't like the resident's behaviors and directed her to give him everything he could have, give him a cocktail (a combination of medications), Staff D had directed her to administer the medications together on several evenings when she worked on that unit, if the nurse directed the Medication Aides to administer prn medications for behaviors or anxiety, the nurse was supposed to document that, it wasn't the responsibility of the Medication Aide. Staff E heard the resident would try to get up and had fallen, but she had never observed that or any behaviors, the resident was always agreeable with her when she administered his medication. Staff E stated she administered [MEDICATION(S)] on the morning of 9/8/21 because she was directed to by the nurse. On 10/18/21 at 4:12 p.m., when asked about [MEDICATION(S)] administrations that she recorded on the Narcotic Inventory Control Sheet but not on the MAR, Staff E stated she administered the medication and must not have documented it in the computer, and did not know how there could be 17 doses of [MEDICATION(S)] undocumented or unaccounted for. b. On 10/12/21 at 10:43 a.m. Staff F, CMA, stated she administered as needed medications when directed by the nurse, but nurses were to document why the medication was given, she never administered prn medication unless the nurse instructed her to. When she worked on the resident's unit the nurse often asked if he could have anything yet, related to medication for anxiety or behaviors, and sometimes the resident's family asked if he could have something for pain, he had headaches. Staff F stated she heard the resident climbed out of bed and had behaviors, but had not witnessed that herself and the resident cooperative when she administered his medication. c. On 10/6/21 at 3:34 p.m. Staff D, RN, stated the resident had behaviors every day, tried to get up, couldn't say what he wanted or needed, or where he wanted to go as he made the attempts. The resident had medications to treat the behaviors, and [MEDICATION(S)] for pain, sometimes he said he had pain, other times he didn't or couldn't say. The medication helped for 3 to 4 hours and sometimes the symptoms returned, you couldn't reason with him, he wouldn't leave the cervical collar on and he usually did better if the family was there. On 10/18/21 at 10:18 a.m. Staff D stated she directed the CMA to administer [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] together at the same time 2 or 3 times due to his behaviors that included trying to get up and if he had a hold of anything he threw it. When asked if there were any attempted interventions prior to administration of the prn [MEDICATION(S)] or [MEDICATION(S)], Staff D stated they probably tried 10 things and nothing worked. Staff D stated if CMA's administered his prn [MEDICATION(S)], [MEDICATION(S)] or [MEDICATION(S)], the CMA's documented the behaviors on the MAR, there wasn't any other place to document that but staff could record the medication was effective on the MAR. When asked where 17 missing [MEDICATION(S)] doses could be, Staff D stated the CMA's could have administered it and not told her. d. On 10/6/21 at 12:55 p.m. Staff A, LPN, stated she worked the night shift (10 p.m. to 6 a.m.), the resident had good and bad nights, sometimes was restless and tried to get up, he'd fallen a few times. When he was restless or anxious he did better if they got him up and kept him where he could see the staff, which seemed to calm him. e. On 10/6/21 at 12:26 p.m. Staff P, LPN, stated she had assessed the resident and directed the CMA's to administer anti-anxiety medications and analgesics when needed, and then reassessed the resident for medication effectiveness. Staff P was certain she did not and would not direct a CMA to administer [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] at the same time, and quite certain she didn't instruct the CMA to administer [MEDICATION(S)] to the resident at 10:30 a.m. on 9/8/21. f. On 10/14/21 at 2:53 p.m. Staff H, LPN, stated she had not observed aggressive behaviors from the resident, he would yell out and get your attention, he thought he could walk and would try to get up, required frequent redirection and seemed to do better with 1 to 1 direction by staff when he was like that so she put him with her in the hall when needed. When asked about [MEDICATION(S)] and [MEDICATION(S)] medication administration that she had recorded on inventory control sheets but not on the MAR, Staff H stated she had not recorded the administration in the computer, sometimes due to Internet issues/computer problems but tried to improve on that, and made attempts to make sure the documentation was done before she did anything else. When asked where 17 unaccounted doses of [MEDICATION(S)] could have gone, Staff H stated she didn't know but wouldn't be surprised if staff that couldn't deal with behaviors administered it to Resident #3. Staff H stated when she started at the facility 9/1/21 there was a lot of agency staff there, organization was needed and has since improved. g. On 10/7/21 at 3:19 p.m. Staff O, Occupational Therapist (OT), stated if the resident was awake and not in pain, he did better in therapy, was able to follow cues. His participation in therapy was impeded if he was too tired to follow cues or was in pain. h. On 10/7/21 at 11:09 a.m. the Director of Nursing (DON) stated she expected the nurses to assess resident anxiety, attempt at least 3 interventions such as offer a snack or provide 1 to 1 attention prior to me

Based on record review, staff interviews and facility policy, the facility failed to ensure residents were free of abuse for one of four sampled. Concerns identified for Resident #1. The facility reported a census of 128 residents. Findings include: According to the Admission Record dated 11/17/16 Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #1 had severely impaired cognitive impairment. Resident #1 required limited assistance of one staff with transfers, dressing, and personal hygiene. Resident #1 required extensive assistance of two staff with bathing. The Plan of Care dated 4/4/16 directed the staff to provide assistance of one staff with bathing in the shower room, remove from public area if removing clothing and minimize potential of behavior problems by modifying environmental factors and daily routines. On 10/17/16, the facility reported to DIA an allegation of abuse that allegedly occurred on 10/12/16. An interview on 11/17/16 at 12:50 p.m. Staff B reported Staff C had the shower wand and sprayed Resident #1 in the face multiple times. Staff B reported Resident #1 had verbally abusive and combative behaviors during the shower. Staff B reported each time Resident #1 cussed, Staff C sprayed Resident #1 in the face. The Abuse and Neglect Policy dated 9/13 revealed the resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision to protect against hazards from self and elements in the environment (Resident #1). The facility failed to adequately supervise the resident while in an elevated bed. The resident rolled out of the bed and hit head on the metal base of the tray table. The resident sustained [REDACTED]. The sample consisted of 4 residents and the facility reported a census of 144 residents Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 9/3/15. The MDS reflected the resident had short term and long term memory problems and severely impaired for daily cognitive decision making skills. The MDS identified the resident required extensive assistance with bed mobility and transfers. The MDS indicated Resident #1 required staff assistance to stabilize when transferring from surface to surface. The Care Plan identified the resident had a risk for falls regarding gait/balance problems. The interventions directed the resident would use a perimeter mattress, fall matt when in bed, use a clip alarm when up in the chair, motion detector alarm on the head of the bed. The Care Plan directed the staff to turn on the motion alarm when the resident laid in bed. The motion alarm was to be used to alert staff of the resident's movement and to assist in monitoring movement. The Cardex (not dated) (information regarding the resident and needs) and the Care Plan identified the resident as blind and no longer wore glasses. The Cardex directed the staff members to not turn their back on the resident when providing cares and to have supplies ready at the bedside. The Progress Notes dated 10/3/15 at 5:10 p.m. identified a staff person was getting the resident up for dinner (in the resident ' s room) and the staff member turned to grab a towel and the resident fell on the floor. The resident bled a lot from the laceration on the head and 911 was called. The emergency personnel came and took the resident to the hospital emergency department for treatment. The Progress Notes dated 10/3/15 at 7:25 p.m. reflected the resident returned to the facility from the hospital emergency room . The resident required 9 stitches and 6 staples. The resident ' s head had wrappings of Kerlix and netting in order to keep the dressing in place. The physician ordered the staff to administer hydrocodone/apap (narcotic analgesic), 1 tablet every 6 hours as needed for pain for 3 days. On 10/28/15 at 3:12 p.m. the Director of Nursing (DON) was interviewed and stated initially the facility did not know how Resident #1 fell . Staff A, present during the fall, was not forthcoming with the details. After several interviews, the DON learned Staff A stepped away from the bed, with the bed elevated, and the motion alarm not in place. The DON stated Staff A reported she did not see the fall occur. The DON reported the facility provided safety education to all nursing staff on 10/12 and 10/22/15. On 10/29/15 at 9:01 a.m. Staff A (Certified Nursing Assistant) was interviewed and reported she raised Resident #1 in the bed to provide a bed bath. Staff A stated she stepped away from the bed to get a wash cloth in the resident ' s bathroom. Staff A reported she did not lower the bed or put the motion sensor in place. Staff A reported she did not see the resident fall. Staff A returned to the bedside to find Resident #1 on the floor. Staff A reported Resident #1 hit his/her head on the metal base of the tray table. The policy/procedure titled Bathing, revised on 11/6/14, directed the staff to not leave a resident unattended. The resident may be unattended during bath per his/her request and if assessed by the interdisciplinary team to be safe/independent. The Safety In-Service sheet dated 10/5/15 reflected the facility reviewed resident safety with employees. The facility reviewed ensuring all precautions on the care plan are in place, never walk away from a resident that is not 100% secured in their environment, always report the facts and never leave out details of any situation so that a solution can be found quickly, it is the staffs job to follow the care plan at all times, and staff will be held accountable for any harm to the residents. On 10/9/15 the facility had a meeting (huddle) at shift change and reminded the staff to follow the plan of care. The facility educated the staff to never walk away from a resident with the bed in the high position.

Based on clinical record review, staff interviews and review of facility policy/procedures, the facility failed to provide adequate supervision and use an assistive device to prevent accidents for 1 of 4 residents reviewed (Resident #2). On 2/15/15 a staff person transferred Resident #2 alone from the bed and did not use a gait belt which compromised the resident's safety. The resident sustained [REDACTED]. The facility reported a census of 138 residents. Finding include: 1. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date of 12/16/14. The MDS identified Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 12 out of 15. A score of 12 identified the resident's cognitive status as moderately impaired. The MDS reflected Resident #2 required extensive assist of two staff members to physically assist with transfers, and assist of one staff member for bed mobility, ambulation, dressing, toilet use, and personal hygiene. The MDS documented the resident had no falls since the prior assessment completed. The MDS documented the balance assessment during transition and walking indicated the resident as not steady and only to stabilize with staff assistance. The MDS reflected the resident had no functional limitations in both upper and lower extremities and in range of motion. Review of the Care Plan dated 8/11/14, for Resident #2, reflected an area for ADL (Activity Daily Living) self care performance deficit related to impaired mobility. The Care Plan reflected the resident required extensive assist with ADL's. The interventions directed staff to: a) assist the resident with lace up braces on in am and off at time of sleep. b) resident is able to bear weight, pivot, use arms to support with crutches, take steps as tolerated. c) resident requires one staff participation with transfers, uses crutches for transfers (the intervention had a revision date of 12/4/14, however, the transfer did not address this revision and the MDS of 12/16/14 reflected the resident required 2 staff to transfer the resident). Review of the Slipped or Fall report dated 2/15/15 at 8:40 a.m., reflected the certified nursing assistant informed the nurse that Resident #2 was on the floor next to and at the foot of the resident's bed. The resident reported left rib and thigh pain. The report identified the resident as alert and verbally communicating. Resident has bilateral lower extremity braces on. Resident saying he/she fell and don't know how it happened. Resident found with a skin tear to the left arm, area cleansed and dressing applied. Left elbow abrasion cleaned and Band-Aid applied. Resident expressed pain of 9 out of 10 on a scale 0 to 10 to left knee and left rib area. Resident also noted to have a bruise to the face. The nurse instructed the resident not to move (the resident) and vitals signs and neurological assessment completed. The nurse supported the resident with pillows and blankets to stabilize the resident. The resident transferred to the hospital. Review of the the physician's History and Physical report dated 2/15/15 revealed Resident #2 has a history of [DIAGNOSES REDACTED] and wears crutches on both legs and uses a walker to walk , fell . The resident complains of severe pain in left chest wall area and left knee. The resident was noted to have a bruise around the left eye. A chest x-ray performed in the emergency room identified fractures of the left 7th and 8th ribs. The knee x-ray identified swelling, possible hemarthrosis (accumulation of blood in the joint) with out clear fat-fluid level. The resident was admitted to the hospital for pain control and physical and occupational therapy. Review of the Progress Notes dated 2/16/15 at 3:39 p.m. reflected Resident #2 returned to the facility from the hospital at 2:50 p.m. The Progress Notes document the resident as now a total-lift (for transfers). On 2/25/15 at 10:11 a.m., Staff A, LPN (Licensed Practical Nurse) was interviewed and stated she worked 2/15/14 and was assigned to care for Resident #2. Staff A reported passing (administering) medications when Staff B informed her the resident's on the floor. Staff A stated she went to the resident's room and found the resident lying on his/her back and near the end of the bed. Staff A noted the resident complaining of left knee pain and left rib pain, skin tears to left arm and bruise to left side of resident's face. Staff A reported she noted the resident's gait belt not on and saw it lying in the chair (in the resident's room). Staff A instructed Staff B, to grab the gait belt and made a motion to put it on the resident and to not touch the resident. Staff A stated she contacted the physician, family, and ambulance to transport the resident to the emergency room . On 2/26/15 at 1:32 p.m., Staff B, CNA (Certified Nursing Assistant) was interviewed and stated she was assigned to care for Resident #2 on 2/15/15 during the day shift. Staff B stated she had taken care of the resident several times before 2/15/15 and knew the resident required a gait belt for transfers. Staff B reported she transferred the resident around 8:30 a.m. that morning from the bed. Staff B reported the resident wore braces on each leg and had crutches as required for transfer and sitting at the side of the bed. Staff B stated she stood in front of the resident. The wheel chair was located a couple steps away at the end of the bed. The resident placed his/her right hand on the wheel chair arm rest and then fell to the left side, onto the floor. Staff B stated she did not have the gait belt on the resident at the time of the transfer and fall because she had forgotten. Staff B confirmed the gait belt should have been on the resident, and it is the facility's policy to use a gait belt when a resident needs assistance with transfers. On 2/24/15, the DON (Director of Nursing) was interviewed and stated Staff B admitted not using a gait belt when transferring Resident #2 because she had forgotten. Review of the facility's Procedure Gait (Transfer) Belt, revised on 10/13, identified purposes for the gait belt. The policy identified the purpose to be for safely transfers or ambulating resident, to aid resident in maintaining balance, to avoid injury to both resident and staff member and gait belts are to be used unless medically contraindicated. The policy directed staff to show the gait belt to the resident and explain its use, place belt around resident's waist over clothing, belt can be applied while the resident is sitting or lying in bed, transfer or ambulate the resident and then remove belt.

Based on record review and interviews, the facility failed to implement the written care plan intervention and failed to provide adequate supervision to protect 1 of 4 residents from hazards (Resident #2). On 1/18/15, staff failed to provide stand by assistance (SBA) to Resident #2 when he/she attempted to use the bathroom and fell fracturing his/her hip. Staff interviews revealed staff unaware the resident required SBA at the time of his/her fall on 1/18/15 and multiple inconsistencies regarding the care plan interventions. The facility reported a census of 139 residents. Findings include: According to the Admission Record dated 1/22/15 Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had modified independence with decision making. The activities of daily living (ADLs) functional status revealed Resident #2 needed one staff person to provide physical support with transfers, bed mobility, walking in the room, walking out room, on the unit, off the unit, dressing, eating, toilet use, and personal hygiene. The ADL functional status revealed the resident could self-perform transfers, walking in room or eating with supervision (oversight, encouragement or cueing). The assessment defined " independent " as no help or staff oversight. The assessment revealed the resident had no history of falling. Record review of Incident descriptions dated 11/14/14 and 9/8/14 identified Resident #2 had fallen without injury. The Care Plan dated 12/24/14, revision date 12/26/14 revealed Resident #2 independent with ambulation with a walker. The Care Plan revealed Resident #2 required standby assist of one with dressing, grooming and toilet use. The cardex print dated 1/19/15, revealed the resident needed standby assist of one with dressing, grooming and toilet use. The cardex revealed the resident independent with transfers, bed mobility and ambulation with walker. The Progress Note entry dated 11/201/4 revealed the staff updated the Care Plan to provide standby assist of one with dressing, grooming and toileting. The entry revealed Resident #2 remained independent with transfers with the use of a walker. The Progress Note dated 12/15/14 revealed Resident #2 more confused at night and a motion alarm added to the bed at night. The Incident Report sheet dated 1/18/14 at 7:42 p.m. revealed the staff observed Resident #2 lying on the left side on the floor in front of the bathroom. Resident #2 report he/she tripped over a pair of shoes on the floor beside the nightstand. The staff attempted to assist Resident #2 to a sitting positon and Resident #2 complained of increased pain. The staff lowered Resident #2 back to the floor. The sheet revealed Resident #2 transferred to the emergency room for evaluation. The Progress Note entry dated 1/18/15 at 9:25 p.m. revealed Resident #2 tripped over a pair of shoes on the way to the bathroom. The Emergency Department Notes dated 1/18/15 revealed Resident #2 sustained a left femoral neck fracture (hip fracture). Resident #2 admitted to the hospital for surgical repair of the fracture. According to interviews on 1/17/15 at 2:47 p.m., and on 1/28/15 at 3:34 p.m. Staff F, Certified Nurse Aide (CNA), reported Resident #2 was independent in the room with his/her walker. Staff F reported the resident toileted him/herself, and staff would check with the resident to make sure he/she was clean and tell him/her to change before bed. Staff F reported he/she went in the room prior to the fall and Resident #2 had been sitting on the edge of the bed. Staff F told Resident #2 to get ready for bed. Staff F asked Resident #2 if he/she needed assistance and Resident #2 declined. Staff F reported Resident #2 was independent with transfers in the room, toileting and dressing. Staff F heard Resident #2 yell for help from the hall. Staff F found Resident #2 on the floor in his/her pajamas. Resident #2 had the pants he/she wore that day in his/her hands. Staff F reported she checked the cardex each shift and it doesn't take long to review them. Staff F reported she didn't recall what Resident #2's cardex said, just knew the resident was independent in room with toileting, transfers and dressing. An interview on 1/29/15 at 1:12 p.m. the Director of Nurses reported stand by assist requires to the staff to be physically present while the task is completed. The DON reported earlier on 1/12/15 at 12:32 p.m., the cardex printed on 1/19/15 was the current cardex for when the resident fell on [DATE]. An interview on 1/27/15 at 3:03 p.m. Staff B, Certified Nurse Aide, (CNA) reported Resident #2 was independent in the room with a walker. Staff B reported Resident #2 was independent with dressing, toileting and transfers. Staff B reported the staff just had to check to make sure Resident #2 changed his/her clothes at bedtime. An interview on 1/28/15 at 4:40 p.m. Staff C, Certified Nurse Aide (CNA) reported Resident #2 completed transfers, dressing toileting and grooming independently. Staff C reported standby assist means staff stand by the resident during cares in case the resident needed assistance. Staff C reported Resident #2's Cardex indicated he/she was independent with all ADL' s prior to the fall. An interview on 1/29/15 at 12:03 p.m. Staff D, registered nurse (RN) manager reported the 11/20/14 care plan update and cardex both reflected the resident needed SBA (which means staff need to be present). Staff D reported at the time of the fall 1/18/15, staff needed to present during dressing, grooming and toileting. Staff D reported Staff G no longer works at the facility and she had been the employee that changed the care plan. Staff D though the resident was independent with transfer, ambulation dressing and toileting. Staff D reported she was not aware the care plan changed on 11/20/14. During another interview with Staff D, on 1/27/15 at 12:52 p.m., she reported prior to the resident fall on 1/18/15, Resident #2 required the assistance of one (1) staff and gait belt. Staff D reported now Resident #2 requires the assistance of two (2) and gait belt, wheelchair and geri chair prn (as needed). An interview on 1/29/15 at 12:06 p.m. Staff E, Certified Nurse Aide (CNA), reported Resident #2 was independent with transfers, but was SBA (stand by assist) prior to the fall on 1/18/15 for dressing, toileting and grooming. Staff E reported SBA means to cue the resident, set out his/her clothing, take him/her to the bathroom. Staff E reported he/she always stayed in the room with Resident #2 to make sure Resident #2 completed cares. Staff E reported Resident #2's breathing was not good and required assistance with dressing, toileting and grooming. Staff E reported the resident's cardex indicated he/she was independent for all cares (ADLs). An interview on 1/29/15 at 12:38 p.m. revealed Staff G, RN (who updated the care plan on 11/20/14) did not recall the reason he/she updated the care plan. Staff G no longer worked at the facility.

Based on observation, record review, staff interviews and review of facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards for 3 of 16 residents reviewed (Resident #11, #21 and #24). The facility reported a census of 135 residents. Findings Include: 1. Resident #24 had a Minimum Data Set (MDS) Assessment with a reference date of 11/08/11 which identified [DIAGNOSES REDACTED]. The MDS indicated the resident had a history of [REDACTED]. The MDS indicated the resident had short and long term memory problems and moderately impaired with decision making skills. The resident required limited assistance with 1 staff person for bed mobility and personal hygiene, required extensive assist of 1 staff person for transfers, walk in room and corridor, dressing and toilet use. The resident's Care Plan dated 11/04/11 identified the resident had a history of [REDACTED]. The Care Plan directed staff to apply a motion sensor alarm on the bed at all times, apply a sensor pad alarm at all times, and a body clip alarm at all times, and to monitor for attempts to self transfer. The resident had an admission date of [DATE] from a local hospital due to increased weakness resulting in a fall at home. Review of the admitting Daily Skilled Nurse's Note dated 11/4/11 revealed an initial assessment by Staff Q (Licensed Practical Nurse/LPN). The assessment indicated the resident had a history of [REDACTED]. The assessment made no documentation of alarms applied to the resident as care planned. Review of the Daily Skilled Nurse's Notes from 11/04/11 till discharge from the facility on 11/8/11, revealed documented the resident as post hospital skilled services due to increased weakness and falls at home. Further review of the Daily Skilled Nurse's Notes indicated at no time did the nurses document any alarms were in place for Resident #24. The Daily Skilled Nurse's Note dated 11/08/11 revealed Resident #24 was found on the floor at the foot of the bed per Staff R (LPN) at 2:00 a.m. An assessment completed per Staff R indicated no shortening of extremities or bulges noted, 2 man lifted to bed after the resident attempted to stand with a walker and complained of pain in the pelvis area. Call placed to on-call doctor and orders received to transport, family member notified. A notation at 3:30 a.m. revealed a family member notified the facility that Resident #24 sustained a hip fracture. The incident report for Resident #24 dated 11/8/11 revealed Staff R had documented the resident had been found on the floor at the foot of the bed at 2:00 a.m. The report indicated immediate interventions put in place to prevent another occurrence. The incident report identified factors which contributed to the incident. The factors were identified as no alarms in place as noted on the Care Plan to help prevent falls. During an interview on 11/22/11 at 3:40 p.m., Staff G (Registered Nurse/RN) indicated had worked with Resident #24 on 11/7/11 during the afternoon/evening shift. Staff G reported had started the resident's assessment earlier in the shift after the resident had returned from dialysis. Staff G stated between 7:30 p.m. and 8:00 p.m. went back to do an accucheck (blood sugar check) and finish the assessment of the resident. The roommate's motion detector alarm sounded and the family members asked if the resident could have one of those alarms. Staff G reported she told the family she would check and see if the resident had been care planned for them and noted a blue pad sensor alarm in the room on the bedside table. Staff G took the alarm off the table and demonstrated how it worked on the bed and showed the family members there was no alarm box at that time connected to the sensor pad. The family seemed to be aware the resident required an alarm. Staff G admitted she checked the care plan for the resident and noted the resident care planned for the alarms. Later in the shift possibly 20-25 minutes later after leaving the resident's room, the family approached the Nurse's Station. The family inquired about the resident's fatigue and dialysis. Staff G reported to the family that she had checked the care plan and the resident was care planned to have the alarms. Staff G indicated at no time did she return to the resident to put on or check for alarms, but had presumed that the Hand Held (Palm Pilot) had the resident's care plan in it (carried by the nursing assistants). Staff G reported at no time before shift end did he/she return to the resident's room. Staff G indicated the CNA's are expected and know they are responsible to look at the hand held as it told what the plan of care is. The hand held palm pilot is the CNA's way of recording cares and to ensure alarms are in place, transfers, and is where it is recorded when completed. Staff G reported when left that night, she had no idea there was anything wrong and thought all was in place for the resident and realized later the alarms never had been in place for the resident since admit and should have been in place. During an interview on 11/22 11 at 4:45 p.m., Staff H (CNA), indicated she did work with the resident on the night of admit, 11/4/11 till shift ended at 9:00 p.m. Staff H admitted she did not know much about the resident when the resident arrived per ambulance from the hospital. Staff H stated it took awhile till knew what all the resident needed. Staff H stated she did know the resident had a special diet due to dialysis. Staff H did not remember the resident on the hand held device as marked for alarms. Staff H commented about another admit that same night and did remember that the hand held did mention alarms for that resident During an interview on 11/23/11 at 6:40 a.m., Staff I (CNA) reported she worked the overnight (third shift) on 11/7/11 into 11/8/11 from 10:15 p.m. till 6:45 a.m. Staff I indicated she did not work with the resident the night of the fall, but did work with the resident on 11/4/11 when admitted . Staff indicated the night she worked with the resident, the resident was on the call light numerous times and remembered for a fact no alarms on the resident. Staff I stated had wondered about that and since the resident utilized the call light appropriately, thought it was alright the resident had no alarms on. Staff I reported a second admit the same night of Resident #24 had alarms in place. Staff I revealed she assisted the resident into the bathroom that night and recalled looked at the hand held for the transfer assistance, but did not recall have seen any notation about alarms. During an interview on 11/23/11 at 6:55 a.m., Staff J (CNA) reported she had worked the 3rd shift, 10:45 p.m. till 6:45 a.m. on 11/7/11 and had been the first time had cared for the resident. Staff J reported did recall the resident used the call light sometime between 11:00 p.m. - 12:00 a.m., and responded to the light. Staff J asked the resident what he/she wanted and the resident reported wanted to get up. Staff J explained what time it was to the resident and probably would be better to go back to sleep, Staff J reported did admit offered for the resident to use the toilet and the resident declined. Staff J did recall the resident had oxygen per nasal cannula and was not properly placed and out of the resident's nose. Staff J readjusted the oxygen and the resident relaxed in bed. Staff J reported at no time did she see alarms in place for the resident, and had not checked the hand held device for the resident to get any information. The previous shift had only passed along the resident used the call light frequent times. Staff J reported back in the resident's room again approximately between 1:15 a.m. - 1:30 a.m., checked the resident and asleep in bed. Staff J reported she learned of the resident's fall from Staff R (LPN). Staff R had been in the resident ' s room to see the roommate. . The resident kept asking to get up and after Staff R assessed the resident, got the resident up as near the bed and pivoted the resident to bed and laid the resident down which happened at approximately 2:00 a.m. on 11/8/11. Staff J indicated the resident did not complain about pain right away till after laid down in bed and calmed down. Staff J reported the resident started to complain of leg pain, but could not remember which leg and the resident kept saying help me. At the time of the resident's fall Staff J could not recall the resident had alarms. After the fall Staff J did go obtain 3 alarms (sensor pad alarm, clip alarm, and motion alarm) One half hour later the resident was transported to the hospital. Staff J did report checked the hand held after the resident fell and found the resident care planned for all 3 alarms. Staff J reported since she did not observe alarms in the resident's room and the resident had been in the facility a few days didn't think alarms were needed. Staff J indicated the admitting nurse does the assessment and does the initial placement of alarms or tells the CNA's who worked with the resident at admit to place alarms on the resident. Staff J admitted the care plans have become a priority more so since this. During an interview on 11/23/11 at 7:30 a.m., Staff K (CNA) reported she worked with Resident #24 only one night, during the 3rd shift on 11/6/11- 11/7/11. Staff K reported usually check the residents every 2 hours. . Staff K reported the night she worked had noted the resident had no alarms in place. Staff K stated had looked at the palm pilot device and care plan called for alarms. Staff K stated had gotten busy and didn ' t recall the alarms that night. Staff K stated she knew from being a new staff to read the resident care plan before even starting the rounds and know know to check alarm placement. Staff J recalled it was mentioned the resident used the call light a lot the first night, but at no time did anyone mention alarms for the resident. During an interview on 11/23/11 at 8:38 a.m., Staff L (CNA/Certified Trainer) reported she had worked with the resident on 11/6/11 (first time) and did recall the resident had no alarms in place when worked with the resident. Staff L indicated since the resident had already been in the facility a few days assumed since had no alarms on the resident didn't require an alarm. Staff L reported the procedure was the nurse supplied the alarms right away if a resident needed one and usually the nurse puts the alarm on, but if unable the nurse would ask the CNA to get the alarms in place. Staff L admitted she had looked at the hand held device the day worked with the resident for transfer assist, but didn't scroll down further if needed any alarms. Staff L revealed a care plan book at the nurse's station, but not always updated as quickly as the hand held devices. Staff L reported the hand held is like a Bible for the CNA's to refer to for information in regards to residents' cares, transfers, and alarms. Staff L admitted to assisting the resident briefly on 11/7/11 prior dialysis and not again prior the fall. Staff L indicated the resident still did not have any alarms on when staff helped prior the resident left for dialysis. During an interview on 11/23/11 at 9:40 a.m., Staff M (RN/Nurse Manager) reported an admission meeting is held daily Monday - Friday to talk about possible admits. Staff M stated she did not have any contact with the resident except passed by the room and greeted the resident. Staff M revealed at no time did staff approach her about alarms for Resident #24. Staff M indicated the need for alarms for possible admits were discussed at a Admissions Meeting and if decided the resident needed alarms, the MDS Coordinator or the Rehab Nurse enters the information into the hand held device. Staff M indicated the Admission Team discussed Resident #24 prior admit and decided no alarms at the time due to lethargy seen in the hospital. Staff M reported she believed alarms were care planned for the resident in the hand held. Staff M explained the nurses get report at shift change and on 11/4/11 the 2nd shift nurse would have verbally gotten pertinent information on Resident #24 including if had alarms, transfer needs, and had dialysis prior coming to the facility. Staff M indicated the CNA's are expected to look at the hand held device to get pertinent information about a resident or the nurses verbally pass the information on in regards to the residents. During an interview on 11/23/11 at 1:28 p.m., Staff N (CNA) reported had worked with the resident 1st shift on 11/5/11 and worked only weekends. Staff N indicated when worked with Resident #24 there were no alarms on the resident, and during report no one mentioned alarms for the resident to be in place. Staff N admitted she reviewed the hand held device regarding this resident and did not see notation for alarms. During an interview on 11/23/11 at 2:08 p.m., Resident O(CNA) reported she worked with the resident 2nd shift 4:00 p.m. - 9:00 p.m. on 11/7/11 and had contact with the resident for the first time approximately 5:00 p.m. or 6:00 p.m. after the resident returned from dialysis. Staff O indicated she did not notice any alarms on the resident On 11/23/11 at 3:43 p.m., the Director of Nursing (Staff P) was interviewed and stated she knew the resident was care planned for alarms and the resident never had the alarms placed on them. Staff P reported she knew a couple of CNA's had checked off of alarms on the resident, but felt was done by habit and the CNA's did not realize what had been done. During an interview on 11/29/11 at 4:10 p.m., Staff Q ( LPN/2nd Shift Charge Nurse) admitted not remembering asking or directing the CNA's to put alarms on the resident and personally did not put any alarms on the resident. Staff Q indicated worked with the resident the night of 11/4/11, 11/5/11, and 11/6/11 and the resident did not have alarms. Staff Q admitted later in the night of 11/4/11, she got the resident's care plan and placed it in the care book but never reviewed or reviewed the care plan. During an interview on 11/30/11 at 9:34 a.m., Staff R (LPN) reported worked the 10:00 p.m. -6:00 a.m. shift on 11/7/11 into 11/8/11. Staff R indicated went into the resident's room about 11:00 p.m. -11:30 p.m. to assess vital signs and the resident dozed off and on and answered questions. The resident's roommate had a scheduled pain medication around 2:00 a.m. and Staff R entered the room at approximately 1:30 a.m. and found the resident on the floor with no alarms going off. Staff R reported this the first night to work with the resident and had not reviewed the care plan yet and was not aware the resident was to have alarms in place. Staff R indicated did not recall the resident used the call light prior found on the floor, and when found was flat on back and Staff R asked the resident what he/she was doing. Staff R asked a CNA (Staff J) to assist with the resident as assessed while the resident on the floor, Staff R completed Range of Motion (ROM) exercises and noted no shortening of either leg or the resident complained of no pain and had no loss of consciousness. When Staff R and Staff J assisted the resident up with a front wheeled walker and tried to take a step then stated it hurt and Staff R and Staff J 2 person lifted the resident and put into bed. Staff R indicated once the resident in bed checked lower extremities still no shortening of legs and palpated the right and left hip area and the resident complained of pain with the left hip area but noted no deformity when palpated. Staff R reported called the doctor and explained what had happened and the pain the resident having and an order received to transport the resident to the ER for evaluation and possible treatment. Staff R revealed contacted the family, then called the DON and Administrator's work phones and left a message of the fall. Staff R reported learned of the left hip fracture for the resident when a family member called back to the facility. Staff R reported did call Staff P (DON) on cell phone approximately 6:25 a.m. - 6:30 a.m. as DON coming up facility driveway to report the resident's fall and the family would be calling the DON. Staff R indicated knew the CNA's reviewed the hand held, but not sure how often and no one mentioned that the resident care planned for alarms. Staff R explained when came on shift 11/7/11 no one at report said the resident had alarms, staff spoke of the resident as a recent admit but do not recall anyone mentioned the resident care planned for alarms. Review of the Alarms: Bed, Chair, and Door Policy & Procedure dated as revised October 2008 indicated the center will ensure that a system is in place for all bed, chair, and door alarms and these alarms are in proper working order. Alarms will be installed and placed according to the manufacturer's instructions. The procedure directed the nursing staff will be responsible for visually checking the placement of alarms; a system will be in place to determine which residents have a need for alarms and can be done utilizing the pre-defined resident notes area on the physician's orders [REDACTED]. Use of an alarm will be documented on the resident's care plan and will be included on the Certified Nursing Assistant flow sheets. The charge nurse will notify the family of the use of the alarm and ensure that staff are knowledgeable regarding the alarm system. Review of the Care Plan Policy dated as revised January 2009 indicated residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial and educational needs. Through use of departmental orders, any problems, needs and concerns identified will be addressed. Review of the Guidelines for Prevention and Management of Falls dated as revised April 2011 indicated in order for a Falls Prevention Program to be successful, there must be accountability at the center level from the leadership and caregivers in the center, as well as National Campus support. Under the Risk Evaluation section of the guidelines instructed nursing staff that upon admission each resident will be evaluated to determine his or her risk for falling and will include the following components for review: a. Identification of environmental hazards and any individual resident risk of an accident, including the need for supervision. b. Evaluation and analysis of the hazards and risks related to potential falls. c. Implementation of interventions, including adequate supervision, consistent with resident needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident. d. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards or practice. 2. A History and Physical report dated 9/26/10 indicated Resident #11 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment with a reference dated 8/02/10 revealed Resident #11 had two falls with no injury and one fall with a minor injury since admission. The MDS documented the resident had impaired memory loss. According to the MDS, the resident needed extensive assistance of two staff for transfers, bed mobility, ambulation in the room and toilet use, and two staff assistance with ambulation in the hallway. The MDS documented the resident as not steady (only able to stabilize with human assistance) during ambulation, moving on an off the toilet, turning around, and moving from seated to a standing position. The MDS revealed the resident had impairment to one lower extremity, and mobility device documented as a walker and wheelchair. A Care Plan dated 8/09/11 identified a problem with potential for falls related to cognitive deficit, unsteady gait, and history of falls. The goal indicated the resident would have no falls and injury would be minimized in the event of a fall. The care plan directed staff to have a clip alarm in place at all times, and a motion alarm in place when the resident in bed. The Incident Details dated 9/8/11 documented the resident laying on the floor on the right side with gripper socks on, and the personal alarm did not sound. The documentation revealed the resident obtained a skin tear to the right hand. The documented skin tear size revealed 1.7 centimeter by 0.1 centimeter. The Incident Report dated 9/15/11 documented results of the investigation as follows: The resident had been transferred from a regular stuffed chair to a wheelchair so the resident could sit at a desk. The resident had an alarm on when in the chair. When the certified nursing assistants transferred the resident to the wheelchair, the clip alarm had been attached to the wheelchair but not the resident. During an interview on 12/01/11 at 7:36 a.m. Staff U, Certified Nursing Assistant reported the resident needed a clip alarm at all times. 3. A History and Physical dated 12/04/09 documented Resident #21 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment with a reference date of 9/07/11 revealed Resident #21 had two falls with no injury, and one fall with a minor injury. The Care Plan dated 9/27/11 identified a concern for Resident #21 to have a potential for falling related to an unsteady gait manifested by a history with falls. The Care Plan goal revealed the resident will have no falls, and injury will be minimized in the event of a fall. The Care Plan directed staff to apply a Primus alarm at all times on the resident, and to ambulate the resident with assist of one staff member and the use of a walker. The Incident Detail dated 9/17/11 documented the resident sustained [REDACTED]. The documentation revealed the personal alarm did not sound, a certified nursing assistant in the hallway heard someone yelling, and then entered the resident room and the found the resident on the floor. The Investigation Incident Report documented a physical therapist had been working with the resident and left the resident in bed without activating the motion alarm, and did not notify the nursing staff that the resident was left alone in the room.

Based on observation, record review and staff interviews, the facility failed to routinely assess a heel ulcer and prevent pressure ulcer development for one of twenty- one residents reviewed (Resident #14). The facility identified a census of 151 residents. Findings include: 1. Resident #14 had an admission MDS (Minimum Data Set) assessment with a reference date of 8/6/2010, with [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance with bed mobility and activities of daily living and had 1 stage 1 (a persistent area of skin redness that did not disappear when pressure relieved. The RAP (Resident Assessment Protocol) completed on 8/11/2010 triggered pressure ulcers. The RAP identified the resident at risk for additional skin breakdown due to impaired mobility and a history of [MEDICAL CONDITION]. The RAP confirmed the resident had a stage 1 pressure ulcer on the right lateral heel. When the resident laid on back, the right leg would externally rotate. Do to pain, the resident laid on bed. The resident wore Prevalon boots on both feet when in bed and wore a shoe for transfers only. A 60 day MDS assessment was completed on 10/8/2010Resident #14 continued to require extensive assistance with bed mobility and activities of daily living. The assessment identified an unstageable pressure sore which measured 4 centimeters (cm) by 3.2 cm. The assessment did not identify arterial or venous ulcers A care plan dated 8/24/10 identified a problem with alteration in skin integrity related to impaired mobility. On 9/13/2010 the skin had a stage 2 (partial loss of skin tissue) ulcer located on the right outer calf area The care plan identified an area of deep tissue injury on the right heel. A goal date of 11/16/2010 of progressive healing evidenced by weekly assessments. A Braden Scale(used to determine risk of pressure sore development) and had [MEDICAL CONDITION] The interventions directed staff to: a. Monitor and evaluate status of area surrounding the ulcer daily for freedom of possible complications, b. Check leg bag straps to make sure the straps are not too tight and fasteners not pressing into skin and to wear the leg bag only on the left leg. c. Weekly documentation of skin assessment flow sheet d. Prevalon boots to be worn on both feet when in bed., e. Low air loss mattress to be on bed with comfort setting at 4-5. f. Pink foam elevator with strap under the right leg when lying supine and to avoid bandaged area (no date). The Wound Flow Sheet dated 8/22/10 identified the right posterior heel to contain a 3.0 centimeter (cm) length, 1.8 cm width, no depth pressure ulcer at a stage one. Further assessments to this area were documented for dates 8/25/10, 9/3/10, 9/10/10, 9/16/10, and 9/22/10. The documentation on 9/22/10 described the area to be the same size, and as a dry blister peeling off, with the top layer of skin missing. The next documentation in the clinical record dated 11/14/10 to the right heel 0.25 cm length, no width, and zero for depth. The next documentation dated 11/16/10 identified the right heel wound as 1.7 cm length, 1.9 cm width, and zero depth, with dark tissue, and described as a suspected deep tissue injury. The clinical record lacked an assessment of the wound between 9/22/2010 and 11/14/2010. The Wound Flow Sheet dated 9/13/10 identified the right outer calf area to contain a stage 2 pressure area which measured 1.7 cm by 1.5 cm and scabbed with 100% slough tissue. The Wound Flow Sheet revealed the area on the right outer calf presents as a thin scab area, and appears to be caused by the fastener of the Foley leg bag (leg bag holds urine from indwelling bladder catheter). The assessments dated 9/16/2010, 9/21/2010, 9/27/2010, 10/1/2010, 10/9/2010, 10/14/2010, 10/20/2010, 10/29/2010, 11/3/2010, 11/10/2010 and 11/17/2010 identified enlargement of the calf wound. The assessment indicated on 11/17/2010 the wound measured 7.9 cm by 2.8 cm and 0.4 cm in depth. The laboratory report dated 10/4/2010 indicated a culture of the calf wound was obtained. The culture identified a heavy growth [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant S. Aureus present. The Wound Flow Sheet indicated the resident expressed pain beginning 10/14/2010. During an interview on 11/16/10 at 11:00 a.m. Staff H (Registered Nurse), stated the resident had a right heel pressure ulcer maybe caused by a shoe, and a stage three pressure ulcer to the right outer calf caused by a Foley leg bag strap. Staff H reported the resident had poor circulation. During an interview on 11/18/10 at 11:45 p.m. Staff CC (MDS Coordinator/Registered Nurse), reported finding the outer calf pressure ulcer, and described the area as the size of the plastic button on the leg strap used for the Foley bag. The resident was identified at risk for pressure ulcers. The Foley drainage bag strap and the shoe caused pressure to the right calf wound and right heel. Due to the resident ' s [DIAGNOSES REDACTED].