Every finding on record at Good Samaritan - Indianola

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure hot foods were held at minimum required temperatures for 1 of 1 meals observed and for 2 of 18 interviewable residents reviewed for food(Residents #50 and #47). The facility reported a census of 80 residents.Findings included: 1. On 5/13/26 at 12:22 p.m., Staff A [NAME] prepared a test tray and placed it on a food cart in the kitchen. Staff A continued to plate meals and place them on the cart. At 12:28 p.m. Staff D [NAME] brought the cart out of the kitchen and took it to the nursing station. Staff started passing room trays at 12:30 p.m. and Staff E Certified Medication Assistant(CMA) distributed the last resident tray at 12:34 p.m. The surveyor immediately obtained the following temperatures from the test tray utilizing a facility-provided thermometer:Mashed potatoes: 126 degrees FahrenheitCarrots: 131 degrees Fahrenheit The surveyor tasted the above foods and they were warm but not hot. On 5/13/26 at 3:29 p.m. the Nutrition and Food Manager stated food should be held at a minimum of 135 degrees Fahrenheit but stated they wanted it to be above this. The facility policy Food Temperature Monitoring, reviewed 3/23/26, higher than 135. 2. Review of the clinical record for Resident #50 revealed he scored 13 on his Brief Interview for Mental Status, indicating intact cognition. In an interview on 5/11/26 at 1:25 PM Resident #50 stated he gets his food last an it's not always warm. They also don't always use a cloche to cover the food when they bring it. 3. The MDS assessment dated [DATE] revealed Resident #47 had a Brief Interview for Mental Status score of 15, indicating intact cognition. In an interview on 5/11/26 at 2:51 PM, Resident #47 reported the food was often cold and tasteless. Resident #47 stated she did not look forward to the meals that were served at the facility.

Based on clinical record review, observations, resident and staff interview and policy review the facility failed to ensure the call light was within reach for 2 of 20 residents sampled (Resident #63 and #72). The facility reported a census of 80 residents.Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS recorded the resident had dependence on staff for bed mobility and transfers, and had impaired range of motion to the upper extremity on one side. The Care Plan revised 1/22/26 revealed Resident #63 had a performance deficit in activities of daily living (ADL's) related to extremity weakness and paralysis, and at risk for falls. The Care Plan directed staff to modify the environment to maximize safety. During observation on 5/11/26 at 12:40 PM, observed the call light cord wrapped on the bed handrail. Resident #63 reported he had trouble reaching the call light. Resident #63 had contractures to his hand and fingers. On 5/13/26 at 1:25 PM, observed Resident #63 lying in bed on his back. The call light was lying on the floor by the bed. In an interview on 5/14/26 at 12:30 PM, Staff C, Clinical Care Lead, reported he expected the call light kept in reach for the resident. Staff C reported he planned to check with maintenance about getting a touch pad call light for Resident #63. 2. The MDS dated [DATE] indicated that Resident #72 had diagnoses of paraplegia, multiple sclerosis, muscle weakness and lack of coordination. It also indicated that she was dependent on staff for toilet hygiene, personal hygiene, toilet transfer, sit to stand and chair/bed-to-chair transfers. She also needed partial/moderate assist to roll left and right in her bed. She had a Brief Interview for Mental Status (BIMS) score of 14 indicating she was cognitively intact. The Care Plan initiated on 11/14/24 lacked documentation of call light use or being in reach of Resident #72. During an observation on 5/11/26 at 1:01 PM observed Resident #72 in her bed and did not have her call light within reach and actually waved to the surveyor to come into the room. Observed her call light lying over the side of the bed in the railing. Her roommate handed it to her. During an observation on 5/12/26 at 2:30 PM observed Resident #72 in her bed and waved at the surveyor to come into the room. She wanted her TV adjusted but her call light was noted to be lying over the bed railing and touching the floor. Her roommate handed it to her. During an observation on 5/14/26 at 9:25 AM observed Resident #72 in her wheelchair next to her bed. Her call light was not in reach and was actually on the bed railing behind her. In an interview on 5/11/26 at 1:01 PM Resident #72 stated she could not reach her call light. In an interview on 5/12/26 at 2:30 PM Resident #72 stated she needed her TV adjusted. The surveyor asked her to put on her call light. She stated that she could not reach it. In an interview on 5/14/26 at 9:25 PM Resident #72 stated that she could not reach her call light or even see it as it was behind her. In an interview on 5/14/26 at 9:28 AM Staff O, CNA was informed that Resident #72 could not reach her call light. She stated she should have had it and gave it to her. A Call Light policy reviewed/revised 7/8/25 revealed the call light placed within easy reach of the resident when staff leave the room. An adaptive call light provided if applicable.

Based on clinical record review, resident and staff interviews, grievance/concern forms, and policy review the facility failed to ensure a system for tracking and making an effort to follow up on the residents' concerns regarding missing belongings for 2 of 3 residents reviewed for personal property (Resident #6 and #47). The facility reported a census of 80 residents. Findings include: 1.The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had diagnoses of cerebral vascular accident (CVA) (stroke), Post-Traumatic Stress Disorder (PTSD), and depression. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the care of personal belongings was very important to the resident. In an interview on 5/12/26 at 9:37 AM, a family member reported the facility had lost so many of Resident #6's clothes, a pair of black shoes and a blue walker with a seat that folded up had been missing in the past year. The family member voiced concern related to staff turnover and she thought the belongings came up missing after the resident got moved to another room. The family member reported the missing belongings was brought up at a care conference but nothing ever came of it. The family member was unaware of any grievance form.Review of Resident Inventory of Personal Effects forms, provided by the facility to the surveyor during the survey week, revealed no inventory form for Resident #6.A Grievance Suggestion or Concern form dated 2/16/26 revealed the resident reported colored t-shirts with pockets, white t-shirts, and six to eight white jockey shorts missing. On 2/18/26, an Investigation revealed clothing sent to the laundry daily. Laundry staff reported the resident's laundry was delivered on 2/17/26. Ancillary staff and Administrator aware of concern and continue to look for the articles. Will continue to investigate. On 2/19/26, the resident's son was to have more clothing delivered on 2/18/26 to have more pants and t-shirts in the closet. In an interview on 5/13/26 at 10:10 AM, Staff J, Social Services (SS), reported she started in the SS role on 12/1/25 and also worked at the facility for 2 years as a nurse prior to working in the SS role. Staff J stated she was told that the inventory sheets for resident belongings were kept at the nurse's station in a file. She cleaned the nursing station area often and never came across any inventory sheets. Staff J stated she filled out a grievance form if a resident reported something missing. The form was given to SS, the Director of Nursing (DON) and the Administrator. They notified ancillary staff to look for the item. She also checked the lost and found to see if they could find the item but a lot of times things were not labeled. Staff J reported she kept the paper inventory form in a file in the SS office effective 1/2026. The family was provided the inventory form to fill out and sign when a resident admitted to the facility. Another inventory form was filled out when additional items had been brought in for a resident. The inventory form was given to SS. In an interview on 5/13/26 at 10:20 AM, Staff H, Activities Assistant, reported she checked the resident rooms and tried to look for missing items whenever a resident reported something missing. She filled out a grievance form if a resident reported to her that something was missing. Staff H reported she was unaware of Resident #6's walker but she thought a family member took the walker home.In an interview on 5/13/26 at 1:20 PM, Staff F, certified nursing assistant (CNA) reported she filled out a grievance form if a resident had a concern or reported something missing. Staff F stated she also checked laundry to see if she could find the missing item. In an interview on 5/13/26 at 1:30 PM, Staff G, CNA, reported she looked for the missing item, checked the lost and found, and let SS, the DON, and the Administrator know when someone reported a concern about a missing item. Staff G reported the inventory forms should be located at the nursing station. At the time, Staff G checked the file cabinet and the nurse's station area on the 100/200 hall and found no inventory forms. On 5/13/26 at 1:40 PM, Staff J, SS, reported no any inventory forms found for Resident #6. In an interview on 5/14/26 at 12:30 PM, Staff C, Clinical Care Lead, reported Resident #6 had a pair of shoes but he thought the resident's wife took the shoes home. Staff C reported the inventory forms were filled out by SS, and the resident or family member signed the sign the form. A copy of the inventory form was placed on the back of the resident's room door. Staff updated the form whenever items were brought in or removed. Staff C reported the policy had not stuck. There had been a turnover in SS staff at the facility. 2. The annual MDS assessment dated [DATE] revealed Resident #47 had intact cognition. The MDS indicated the care of your personal belongings or things as very important to the resident. In an interview on 5/11/26 at 2:53 PM, Resident #47 reported her things went to the laundry but don't come back. The resident reported a dusty-rose colored pants with flowers on one pant leg had been missing for 6 months and she had many other clothing items lost. Resident #47 stated she let the facility staff know the items were missing but they never got replaced. Review of Resident Inventory of Personal Effects forms revealed no inventory form for Resident #47. In an interview on 5/13/26 at 10:20 AM, Staff H, Activities Assistant, reported Resident #47 misplaced items a lot. Staff H stated she often had to look for the things the resident reported missing. On 5/13/26 at 1:40 PM, Staff J, SS, reported no inventory form for Resident #47. A Grievance, Suggestions or Concerns policy reviewed/revised 12/15/25 revealed concerns are to be deemed high priority customer satisfaction issues. Facility staff will make prompt efforts to resolve a grievance and keep the resident/resident representative apprised of progress toward resolution. The admission Agreement revealed the facility is not liable for loss or damage of the resident's personal possessions unless such loss is the result of any negligent act or omission of the facility.

Based on clinical record review, staff and family interviews, and policy review, the facility failed to provide documented evidence in the resident's medical record to support the basis to necessitate the resident's discharge and transfer to an affiliated facility. The facility also failed to provide the required 30-day advance notice of discharge to the resident's representative and the Long-Term Care State Ombudsman. The facility reported a census of 80 residents.Findings include:Resident #92's MDS assessment dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, dementia with other behavioral disturbances, and diabetes mellitus. It revealed the resident required supervision with eating, required maximal assistance with oral hygiene, upper body dressing, bathing, and bed repositioning, and was dependent with all other ADLs and mobility.The Care Plan revised 5/17/23 included a focus which indicate the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. It also indicated the resident understood consistent, simple, direct sentences and directed staff to ask the resident yes/no questions to determine the resident's needs.A Health Status Progress Note dated 2/23/25 at 11:00 AM revealed the resident exhibited hypersexual behavior toward a female resident.An Incident Progress Note dated 2/23/25 at 12:58 PM revealed he was moved to a room closer to the nurses' station and by other male residents.A Health Status Progress Note dated 9/25/25 at 12:34 PM revealed the resident was no longer able to ambulate.The Progress Notes dated from 2/24/25 to 2/28/26 revealed the resident exhibited no sexual behaviors other than to staff. There is no progress note documentation that Resident #92 exhibited hypersexual behavior toward other residents.A Health Status Note Progress Note dated 10/06/25 3:11 PM revealed multiple medications, including the medication used to control the resident's hypersexual behaviors, were discontinued due to a decline in health.A Health Status Note Progress note dated 1/16/26 at 11:43 AM indicated the facility restarted the medication used to control the resident's hypersexual behavior.A SAFE Event-Incident Report - SPN Progress Note dated 2/28/26 at 1:32 PM indicated the resident was involved in a resident-to-resident, physical contact incident with another resident.A Communication/Visit with Physician Progress Note dated 3/03/26 at 2:28 PM revealed the medication used to control the resident's hypersexual behaviors was increased.A Hospice Progress Note dated 3/04/26 at 5:21 PM revealed the resident was on a 1:1 supervision with no sexual behaviors noted. There are no documented progress notes which indicated the resident exhibited hypersexual behaviors toward other residents after 3/02/26.A Communication with Resident/Family Progress Note dated 3/11/26 at 11:57 AM revealed the resident representative was notified the resident was being transferred to an affiliated facility. The Progress Note also revealed the representative was not happy with this decision and informed the facility they should give the medication longer to work. The Social Worker advised the representative they would keep her informed of the date and time of the resident's move.A Communication with Resident/Family Progress Note dated 3/18/26 at 10:54 AM revealed the resident was being discharged to the affiliated facility on 3/18/26 at 11:00 AM and would be living there permanently. It also revealed the resident's representative verbalized understanding. The facility provided no other documentation that the resident, the resident's representative, or the Long-Term Care State Ombudsman (LTCSO) was given the required 30-day notification of transfer and/or discharge.On 5/13/26 at 10:41 AM, Staff M, Certified Medication Aide (CMA) stated Resident #92 was hypersexual and moved to another area in the facility and isolated from women the day of the incident on 2/28/26. She also stated he on line-of-sight supervision. She further stated the resident would sit along at a dining table separated from female residents. She stated the incident on 2/28/26 was the only time the resident exhibited hypersexual behaviors toward another resident since she started in [DATE].On 5/13/26 at 11:01 AM, Staff B, Licensed Practical Nurse (LPN) stated the resident was moved to the rehabilitation area for more direct oversight. His room was in a location where staff could have direct observation of him if he were in his room. She also stated his only prior resident-to-resident incident was in early 2025. She further stated the resident was placed on hospice care in 2025 and no longer exhibited a risk.On 5/13/26 at 12:54 PM, the resident's representative stated she visited Resident #92 at the new facility and his room was not located in a locked unit. She stated the facility Administrator told her Resident #92 would get 1:1 supervision at the new facility. She also stated she was informed of the resident's transfer to another facility two (2) days prior to the scheduled date but it was delayed by one (1) week.On 5/13/26 at 1:36 PM, the Social Worker (SW) stated the resident had behaviors sexually grabbing at staff and residents. The facility contacted corporate because he was taken off of the medication that controlled his hypersexual behaviors. She also stated he inappropriately touched a resident on her thigh but added it was the first one he did in a long time. She further stated when he came off of hospice, he touched other residents and staff, so the facility contacted corporate to get him transferred to another affiliated facility, primarily within the same corporation. She said they tried to locate a facility with all-male units but their corporate owned facilities do not have one. She also said a second option the facility considered was to get him into another affiliated facility with fewer residents with a locked unit. She indicated the receiving facility had a locked unit and thought he was admitted to a room in the locked unit but wasn't sure. She admitted on [DATE] the resident had cognitive impairment and wouldn't have been able to understand why he was being transferred. She stated she was not directly involved in this transfer.On 5/13/26 at 1:51 PM, the Administrator stated after the 2/28/26 incident, he made a referral to an all-male unit two (2) separate facilities. One was full and the other denied acceptance based on unmet resident criteria. He further stated after the transfer referrals were unsuccessful, he and the DON contacted the receiving facility's Administrator, the DON, and the Senior Director of Long-Term Care to discuss the transfer. The Administrator and Director of Nursing (DON) stated the resident's BIMS was a 04 (out of 15), so he was not cognitively intact to understand his transfer. The Administrator also stated he discussed the transfer with the resident's representative but admitted she did not have input in the transfer location.On 5/13/26 at 1:59 PM, the DON stated the resident was moved to a room in a separate part of the facility so he could eat in that area's lower populated dining room. She also stated the resident's behaviors were directed toward staff and not at other residents after he changed rooms.On 5/13/26 at 2:24 PM, the Regional Clinical Services Director clarified the resident was admitted directly into the receiving facility's regular unit but in a low-stimulation area room.On 5/13/26 at 4:02 PM, the Administrator stated the resident's representative was in understanding of the transfer on 3/18/26. He stated there was no documentation of any other communication with her other than what was already in the EHR.On 5/14/26 at 10:56 AM, the SW confirmed the resident's representative was unhappy of the transfer because she verbalized it to the SW during a phone conversation on 3/18/26. The SW stated the representative stated moving the resident to the affiliated facility would limit her visitation ability to once monthly because of the extra 1 1/2 hour drive to the new facility. The SW also stated the representative indicated the facility hadn't given the resumed medication enough time to work. The SW revealed the Administrator notified her the resident was going to move to the receiving facility on 3/18/26 and asked her to contact the representative. The SW also stated the representative didn't verbalize any complaints on 3/18/26 when she was told the resident was leaving at 11:00 AM.A policy titled Discharge And Transfer-Rehab/Skilled, Therapy & Rehab revised 1/15/26 indicated When a transfer or discharge occurs, the location must ensure that the transfer or discharge is documented in the medical record and appropriate information is communicated to the receiving healthcare center or provider. The location permits each resident to remain in the location and does not transfer or discharge the resident from the location unless:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the location. Documentation in the resident's record must include the specific resident needs that cannot be met, the location's attempts to meet the resident's needs and the services available at the receiving location to meet the needs. This documentation must be made by the resident's physician. Notice must be made at least 30 days before the transfer or discharge.The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the care and/or services provided by the location. Notice must be made as soon as practicable.The safety of individuals in the location is endangered due to the clinical or behavioral status of the resident. The basis for the transfer must be documented in the resident's record by a physician. Notice must be made as soon as practicable.The health of individuals in the location would otherwise be endangered. The basis for the transfer must be documented in the resident's record by a physician. Notice must be made as soon as practicable.The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare and Medicaid) a stay at the location. Non-payment applies if the resident does not submit the necessary paperwork for third-party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a location, the location may charge only allowable charges under Medicaid. Notice must be made at least 30 days before the transfer or discharge.The location ceases to operate. The administrator of the location must provide written notification, as well as the plan for the transfer and adequate relocation of the residents, prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the location and the resident's representatives.The resident has the right to appeal a transfer or discharge notice from the location. The location may not transfer or discharge the resident while the appeal is pending unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the location. The location must document the danger that failure to transfer or discharge would pose. Additionally, if a resident's initial Medicaid application is denied but appealed, the resident is not considered to be in nonpayment status. Notice must be made at least 30 days before the transfer or discharge.

Based on clinical record review, staff and family interview and policy review the facility failed to provide bed hold information for 3 of 3 residents admitted to the hospital (Residents #11, #1, #6) and failed to notify the resident, the resident's representative, or the Long-Term Care State Ombudsman (LTCSO) of a discharge at least 30 days in advance for 1 of 1 residents discharged (Resident #92). The facility reported a census of 80 residents.Findings included:1. The Minimum Data Set (MDS) dated [DATE] for Resident #11 lacked a Brief Interview for Mental Status (BIMS) score and had diagnoses of multiple sclerosis, quadriplegia and neurogenic bladder. The Electronic Health Record (EHR) indicated that Resident #11 had a suprapubic catheter and a history of Urinary Tract Infections (UTIs). She was transferred to the hospital on 5/5/26 for verbal unresponsiveness from baseline, dilated pupil and possible sepsis. She was admitted to the hospital for a UTI and altered mental status. The documentation revealed that the family was notified but did not include that a bed hold was offered or discussed. On 5/13/26 at 10:15 AM., via email, the Administrator indicated that there was no bed hold on file for Resident #11 for 5/5/26. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses diabetes mellitus and traumatic brain injury. It revealed the resident was independent with eating, bed repositioning, sit-to-lying, and lying-to-sitting, required setup assistance with oral hygiene, moderate assistance with sit-to-stand and transfer mobility, and maximal assistance with all other Activities of Daily Living (ADLs) and mobility. The Care Plan revised 5/10/24 included a focus which indicated the resident had impaired cognitive function/dementia or impaired thought processes due to traumatic brain injury. A Health Status Note Progress Note on 12/19/25 at 3:17 PM revealed the resident experienced a drop in oxygen level and was sent to the hospital. An eINTERACT SBAR Summary for Providers Progress Note dated 12/19/25 at 3:19 PM revealed the nurse contacted the resident's representative but did not include documentation a bed hold was offered or discussed. The Clinical Census information indicated the resident changed to a hospital leave admission status. On 5/13/26 at 7:58 AM, Staff L, Licensed Practical Nurse (LPN) stated bed holds are documented on paper. The Electronic Health Record (EHR) document list did not include a bed hold or representative notification of hospital transfer for 12/19/25. On 5/13/26 at 9:04 AM, the Administrator stated the facility did not have a bed hold or resident representative notification of transfer documentation for Resident #1. 3. The MDS assessment dated [DATE] revealed Resident #6 readmitted to the facility on [DATE] from the hospital. The Progress Note dated 3/3/26 at 10:08 PM, revealed the resident's spouse called with a concern about the resident possibly having a stroke. Resident observed in the dining room. He was responsive, alert and oriented, and leaning to his left side while seated in the wheelchair. Spouse notified of assessment but spouse still unsettled. Spouse requested evaluation at the hospital. The on-call provider was notified and approved to send the resident to the hospital. Resident was sent to the hospital at 7:49 PM. The record lacked documentation that a bed hold was offered or discussed. On 5/13/26 at 7:58 AM, Staff L, LPN, stated bed holds are documented on paper. In an interview on 5/14/26 at 12:50 PM, Staff B, Clinical Care Lead, reported Resident #6 went to the hospital on 3/3/26 and returned to the facility on 3/6/26. Staff B reported an E-interact transfer form filled out and saved in the computer when a resident had a change in condition or transferred to the hospital. The staff normally called report to the hospital staff and a copy of the face sheet, IPOST (advanced directive) and medication list sent with the resident. Staff B reported she would look to see if she could find documentation about a bed hold for Resident #6. A Bed-Hold Policy reviewed/revised 12/23/25 revealed the facility will provide written information to the resident or resident's representative at the time of a transfer about the duration of the bed-hold policy, the reserve bed payment policy in the State plan, and the policy regarding the bed-hold period permitting a resident to return to the facility. The purpose of the bed hold was to ensure the resident was made aware of the bed hold policy and to determine if the resident/representative wanted to hold the bed. 4. Resident #92's MDS assessment dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, dementia with other behavioral disturbances, and diabetes mellitus. It revealed the resident required supervision with eating, required maximal assistance with oral hygiene, upper body dressing, bathing, and bed repositioning, and was dependent with all other ADLs and mobility. The Care Plan revised 5/17/23 included a focus which indicate the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. It also indicated the resident understood consistent, simple, direct sentences and directed staff to ask the resident yes/no questions to determine the resident's needs. A SAFE Event-Incident Report – SPN Progress Note dated 2/28/26 at 1:32 PM indicated the resident was involved in a resident-to-resident, physical contact incident with another resident. A Communication/Visit with Physician Progress Note dated 3/03/26 at 2:28 PM revealed the medication used to control the resident's hypersexual behaviors was increased. A Hospice Progress Note dated 3/04/26 at 5:21 PM revealed the resident was on a 1:1 supervision with no sexual behaviors noted. There are no documented progress notes which indicated the resident exhibited hypersexual behaviors after 3/02/26. A Communication with Resident/Family Progress Note dated 3/11/26 at 11:57 AM revealed the resident representative was notified the resident was being transferred to another facility owned by the same company. The Progress Note also revealed the representative was not happy with this decision and informed the facility they should give the medication longer to work. The Social Worker advised the representative they would keep her informed of the date and time of the resident's move. A Communication with Resident/Family Progress Note dated 3/18/26 at 10:54 AM revealed the resident was being discharged to the other company owned facility on 3/18/26 at 11:00 AM and would be living there permanently. It also revealed the resident's representative verbalized understanding. The facility provided no other documentation that the resident, the resident's representative, or the Long-Term Care State Ombudsman (LTCSO) was notified of the discharge in writing and in a manner they understood at least 30 days in advance of the discharge. On 5/13/26 at 4:02 PM, the Administrator stated the facility had no other communication documentation about the resident's transfer other than what was in the EHR.

Based on clinical record review, staff interviews, and policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment and a comprehensive care plan for 2 of 4 residents (Residents #22 and #72) reviewed for Pre-admission Screening and Resident Review (PASRR). The facility reported a census of 80 residents.Findings include:1. The MDS dated [DATE] revealed that Resident #22 had diagnoses of depression, bipolar disorder, anxiety disorder and other hallucinations. Question A1500 indicated that she was not considered a Level II PASRR by the state Level II PASRR process. Question A1510 lacked documentation.The Care Plan initiated 1/25/21 lacked documentation concerning Level II PASRR status.The Notice of PASRR Level II Outcome dated 9/19/24 indicated Resident #22 was approved with specialized services. It further indicated diagnoses of Bipolar disorder, major depressive disorder and paranoid disorder. 2. The MDS dated [DATE] revealed that Resident #72 had diagnoses of anxiety disorder and bipolar disorder. Question A1500 indicated that she was not considered a Level II PASRR by the state Level II PASRR process. Question A1510 lacked documentation.The Care Plan initiated 11/14/24 lacked documentation concerning Level II PASRR status.The Notice of PASRR Level II Outcome dated 11/11/24 indicated Resident #72 was approved with specialized services. It further indicated diagnoses of dementia, anxiety disorder and bipolar disorder.In an interview on 5/12/26 at 2:45 PM Staff J, Social Services Coordinator stated that Resident #22 and #72 are both Level II PASRR residents.In an interview on 5/14/26 at 10:02 AM Staff P, MDS Coordinator stated that she does not do the PASRR portion of the MDS or the Care Plan. Staff J, Social Services Coordinator does them. Stated she thought that Resident #22 was a Level II but was sure if Resident #72 was.In an interview on 5/14/26 at 10:15 Staff J, Social Services Coordinator stated that she took over for PASRR in December of 2025. She confirmed again that Resident #22 and #72 were both Level II PASRR residents. She realized recently that she incorrectly marked no to the MDS question A1500 when they should have been marked yes for several residents. She marked Resident #22 incorrectly as no. She did not do the MDS for Resident #72 but said that it should have been marked yes as well. She also does the Care Plan portion for PASRR. She stated she should have had PASRR documentation on the Care Plan for both Resident #22 and #72.The Notice of PASRR Level II Outcome for both residents indicated they have PASRR conditions and if they admit to a Medicaid-certified nursing facility, or if they are currently in a Medicaid-certified nursing facility, the facility should mark yes for question A1500 on the MDS and the specific condition should be checked in question A1510.In a policy titled Pre-admission Screening and Resident Review (PASARR)- Rehab/Skilled dated 12/29/25 it indicated that Preadmission Screening and Resident Review (PASARR) - A federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.In a policy titled MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument)- Rehab/Skilled & Therapy and Rehab dated 10/27/25 it indicated that a significant correction is an assessment that is completed when it is determined that a resident's prior comprehensive assessment contains a significant error. It also indicated that A significant error is an error in an assessment where: a. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment; and b. The error has not been corrected via submission of a more recent assessment.

Based on clinical record review, staff interviews and policy review the facility failed to submit a Preadmission Screening and Resident Review (PASRR) within a time-limited review timeframe for one of four residents reviewed for PASRR (Resident #63). The facility reported a census of 80 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had diagnoses of anxiety disorder and psychotic disorder. The MDS documented the resident not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident took an antipsychotic and antidepressant medication during the seven-day look-back period. A PASRR Level II determination date 10/22/24 revealed a short-term approval ended 2/19/25. In an interview on 5/13/26 at 1:40 PM, Staff J, Social Services (SS), reported she had worked in the SS role since 12/1/25. Staff J was not aware she needed to do PASRR's. She realized some PASRR's were only in effect for 120 or 180 days and then a PASRR needed to be resubmitted. Staff J reported she was in the process of setting up a schedule for when a PASRR would be due. On 5/14/26 at 9:50 AM, Staff J checked the computer for the PASRR's completed on Resident #63. Staff J reported Resident #63's PASRR was last completed on 10/22/24 and the PASRR had a recommendation for an onsite review. Staff J checked the PASRR vendor website to review the PASRR's completed. A Level II PASRR was completed on 2/19/25 with a time-limited follow up review needed. Staff J reported she completed Resident #63's PASRR on 4/17/26. A PASRR policy reviewed/ revised 12/29/25 revealed a PASRR ensured that individuals with a mental diagnoses or intellectual disability receive the care and services they need in the most appropriate setting. A Level II PASRR screening is conducted by the agency designated by the state. The facility should reference the state PASRR program requirements for specific procedures.

Based on clinical record review, observations, resident and staff interviews and policy review, the facility failed to implement and follow interventions on the care plan to use an apron whenever the resident smoked for 1 of 1 resident reviewed for smoking (Resident #49). The facility reported a census of 80 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview for Mental Status score of 13 out of 15, indicating cognition intact. The MDS indicated the resident used tobacco.The Care Plan revised 3/19/26 revealed Resident #49 used cigarettes. The Care Plan directed staff to put a smoking apron on the resident (initiated 4/4/26), store cigarettes and lighter at the nurse's station (initiated 4/4/26) and supervise the resident to smoke.A Tobacco Evaluation dated 3/18/26 revealed the resident required supervision for smoking. The evaluation lacked documentation about smoking apron use.During observation on 5/12/26 at 9:35 AM, Resident #49 held a lit cigarette in his hand and smoked as he sat in a motorized wheelchair on the outside patio. The resident did not have an apron on. A staff person was in attendance outside. During continuous observations of residents smoking outside on 5/13/26 at 1:03 PM to 1:18 PM, nine residents sat outside on the patio smoking with Staff K, Maintenance, in attendance. Aprons hung on the coat hooks inside the alcove by the exit door to the patio. None of the residents had an apron on as they smoked. Staff K lit a cigarette for the resident. In an interview on 5/13/26 at 9:30 AM, Resident #49 reported he smoked cigarettes. He kept a lighter in his pocket but he could not do anything with the lighter if he did not have a cigarette to light. Resident #49 reported sometimes staff put an apron on him but he did not know why. Resident #49 stated he has not burned himself. In an interview on 5/13/26 at 1:20 PM, Staff F, certified nursing assistant (CNA), reported she looked at the care plan to know what a resident needed to have done or if the resident had privileges to go out to smoke. She also looked at the care plan to know If a resident needed supervision or had to wear an apron when the resident went out to smoke. In an interview on 5/13/26 at 1:25 PM, Staff K, Maintenance, reported on 5/13/25 at 1:00 PM was the second time he took residents out to smoke. Staff Q, Maintenance, normally took the residents out at 1 PM to smoke but Staff Q was off. Staff K reported the residents' cigarettes and lighters were kept in a large box and locked in a room by the nurse's station. Staff K reported Resident #21 was the only resident that he knew had to wear a bib (apron) when he smoked.In an interview on 5/14/26 at 12:30 PM, Staff C, Clinical Care Lead, reported he expected the care plan to be followed. The resident should have an apron if the care plan indicated the resident needed to wear an apron while smoking. Staff C reported only Resident #49 and Resident #21 needed to wear an apron when they smoked. The Administrator had talked to a resident about wearing an apron when smoking and it was a safety concern.The facility's Smoking and Tobacco Policy revealed residents who need protective wear should wear the protective attire at all times when smoking.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to properly disinfect a glucometer (a machine which obtained blood sugar readings) for 2 of 3 residents observed during blood sugar checks (Residents #38 and #6). The facility reported a census of 80 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool, dated 4/2/26, listed a diagnosis of diabetes for Resident #38 and listed his Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition.A 1/20/25 order directed staff to check the resident's blood sugar before meals and at bedtime. 2. The MDS assessment tool, dated 3/19/26, listed a diagnosis of diabetes for Resident #6 and listed his BIMS score as 11 out of 15, indicating moderately impaired cognition.A 1/10/26 order directed staff to check the resident's blood sugar before meals and at bedtime. On 5/14/26 at 10:03 a.m., Staff N Certified Medication Aide (CMA) obtained Resident #55's blood sugar and wiped off the glucometer with an alcohol pad. Staff N then obtained Resident #38's blood sugar and wiped off the glucometer with an alcohol pad. Staff N then obtained Resident #6's blood sugar. Following the blood sugar checks, Staff N stated she was supposed to wipe off the glucometers with a disinfectant wipe but did not have those on her cart.On 5/14/26 at 10:12 a.m., the Director of Nursing(DON) stated staff should utilize disinfectant wipes to sanitize glucometers and should let the wipes set for 5 minutes. The facility policy Blood Glucose Monitoring, Disinfecting and Cleaning, dated 9/30/26, directed staff to utilize a disinfectant or germicide wipe to sanitize a glucometer.

Based on direct observation, clinical record review, staff interview, resident interview, and facility policy review, the facility failed to maintain appropriate staffing levels to ensure call lights were answered in a timely manner. The facility reported a census of 82. Findings include: A direct observation on 01/13/2026-01/14/2026 during the overnight shift it was observed that three Certified Nurse Aides (CNA) and two Nurses were in the building until Staff B, CNA arrived, increasing the number of certified nurse aides to 4. The building has 4 halls, with the rehab care hall being largely isolated from the building by distance and doors. 1 staff member was observed to be assigned to the rehabilitation hall. In an interview on 01/12/2026 at 01:04 PM with Resident #2, whose brief interview for mental status (BIMS) score was reported in the Assessment Scoring Report as 15, indicating intact cognition, he stated he could not get to the bathroom on his own, and while the staffing levels during the day are often sufficient, at night time there aren't enough staff to assist everyone and as a result they often do not answer call lights in a timely manner. He reported feeling like he had to defend and stick up for other residents in the facility to ensure they get their needs met, because there aren't enough staff to go around and he keeps repeating these issues to the facility.In an interview on 01/14/2026 at 11:05 AM with Resident #3, whose BIMS was reported by the Assessment Scoring Report as 15, indicating intact cognition, she stated she can't do anything for herself and as a result she knows the facility doesn't have enough staff members. She stated that the previous weekend she waited at least 45 minutes for her call-light to be answered, but she believed it to have been over an hour. She stated she watches the clock on her phone but she stopped keeping track after 45 minutes. She had pressed her call light because she had soiled herself and needed staff assistance in cleaning up, but she just kept waiting. She stated that when the staff members finally got around to her she was miserable. She reported feeling shame having to sit that long in her own urine and feces. She stated this is a daily and nightly occurrence, with the night and weekend shifts being the most concerning. In an interview on 01/14/2026 at 12:53 PM with Resident #5, whose BIMS was reported on the Assessment Scoring Report as 15, indicating intact cognition, she stated her call light times are usually 45 minutes or longer. As a result she has reduced how often she pushes her call light because help is not coming. She stated it is that bad at least two days out of the week, as well as every night shift and every weekend shift. She stated as a result of the low staffing the staff members often don't get her water at night and when she does need assistance she knows it will be a wait.In an interview on 01/14/2026 at 01:58 PM with Resident #9, whose BIMS was reported on the Assessment Scoring Report as 15, indicating intact cognition, she stated staffing is usually bad at night, and she typically waits over an hour after requesting to go to bed for assistance in getting to bed and at night the wait is worse for assistance. She stated she knows the facility needs more staff because the night and weekend staff are consistently reporting they are short staffed. Review of the Resident Council Minutes from 10/06/2025 documented not enough staffing under the old business heading, indicating the facilities awareness of staffing issues brought to them by residents. Review of the Resident Council minutes from 12/01/2025 documented We want enough CNAs, We want one in the lunch room. We want our call lights answered within 15mins under the Old Business heading, indicating the issue was still unresolved from October. Call Light Response Logs dating from 01/09/2026 to 01/11/2026 were pulled for Resident #2, Resident #3, Resident #5, and Resident #7. They revealed the following information to include the length of the call light time and when the call light was activated: Resident #2: 01/09/2026 - 46 minutes (m) 56 seconds (s) call light at 05:37 PM01/11/2026 - 18m 56s call light at 10:17 PMResident #3: 01/09/2026 - 57m 42s call light at 05:59 PM01/10/2026 - 25m 04s call light at 04:04 AM01/10/2026 - 2hr 4m call light at 03:26 PM01/11/2026 - 49m 29s call light at 06:42 PMResident #5: 01/09/2026 - 24m 05s call light at 07:46 AM01/09/2026 - 29m 12s call light at 02:27 PM01/09/2026 - 1hr 22s call light at 04:16 PM01/10/2026 - 44m 52s call light at 07:08 AM01/10/2026 - 23m 11s call light at 11:13 AM01/10/2026 - 37m 36s call light at 03:41 PM01/11/2026 - 32m 24s call light at 07:51 AM01/11/2026 - 40m 24s call light at 10:45 AM01/11/2026 - 27m 55s call light at 07:34 PM Resident #7: 01/09/2026- 29m 19s call light at 03:18 AM01/09/2026 - 38m 06s call light at 06:08 AM01/09/2026 - 23m 36s call light at 11:57 AM01/09/2026 - 22m 53s call light at 05:46 PM01/10/2026 - 34m 52s call light at 03:27 PM 01/10/2026 - 44m 45s call light at 05:32 PM01/11/2026 - 1hr 12m call light at 08:04 AM01/11/2026 - 21m 46s call light at 09:32 AM01/11/2026 - 21m 01s call light at 10:40 AM01/11/2026 - 38m 22s call light at 12:09 PM01/11/2026 - 53m 03s call light at 03:23 PM 01/11/2026 - 34m 51s call light at 07:23 PMIn an interview on 01/13/2026 at 11:51 PM with Staff A, Certified Nurse Aide (CNA), they stated their work load varies significantly over the nights, with some nights having manageable work loads and some nights not being able to manage. He stated he did not feel the facility had enough staff. In an interview on 01/14/2026 at 12:07 AM with Staff B, CNA, she stated the facility is always short staffed and it gets worse when there are call ins. She stated she works a weekend package but gets called most days to see if she was willing to work. She stated she started getting calls to come in tonight at 8am. She stated she only came in tonight because one of the people working the overnight shift was a friend and asked her to come in as a personal favor. She stated the facility is always short staffed and has been for years. She stated four CNAs and two nurses was considered a good night, but they often operate with just two-three CNAs. She does not feel this is enough staff to meet resident needs. In an interview on 01/14/2026 at 12:26 AM with Staff C, Registered Nurse (RN), she stated the facility does not have enough staff to meet resident needs on the overnight shift. She feels the number of staff they are given causes slow light times and has increased falls on the overnight shift because they cannot effectively monitor the residents the facility has.In an interview on 01/14/2026 at 12:34 AM with Staff D, CNA, she stated residents often expressed frustration with her about the situation and she feels the same. She reports previously having more staff, but for months they have only had 1 CNA per hall at most. She stated it is dangerous to run a facility with so few staff because they can't monitor all of the residents they have. She reported the facility having had more staff in the past but it changed a while ago and now they're always short staffed. In an interview on 01/14/2026 at 12:40 AM with Staff E, Licensed Practical Nurse (LPN), she stated the facility doesn't have enough staff for the number of residents it has and the cares they need. She stated when they are responding to a call light, with so few staff it can be 45 minutes or more before they can answer other call lights. She stated they just can't be everywhere they are needed with so few staff. In an interview on 01/14/2026 at 12:27 PM with the Director of Nursing (DON), she confirmed the facility should have 5 CNAs during the overnight shift. She stated she had recent resignations as well as staff members off for paternity and maternity leave which has led to them operating with fewer staff than was typical. She reported she had not been the DON for very long, taking over only in December. She stated her expectation is for staff to answer call lights within a 15 minute period and acknowledged the call lights from the previous weekend were ridiculous. She stated the facility does not have a chain of command to call when the manager on-call is unavailable, leaving the facility without protocols to reach out for help when required. In an interview on 01/14/2026 at 03:18 PM with the Administrator, he stated the facility had been aware of the need for more staff since before he took over as Administrator in November. He acknowledged the staffing issues have been a repeat facility failure but was unable to speak on why the failure had occurred due to his limited time with the facility. Review of the Facility assessment dated [DATE] documented on page 19 the following: How do you staff on all shifts, including nights and weekends, to meet acuity & needs of residents: Staff based on feedback and amount of care required for residents. Nurse consultant recommendations. Utilization of Pool Staff and Agency Staff as needed.

Based on clinical record review, staff interview, and State Agency Website, the facility failed to make a good faith effort to correct deficient practices resulting in repeated sufficient staffing violations over a three-year period. The facility reported a census of 82. Findings include:Review of the state agency's public website https://dia-hfd.iowa.gov/ contained the following certification actions during the following surveys:Ending on 07/29/2025 resulted in a deficiency cited related to staffing. Ending on 04/24/2025 resulted in a deficiency cited related to staffing. Ending on 01/30/2025 resulted in a deficiency cited related to staffing. Ending on 06/18/2025 resulted in a deficiency cited related to staffing. Review of the Quality Assurance and Performance Improvement Meeting notes dated 12/15/2025 identified assuring appropriate staffing as an active area of the QAPI action plan. In an interview on 01/14/2026 at 03:18 PM with the Administrator, stated the facility had been aware of the need for more staff since before he took over as Administrator in November. He acknowledged the staffing issues were a repeat facility failure but was unable to speak on why the failure had occurred due to his limited time with the facility. He stated in an email sent earlier the same day that the Quality Assurance and Performance Improvement meeting notes from before December were unavailable but that he was aware the facility leadership knew about staffing issues for a while.

Based on observation, resident and staff interview, and policy review, the facility failed to respond to resident call lights within 15 minutes for 3 of 6 residents reviewed (#7, #8, #9). The facility also failed to document 15-minute resident checks for Resident #12. The facility reported a census of 88 residents. Findings include: On 7/26/25 at 8:20 PM, State Surveyors entered the facility and observed activated resident call lights (#1, #4, #7, and #8). At 8:23 PM, the State Surveyor was near the nurse's station but without a direct line-of-sight. Staff was overheard having personal conversations while visiting amongst themselves. At 8:25 PM, Resident #9's call light was activated. At 8:26 PM, two (2) staff members passed Residents #1, #4, and #7's rooms and left the unit. At 8:29 PM, a staff member turned off Resident #13's call light and entered Resident #11's room with a mechanical lift. At 8:32 PM, the resident call light notification device at the nurses' station revealed Resident #7's call light had been activated for 20 minutes. At 8:42 PM, a staff member was observed entering Resident #9's room. The resident call light notification device revealed her call light had been activated for 16 1/2 minutes. At 8:43 PM, the resident call light notification device at the nurses' station revealed Resident #8's call light had been activated for 29 minutes. At 8:48 PM, Resident #4 stated evening shift is always short staffed in her opinion. At 9:02 PM, Staff F, Certified Medication Aide (CMA) and Staff G, Certified Nurse Aide (CNA) stated Resident #13 complained that evening about long call light response times. At 9:16 PM, Resident #13 confirmed she complained to staff about long call light response times on 7/26/25. She also stated it happens all the time and on 7/26/25, it took staff 45 minutes to respond to her call light. She stated staff has previously entered her room, turned off the call light, and left. At 9:28 pm, a staff member was observed walking past Resident #8's activated call light and responded to Resident #9's call light. On 7/28/25 at 3:14 PM, Resident #1 stated, she had to wait more than 15 minutes on 7/27/25 to get bathroom assistance after lunch because of lack of staff. 2. The Minimum Data Set (MDS) assessment for Resident #1 dated 7/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hypertension, chronic obstructive pulmonary disease (COPD), difficulty walking, and abnormalities of gait and mobility. It indicated she was independent with eating and oral hygiene, required setup assistance with bathing and personal hygiene, supervision with toileting, upper body dressing and sitting-to-lying mobility, and moderate assistance with all other Activities of Daily Living (ADLs) and mobility. The undated Care Plan indicated the resident was non-ambulatory and preferred to use the commode for urinary elimination. It directed staff to encourage and assist the resident with repositioning frequently in bed and wheelchair. On 7/28/25 at 3:31 PM, Resident #4 stated it took staff so long to respond to her call light on 7/27/25 around 4:00 PM, she urinated on herself because she couldn't hold it any longer. 3.The Quarterly Minimum Data Set (MDS) assessment for Resident #4 dated 6/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of cerebrovascular accident (stroke), hemiplegia (one-sided weakness), and chronic obstructive pulmonary disease (COPD). It also indicated the resident required setup assistance for eating and oral hygiene, maximal assistance with upper and lower body dressing and personal hygiene, and was dependent with all other aspects of Activities of Daily Living (ADLs) and mobility. It also revealed she was incontinent or bladder and bowel. The undated Care Plan revealed the resident had bladder incontinence and directed staff to check and change her frequently. 4 4. The Quarterly MDS assessment for Resident #12 dated 7/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15, which indicated severely impaired cognition. It included diagnoses of cancer, coronary artery disease (narrowed heart arteries), diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia with other behavioral disturbances. It indicated he was independent with eating and toileting, required setup assistance with oral and personal hygiene, and dressing, and supervision bathing. It also indicated he was independent with mobility. It further revealed the resident experienced hallucinations and delusions.The Care Plan dated 11/07/24 indicated the resident displayed inappropriate sexual advances towards another resident related to Fondling, Grabbing, Touching. A Care Plan revision dated 4/16/25 directed staff to perform 15-minute checks on resident while using monitor at nurses' station which room. is in line of site, and when outside of room resident is to be a 1:1.On 7/26/25 at 8:56 pm, a form titled 15-minute checks was observed at the nurses' station. It was filled out through 8:30 PM. An observation started at 8:58 pm and at 9:11 pm, a staff member was observed checking on the resident. A room sensor beeped when anyone entered or exited the room. On 7/29/25 at 12:56 PM, a record review revealed missing 15-minute checks documentation for the following dates:a. 7/19/25 at 2:45 PM and 3:00 PMb. 7/20/25 at 2:30 PM and 2:45 PMc. 7/22/25 from 2:30 PM through 5:45 PMd. 7/24/25 from 6:15 PM through 11:45 PMe. 7/25/25 from 12:00 AM (midnight) through 5:45 AMf. 7/27/25 from 6:30 AM through 9:45 AMg. 7/28/25 at 12:15 PMStaff H, Registered Nurse (RN) stated the missing documentation could be due to the 15-minute checks being documented on a different sheet and not transferred over to the current papers. He also stated missing documentation could be it just wasn't done. He stated he felt the resident could be put on hourly checks due to current physical limitations but is currently still on 15-minute checks.A policy titled Call Light-R/S, LTC, Therapy & Rehab revised 07/08/2025 indicated the purpose of the policy was:a. To ensure residents always have a method of calling for assistanceb. To promptly answer resident's call light It also indicated the procedure as:1. New admission - explain and demonstrate the use of call light system.2. When resident's call light is observed/heard, go to resident's room promptly.3. Respond to request as soon as possible. Turn call light off and inquire about resident's request.4. When leaving the room, place call light within easy reach of resident.5. For residents unable to use call light, care plan appropriate interventions and provide an adaptive call light if applicable.6. Each facility is responsible for having an alternate method of communication during a loss of power or call light system failure. On 7/29/25 at 3:30 PM, the Administrator stated staff should walkie-talkie for staff assistance with call lights and/or transfers. On 7/29/25 at 1:31 PM, the Director of Nursing (DON) stated the 15-minute checks form is the only place staff should document checking on the resident.

Based on observations, record review, resident and staff interview, and policy review, the facility failed to speak to the resident in a manner that maintained dignity, failed to change a resident's stained shirt after putting the resident in bed (#4), and delayed feeding a dependent resident (#3). The facility reported a census of 88 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 6/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of cerebrovascular accident (stroke), hemiplegia (one-sided weakness), and chronic obstructive pulmonary disease (COPD). It also indicated the resident required setup assistance for eating and oral hygiene, maximal assistance with upper and lower body dressing and personal hygiene, and was dependent with all other aspects of Activities of Daily Living (ADLs) and mobility. The undated Care Plan revealed the resident had an ADL self-care performance deficit related to a stroke and indicated she required one (1) person assistance with getting dressed. On 7/29/25 at 8:35 am, Resident #4 asked Staff E, Maintenance Mechanic (MM) to take her out to smoke. Staff E abruptly replied “No, it's not my time. My time is 2:30” and walked away. At 8:38 am, Resident #4 was observed sitting in a wheelchair across from the nurses’ station wearing a shirt with a food stain down the center. She stated it happened during breakfast but stated it bothered her to be out in the hall in front of everyone with it stained. She said she would've liked to have had her shirt changed after breakfast. At 8:43 am, Staff A, Certified Nurse Aide (CNA) approached Resident #4 if she'd worn that shirt the previous day. Resident #4 replied it was the same color but was a different shirt. Staff A stated if it was the same shirt, she'd have to take her down to her room to change her. At 8:52 am, Staff A stated she asked Resident #4 about her shirt because of the stain on it. She also stated staff changes Resident #4’s shirt when they lay her down after she goes outside to smoke. She confirmed the scheduled smoking time was 9:00 am. At 9:16 am, Staff A transferred Resident #4 to bed and exited the resident’s room. At 9:18 am, Resident #4 was still wearing the stained shirt. At 9:55 am, Resident #4 stated she felt small and like she didn't matter when Staff E responded to her request to be taken outside to smoke. Resident #4 was still wearing the stained shirt. The facility policy titled Resident Dignity-Rehab/skilled revised 12/11/2024 indicated the purpose of the policy was: a. To maintain the dignity of all residents b. To promote, encourage, support and enhance the residents’ self-esteem c. To promote a sense of self-worth d. To assist with respecting and ensuring resident rights On 7/29/25 at 3:30 pm, the Director of Nursing (DON) stated the staff should have said the designated department will take you out to smoke at 9:00 am. She also stated staff should have changed her shirt after putting her in bed. 2. The MDS of Resident #3 dated 4/24/25 identified a BIMS score of 15, which indicated intact cognition. The MDS coded the resident required maximal assistance for eating. The MDS documented diagnoses which included multiple sclerosis and quadriplegia. The Care Plan of Resident #3 identified an undated Focus area of Activities of Daily Living (ADL) self care performance deficit related to quadriplegic, multiple sclerosis. The Care Plan directed the resident was dependent upon 1 staff assist for eating and must be at a 90 degree angle. On 7/29/25 at 11:50 am, Resident #3 arrived at the dining room with a large number of other residents having already received their meals. At 11:55 am a staff member arrived and took the resident's order for lunch. Her food arrived at 12:05 pm. Within one minute, the Administrator sat down to assist the resident with her meal and stayed with her for the approximate 30 minutes it took for her to finish her meal. On 7/29/25 at 12:39 pm, Resident #3 stated that it was unusual that the Administrator was the one to assist her with her meals. She stated other staff members are supposed to help her with her meals but they don't make it to the dining room on time. She stated she is normally the last person to get served because she does not get served until someone is available to help her eat. She stated she had raised concerns about this in the past. She stated she felt the staff cared about the other residents more than they did her and it was only their job to take care of the gray haired people and felt because she is a younger resident she does not get as much help. She stated she had reported this to the Registered Dietitian (RD) who spoke to the Administrator about her concerns. On 7/29/25 at 1:08 pm, the Administrator stated she was not typically the one to feed Resident #3 but if there is nobody else available she will assist her. She stated the Restorative Aide frequently helps. The Administrator stated Resident #3 had not directly ever stated any concerns to her about her meal service. She stated she has brought other concerns to her and tends to be very vocal. The Administrator stated she was not aware of concerns with meals. On 7/29/25 at 1:23 pm, the RD stated Resident #3 had brought concerns to her about eating assistance. She stated the former Activities Director used to assist her a lot and she is no longer employed at the facility. She stated Resident #3 had known the Activities Director a long time and they spent much time together. She stated Resident #3 prefers to skip breakfast but eats lunch in the dining room daily. She stated she often prefers the evening meal in her room which has been problematic with which staff member was responsible for getting her tray from the dining room and bringing it to her to feed her. Trays are not served to residents who need feeding assistance unless a staff member is available to assist so the food stays warm. She stated the resident had brought concerns to her more than once and she offered to discuss it with the facility management which Resident #3 agreed to. She stated she reported the concern to both the Administrator and the Director of Nursing. She stated the resident is unable to feed herself so the facility must provide that service regardless of if she eats in the dining room or her room. Due to her diagnosis of multiple sclerosis, she will always need the assistance. On 7/29/25 at 1:34 pm, the Certified Dietary Manager (CDM) stated Resident #3 typically does not receive her meal until someone is available to assist her with feeding. She explained that the resident chooses not to sit at the feeding assistance table, and staff feed the residents at that table before assisting Resident #3. The CDM further stated that if Resident #3 opts to eat in her room, this causes an additional delay. She explained that the resident must wait until a CNA is available to leave the floor, retrieve her meal from the dining room, and then feed her. The CDM confirmed that on the day of the observation, Resident #3 was the last resident to be served lunch and stated this occurs fairly often. The CDM reported that she had previously discussed this concern with facility management, which led to the intervention of Resident #3's meal not being served to her until a staff member was available to assist in feeding her, in an effort to ensure the food remained fresh and at an appropriate temperature. On 7/29/25 at 1:50 pm, the RD stated she had located an email she had sent to the Administrator and the Director of Nursing regarding Resident #3's concerns about meal service. The email, dated 6/10/25, documented that Resident #3 was experiencing long wait times to be fed since the departure of the Activity Director. The email noted that the RD had spoken directly with Resident #3, who had expressed a preference for the RD to advocate on her behalf. Resident #3 conveyed that she felt forgotten during meals. The RD explained that the resident required total assistance with eating and drinking and preferred to sit at a specific table. However, the RD noted that even relocating her to the front of the dining room would not resolve the issue as the Restorative Aide was often responsible for feeding, assisting and monitoring 8-10 other residents during meals. She concluded by asking the leadership team to collaborate to reach potential solutions to improve Resident #3's dining experience. The Director of Nursing replied to the email the same day stating she had just had a discussion in huddle regarding staff being present in the dining room for meals and would keep working on it. The Administrator also replied to the email stating she had checked on the presence of staff in the dining room the prior evening.

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 88 residents.Findings included: On 7/29/25 at 9:44 AM, Staff D, Certified Medication Aide (CMA) was observed administering resident's medications. She locked the medication cart and walked into the resident's room. An opaque medication cup was observed on the medication cart with an orange, round pill. A resident who self-propelled in his wheel-chair was observed 3 doors away.At 9:46 AM, Staff D returned to the medication cart, poured water into a cup and returned to the resident's room. The orange, round pill was observed still in the opaque medication cup on the medication cart.At 9:47 AM, Staff D returned to the medication cart. She stated the facility's medication handling and storage process was narcotics were locked in the lock box in the medication cart and all other medications were to be secured in the medication cart and not left accessible when staff leaves the cart unattended. At 9:49 AM, Staff D identified the orange, round pill as Senna (stool softener) and confirmed it should have been disposed of and not left unattended on the medication cart.A policy titled Medications: Acquisition Receiving Dispensing and Storage - R/S, LTC revised 03/04/2025 indicated:3. an employee will be responsible for signing for receipt of medication and obtaining the signature of the delivery person. It is preferred that a licensed nurse receive and verify the medications. Once medications are received, they will be secured in the appropriate storage area (i.e., medication cart or medication room). Licensed nurses and medication aides (when allowed by state law) are responsible for reconciling medications received.5. Medications will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas.On 7/29/25 at 4:19 PM, the Director of Nursing (DON) stated medications should be secured in the medication cart of appropriately disposed of not left unattended.

Based on observations, staff interview, and policy review the facility failed to implement the infection control policy as staff failed to disinfect a mechanical lift between two residents' use (#4, #11). The facility reported a census of 88 residents.Findings include:On 7/29/25 at 9:16 AM, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA transferred Resident #4 from her wheelchair to her bed. Staff A brought the mechanical lift out of Resident #4's room and placed it against the wall outside, beside Resident #4's door. The mechanical lift was not disinfected. At 9:41 AM, Staff B, CNA and Staff C, CNA took the mechanical lift into Resident #11's room to get Resident #11 out of bed. The mechanical lift was not disinfected prior to use. At 9:49 AM, Staff B, CNA brought the mechanical lift out of Resident #11's room and placed it against the wall between rooms 212 & 214. It was not disinfected. At 9:51 AM, Staff D, Certified Medication Aide (CMA) and Resident #11 stated there was no disinfectants (Saniwipes) kept in the resident's room. Staff D also stated disinfectants were not stored in any residents' rooms but were located at the nurses' station. At 9:57 AM, Staff C, CNA stated the Saniwipes were in the storage pouches on the back of the reusable equipment. At 9:58 AM, there was no Saniwipes observed in the storage pouch on the back of the mechanical lift. At 9:59 AM, Staff C, CNA stated staff wipes down the reusable equipment in the hallway after each use and during the night. She added that reusable equipment is not wiped down before being used. She stated the mechanical lift should have been wiped down after being used in Resident #4's room. On 7/29/25 at 3:30 PM, the Director of Nursing (DON) stated staff should have found the Saniwipes and disinfected the equipment. At 5:43 PM, the Administrator provided an email that the facility did not have a policy specific to disinfecting reusable equipment but indicated staff was expected to wipe down the lifts between use.

Based on record review, observations, resident and staff interview, and policy review the facility failed to protect residents from abuse for 1 of 2 residents reviewed for abuse (Residents #69). The facility reported a census of 81 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had diagnoses of cancer, Alzheimer's Disease, dementia, and diabetes. The MDS recorded the resident had impaired short-term and long-term memory, severely impaired decision-making skills, and inattention. The MDS revealed the resident had a wanderguard alarm, and had independence with transfers. The MDS assessment dated [DATE] revealed Resident #50 had diagnoses of sexual dysfunction not due to a substance or known physiological condition, dementia, and malignant neoplasm of the pancreatic duct. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS recorded the resident had no behaviors, and did not have an alarm or wanderguard. The MDS indicated the resident independent for transfers and had the ability to ambulate at least 150 feet independently. The Care Plan initiated 11/7/24 and revised on 2/28/25 revealed the resident had impaired cognition and thought processes related to dementia. The resident ambulated and transferred independently with and without a cane. The Care Plan revealed the resident displayed inappropriate sexual advances towards another resident related to fondling, grabbing and touching the resident (initiated 11/7/24). The Care Plan directed staff to monitor the involved residents and know the resident's whereabouts, specifically while the resident was in the hallway (added on 11/7/24). A motion detector sensor was placed on the resident's door (added on 2/27/25), and 15-minute checks utilizing a monitor at the nurse's station and 1:1 whenever the resident was outside of his room (added to the care plan on 4/16/25). The Order Summary revealed the following orders: 11/7/24 - Medroxyprogesterone Acetate (a hormone) 20 milligrams (mg) daily for hypersexual behavior 2/24/25 - send Resident #50 to the Emergency Department (ED) for complaints of chest pain, shortness of breath (SOB), and elevated blood pressure. 2/24/25 - Sertraline (an antidepressant) increased to 75 mg by mouth (PO) daily 2/25/25 - obtain a UA (urinalysis) for increased behaviors for 2 days. 2/26/25 - Doxycycline (antibiotic) 100 mg BID (twice a day) for 10 days and Prednisone 20 mg daily for 7 days for pneumonia. 4/24/25 - increase Medroxyprogesterone to 40 mg PO daily for hypersexual behavior Incident reports revealed the following: a. On 11/5/24 at 4:42 PM, Staff H, certified nursing assistant (CNA), heard a female resident state no, no, no and turned to see Resident #50 cupping the female resident's vagina through her clothing while the resident stood in the hallway. Resident #50 was told to stop. Resident #50 stopped and walked away from the female resident. Resident #50 was placed on medication for sexual behavior. Resident #50 ambulatory without assistance and oriented to person. Resident #50 snickered when staff asked him what happened. Resident #50 said no when staff asked him if he touched the lady. Resident #50 educated is was inappropriate to touch other residents. A medication review was completed. b. On 2/23/25 at 11:00 AM, Registered Nurse (RN) paged to a resident's room STAT (immediately). CNA notified the nurse a male resident was in a female resident's room touching the resident inappropriately. CNA immediately told male resident to stop, do not touch her, get out, that is not ok. Male resident was directed back to his room. A full assessment was completed. Female resident was lying in bed sleeping with her brief pulled down. She stated not remembering what happened. Female resident notified of what occurred and became tearful. Resident #69 said she did not say Resident #50 could do that. Male resident placed on 1:1 observations. Resident #50 stated I know what I was doing, I needed to please her and that is what I was going to do. Resident #50 notified he could not to go into (resident) rooms that aren't his. The Director of Nursing (DON), Nurse Practitioner (NP), Assistant Director of Nursing (ADON), Administrator, and family were notified. The Quarterly MDS dated [DATE] documented Resident#69 had diagnoses including, Stroke, difficulty swallowing, left sided weakness, slurred speech, and muscle weakness. The MDS revealed the resident required total assistance of staff for transfers, and dressing. The MDS did not reveal any mood or behavior concerns. The Annual Assessment MDS dated [DATE] documented Resident#69 had the following symptoms present nearly every day over the last two weeks; trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy. The MDS revealed the resident had the following symptoms present 2-6 days in a 14 day look-back period, trouble concentrating on things, such as reading the newspaper or watching TV, moving or speaking so slowly that other people could have noticed, to the opposite- being so fidgety or restless that you have been moving around a lot more than usual. The Facility's Investigation File revealed a summary of the incident that occurred on 2/23/25: Staff G, RN, paged to Resident #69's room STAT. Staff F, Certified Medication Aide (CMA), notified Staff G she walked in on Resident #50 in Resident #69's room and found him touching Resident #69 inappropriately. The residents were separated immediately. Staff F stated to the Administrator she saw Resident #50 within the last 5 minutes and at that time he was not in Resident #69's room. Resident #50 had not had previous inappropriate sexual behaviors with Resident #69. The staff noted Resident #50 was not at baseline on this day. He spoke non-stop and something just seemed off. It was noted later that he had an infection (pneumonia). A UA was obtained on 2/28/25. Resident #69 had a BIMS of 13, indicating intact cognition. Resident #69 stated to Staff G she was confused about what was going on and she was alarmed by all of the yelling by staff as she had been relaxing in her bed half asleep when Resident #50 came into the room. She told the nurse she was not traumatized by the event. A full body assessment revealed no concerns. Social Services (SS) followed up with both residents for 3 days. Resident #50 had a BIMS of 3. He was unable to sign a statement due to his cognition and functional conditions. Resident #50 had expressed his preference to spend most of the time in his room but he came out of his room at times. Resident #50 moved to a different room away from Resident #69, by all male residents and nearby the nurse's station in order to keep an eye on him. Staff stated they felt the root cause of the resident's behavior may have been related to an infection. The police were contacted. A Psychiatry (Psych) visit occurred on 2/27/25. The physician reviewed the resident's medication and increased Sertraline to 75 mg for sexual behavior on 2/23/25 at 4:04 PM. An order for Prednisone 20 mg daily for pneumonia started on 2/26/25. The Ombudsman visited the facility on 2/27/25. Resident #69 had no concerns regarding the event and felt the facility addressed everything accordingly. A room change was offered to her but she declined. A motion detector monitor and baby monitor placed to ensure staff got alerted if Resident #50 was awake and to monitor if he came out of his room. Other female residents in the facility that had the potential to be impacted stated they felt safe and had no issues with the male resident. A typed statement dated 2/23/25 revealed Staff F, CMA, went to get a blood sugar on Resident #50's roommate. Resident #50 was not in the room. Staff F went to look for Resident #50 throughout the building where he normally went. Staff F started opening doors and checked other residents' rooms and found Resident #50 in Resident #69's room. Staff F saw Resident #50 sitting at the foot of Resident #69's bed with her brief all the way undone and his hand between her legs. Staff F was unsure if Resident #50 penetrated Resident #69. Staff F told Resident #50 to stop, don't touch Resident #69, that is not ok, this is not his room. Resident #69 woke up and looked like what is going on? Resident #50 got out of Resident #69's room. Staff F called for Staff G to get there STAT. Staff then met up at the nurse's station to call the people that needed notified. Resident #50 came out of his room looking for Resident #69 again. The police came ten minutes later. Staff F showed the police officer what happened and what she walked into. Resident #50 was placed on 1:1 watch while staff figured out what to do. An undated typed statement from the Administrator revealed the Administrator spoke with Staff F again on 2/28/25. Staff F witnessed the female resident's brief located to the side and the male resident by the bed next to her in a wheelchair with his hand by her legs. Staff F had just seen Resident #50 less than five minutes before. Staff F went to administer medications to Resident #50's roommate, then Staff F went to administer Resident #50's medications and found Resident #50 in Resident #69's room. Staff F screamed at Resident #50 because she assumed he was touching Resident #69 because her brief had been pulled to the side. Staff F said that startled Resident #69. She again told the Administrator she immediately separated the two residents and got the nurse. A written statement by Staff G, RN, revealed: RN was paged to Resident #69's room STAT. The CNA notified the nurse that the male resident was in the female resident's room touching the resident inappropriately. The CNA told the male resident to stop, do not touch her, get out, that is not ok. The male resident was directed back to his room. A full assessment was completed. The female resident was lying in bed with her brief pulled down. Resident #69 stated not remembering what happened. Resident #69 was notified about the incident and she was tearful. Resident #69 stated she did not say he could do that. Resident #69 stated she is ok at that time. Resident #50 in his room on 1:1 observation. Resident #50 stated he knew what he was doing. He needed to please her and that is what he was going to do. Resident #50 was notified he could not go into rooms that are not his. The DON, NP, ADON, Administrator and families of both residents notified. A typed statement signed by Resident #69 on 2/23/25 revealed the resident stated she did not remember what happened. Resident #69 said she did not say that Resident #50 could do that. Police Reports revealed: a. On 11/04/2024 at approximately 3:35 PM, an officer responded to the facility for a report of sexual abuse between residents. The officer met with the staff who witnessed to event. Staff O stated that at approximately 5:00 PM, Resident #50 and Resident #37 walked down opposite sides of the hallway. Staff O stated she saw Resident #50 grab Resident #37 vagina over her clothing and stated there it is. Staff O escorted Resident #50 back to his room and he was giggly but that is his normal demeanor. Staff O stated that Resident #50 had dementia and did not understand what he had done due to his mental status. Staff O also stated that Resident #37 was autistic and unable to comprehend what had happened. Staff at the facility stated they contacted the family members of both individuals regarding plans moving forward. It was reported that Resident #50 would have another psych evaluation and medication review to help treat his condition and for the safety of others in the facility. Staff reported they would make sure Resident #50 kept separate from Resident #37 in the future. b. On 2/23/2025 around 10:56 AM, a police officer was dispatched to the facility for a report of sexually inappropriate activity. Staff G stated that earlier that AM, a nurse walked into a female resident's room and observed her diaper around her ankles while a male was performing a sex act on her. The female victim, Resident #69, was sleeping during the assault. Resident #69 suffers heavily from dementia. She stated that she did not remember anything that happened. Resident #69 stated that she was told a man was in her room that AM. Resident #69 stated that she did not remember anything about the incident. She stated that her legs were in some pain, but that she had leg pain daily. Resident #69 stated that she had no knowledge of who the male was. The Officer then spoke with Resident #50. Resident #50 stated that he went into Resident #69's room and asked her if he could try what I wanted to try and she agreed. Resident #50 then began rambling incoherently about sexual things that happened in his past. Resident #50 stated that he knew what he was doing and also acknowledged that it was wrong. Resident #50 began rambling incoherently about people unrelated to the incident. The police officer asked Resident #50 if he knew he was supposed to stay in his room and not visit Resident #69 anymore and Resident #50 acknowledged. The officer then spoke with staff who witnessed the incident. Staff F stated that when she walked into Resident #69's room, Resident #50 was sitting at the foot of Resident #69's bed. Resident #69's undergarments were around her knees/ankles and Resident #50 appeared to be touching Resident #69's vagina. Staff F then confronted Resident #50 and he exited the room. Resident #50's Progress Notes revealed the following: a. On 10/24/24 at 5:17 PM, resident inappropriately touched a CNA while she gave him medication. Resident educated and hand removed (from the area). b. On 11/4/24 at 5:44 PM, resident touched another resident in the private area as he passed by her in the hallway. CNA present at this time and separated the residents. Resident #50 snickered when he was asked what happened. Resident #50 asked if he touched the lady resident. He said no. Resident educated not to touch other residents. Medications reviewed. c. On 11/6/24 at 1:15 PM (late entry), around 7:45 AM, Resident #50 asked the housekeeper to get into bed with him. He then stated, your pants are baggy. Your ass would look better if your pants were off. d. On 11/6/24 at 1:49 PM, attempted to call the resident's representative to inform of the resident's behaviors. New orders received from the NP to start hormone and antidepressant medications for hypersexual behaviors. NP declined to refer the resident to psych because the resident had declined to see psych in the past. e. On 11/8/24 at 3:10 PM, information added to the Care Plan to include monitoring the resident in the hallways because he most frequently exhibited behaviors with other residents in this area, and to monitor the resident during meal times when he was outside of his room as well as in the dining room. f. On 11/21/24 at 8:32 AM, CMA tried to administer Medroxyprogesterone medication for hypersexual behavior but the resident refused the medication three times. g. On 1/29/25 at 5:35 PM, resident came up behind dietary aide and tried to get handsy with her. Resident was asked to leave the dining room. h. On 2/23/25 at 11:00 AM, RN paged to Resident #69's room STAT. The CNA notified the RN that Resident #50 found in Resident #69's room touching a female resident inappropriately. CNA immediately told Resident #50 to Stop, do not touch her, get out, and that his actions were not okay. Resident #50 was directed back to his room and placed on 1:1 observations. Resident #50 stated I know what I was doing, I needed to please her and that is what I was going to do. Resident #50 notified he was not to go into any rooms that are not his. i. On 2/23/25 at 12:58 PM, Resident #50 moved to another room away from the female resident, closer to the nurse's station, and by other male residents. A motion sensor was placed on the door. j. On 2/23/25 at 4:04 PM, order obtained to increase Sertraline to 75 mg PO once a day for hypersexual behaviors. k. On 2/24/25 at 12:01 AM, resident on 1:1 for sexual behaviors. At 12:15 AM, resident sent to the ED for complaints of chest pain and shortness of breath. At 5:55 AM, the ED nurse advised the facility that the resident would be returning to the facility. l. On 2/24/25 at 3:35 PM, psych referral for sexual aggression and medication management. Hope Harbor was called to look for a locked male unit. m. On 2/25/25 at 2:39, resident talked to the aide in his room and stated he and his buddy used to go looking for 5-year olds and used to molest/please the little girls. n. On 2/25/25 at 5:42 PM, order for UA collected due to resident increased behaviors. o. On 2/26/25 at 2:58 PM, visual monitor in resident's room and at the nurses station to monitor Resident #50's activity. Resident room is insight of the nurse's station. p. On 2/27/25 at 1:16 AM, resident noted to be playing with his penis upon check and change. Resident advised to stop but not easily redirected. q. On 2/27/25 at 7:31 AM, SS Coordinator attempted to talk to Resident #50 over the past two days about the incident but he was sleeping. r. On 3/13/25 at 12:56 AM, resident yelling at staff for not letting him go to his old room. s. On 3/26/25 at 2:11 AM, resident not been sleeping at night. He requested all night long to go to the dining room. He was not easily redirected because within a few minutes he was back up and tried to go to the dining room again. A message was sent to the physician. t. On 4/9/25 at 1:45 AM, resident asked staff about people being up and down the hall having sex. Resident talked about his penis and how big or small his penis was and he talked about having sex. Resident not easily redirected. u. On 4/16/25 at 9:48 PM, per the Administrator on 4/16/25 at 9:41 PM, the resident is supposed to be on routine 15-minute checks for being outside of his room without supervision due to an allegation incident that was unwitnessed earlier in the day. v. On 4/24/25 at 9:04 AM, SS Coordinator left a message for Hope Harbor to see if the resident would qualify for placement. A NP Visit Note dated 2/24/25 revealed Resident #50 had increased sexual aggressive behaviors and a fall over the weekend. The resident was evaluated in ED but had no new diagnosis or change in the plan of care. He is on Sertraline and Medroxyprogesterone for hypersexual behavior. The NP recommended a psych consult for sexual aggression and medication management. Resident #50 was moved closer to the nurse's station and the plan of care was reviewed. Medications reviewed with no changes. The Plan of Care included to observe for change in condition and notify the provider with any questions or concerns. Continue prevention, and practice proactive medical treatment to allow the resident to remain in the home. The Physician's Encounter Note dated 3/3/25 revealed Resident #50 was evaluated in the ED for an atypical infection. Resident #50 started on doxycycline and Prednisone. A UA was negative. Pulse oximetry 96% on RA (room air). A previous visit on 2/26/25, it was reported Resident #50 had an inappropriate altercation with a fell ow resident as he had entered the resident's room and grabbed the genital area. The action was unprovoked. He was with recall and stated he was talked to and he had told the staff he would not do again. He was placed in another room and required 1:1. Resident #50 sustained a fall and was transported to the ED. The CT findings revealed suspected pneumonia. Resident #50 had decreased appetite and slept more than fifteen hours a day. Reported the resident had increased sexual behaviors and inappropriate verbalization and physical contact. Sertraline and Medroxyprogesterone was initiated. The resident also had diagnosis of progressive dementia and pancreatic cancer. A Psychiatric assessment dated [DATE] revealed Resident #50 referred for sexually inappropriate behavior. The resident had diagnoses of adjustment disorder with mixed disturbance of emotions, Alzheimer's Disease, and dementia with behavioral disturbance. No new orders. A Fax communication dated 3/26/25 revealed the resident antsy, not sleeping at night, and came out of his room at night. Observations revealed the following: a. On 4/22/25 at 9:58 AM, Resident #50 smiled and laughed as he spoke to the surveyor. An alarm sounded while the resident was lying in bed. Staff A, RN, responded to the resident's room. Staff A adjusted the alarm pad under the resident and reset the alarm but the alarm continued to sound. Staff A stated he thought maybe the batteries needed to be replaced. b. On 4/23/25 at 7:43 AM, Resident #50 sat in bed looking toward the doorway of the room and smiled. The door to the DON's office was closed and locked. Staff A, RN, stood by the nurse's desk. c. On 4/23/25 at 11:10 AM, Resident #50 sat on the bed in his room. The DON's office door was open but no staff observed in the office. A staff person walked with another resident down the 200 hall. d. On 4/23/25 at 12:14 PM, Resident #69 sat in a wheelchair by the nurse's station (2 doors from Resident #50). e. On 4/23/25 at 2:54 PM, Resident #69 propelled her wheelchair down the 200 hall until Staff A offered to push the resident in the wheelchair to her room. f. On 4/23/25 at 3:00 PM, Resident #50 sat in a chair in his room approximately 5 feet from the doorway of his room. The resident smiled and talked to himself. 2. The MDS assessment dated [DATE] revealed Resident #69 had diagnoses of cerebrovascular accident (CVA)(stroke), hemiplegia, and muscle weakness. The MDS documented the resident had a BIMS of 13, indicating intact cognition. The MDS recorded the resident had impaired range of motion on one side of her body. She required partial to moderate assistance for bed mobility, and had dependence on staff for lower body dressing and transfers. The MDS documented the resident had no behaviors. The Care Plan revised on 6/11/24 revealed Resident #69 had limited physical mobility related to a stroke and hemiplegia that affected the left side of her body. The resident was non-ambulatory and required assistance with activities of daily living (ADL's) such as dressing and bed mobility. The Care Plan lacked information about a resident-to-resident incident. An Incident Report completed on Resident #69 revealed a staff statement entered on 2/23/25. Staff F found Resident #50 wandering the halls going in and out of female resident rooms. Staff redirected Resident #50 to his room. Staff F took him back to his room where he told Staff F he was going to pleasure her, she needed to be pleasured. Resident #50 then went into his room and went into the bathroom. Staff F then went and did blood sugars on the [NAME] Hall. Staff D and Staff E shut all of the female doors. When Staff F went to get a blood sugar on Resident #50's roommate, Resident #50 was not in the room. Staff F then looked for Resident #50. Staff F checked the building on where Resident #50 normally went. Staff F began to open the doors to the female rooms and found Resident #50 and Resident #69. Staff F saw Resident #50 sitting at the foot of Resident #69's bed with her brief all the way undone and Resident #50's hand between Resident #69's legs. Resident #50 was touching Resident #69. Staff F told Resident #50 to stop, don't touch her, that is not ok, this is not your room. That is when Resident #69 woke up and looked at Staff F like what is going on? Resident #50 got out of the room and Staff F called for the RN STAT. When staff met at the nurse's station to call people, Resident #50 came out of his room looking for Resident #69's room again. The police arrived 10 minutes later. Staff F told the police what happened and what she walked into. Resident #50 placed on 1:1 while staff figured out what to do next. The physician, Administrator, police, and family were notified. The Weekly Skin Observation dated 2/21/25 at 9:27 PM revealed no skin conditions observed. On 2/28/25 at 4:14 PM, no skin concerns noted. Barrier cream continued to her groin. A Progress Note dated 2/23/25 at 11:45 AM but created on 2/27/25 at 12:57 PM revealed a complete RN assessment completed on Resident #69. No signs of physical trauma noted to the resident's body. The resident denied pain. Staff stayed with the resident and assisted with cares and ADL's, then assisted the resident into the wheelchair per her request. Staff continued to monitor the resident. Progress Notes revealed the following: a. On 2/23/25 at 12:46 PM, Staff G stated to the Administrator that she had spoken with Resident #69 right after the incident with the male resident. At first Resident #69 was tearful because she was not sure what was going on initially but stated that it was not traumatic to her. Social Services to follow up for 3 days. b. On 2/24/25 at 12:16 AM, Resident #69 spoke with the nurse about the incident this morning and resident very sad that it happened. Encouraged her to seek out staff if she needs to talk. c. On 2/24/25 at 3:49 PM, SS Coordinator asked Resident #69 what happened over the weekend. Resident #69 advised she was awakened by screaming and it scared her as she thought she was hurt. A male resident was removed from her room. She later stated she noticed hand marks where the male resident apparently held her down. She was upset and stated she had reached out to have her therapist work with her. She was more upset from the commotion rather than the actual situation. d. On 2/25/25 at 3:04 AM, resident does not remember any of the incident that happened. Resident states she only knew what people had told her what happened. She stated she knew he was not supposed to be around her. She stated she didn't even know what he looked like. e. On 2/25/25 at 12:10 PM, SS Coordinator spoke to resident regarding the incident over the weekend. She stated she was not traumatized by the issue. She just wanted to know why it happened. She thought she did something. Resident was reassured it was not her. In an interview on 4/22/25 at 9:45 AM, Resident #69 reported a male resident lived down the hall from her. He came into her room and raped her a month or so ago. She was lying in bed. He took her brief off. She doesn't think he penetrated her but she doesn't know for sure. Staff yelled at him and asked him what he was doing, and got him away from her. Resident #69 stated the male resident had come and stood at her door but staff had caught him in time. Resident #69 reported she had a stroke and unable to move her left arm or leg. Resident #50 got moved to another room down the hall from her. The facility staff put a motion detector on him to keep track of him. Resident #69 stated she was concerned if he would come into her room at night. Resident #69 was tearful as she spoke with the surveyor about the incident. During confidential interviews with three other interviewable residents on 4/24/25, the female residents reported they had not had any staff or residents touch them inappropriately. The female residents reported they would yell if that happened to them. One female resident reported the staff don't like it when she spoke up about something that was not right. Staff told her to mind her own business and worry about herself. Resident #69 told one female resident what happened. One female resident didn't think the facility did enough to keep the male resident from going into other people's rooms. The female resident had asked the facility staff to move her bed to face the door so she could see if someone was coming into her room but they never moved her bed to face the door. One female resident recalled Resident #69's bed faced the window at the time of the incident but now her head of the bed faced the door. The female residents voiced concern the facility could retaliate for talking with the surveyor. Another female resident reported a male resident came into her room uninvited one time looking for his wife. When asked if she would feel uncomfortable with a male resident coming into her room, she said it would depend if the resident was with it. Some people had dementia or another diagnoses and that made people sometimes do things. Another female resident reported Resident #50, a male resident, walked into her room uninvited but she yelled at him and scared him off. She was fortunate. Resident #50 is wacko. The female resident reported an alarm goes off now if Resident #50 went out of his room. She had worked with therapy and built up her strength. She thought she would be able to flatten him if he tried to do anything to her. On the day Resident #50 came into her room she turned on her call light. Staff were busy with other residents at the time. When the CNA came in, she told the CNA she saw Resident #50 going in and out of the resident rooms. Staff got him to his room. The next thing she heard was a big commotion going on next door to her and he was found in Resident #69's room. The resident stated staff can't always come right away but she wanted to feel safe in her home. She is able to stand up for herself and she could talk or yell but not all residents could. In an interview 4/24/25 at 9:00 AM, Resident #69 reported she talked with another female resident about the incident that occurred with a male resident. A staff member came up to her and the resident and told her not to say anything about the incident. In an interview 4/22/25 at 2:45 PM, Staff A, RN, reported Resident #50 tended to be a lot more mobile at night and he slept during the day. He shared a bathroom with another male resident. Resident #50 had some behaviors. The resident's door had a motion sensor and the bathroom door had a doorbell chime. The chime was plugged into an outlet and sounded at the nurse's station. The alarms had distinct sounds. Staff A reported he kept Resident #50 in his line of site and listened for the doorbells. An alarm also went off if Resident #50 tried to get up without assistance. The resident mainly came out of his room for a shower and some meals. Resident #50 was 1:1 after the incident with Resident #69, but he had been on 15-minute checks for the past week due to him being more mobile. His room was located right across from the DON's office. Staff A reported Resident #50 came out of his room at night, walked to the nurse's station to get a snack or talked to staff, then went back to his room. He was not a group social person but he would talk 1:1 and had a conversation with people. Staff A reported he was not aware of other incidents when Resident #50 had been inappropriate with other residents. Staff A reported Resident #69 was alert and oriented x 4. She could be dramatic and get things blown out of proportion. She had nightmares or vivid dreams and said things happened but in reality things had not happened. In an interview 4/22/25 at 2:55 PM, Staff G, RN/Clinical Care Coordinator reported on the day of the incident with Resident #50 and Resident #69, Staff G got called to Resident #69's room. Resident #69 was in her room sleeping. Resident #50 went into Resident #69's room. Staff F told Staff G she found Resident #69's brief undone. Staff F told Resident #50 he needed to leave. Resident #69 was ok. Social Services came and talked with her. Resident #50 was placed on 1:1. Staff G called activities in to sit with him and called the physician. The police came in. Resident #50 had made sexual remarks in the past. He randomly said things to staff that made them feel uncomfortable. There was a note in the computer for staff to be aware of him and monitor for any behaviors. Resident #50 had some medication changes as he had had a mental health diagnosis in the past. Staff G reported when she first started working at the facility she worked in another unit but she observed residents in the dining room. She saw Resident #50 and his interactions with staff and the residents. He was more reserved. He would get up and go out of the dining room or the area. He was not a big communicator. He walked independently. He would come out of his room and ask for snacks. Staff [TRUNCATED]

Based on clinical record review, policy review, and staff interview, the facility failed to ensure staff had access to an accurate code status for 1 of 24 residents reviewed for advance directives (Resident #16). The facility reported a census of 81 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated [DATE], listed diagnoses for Resident #16 which included mild intellectual disabilities, heart failure, and depression. The MDS listed a Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. The facility policy Advance Directives including Cardiopulmonary Resuscitation(CPR) and Automated External Defibrillator(AED), revised [DATE], stated the facility would keep advance directive orders in a binder easily accessible to the nursing staff. On [DATE] at 11:42 a.m., Staff A Registered Nurse(RN) stated he would look in the computer first for code statuses and then would look in the binder at the nursing station next. On [DATE] at 11:42 a.m., a binder at the 100 Hall nursing station contained Resident #16's Iowa Physician Orders for Scope of Treatment(IPOST), dated [DATE]. The IPOST directed staff to carry out CPR if the resident had no pulse and was not breathing. On [DATE] at 11:42 a.m., the resident's electronic health record(EHR) face sheet stated the resident wished to be a Do Not Resuscitate(DNR) status. Resident #16's Iowa Physician Orders for Scope of Treatment (IPOST), dated [DATE], stated the resident wished to be a DNR status. On [DATE] at 12:31 p.m., the Director of Nursing(DON) stated she expected the IPOSTs in the binders at the nursing station to be accurate.

Based on observation, policy review, and staff interview, the facility failed to ensure floors were clean and non-sticky for 1 of 24 resident rooms reviewed (Resident #16). The facility reported a census of 81 residents. Findings include: The facility policy Housekeeping, Resource Packet, revised 10/2/24, stated the facility would keep a daily schedule for cleaning floors that included more thorough cleaning on a routine schedule. On 4/22/25 at 9:15 a.m., the floor of Resident #16's bathroom was very sticky throughout. While walking, shoes noticeably stuck to the floor. Subsequent observations on 4/23/25 at approximately 8:15 a.m. and 4/24/25 at 9:48 a.m., revealed the floor remained sticky. On 4/24/25 at 1:02 p.m., the Ancillary Services Manager stated he was informed of Resident #16's bathroom floor stickiness today and contacted the floor cleaner company to make sure the cleaning solution dilution ratio was correct. On 4/24/25 at 3:01 p.m., the Administrator stated she had a conversation with the Ancillary Services Manager last week about the solution being too concentrated. She stated the cleaner company was coming next week to remedy the situation.

Based on record review, resident and staff interview, and policy review, the facility failed to update and revise the Care Plan to reflect a resident-to-resident incident and interventions for one of two sampled residents in order to maintain a resident's mental and psychosocial well-being (Resident # 69). The facility reported a census of 81 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had diagnoses of cerebrovascular accident (stroke), hemiplegia, and muscle weakness. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated impaired cognition. The MDS recorded the resident had little interest or pleasure in doing things and felt down and depressed 12-14 days during the look-back period. The resident had impaired range of motion on one side of her body, required partial to moderate assistance for bed mobility, and had dependence on staff for lower body dressing and transfers. The Care Plan revised on 6/11/24 revealed Resident #69 had limited physical mobility related to a stroke and hemiplegia that affected the left side of her body. The resident was non-ambulatory and required assistance with activities of daily living (ADL's) such as bed mobility and dressing. The Care Plan lacked information about a resident-to-resident incident that took place on 2/23/25, and interventions to address her psychosocial and mental health needs. An Incident Report completed on Resident #69 revealed a staff statement entered on 2/23/25. Staff F, certified medication aide (CMA) found Resident #50 (male) wandering the halls going in and out of female resident rooms. Staff redirected Resident #50 to his room. Staff F then went and did blood sugars on the [NAME] Hall. Staff D, CMA, and Staff E, CMA, shut all of the female doors. When Staff F went to get a blood sugar on Resident #50's roommate, Resident #50 was not in the room. Staff F then looked for Resident #50. Staff F checked the building on where Resident #50 normally went. Staff F began to open the doors to the female rooms and found Resident #50 and Resident #69. Staff F saw Resident #50 sitting at the foot of Resident #69's bed with her brief all the way undone and Resident #50's hand between Resident #69's legs. Resident #50 was touching Resident #69. Staff F told Resident #50 to stop, don't touch her, that is not ok, this is not your room. Resident #69 woke up and looked at Staff F like what is going on? Resident #69 notified of what occurred and became tearful. Resident #69 said she did not say Resident #50 could do that. In an interview on 4/22/25 at 9:45 AM, Resident #69 reported a male resident lived down the hall from her. He came into her room and raped her a month or so ago. She was lying in bed. He took her brief off. She doesn't think he penetrated her but she doesn't know for sure. Staff yelled at him and asked him what he was doing and got him away from her. Resident #69 stated the male resident had come and stood at her door but staff had caught him in time. Resident #69 reported she had a stroke and unable to move her left arm or leg. She was concerned if he would come into her room at night. Resident #69 was tearful as she spoke with the surveyor about the incident. In an interview 4/24/25 at 2:00 PM, the MDS Coordinator reported she began to work at the facility on 3/5/25. The MDS Coordinator reported she updated the resident's care plan whenever the care plan needed updated or revised. She looked at the resident's chart, notes from other departments, orders, and the progress notes to develop and update the care plans. She also entered a progress note or summary regarding the care plan review. The MDS Coordinator reported she wasn't involved or working at the facility when the Resident-to-Resident incident occurred between Resident #50 and Resident #69. She would expect a resident-to-resident incident and resident behaviors would be on the care plan along with any related interventions for the situation. The facility's Comprehensive Care Plan Policy reviewed 1/31/25 a person-centered Care Plan is developed for each resident that included measurable objectives and timetables to meet the resident's physical, mental, spiritual and psychosocial well-being. The resident's care plan updated and included trauma informed care. The care plan became a powerful and practical tool to represent the best approach to providing quality of care and quality of life. If a resident has specific behavioral interventions, they needed to be reflected on the care plan. Care plans must be revised as the resident's needs and/or status changed.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure a resident received assistance with incontinence care and nail care for 1 of 4 residents reviewed for activities of daily living(Resident #16). The facility reported a census of 81 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 2/12/25, listed diagnoses for Resident #16 which included mild intellectual disabilities, heart failure, depression. The MDS stated the resident required partial to moderate assistance with toileting hygiene and listed a Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. Care Plan entries, dated 1/15/24, stated the resident used adult disposable briefs and directed staff to check the resident approximately every two hours and assist with toileting as needed. The facility policy Incontinence Care, revised 5/20/24, stated the facility would identify the proper care for residents who needed assistance managing their incontinence and stated all residents needed thorough and routine perineal area skin care when incontinence occurred. A 10/22/24 Care Plan entry stated the resident was incontinent of bowel and bladder. The facility policy Nail Care, revised 4/6/25, directed staff to keep nails clean and trimmed to promote well-being. On 4/22/25 at 9:15 a.m., Resident #16's nails were untrimmed and a black substance was present under several nails. On 4/23/25 at approximately 8:15 a.m., the resident laid in bed. On 4/23/25 at 9:45 a.m., the resident laid in bed. Continuous observation until 11:32 a.m. revealed no staff entered the room to offer him toileting or incontinence care assistance. At 11:32 a.m., the resident wheeled himself out of his room in his wheelchair. The resident's shorts were not pulled all the way up in back and one side of his incontinent brief stuck out of the front of his shorts. At 11:33 a.m., the resident sat in his wheelchair outside of his room and asked Staff M Certified Nursing Assistant(CNA) if it was lunch time and she said it was. Staff M did not attempt to assist the resident with incontinent cares and the resident propelled himself down to the dining room. At 11:46 a.m., the resident sat at the dining room table. One side of his incontinent brief still protruded from his pants and was visible. At 12:26 p.m., the resident wheeled himself out of the dining room to his room and transferred himself into bed. At 12:34 p.m., the State Agency(SA) queried Staff A Registered Nurse(RN) with regard to when staff assisted the resident with incontinence cares. Staff A stated they checked him before meals. He stated he would inform Staff M that the resident needed changed after she finished with another resident. At 12:40 p.m., Staff A and Staff M rolled the resident over on his left side in bed and his incontinence brief was heavily saturated with urine and a urine odor was noted. Staff M cleansed the resident's perineal area and placed him in a clean brief. Staff did not offer to assist the resident with toileting or incontinence cares from 9:45 a.m. until 12:40 p.m., after the SA inquired. On 4/23/25 at 12:49 p.m., Staff M stated she did not assist Resident #16 to get up for lunch as she helped other residents. Staff M stated she was the only one working on the hall. On 4/23/25 at 12:50 p.m. Staff A stated staff should check residents (incontinent briefs) every two hours. On 4/23/25 at 3:12 p.m., the resident's nails remained untrimmed and a black substance was present under three nails on his right hand and two on his left hand. On 4/24/25 at 11:22 a.m., when queried with regard to Resident' #16's regular incontinence care routine, Staff N CNA stated when she cared for him, she attempted to change him prior to lunch and supper. On 4/24/25 at 12:31 p.m., the Director of Nursing(DON) stated staff should offer to check and change residents every two hours. She stated nails should be kept clean and trimmed.

Based on observation, record review, and staff, interviews the facility failed to provide treatments as ordered for one of three residents reviewed for treatment. The lack of treatment for (R#33) may have lead to a hospitalization . The facility reported a census of 86. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 has Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment, and diagnosis of Non-Alzheimer's Dementia, Atrial Fibrillation (A-fib), Congestive Heart Failure (CHF), muscle weakness, lymphedema, and cognitive communication deficit. MDS documented admission to care facility began 11/15/2023. The Care Plan dated 4/17/24 revealed Resident #33 is non-verbal, shakes and nods head to respond. Resident #33 is non-ambulatory and totally dependent on staff for transfers and cares. Receives anticoagulant (blood thinners) medication, diuretics for A-fib and CHF. Hospital Discharge Summary dated 11/11/2023 documented as follows; Review of resident #33's records revealed he was admitted to the facility on [DATE] for long term care after a hospitalization for pubic fracture. Hospital discharge documents revealed resident #33 had chronic lymphedema (swelling caused by buildup of lymph fluid in the body between the skin and muscle) treated with Lasix (diuretic) and use of lymphedema pumps (a device that treats chronic edema and venous disease with the use of air and compression into a stocking), peripheral venous insufficiency (circulation disorder), A-fib, stage 3 chronic kidney disease, a history of blood clotting disorder with deep vein thrombosis (DVT, blood clots in the veins), intellectual disability. Hospital discharge orders included medication list and use of lymphedema pumps from home, one hour in the morning and one hour in the afternoon. Plan of Care Note from Hospital Social Worker dated 11/14/23 at 9:20 AM documented Group Home to bring Lymphedema pumps to bedside to go with the resident for the admission to the nursing home. Skilled Nursing Facility/Nursing Facility to Hospital Transfer Form dated 2/11/24 documented the following; Resident#33 was transferred to the hospital on 2/11/24 for shortness of breath and admitted to the ICU (intensive care unit) and diagnosed with urosepsis, septic shock, DVT in both legs with cellulitis in the right lower leg. Resident #33 was discharged from the hospital returning to the facility on [DATE] with continued medications including an anticoagulant medication and to restart lymphedema pumps the day of discharge. Hospital Progress Note dated 2/13/24 at 8:31 AM documented that the resident previously had one year ago DVT's and PE (pulmonary embolism (blood clot)). The resident's bilateral lower extremities are swollen, and his right leg is very painful. The lower extremity swelling and pain may be due to the DVT's, but can't rule out necrotizing fasciitis with the organism in his blood. Physicians Order dated 2/26/24 for the resident documented lymphedema pump to bilateral lower extremities once daily. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 11/1/23-6/1/24 failed to reveal order for lymphedema pump and documentation of administration. On 6/13/24 at 2:20 PM revealed the resident laid in bed with no lymphedema pump in the room. On 6/17/24 at 12:17 PM Staff C, Registered Nurse (RN) reported the resident did not have a lymphedema pump in his room, and had not received this treatment. Staff C recalled this being discussed after hospital discharge on 2/21/24 but could not recall why this had not been initiated. On 6/17/24 at 2:21 PM the Director of Nursing (DON) stated the lymphedema pump order had not been sent with the original admission in November, and should have been clarified by the nurse at that time. An order was received from a physician on 3/3/24, that was not processed accurately to TAR, and had not been administered as ordered. The DON did confirm the lymphedema pump is in the facility, and the TAR had been corrected and treatments will be started. On 6/17/24 at 4:30 PM the DON was presented with the orders for the lymphedema pump that were received on initial admission documentation on 11/15/23. DON acknowledged the orders and identified the facility failed to accurately review, process and implement the orders for the lymphedema pump. Physician Orders Policy dated 4/1/24 directed staff as follows, Purpose to provide care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. Following hospitalization when a resident returns from the hospital, physician/practitioner orders must be updated to reflect the resident's current needs. Admission orders and orders received throughout the resident's stay are processed and transcribed into PCC-Clinical-orders (electronic health record), immediately upon receipt of the order. The orders must be noted by the licensed nurse who has processed the order and filed in the central supervised location for scanning/indexing.

Based on observation, clinical record review, interviews, and policy review, the facility failed to administer medications to the correct resident (Resident#87) and, administer the correct dose of a pain medication to (Resident#3). Resident#87 was taken to the emergency room , and treated for the overdose of medications as a result of the incident when the resident experienced low blood pressure, and low pulse rate. The facility staff also left medication unattended. Seven residents were reviewed for medications. The facility reported a census of 86 residents. Findings include: 1. The Minimum Data Set (MDS) Admission assessment for Resident #87 dated 4/23/24 documented a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicated intact cognition for decision making. The MDS revealed he had diagnoses of cerebral infarction referring to a recent stroke, renal disease, urinary tract infection, diabetes, depression and age-related cognitive decline. The Care Plan initiated 4/19/23 documented Resident #87 resident will be free from discomfort of preventable adverse reactions related to medication. A Progress Note dated 4/29/24 12:51 PM by Staff A, Registered Nurse (RN), late entry documented Resident#87 spouse medications sitting on bedside, waiting for blood pressure to be obtained, Resident #87 reached and took spouses medication. Provider, Nurse Practitioner (NP) at the facility notified, family aware, monitored per order and sent to ER for evaluations. A Progress Note 4/29/24 9:35 AM documented by Staff B, revealed provider, NP in facility notified took own medication as well as spouses who takes several blood pressure medications. Received new order to monitor blood pressure and pulse every two hours for 8 hours. A Progress Note dated 4/29/24 by Staff B, effective time 11:50 AM documented family notified took spouses medication this morning and blood pressure 82/46 at 11:30 AM. Resident # 87 on way to hospital. A Progress Note dated 4/29/24 by Staff B, created 12:18 PM documented, called and informed the hospital, resident took the wrong medications and has allergies to Atrovastatin and Simvastatin and the resident did take Pravastatin. Informed the Emergency Department (ED) that the medications and recent blood pressures were provided to the paramedics for the ED to review. A statement signed by the Director of Nursing (DON) on 4/29/24 documented on the morning of 4/29/24 at 9:20 AM received a message, Resident #87 received incorrect medications. An investigation revealed, the Registered Nurse (RN), Staff A placed the medication cup of Resident #188 on the bedside table of spouse, Resident #87. The RN left to obtain a forgotten alcohol wipe, when RN Staff A returned the medication cup was empty. Resident #188 and RN Staff A realized Resident #87 had taken the pills. The provider, Nurse Practitioner (NP) was in the facility, was notified along with family. Resident #87 was sent to ER for evaluation, was treated with calcium gluconate and fluids and returned to the NF, no other new orders. Nurse interviewed revealed no other residents affected, no other residents were left with medication unsupervised. A Facility Incident Report dated 4/29/24 documented, Resident #87 reached over and took Resident #188 medications, not remembering he had already taken his medication. Noted medication error, wrong medication and indicated Resident #87 blood pressure was monitored, resulted in hospital, ED visit. Hospital ED Physician Notes dated 4/29/24 documented inadvertent overdose on medication, diagnosis of beta blocker overdose (refers to mediations to lower blood pressure. Documented inability of Resident #87 to provide clear information, some confusion, undetermined if is baseline. Resident #87 blood pressure dropped to 80/40 after the incident, resident was bradycardic (low pulse rate) and hypotensive (low blood pressure) was treated with intravenous (IV) fluids and IV calcium, observed for seven hours post ingestion until blood pressure and heart rate improved. Coded complexity of problem, high an illness or injury that posed life threat or bodily function threat. The Medication Administration Record (MAR) April 2024 for Resident #87 documented took as directed on 4/29/24. a. Calcium-Vitamin D3 600-10, 1 capsule by mouth in the morning b. Apixaban oral tablet 5 MG, two times a day for anticoagulant c. Atenolol oral tablet 25 MG two times a day for hypertension d. Cetirizine HCl oral tablet 10 MG 1 tablet daily for allergies e. Docusate Sodium oral tablet 100 MG 2 tablet daily, constipation f. Escitalopram oral tablet 10 MG 1 tablet daily for depression g. Ferrous sulfate oral tablet 325 (65 Fe) MG two times a day h. Fish Oil, one oral capsule in the morning i. Magnesium Ox oral tablet 400 MG supplement, two times a day j. Metformin HCl oral tablet 500 MG two times a day for diabetes k. Multivitamin Men 50+ tab daily, ensure no Vitamin K additive l. Oxybutynin oral tablet 5 MG, two times a day for urinary spasms m. Pantoprazole Sodium oral delay release 40 MG daily, heart burn n. Theophylline ER oral extended release, 400 MG daily for asthma o. Macrobid oral capsule 100 MG two times a day for urinary tract infection (UTI) for 7 days beginning 4/27/24 The MAR, April 2024 for Resident #188 documented the following morning medications, reported was taken by Resident #87 accidentally. a. Calcium, Vitamin D Oral Tablet 600-3.125, supplement, daily b. Cholecalciferol Oral Capsule 50 MCG (2000 UT) supplement, daily c. Docusate Sodium Oral Tablet 100 MG daily for colon health d. Famotidine oral Tablet 20 MG daily for stomach upset/acid reflux e. Ferrous Sulfate Oral Tablet 325 supplement one, Monday & Friday f. Levothyroxine Sodium Oral Tablet 75 MCG one daily for thyroid g. Methylcobalamin Oral Lozenge 1000 MCG supplement daily h. Multivitamin Oral Tablet one time a day for supplement i. Pravastatin Sodium Oral Tablet 20 MG one daily for hyperlipidemia j. Valacyclovir Oral Tablet 500 MG daily for preventative k. Vitamin B12 Oral Tablet 500 MCG one supplement daily in AM l. Amlodipine Besylate Oral Tab 5 MG twice daily for hypertension m. Buspirone HCl Oral Tablet 10 MG twice daily for anxiety n. Labetalol HCl Oral Tablet 200 MG twice a day for hypertension o. Verapamil HCl Oral Tablet 120 MG three times a day for hypertension In an Interview on 06/13/24 at 09:34 AM, RN Staff A reported she did prepare medications for Resident #188 set them on the table per resident requested, went out of the room and came back, Resident #188 said you didn't set my pills there. Was determined Resident #87 took the pills, was evident as blood pressure assessed and it continued to go down, Resident #87 sent out to the hospital In an interview on 6/13/24 01:44 PM, RN Staff B recapped events of 4/29/24 relayed was the charge nurse, other RN, Staff A was working to administer medications relayed, can't believe what happened, relayed had put Resident #188 pills on the table left to get an alcohol wipe and came back the pills were gone. Staff A asked where are pills went, Resident #188 replied, Resident #87 took them. Staff B also relayed she alerted the ED what medications were taken by printing off both resident MAR's and highlighting the AM medications taken, from Resident MAR's # 188 and 188. Staff B recalled hospital report of treatment included calcium gluconate and fluids and thought a Beta blocker reversal was indicated medications to reverse the low blood pressure in regards to the extra medications taken. In an interview on 06/13/24 at 07:57 AM the DON relayed medication should not be left unattended. Facility Electronic file dated 4/29/24 revealed hospital visit summary dated 4/29/24, diagnosis noted, Poisoning by beta-adrenoreceptor antagonists, accidental (unintentional toxicology problem). Medication Policy with revised date 5/21/24 directed staff as follows; *To administer medications correctly and in a timely manner *Once medication pass has begun, interruptions should be avoided. Unless emergent, no one should interrupt the nurse/medication aid during the medication pass. *Medications are administered to the resident according to the Six Rights. -Right resident -Right medication -Right dose -Right time -Right route -Right documentation *Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. 2. Observation on 6/11/24 from 7:20 AM to 8:25 AM of medication administration by Registered Nurse (RN) Staff C, prepared med's and went to residents' room to give medication, cart unattended, prepared med's for another resident, left cart to go to resident room and repeated leaving cart unattended while entering rooms of five (5) residents to administer medications. On top of the medication cart a plastic container with individual boxes labeled for residents, translucently viewed various insulin medication pens in the individual boxes, the container also contained diabetic supplies a glucometer, cotton, cleansing wipes, a cup of insulin pen needles was also observed on the top of the cart. On 6/11/24 at 8:25 AM, Staff B, RN queried regarding diabetic supplies and insulin left on the cart unattended. Staff B relayed in the morning took diabetic medications and supplies from the med room and is usual to leave it on the cart, generally they sit out when actively used in the mornings. Staff C, RN reported, she felt the pens need a needle added to inject so felt it was not a concern. A separate cup of insulin needles observed remained accessible on the top of the cart. Staff C in addition relayed, was not told not to do this. In an interview on 06/13/24 at 7:57 AM with the Director of Nursing (DON) acknowledged medication should not have been left unattended. 49698 3. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had diagnoses including of Multiple Sclerosis (MS), Malnutrition, Stage 4 pressure ulcers, anxiety, depression, and diabetes. The MDS documented that the resident received scheduled pain medication.The MDS documented the residents pain as follows; pain experienced almost constatly, pain frequently made it difficult for the resident to sleep, pain frequently limited the residents day-to-day activities. The MDS documented the resident described her pain as a 7 on a scale of 0 to 10. The Care Plan dated 3/11/24 revealed Resident #3 had unclear speech, slurred or mumbled words, receives pain medication due to chronic pain, is immobile and needs total assistance for all transfers and cares. Review of resident #3's physicians orders revealed the following orders: 3/21/24 Fentanyl Patch 72 hour 25 MCG/HR, Apply one patch transdermally every 72 hours for pain and remove per schedule. Discontinued on 3/25/24 3/25/24 Fentanyl Patch 72 hour 50 MCG/HR, Apply one patch transdermally every 72 hours and remove per schedule. Review of resident #3's Medication Administration Records (MAR) for 3/1/24-6/12/24, revealed on 4/9/24 no nurse's signature was noted, indicating no Fentanyl patch had been administered. Review of Controlled Drug Receipt/Record/Disposition Form (form used to document dispensed and inventoried controlled medications) revealed the following: On 4/10/24 at 1600, two 25 MCG/HR Fentanyl patches were signed out. Indicating these patches were administered late. (scheduled to be administered on 4/9/24) On 5/18/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/21/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/24/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/27/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 5/30/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. 6/8/24 at 7:45 PM, one 25 MCG/HR Fentanyl patch was signed out, indicating the wrong dose was administered. Review of resident #3 ' s nurses progress notes revealed, on 4/9/24 the nursing staff failed to document the scheduled Fentanyl 50 MCG/HR patch had not been administered, reason for not being administered, and notification to family and physician. On 4/10/24 nursing staff failed to document two 25 MCG/HR Fentanyl patches had been administered late and notification to family and physician was made. Review of the controlled medication receipts, provided by the pharmacy, verified the quantity of Fentanyl patches, date, time and signature of staff who received the delivery from the pharmacy. Interview on 6/12/24 at 9:27 AM, A Pharmacy Technician with the Facility ' s contracted pharmacy revealed the process of receiving new and discontinued orders. The order is faxed from the facility to the pharmacy. When it is a controlled substance, the pharmacy will contact the writing physician for signature of ordered medication. When a controlled substance is discontinued by the physician, the pharmacy is to be notified by a faxed discontinuation order from the facility. The facility is responsible for disposing of the discontinued controlled medications by destroying them in a pharmacy provided, DEA approved, Rx destroyer. This is a container that contains a formula that neutralizes the substances placed inside. The Pharmacy Technician confirmed the facility has been provided a Rx destroyer. During an interview on 6/17/24 at 3:35 PM, the facility Administrator acknowledged administering the 25 MCG/HR Fentanyl patch was not following physicians orders, indicated a significant medication error. Review of Medication Administration policy dated 5/21/24 revealed: 1. Medications are administered to the resident according to the Six Rights. (Right medication, right dose, right resident, right route, right time and right documentation). 2. Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication. Document that the medication was given as soon as possible after administration. 3. Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. If the resident has not been assessed for safety of self-administration and there is not a physician order to leave the medication with the resident, stay with the resident until the medication is taken and you observe the resident swallow. 4. An incident report will be completed for all medication errors. If a medication is not available for 24 hours, the provider must be notified. Review of Maintenance of Active Medical Records dated 5/11/23 revealed, the location will maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized.

Based on clinical record review, facility record review, facility policy review, resident interview (Resident #9), provider interview and staff interviews, the facility failed to provide skin assessments per policy, failed to implement interventions and provide treatments per physician orders which resulted in the deterioration of pressure ulcers for 2 of 4 (Res #2, #8) residents reviewed. Both residents had ulcers which worsened to Stage IV pressure ulcers, became infected and subsequently were hospitalized for the treatment of the pressure ulcers and need for surgical intervention. There was an immediate need for the facility to take steps to ensure residents were protected from the risk of development or worsening of wounds. The facility reported a census of 73 residents. On January 8th, 2024 at 3:00 pm, the State Survey Agency informed the facility the staff''s failure to assess and document skin assessments, implement interventions and failure to provide treatment orders per recommendations created an Immediate Jeopardy situation resulting in deterioration of wounds, which began on September 4, 2023. The facility staff removed the immediacy on January 9th, 2024 when facility staff implemented the following Corrective Actions: a. Braden Assessments and Skin Assessments of all current residents. b. All staff education regarding all aspects of skin and wound care. c. Steps to ensure timely completion of Assessments. d. Audits for skin treatments. e. Procedures for follow up of Registered Dietian recommendations. f. Care Plan intervention education. g. Audits of wound recommendations and skin assessments and brought to Quality Review. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuant) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 1. The Minimum Data Set (MDS) dated [DATE] of Resident #2 reflected that the resident sometimes was able to make herself understood and able to understand others. The MDS identified the presence of short and long-term memory impairment. The MDS documented the resident is at risk of developing pressure ulcers but does not have any pressure ulcers. The MDS documented the use of pressure reducing device for bed and chair and a turning/repositioning program. The MDS dated [DATE] revealed the resident required extensive staff assistance for bed mobility and was totally dependent on staff for transfers. The MDS reflected the resident always incontinent of bowel and the resident had a urinary catheter. The MDS documented the resident did not have any pressure ulcers/injuries. The active diagnoses portion of the Electronic Health Record (EHR) of Resident #2 documented diagnoses of quadriplegia (paralysis of all four limbs), anoxic brain damage (brain injury resulting from complete lack of oxygen to the brain), epilepsy (a condition affecting the brain and causing seizures), and dysphagia (swallowing difficulty). The Comprehensive Care Plan of Resident #2, initiated 7/6/23, identified a Focus Area of an Activities of Daily Living (ADL) performance deficit related to quadriplegia. The Care Plan directed staff the resident required 2 staff assistance for bed mobility and transfers. The Care Plan identified a Focus Area, revised on 9/25/23, identifying the resident to be at risk of skin alterations and pressure injury. The Care Plan documented the following interventions: -Inform resident/family of any new area of skin breakdown, husband takes resident out of facility for several hours at times, education on skin repair provided. Date initiated 9/25/23. -Resident is to be positioned side to side while in bed. Date initiated 9/25/23. -Provide pressure relieving mattress on bed and cushion on wheelchair. Prevalon boots on at all times when allows. May remove for skin checks and bathing. Date initiated 7/27/23. The Care Plan lacked a repositioning schedule for Resident #2 and lacked documentation of education to the spouse on interventions he needed to provide while resident home to prevent skin breakdown. The Progress Notes for the resident documented the following: On 9/2/23 at 5:59 pm the resident left the facility earlier in the day with her spouse and would be gone overnight. On 9/3/23 at at 6:21 pm resident returned to the facility at 4:30 pm. On 9/4/23 at 1:46 pm resident noted to have an open area on the sacrum, noted to be a deep tissue injury with biofilm (a thick, slimy barrier on a wound) to the wound bed. The record lacked a full skin assessment for 9/3/23 or 9/4/23 after returning from the pass with family. The Wound RN assessment dated [DATE] is the first assessment noted to document the sacral wound and the first full assessment performed after the resident returned to the facility on [DATE]. The lock date on the assessment was documented as 9/13/23. This documented the wound as a Stage 3 pressure ulcer measuring 4.5 x 3.0 x 0.1 centimeters. The Nutritional Status note, dated 9/7/23 at 4:02 by the Registered Dietitian documented a recommendation to begin 30 milliliters (mL) of ProStat (a protein liquid for wound healing support) twice a day for wound healing. The record lacked progress notes that documented the physician being notified of this recommendation. The Medication Administration Record (MAR) and the Treatment Administration (TAR) record failed to document the ProStat as being administered anytime in the month of September, 2023. The Wound RN assessment dated [DATE] documented the wound as 4.0 x 3.0 x 0.1 cm. The Progress Note dated 9/16/23 at 10:19 am documented the resident left the building for the day with her husband. No skin assessment was documented upon return to the facility. The Wound Data Collection assessment dated [DATE] at 2:07 pm documented no dressing present, no presence of possible complications to the wound and no complaints of pain. The TAR for 9/16/23 and 9/19/23 failed to reveal documentation of the ordered wound care as being completed. The Wound RN assessment dated [DATE] documented the wound as 3.0 x 2.0 x 0.1 cm. The Progress Note dated 9/23/23 documented the resident left the facility for the day with her spouse. A Wound Data Collection Assessment was signed on 9/24/23 at 4:35 am. Review of the Assessment revealed documentation of a dressing being present and intact with no drainage present on the dressing. The Assessment also documented no presence of possible complications and no complaints of pain. The Nutritional Status note, dated 9/27/23 at 1:09 pm by the Registered Dietitian documented Per last RD note on 9/7/23 - recommended adding ProStat 30 mls for wound healing. Recommend ensuring recommendation is following to encourage wound healing. The Wound RN assessment dated [DATE] documented a significant decline with wound measurements of 6.9 x 5.5 x 0.8 cm. Resident #2 was transferred to an acute care hospital for wound care at 12:51 pm. The Documentation Survey Report for the month of September, 2023 failed to reveal repositioning charting every shift. For the first 27 days of the month, 3 shifts per day, documentation of repositioning left blank 49 shifts out of 81 shifts. The Emergency Department Note from an acute care hospital dated 9/28/23 at 1:37 pm documented Resident #2 as having a decubitus ulcer of the sacral region, Stage 4. On 9/29/23 at 2:45 am resident noted to be discharged from the Emergency Department to the Intensive Care Unit (ICU) of the hospital. The Integumentary Assessment completed upon arrival to the ICU on 9/29/23 at 2:42 am noted the sacrum skin ulcer to be complex - includes bone. The wound was documented as 8 x 4 x 2 cm during this assessment, with a moderate amount of warm, tan drainage and a foul odor. On 9/29/23 at 1:23 pm the laboratory at the acute care hospital documented the resident had Methicillan resistant staphylococcus aureus (MRSA, a bacteria which is resistant to antibiotics). The Internal Med Progress Note dated 10/9/23 documented the assessment and plan for Resident #2 for 6 weeks of intravenous (IV) Vancomycin (an antibiotic) to be completed on 11/10/23; twice daily wound care, frequent repositioning, pain management and plastic surgery debridement and biopsy for the following day. The Operative Note dated 10/10/23 documented a surgical debridement of the Stage IV sacral pressure ulcer completed at the hospital. On 10/10/23 the Surgical Pathology Report documented a diagnosis of the coccyx bone biopsy as abundant acute osteomyelitis (an infection of the bone). Resident #2 returned to the facility on [DATE] and was discharged back to the hospital for an unrelated concern on 10/19/23. Resident #2 had no Positioning Assessment and Evaluation on record and the record failed to have a positioning schedule documented in the Kardex. On 1/2/24 at 9:26 am, a nurse at an acute care hospital stated Resident #2 is currently hospitalized for the continued treatment of her pressure wound. On 1/3/24 at 4:20 pm, the DON stated her expectation is all charting for the cares given needs to be completed. She stated there were a lot of agency staff working at the facility and they were not good about charting. On 1/4/23 at 2:05 pm the Director of Nursing (DON) stated the Registered Dietitians are contracted and they email their notes and recommendations into the Assistant DON. She stated she would follow up regarding the ProStat for Resident #2 not being followed up on at the original recommendation. The DON also stated her expectation is for all skin interventions to be care planned and followed such as air mattresses, dietary supplements, and a repositioning schedule. On 1/4/23 at 2:56 pm, the DON stated she was unable to locate any information as to why the ProStat order for Resident #2 was not followed up on at the first recommendation. She confirmed the order was not put into place until it was recommended a second time on 9/27/23. 2. The MDS dated [DATE] of Resident #8 identified the resident to be in a persistent vegetative state. The MDS revealed the resident required extensive physical assistance of 2 people for bed mobility and revealed the resident totally dependent upon 2 person physical assistance for transferring, toileting, dressing and personal hygiene. The MDS documented diagnoses that included anoxic brain damage(brain injury resulting from complete lack of oxygen to the brain), aphasia (the loss of ability to understand or express speech, caused by brain damage), quadriplegia (paralysis of all four limbs), and seizure disorder. The MDS documented the resident had a pressure ulcer and was at risk of developing pressure ulcers/injuries. The MDS documented the pressure ulcer at a Stage I pressure injury. The Comprehensive Care Plan of Resident #8, review date 4/14/23, revealed the resident to have an Activities of Daily Living (ADL) self care deficit due to brain injury and quadriplegia. The Care Plan directed staff the resident required 2 staff assist for bed mobility and transferring. The Care Plan further directed 2 staff assist to check and change the resident for incontinence cares and emphasized to do so often as the resident was a great risk for pressure and skin issues. The Focus Area of the Care Plan of skin integrity revealed the resident to have acquired a Stage 3 pressure ulcer to the sacrum, dated 4/20/23. It directed staff to provide wound care as ordered and to notify the nurse of any new areas of skin breakdown noted during bathing or daily care. The care plan failed to direct staff of the need to turn the resident side to side in bed or to keep the resident off of his back. The census line of Resident #8 Electronic Health Record (EHR) reflected the resident was hospitalized from 4/8/23 to 4/15/23. The Flowsheet Note from the Acute Care Hospital dated 4/12/23 at 10:46 am documented the resident to have an open area on the left side of his buttocks and a wound consult ordered. The Nursing Admit Re-Admit assessment tool, dated 4/15/23 for Resident #8 reflected the resident to have two wounds upon returning to the facility from the hospital. A deep tissue injury to the forehead and an area on the 5th digit of the left foot were noted. Additionally the assessment noted the resident to have a history of healed pressure ulcers and to have the potential for pressure ulcer development. The assessment lacked any other documentation of skin impairment. The Progress Notes failed to reveal any entries dated 4/15/23 reflecting any skin assessment or skin injury noted upon re-admission. The General Surgery Consult dated 5/16/23 noted an attending addendum that previous medical records were reviewed. It stated Patient was admitted to (hospital) for about a week from 4/8/23 through 4/15/23 with respiratory infection. Note from Wound and Ostomy care RN on April 12 described patient as having shearing blisters to bilateral sides of his buttock. The Wound RN assessment dated [DATE] for Resident #8, 5 days following his return from the hospital, documented a Stage 3 pressure ulcer measuring 6.5 x 6.5 x 0.1 centimeters (cm) on the sacrum (bony structure connected to the pelvis). The Wound Treatment Plan dated 4/20/23 documented the resident recently returned from an acute care setting with an open area on his buttock. The skin inspection documented a sacrum pressure ulcer stage 3 which the physician mechanically debrided during the assessment (removing dead or unhealthy tissue from a wound). The physician recommended discontinuing the current treatment of zinc paste topically and begin cleaning the wound with cleanser of choice, mix 15 milliliters of Desitin 40% zinc with one package of collagen powder, apply the mixture topically, cover with silicone super absorbent dressing daily and as needed. Review of the Treatment Administration Record of Resident #8 for April of 2023 revealed the treatment not documented as being completed on Monday, April 24, 2023. The Wound Physician continued to assess the resident weekly. On the following visit on April 27, 2024, the Physician documented upon her entry into the resident's room, his air mattress was found to be unplugged. The Physician plugged the mattress back in and properly inflated it. On this visit the wound was noted to be 7.8 x 7.5 x 0.1 cm and was mechanically debrided during the assessment. The following two visits the wound was documented as continuing to be larger but was noted to be improving in status. May 4th visit, documented as 9.0 x 11.6 x 0.1 cm. May 11th visit, documented at 9.0 x 10.5 x 0.1 cm with mechanical debridement performed with each assessment. The Health Status note dated 5/16/23 documented the nurse was called to assess the resident's buttocks wound. The note stated there was a copious amount of red, gelatinous fluid noted in the resident's brief and saturating an incontinence pad underneath him. The note documented the wound was unable to be assessed due to the amount of blood obscuring the wound. The resident was then sent to the hospital for evaluation. The Documentation Survey Report for the month of April, 2023 failed to reveal repositioning charting every shift. For the 63 shifts of opportunity to chart (excluding the days the resident was hospitalized ) documentation of repositioning was left blank 32 times out of those 63 shifts. The Emergency Department (ED) Provider Notes dated 5/16/23 documented a large sacral ulcer that is foul smelling and leaking bloody and purulent discharge. The labs that were drawn at the Emergency Department documented a white blood cell count of 19.34 (normal reference range 4.00-11.00, indicating infection) and a Procalcitonin level of 0.66 (normal reference range <.10, indicating the resident to be at risk of developing severe sepsis or septic shock. ) The Clinical Impression documented in the ED provider note included: Subcutaneous emphysema (an infiltration of air underneath the layers of skin) Wound of the sacral region Sepsis (the body's extreme response to an infection, a life threatening emergency) The Computed Tomography (CT) scan of the abdomen and pelvis done on 5/16/23 revealed extensive edematous changes overlying the sacrum. Necrotizing fasciitis (a rapidly progressive infection that destroys deep soft tissues including muscle fascia and overlying subcutaneous fat) was a clinical diagnosis of concern. The History & Physical (H&P) Notes dated 5/16/23 revealed the Principal Problem for the Resident's admission to the hospital to be Severe Sepsis. Active problems were listed as Acute respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily functions) and hypercapnia (high levels of carbon dioxide in the blood) and the sacral ulcer. The Assessment and Plan within the H&P documented Severe Sepsis - appears due to infection of his sacral and buttocks wound. The General Surgery Consult dated 5/16/23 stated in the Assessment & Plan the wound to be most likely a deep large diameter infected wound that started as a sacral decubitus ulcer and may have penetrated to the bone. The Surgical Attending Note dated 5/16/23 stated the doctor did not believe the resident had Necrotizing fasciitis. The resident had a worsening sacral decubitus ulcer and it was prudent for the surgical team to assess and debrided the wound in the operating room. The note further stated the best case scenario would require careful and prolonged wound care with diligent bed positioning changes over a period of many months. The Operative Note dated 5/16/23 documented the procedure of debridement of sacral decubitus ulcer measuring 9 long x 8 wide x 3 cm deep. The ICD Procedures documented the resident ultimately had wound procedures completed on 5/16/23, 5/21/23, 5/23/23, 5/26/23 and 6/1/23. He was discharged to an alternate long term care facility on 6/13/23. The Internal Medicine Discharge Summary following debridement of the wound, the MRI is now concerning for osteomyelitis. Plastic surgery noted the resident was not a candidate for wound closure. The resident was planned for a 6 week course of antibiotics and was to have follow up appointment with Infectious Disease physician. On 1/3/24 at 4:20 pm, the DON stated her expectation is all charting for the cares given needs to be completed. She stated there were a lot of agency staff working at the facility and they were not good about charting. On 1/4/23 at 9:05 am the facility's Wound care Physician stated she first assessed Resident #8 after his hospitalization on [DATE] and his wound was significantly worse than the hospital photo dated 4/12/23. She stated the resident had an alternating air mattress in place and was a check and change for incontinence and his time spent out of bed was limited. On 1/4/23 at 12:30 pm Staff L, Licensed Practical Nurse, stated the wound on Resident #8 was a small open area with discoloration around it when she provided treatments prior to his hospitalization . She stated the area grew larger and they did dressing changes and kept it covered. She stated the discoloration area was the size of both of her fists. On 1/4/23 at 1:43 pm, Staff E, CNA stated the staff use the Kardex to know how to care for the residents. When shown the Kardex of Resident #8, without his name being shown, Staff E was asked how this resident would be cared for. She stated it would take 2 staff members for bed mobility and Hoyer lift transfers. She stated this resident would be able to be laid on his back, left or right side as there was no indication of not lying in any particular position. She stated if someone should be turned side to side only, that needs to be listed on the Kardex. On 1/7/23 at 1:30 pm, Staff M, CNA was shown the Kardex of Resident #8. She stated that because it read to keep the foot of the bed elevated to stop the resident from sliding down, she felt he should be positioned on his back most often but that any resident who needs turned should be turned every two hours. On 1/7/23 at 7:15 pm, Staff N, Registered Nurse (RN) stated Resident #8 had a deep tissue injury upon returning from the first hospitalization . She stated the wound was not open when she provided dressing changes prior to his hospitalization . She stated when the wound became open is when he was sent back to the hospital. The policy Skin Assessment Pressure Ulcer Prevention and Documentation, review date 4/26/23, directed: A systemic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nurse assistant responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. All residents will have a comprehensive skin inspection done by the licensed nurse on admission/readmission to identify any skin issues present including, but not limited to, pressure ulcers, and the results will be documented in the legal medical record. Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool UDA, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnosis, mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation UDA is a required tool that is used to determine and individualized repositioning plan. The positioning schedule should be communicated to the nursing assistants using the Kardex. Resident #8 had a Positioning Assessment and Evaluation last done on 9/14/2020. Resident #8 failed to have a positioning schedule documented in the Kardex. 3. During an interview with Resident #9 (a current facility resident) on 12/28/23 at 11:39 am, she stated that her wound care is supposed to be done twice a day, the staff provides it most days but not all. The MDS of Resident #9 dated 12/7/23 indicated a BIMS score of 14, indicating cognition intact. A review of Resident #9's TAR for December of 2023 revealed 11 treatments out of 34 which were not documented as being complete for multiple wounds which the resident is being treated for.

Based on clinical record review, observation, staff interview, and policy review the facility failed to ensure staff used a gait belt to safely transfer a resident for 1 of 4 residents reviewed for transfers who fell resulting in significant pain and swelling (Resident #4). The facility also failed to ensure a resident's bed was placed in a low position for resident's safety while the resident was lying in bed (Resident #5), and failed to utilize a fall mat and body pillow as care planned for 1 of 7 residents reviewed in the sample who fell from their bed resulting in an eye laceration that required sutures and caused significant facial pain and bruising (Resident #5). The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 4 had a brief interview for mental status (BIMS) score of 10, indicating cognition moderately impaired. The MDS revealed the resident had diagnoses including dementia and heart failure. The MDS revealed the resident required extensive assistance of one for bed mobility and limited assistance of one for transfers, toilet use, and ambulation in the room. The MDS dated [DATE] revealed Resident # 4 had a BIMS score of 10, indicating cognition moderately impaired. The MDS revealed the resident required extensive assistance of one person for bed mobility, toilet use, and ambulation in her room, and extensive assistance of two staff for transfers. The Care Plan revised on 8/24/22, revealed Resident #4 had a risk for falls related to medication side effects, weakness, cognition, and a left lower extremity (LLE) fracture. The Care Plan directed staff to ensure the resident wore appropriate non-slip footwear when ambulated, use a gait belt, walker, and assistance of one staff for ambulation and transfers (added 8/24/22). The care plan intervention added 2/10/23 for physical therapy evaluation upon return from the hospital. A fall tool assessment completed on 8/19/22 due to a fall revealed the resident had a medium risk for falls. A fall tool assessment completed 8/23/22 and 2/10/23 after the resident returned from the hospital revealed the resident at high risk for falls and referred to therapy. An E-interact transfer form revealed the following: a. On 8/19/22, resident transferred to the hospital at 10:50 PM after the resident had a fall. b. On 2/10/23, resident transferred to the hospital at 3:29 PM after trauma related to a fall. An x-ray completed revealed an obvious fracture to the left fibula (long bone in the lower leg). The left ankle/foot swollen and the inner left foot had bruising. The Progress Notes revealed the following: a. On 8/19/22 at 10:50 PM, CNA (certified nursing assistant) called a nurse to the resident's room. The Resident was lying supine in the bathroom doorway. CNA reported she ambulated the resident to the bathroom using a walker when the resident stated I'm falling. The CNA stated she assisted the resident to the floor and then heard a popping sound. Resident very tearful during assessment and complained of feeling dizzy. The resident had removed oxygen after she changed into a gown and prior to ambulating. Gripper socks were on. Vital signs revealed oxygen saturation 80% without oxygen. Oxygen replaced and oxygen saturation then 92%. The resident complained of left hip and leg pain. Slight external rotation noted to the left leg. Physician notified of fall. Order received to send resident to the emergency department (ED) for evaluation and treatment. b. On 8/20/22 at 5:06 AM, ED nurse reported the resident broke her ankle in two places, they planned to admit the resident (to the hospital), and awaited a surgical consult. c. On 8/22/22 at 10:06 AM, social service documented a follow up fall note for therapy to evaluate the resident upon return from the hospital. d. On 8/23/22 at 11:15 AM, an admission/readmission note revealed resident hospitalized post fall and had a left ankle fracture and contusion to her left hip. Resident treated with pain medications and wore a boot due to the fracture. Physical therapy, occupational therapy, and nursing to provide services due to a fall with fracture. e. On 8/29/2022 at 12:43 PM, MDS note revealed the resident had a recent hospitalization after resident lower to the ground during a transfer. Resident diagnosed with a left tibia/fibula fracture and UTI. No surgical intervention for the fracture. Ortho boot worn to the left lower extremity at all times except during hygiene and clothing changes, and Ortho boot worn for stability and for comfort. The resident took Gabapentin and Tramadol routinely, and used Tylenol for breakthrough pain. Required assistance of one staff for all ADL's. Currently receiving skilled services with PT/OT for balance, gait, strengthening, and ADL re-training with a goal of resuming prior functional ability. Plan of Care updated to reflect acute injury and pain. f. On 2/10/23 at 8:00 AM in a communication to the physician revealed a CNA reported to the nurse resident yelled out when she attempted to lift the resident's left leg up while getting resident ready to get up. Upon assessment, the resident's left outer ankle/foot noted as extremely swollen and very tender to touch. The resident had some light purple bruising to her inner left foot. Scheduled pain medication administered for the pain, then wrapped left ankle/foot up to her left knee per an existing order. Physician notified. Order received for a left ankle and foot x-ray. g. On 2/10/23 at 1:36 PM, portable x-ray done. Awaiting results. h. On 2/10/23 at 2:46 PM, physician notified of probable fracture to the resident's left fibula. Order obtained to send the resident to the ED for evaluation and treatment. i. On 2/10/23 at 3:54 PM ambulance service refusing to take resident to the hospital at this time due to not in critical condition. DON (director of nursing) aware. j. On 2/10/23 at 4:17 PM, the nurse practitioner ordered to change Tramadol (an anti-inflammatory pain medication) to every 6 hours PRN (as needed), start hydrocodone 7.5/325 milligrams (mg) every 6 hours for 7 days, Tylenol three times a day, and a cam boot to left leg. k. On 2/10/23 at 4:27 PM, EMS services and non-emergent transports unable to transport resident to hospital Ambulance transport arranged for 2/11/23. l. An incident Progress Note on 2/10/23 at 6:12 PM revealed resident ambulated with assistance using walker from bathroom when her knees became weak and CNA lowered the resident gently to the floor. Resident sat on her bottom when the nurse entered the room. No injuries observed and resident able to move all extremities without pain or discomfort m. On 2/10/23 at 6:37 PM, a new intervention put into place for physical therapy evaluation. n. On 2/11/23 1:41 PM, resident seen in the ED during 7 AM - 7 PM shift. X-ray confirmed the resident had a fracture to the left lower extremity distal fibula. Orders include a CAM boot at all times except for skin and circulation checks each shift, and non-weight bearing status to LLE. o. On 2/16/23 at 4:06 PM, hospital called facility with pre-op instructions. Nothing to eat or drink after midnight and arrive at the hospital ED entrance on 2/17/23 at 5:30 AM. Surgery for an ORIF (open reduction and internal fixation) on the left ankle with plates and screws scheduled. A facility investigation file revealed the following: a. On 2/9/23 at approximately 10:58 PM, Staff A, Registered Nurse, was summoned to the resident's room by Staff B, certified nursing assistant. Resident sat on her buttocks in the bathroom doorway. Staff B stated she attempted to ambulate from the bathroom to her bed when the resident's knees became weak, and bilateral lower extremities criss-crossed. Staff B gently lowered the resident to the floor. Staff A reported she assessed the resident while on the floor. The resident denied pain. Range of motion (ROM) within normal limits and vital signs stable. Two staff assisted the resident back to bed. On 2/10/23 at approximately 8:00 AM, the day shift CNA notified the nurse the resident complained of pain and tenderness to her LLE. The nurse assessed the area and observed area swollen and had discoloration. Physician notified and order received for x-ray. Portable x-ray obtained at 1:36 PM. X-ray results received at 3:30 PM and revealed a probable fracture to the left distal fibula. Nurse practitioner notified of results and ordered to send the resident to the hospital. EMS contacted but upon arrival EMS refused to transport the resident because resident's condition not an emergency and resident in stable condition. Non-emergent transportation services contacted but not able to transport the resident, but agreed to transport the resident to the ED the following AM (on 2/11/23). ARNP and family aware. An addendum added on 2/11/23 revealed the resident sent to the ED by ambulance. At approximately 12:00 PM, call received from the hospital nurse that the resident had a nondisplaced fibula ankle fracture. Resident had a previous fracture to the LLE on 8/19/22 resulting in two fractures to the left ankle. New orders to follow up with orthopedic physician, wear a CAM boot to LLE at all times, and non-weight bearing status to LLE. DIA report submitted on-line. b. An undated written statement by Staff A revealed Staff B called Staff A into the residents bathroom. Staff B stated she transferred the resident from the bathroom. The resident became weak and began to fall. Staff B stated she gently lowered the resident to the floor onto her bottom. Resident assessed for injuries. The resident had no non-verbal signs or symptoms of pain or discomfort and moved all extremities. Resident assisted from the floor by Staff A and Staff B without difficulty, and the resident ambulated with a walker and assistance of one to bed. c. An Incident Report dated 2/9/23 revealed a CNA called the nurse into the residents room. The CNA reported she transferred the resident from the bathroom. The resident became weak and she gently lowered her to the floor. Resident assessed for injuries, and able to move all extremities. Resident assisted from the floor without difficulty, then used a walker and assistance of one back to bed. No injuries observed and no apparent unsafe condition observed. d. In a learning opportunity for employees provided to Staff A on 2/10/23 by the DON revealed on 2/9/23 resident fell in the bathroom. Nurse assessed the resident and then two staff assisted the resident up and ambulated the resident to bed without a gaitbelt. Facility policy after all falls, include resident assisted up with a mechanical lift and assistance of two staff. Staff A aware of policy but policy not followed. Staff A reported the bathroom very small, resident sat up and easily assisted to her feet. Staff education on 2/10/23 revealed: a. Anytime a resident had a fall, a mechanical lift used for assisting resident off the floor. It doesn't matter if the resident was independent, used a stand aid, EZ stand. Do not manually lift a resident off the floor. b. A gait belt must be used at all times whenever a resident ambulated or transferred. All residents had a gait belt in their room. Let the DON know if no gait belt in the resident's room. c. Always check the resident's Care Plan if not sure of their plan of care, or ask another staff member. Never transfer a resident without confirmation on transfer status. The education document was signed by Staff A and Staff B on 2/13/23. A Major Injury Determination Form dated 2/15/23 signed by the ARNP revealed incident causing injury of probable fracture to the resident's left distal fibula was confirmed by x-ray on 2/11/23. The x-ray showed a nondisplaced fibula ankle fracture. The resident required assistance of one staff and front wheeled walker for ambulation prior to the fall. The injury deemed as a major injury pursuant to IA Code. During observation on 5/1/23 at 9:40 AM, Staff G, CNA, and Staff H, CNA, used a mechanical hoyer lift and transferred the resident from a wheelchair to her bed. At 1:50 PM resident lying in bed on her back with bed in high position. At 2:50 PM resident lying in bed on her back. The resident's bed continued to be in a high position. In an interview 5/2/23 at 11:05 AM Staff A, RN, reported she worked at the facility until 2/2023. Staff A stated an assessment completed to determine if a resident had any injuries whenever a resident had a fall. An Incident Report filled out, and information pertaining to the fall documented the EHR. Staff A reported she looked at the resident's Care Plan to know how the resident transferred and the number of staff needed for transfers. The CNA's looked at the Kardex in the EHR. The Kardex is a shortened version of the Care Plan and showed how a resident transferred and the number of staff needed for transfers. Staff A reported Resident #4 had a fall in 2/2023, and fractured her ankle. Staff A stated she was called to the resident's room. The resident was lying in the bathroom doorway. CNA ambulated resident to the bathroom using a walker and said the resident's left leg buckled under her. The CNA told her she lowered the resident to the floor. During an interview 5/2/23 at 12:45 PM, Staff C, RN and former DON, reported she worked at the facility for 3 years but left on 3/9/23. Staff C reported a head to toe assessment completed whenever a resident had a fall, then resident moved off the floor. Staff C acknowledged it was the facility's policy and procedure for staff to utilize a hoyer lift and two staff to move a resident after a fall. Staff C reported an incident report filled out under the risk management section in the EHR and the note in the incident report linked to the nursing Progress Notes. Staff C reported Resident #4 required assistance of one staff and used a walker for transfers and ambulation. After the resident had a fall with a fracture, she was non-weight bearing to lower extremity and needed a hoyer lift for transfers. On the day of the incident (2/9/23), Staff B, CNA, ambulated the resident to the bathroom. Staff B told her the resident legs got weak and criss-crossed, and the resident went down as she walked the resident with a walker back into her room. Staff B didn't use a gait belt when she ambulated the resident to the bathroom or on the way back to the room. Staff C reported a gait belt should be used for any resident that was ambulatory and required staff assistance. Staff C stated the nurse assessed Resident #4 after the fall but neither staff used a hoyer lift when they transferred the resident from the floor. Staff just got the resident up off the floor. The facility's policy required staff use a hoyer and two staff to transfer a resident after a fall. During an interview 5/2/23 at 2:55 PM, Staff D, CNA, reported she looked at the resident's Care Plan to know what cares were needed and how each resident transferred. Staff D reported a hoyer lift used to transfer a resident after the resident had a fall. During an interview 5/3/23 at 10:00 AM, Staff E, LPN, reported she worked at the facility 1/2023 - mid-2/2023. Staff E reported a resident assessment performed and neuro checks completed whenever a resident had a fall. Staff E stated she completed an assessment whenever a resident had a fall, then resident moved with a hoyer and two staff if the resident was able to be moved. Staff E reported during the time she worked at the facility, she spoke with staff who knew about the residents and winged it to know how to transfer a resident and the number of staff required. The facility had no papers to show if a resident required 1 or 2 staff assistance. The DON told her the resident status changed all of the time and she didn't have time to update a pocket care plan or similar type of cheat sheet. Staff E reported the facility was short staffed and several residents required assistance of at least two staff for transfers. During an interview 5/3/23 at 10:50 AM Staff I, LPN, reported she worked the 6 AM - 6 PM shift the day after Resident #4 had fallen in the night. During shift report it was reported the CNA had to lower the resident to the floor during the night but the resident had no injuries. Around 6:30 AM, after report, the resident complained of her foot hurting. The foot/ankle was purple and really swollen, so she requested an x-ray. She called an ambulance but when the ambulance showed up, emergency medical services (EMS) staff said it wasn't an emergency, and since they were short-staffed, EMS wouldn't transport the resident to the hospital. She called a non-emergency transport but they couldn't transport the resident either so they sent the resident to the hospital the next day. Resident able to tell you want she wanted or needed, but not fully cognitive. The resident could stand /pivot / transfer or use EZ stand prior to fall. It depended on the day and her strength. She used an EZ stand and 2 staff for transfers, then had to use hoyer after she had a fracture. When she fell , she doesn't think the CNA used the EZ stand because she was told the resident was lowered to the floor. Staff L stated the Kardex would state how a resident transferred and the number of staff needed for transfers and cares. During an interview 5/3/23 at 6:05 PM, Staff B, CNA, reported she worked at the facility 2 months from 2/6/23 to 4/3/23 on the 2-10 PM shift. Staff B reported her orientation at the facility entailed being shown around facility and how to use a hoyer and [NAME]-lift. The facility didn't explain when to use a gait belt or where gait belts kept. She asked other staff for a gait belt and someone would get a gait belt for her to use on a resident but nobody told her where to get a gait belt if she needed one. The gait belts weren't kept in every resident room until after an incident occurred with a resident falling. Staff B stated staffing at the facility was horrible. Staff B stated the facility often had 3 CNA's working in 2 halls when she worked. Lilac and [NAME] halls were the busiest and most of the residents needed two staff assistance for transfers and cares. There were a couple of times she had to use one person because it was so busy and nobody was able to assist her. Staff B stated on the day Resident #4 fell it was the first time she had worked on the hall where the resident resided, and she worked with a brand new agency nurse and another agency CNA. It was the first time the other agency CNA had worked at the facility. Staff B reported the day shift CNA told her the resident used a walker and didn't have to wear oxygen when she took the resident to the bathroom because the oxygen tubing was a tripping hazard. On the day the resident fell , she assisted the resident to the bathroom. The resident ambulated well to the bathroom. After she changed the resident into pajamas and cleaned the resident up, the resident seemed shaky so she asked the resident if she needed to sit down. The resident ambulated fine but then her leg buckled and her legs criss-crossed. It took 5-10 minutes to get someone to come help her after the resident fell . She believed the resident's oxygen level dropped and the resident went down. The cheat sheet provided by the day CNA showed this resident as a stand by assist and used a walker. Staff B reported she placed the cheat sheet into a shred box at the end of her shift. She didn't use a gait belt because she couldn't find one. She looked in the resident's drawer but no gait belt found. She asked the nurse but the nurse was new and didn't know if Resident #4 needed a gait belt. She didn't put a gait belt on the resident when she transferred or ambulated with the resident to or from the bathroom. During an interview 5/4/23 at 10:30 AM Staff J, CNA, reported gait belt use required if resident required staff assistance during transfers and/or ambulation. Gait belts hung behind the door in the resident rooms. The staff use to carry a gait belt but after COVID-19, gait belts kept in each resident room due to infection control reasons. Staff J reported she looked at the Kardex or asked staff that know how a resident transferred. Staff J reported Resident #4 ambulated by evening shift CNA from the bed to the bathroom and broke her ankle. The resident used a gait belt and walker for ambulation. After the resident fell and fractured her ankle, staff used a hoyer lift. A gait belt Policy revised 4/26/23 revealed gait belts used during an assisted ambulation unless medically contraindicated to safely stabilize a transfer and aid residents in maintaining balance. A fall prevention and management policy revised 3/29/23 revealed the facility had an obligation to provide the safest environment possible for residents trusted in their care. The purpose of a fall prevention program included to identify risk factors and implement interventions before a fall occurred. The proactive approach included communication about fall risks and interventions during 24 hour report, information placed on the Care Plan and Kardex, and discussion during a daily stand-up meeting. If a resident had a fall, the nurse must observe the resident and a full body exam completed to determine if any suspected injury, then direct the staff on whether to move the resident. A total lift used to transfer the resident off the floor when the resident had no suspected serious injury. 2. The MDS assessment dated [DATE] revealed Resident # 5 had impaired short-term and long-term memory. The MDS revealed the resident had diagnoses of Alzheimer's Disease, dementia, and anxiety disorder. The MDS revealed the resident required extensive assistance of two for bed mobility, and had total dependence on two staff for transfers and toilet use. The Care Plan revised on 2/24/23 revealed the resident had a risk for falls related to weakness and a recent history of falls. The resident also had an ADL self-care deficit related to unsteady gait and weakness. The staff directives included the following: a. Use a hoyer and assistance of two staff for transfers. b. Refer to physical therapy and occupational therapy as needed for weakness, c. Keep bed in low position (added 3/4/19) d. Place body pillow to outside edge of bed as boundary identifier (added 12/16/22) e. Instruct staff on proper usage of full mechanical lift (added 2/14/22) f. Body pillow to side of resident that is not against the wall (added 2/27/23) g. Fall mat in place next to the bed (added 2/27/23) An order summary revealed an order to transfer the resident to the hospital 2/24/23 and an order to cleanse the right eyebrow laceration and apply bacitracin twice a day for wound care. The Progress Notes revealed the following: a. On 12/7/22 at 4:03 PM, MDS review for resident with comorbidities of Alzheimer's dementia and anxiety. Dependent for hoyer lift transfers. b. On 12/16/22 at 1:13 PM, at approximately 6:05 AM, the CNA alerted nurse that resident lying on the floor. Resident observed lying on her back on the floor on top of her bed covers. Resident assessed but no injuries observed. Resident assisted back to bed using a mechanical lift and assistance of four staff. Neuro checks initiated. c. On 12/28/22 at 10:29 AM, IDT (interdisciplinary team) note indicated resident found on floor. Pillow to be placed for boundary identification. d. On 2/24/23 at 2:01 PM, Staff E, LPN, called to resident's room by the laundry aide. Resident's roommate stood at the doorway and reported she heard her roommate (Resident #5) fall out of bed. Upon entering the room, resident lying on her stomach parallel to her bed with her hands tucked up under her abdomen and her head turned to the left. A large pool of blood under the resident's head. Resident assisted onto her back by two staff ensuring resident's joints and neck protected due to concern for resident aspirating on her blood. The resident had a laceration above her right eyebrow, and right orbital bruised and swollen. ROM WNLs to all extremities. ROM was not attempted to neck due to facial injury. Physician contacted and ordered to send resident to the ED. e. On 2/24/23 at 6:16 PM, resident returned to facility via EMS. f. On 2/24/23 at 6:59 PM, staff educated on proper placement of body pillow. g. On 2/28/23 at 10:01 AM, IDT note, fall mat to be placed once available. h. On 3/1/23 at 2:31 PM, new wound care orders received for right brow laceration. Cleanse area with cleanser of choice and apply bacitracin twice a day. Incident Reports revealed the following: a. On 12/16/22 at 6:05 AM, resident found lying on the floor in her room. Resident lying on back on the floor on top of her bed covers. Resident assessed for injury. Full ROM ascertained and skin intact. Resident unable to verbalize what happened. Resident assisted back to bed using a mechanical lift and four assist. Neuro checks initiated. b. On 2/24/23 at 2:00 PM, nurse called to the resident's room by the laundry aide. The resident's roommate stood at the doorway and reported she heard her roommate (Resident #5) fall out of bed. Resident lying on her stomach parallel to the bed with her hands tucked up under her abdomen and her head turned to her left side. A large pool of blood observed under the resident's face. Resident assisted onto her back by two staff making sure to protect her joints and neck due to a concern the resident would aspirate on blood. The right eyebrow had a laceration and right orbital area bruised and swollen. Physician notified and ordered to send the resident to the ED. 911 called to transport the resident. Resident confused and incontinent at the time of the incident. During observations on 5/2/23 at 1:22 PM, resident observed lying in bed slightly on her left side. The resident's bed was in high position, no mat on floor by the bed, and no body pillow in place by the resident. At 1:23 PM, Staff D, CNA, denied putting Resident #5 in bed after lunch. Staff D entered the resident's room with the surveyor and reported concerns with the resident's bed left in high position, no mat on the floor by the bed, and no body pillow placed by edge of bed while the resident in bed. At 1:25 PM, Staff F, RN, entered Resident # 5s room with the surveyor. Staff D remained in the room with the resident. At the time, the surveyor advised Staff F of concerns related to Resident #5's bed left in high position, no mat on the floor by the bed, and no body pillow placed by the resident as directed in the resident's care plan. During an interview 4/27/23 at 6:50 PM, a family member reported the resident had a fall in 12/2022 without injury, and another fall in 2/2023. The resident was sent to the ED to get checked out because staff thought she had a concussion or a skull fracture. The resident's roommate told them the resident had slid out of bed. The resident had slid out of bed twice since 12/2022. The facility staff placed a mat by her bed, and got her a body pillow. During an interview 5/2/23 at 12:45 PM, Staff C, RN and former DON, reported she worked at the facility for 3 years but left on 3/9/23. Staff C reported she filled out a report to the DIA when the resident had bruising, and noticed the resident had fallen out of bed before but unsure what intervention put in place. The resident had a recent fall out of bed in 2/2023, so a fall mat placed and a body pillow implemented. During an interview on 5/2/23 at 1:27 PM, Staff K, CNA, reported she helped Staff L, CNA, put Resident #5 into bed after lunch on 5/2/23 but then she left the resident's room to go do something else. During an interview 5/2/23 at 1:30 PM, Staff F, RN, reported she expected staff lower the resident's bed into a low position whenever a resident lying in bed. Staff F reported even when staff had to leave Resident #5's room, they should've lowered the bed toward the floor, placed a fall mat on the floor by the bed, and put the body pillow in place, then return and change the resident when able. Staff F reported she expected staff follow the Care Plan and ensure interventions into place. During an interview 5/3/23 at 10:00 AM, Staff E, LPN, reported she worked at the facility 1/2023 - mid-2/2023. Staff E reported a housekeeper called her to Resident #5's room because the resident was on the floor. The resident's roommate yelled out Resident #5 had slid out of bed. She assessed the resident, then staff helped roll the resident onto her back while she supported her neck, and got her face out of the blood on the floor. The resident had two black eyes. She called the ambulance and sent the resident to the ED. Staff E reported she found out later the body pillow was not in place when the resident slid out of bed. At that time, a CNA trained a brand new CNA. The CNA had left the room and left the brand new CNA with the resident. The brand new CNA tucked the resident into bed but didn't know she needed to place the bed in low position or ensure a body pillow placed. Staff E reported the facility was short staffed. Staff E reported a resident assessment performed and neuro checks completed whenever a resident had a fall. Resident moved with a hoyer and two staff assistance if resident can be moved. Staff E reported during the time she worked at the facility, she spoke with other staff who knew about the residents and winged it to know how many staff required and how to transfer a resident. The facility had no papers to show if a resident required 1 or 2 staff assistance. During an interview, 5/3/23 at 6:05 PM, Staff B, CNA, reported she worked at the facility 2 months for 2/6 - 4/3/23 on the 2-10 PM shift. Staff B stated it's common sense to lower the bed whenever a resident lying in bed. If resident non-verbal and total care, the bed should be lowered after care provided. Staff B reported Resident #5 had a fall from her bed. Staff B reported she was aware a facility CNA trained a new CNA and didn't tell the new CNA she needed to place a mat on the floor and place a body pillow by the resident's side. During an interview 5/4/23 at 10:30 AM Staff J, CNA, reported a resident is a fall risk if the resident tried to climb out of bed or seemed really anxious. Staff J reported bed lowered to the ground after resident placed in bed, and a mat placed on the floor by the bed if care planned for a mat by the bed. Staff J reported resident # 5 had a fall recently when she fell out of bed. Staff J reported she wasn't working on the day the resident fell . But the resident would not be one to move around in bed on her own. During an interview 5/4/23 at 12:45 PM, Staff F, RN, reported a fall tool assessment filled out in the EHR to determine a resident's risk for falls and if the resident attempted to self transfer. Staff F reported fall interventions are individualized for residents.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and proper use of assistance devices to mitigate a resident's risk for elopement (when a resident leaves the facility without staff knowledge or permission). The facility failed to ensure kitchen doors remained securely locked at all times, failed to check a door alarm properly to ensure all residents are accounted for and failed to have policies and procedures in place to address what to do when responding to a door alarm. (Resident #3). These conditions constituted an Immediate Jeopardy to resident health and safety. The facility reported census was 86 residents. Findings include: According to the Minimum Data Set (MDS) assessment with assessment reference date of 7/14/20, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 1 indicating a severely impaired cognitive status. Resident #3 the resident walks independently with limited assistance and requires extensive assistance with dressing, toilet use and personal hygiene needs. Resident #3's [DIAGNOSES REDACTED]. Resident #3's plan of care indicates Resident #3 has potential for elopement related to dementia with interventions which include using a wander guard to alert and assist staff with resident's movements and whereabouts. Resident #3 is also at risk for falls related to loss of left eye and unsteady gait at times with interventions which include ensuring resident is wearing appropriate footwear and providing a safe environment. Incident report dated 9/19/20 at 4:05 p.m. indicated Resident #3 was found outside in parking lot. Wander guard in place. No injury noted. In an interview on 9/24/20 at 10:26 a.m. Staff A, cook, stated on Saturday 9/19/20 at around 3:00 p.m. she had left the kitchen to check on menus for each hall. As she was returning to the kitchen (3:21 p.m. per video), the walkie talkie alerted that a door alarm was sounding. Staff A stated the alert did not identify what door was sounding. As she got to the kitchen, she realized it was a kitchen door leading to the dock. Staff A stated she went to the door and coded it to exit, then looked outside, did not see anyone, cleared the alarm and returned to work. Staff A stated at around 4:05 p.m. she was in the dining room and saw a resident outside through the dining room window. At first she thought it may have been someone from assisted living, but then realized it was Resident #3. Staff A stated she paged for assistance and staff responded immediately and brought Resident #3 back inside. Staff A stated she has been employed since January 2018 and has viewed training video on elopement and clearing alarms, but did not realize she needed to initiate a resident head count when a door alarm sounds and there is no known reason. In an interview on 9/24/20 at 11:04 a.m. Staff B, certified nurse aide, stated on the afternoon on 9/19/20, she was walking toward the front entrance to go on break, when she heard over the walkie that a resident was outside. Staff B ran outside and found Resident #3 standing near the garage area. Resident #3 stated he was tired from walking and lowered himself onto the ground, laying down in the grass. Nurses were aware and responded promptly. Staff B stated they paged the nurses and requested a wheelchair. Resident #3 was assisted into a wheelchair and propelled back inside without any apparent injury. In an interview on 9/24/20 at 11:15 a.m. Staff C, certified nurse aide, stated on the afternoon on 9/19/20, she and Staff B were heading to the front door to go on break at around 4:05 p.m. when they heard over the walkie that Resident #3 was outside. They rushed outside to the resident. Resident #3 stated he was tired from walking so long and sat down in the grass. Nurses were on their way and they called for a wheelchair. Staff C stated Resident #3 was assisted into a wheelchair and brought inside. Staff C stated she did not see any injuries. Staff C stated Resident #3 frequently wanders the facility and has set off door alarms. In an interview on 9/28/20 at 12:23 p.m. Staff D, registered nurse, stated on the afternoon of 9/19/20, Resident #3 was restless and redirected per care plan with offering of a snack. Resident #3 was sitting at the nurse's station. Staff D stated the pharmacy had delivered medications and she was in the process of putting them away when she heard over the radio that Resident #3 was outside. Staff D stated she grabbed the transport chair and responded. Staff D stated Resident #3 indicated he was tired and was sitting in the grass. Staff D stated Resident #3 was assessed and found without injury and then brought back into the facility. Staff D stated since COVID there are fewer areas for Resident #3 to go to. Resident #3 used to go to the dining room for food, but she has never known him to go into the kitchen. Staff D stated standard protocol when door alarms sound are to determine who set the alarm off, check outside as needed and with no explanation as to the cause of the door alarm, staff are to conduct a resident head count. In an interview on 9/24/20 at 9:30 a.m. the Administrator stated on Saturday 9/19/20 she received a call reporting Resident #3 had eloped and was discovered outside. Resident #3 was escorted back into the building and found without injury. Resident #3 was immediately place on 15 minute checks. The Administrator stated she was in Des Moines and did not arrive at the facility until after 6:00 p.m. The Administrator stated she gathered statements and reviewed the facility video. The video indicated at 3:00 p.m. Resident #3 is observed entering the dining room through closed doors and walks into the kitchen. There is no camera view of the kitchen exit door onto the dock. The Administrator stated Staff A reported she was not in the kitchen when the door alarmed, but when she returned at 3:21 p.m. according to video, she responded to the door, looked outside, did not see anyone and cleared the alarm. Staff A reported at around 4:05 p.m. she was in the dining room and saw Resident #3 outside through the dining room window and paged for assistance. The Administrator stated staff education on proper door alarm response was initiated that evening and everyone but two staff were re-educated by 9/22/20, and the 2 staff that weren't will be educated before they are working with residents. Kitchen staff were instructed to keep the kitchen door closed and locked when no one was in the kitchen and signs were posted with those instruction. Stop signs were also placed on the kitchen and exit doors. On Sunday 9/20/20 the kitchen door was adjusted to lock automatically when closed and on Monday 9/21/20 the interior kitchen door had a coded lock installed. The Administrator stated elopement drills are conducted monthly. Review of facilities Elopement and Alarms: Bed, Chair and Door policy and procedures found no instructions related to what to do when responding to a door alarm. Review of Elopement Education 9/19/20 provided by Administrator on door alarm response education directed: If a door alarm is sounding, the door must be checked immediately. You must ensure that a resident did not go out the door unseen. If an alarm is sounding, you need to check the area of the sounding alarm and check outside. You must immediately initiate a resident head count and all missing residents must be searched for until found. DO NOT clear or silence the door alarm without locating the reason the alarm is sounding. The facility was notified of the IJ on 9/25/20, although the facility was cited for past non-compliance because the facility had abated the IJ effective 9/22/20 prior to the surveyor's site visit to investigate the elopement. The facility abated the IJ by taking the following actions: 1. Educated all staff by 9/22/20. 2. Resident #3 placed on 15 minute checks on 9/19/20 3. The kitchen door was adjusted to lock automatically when closed on 9/20/20. 4. The interior kitchen door had a coded lock installed on 9/21/20. 5. The facility will continue to conduct elopement drills monthly.

Based on record review and staff interview the facility failed to ensure residents are free of any significant medication errors for 1 resident, (Resident #1). The facility reported census was 85 residents. Findings include: According to the Minimum Data Set assessment tool with assessment reference date of 12/8/18, Resident #1 was admitted [DATE] and had not yet had a cognitive status completed, but was noted as cognitively alert. Resident #1 required limited assistance with transfers, ambulation, dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. In an interview on 12/18/19 at 3:09 p.m., Staff B, Registered Nurse, stated on the morning of 12/18/19 she was assigned to an unfamiliar hall, but proceeded with her duties which included medication administration. Staff B stated that morning she was dealing with a resident family issue. An aide approached her stating the resident in room [ROOM NUMBER] (Resident #3) was wanting his morning medications. Staff B stated she pulled up Resident #3's Medication Administration Record [REDACTED]. Upon returning the resident from room [ROOM NUMBER] (Resident #1) entered the dining room area. Staff B stated she knew the Resident #1, but had gotten confused with the room numbers and proceeded to punch out the pills belonging to Resident #3, which she had previously brought up on her computer. Staff B stated she approached Resident #1 and asked his name and Resident #1 confirmed he was who she thought he was. When given the cup of pills, Resident #1 made the comment that there was too many pills. Staff B stated she felt certain the pills were Resident #1's, but offerred to re-check. Resident #1 stated that was okay and took the medications. Staff B returned to the medication cart to sign off the medications were given and then noticed her error. The medications given to Resident #1 belonged to Resident #3. Staff B immediately sought out her supervisor, reported the error and contacted the physician. Staff B stated Resident #1 was frequently checked and at 9:33 a.m. was discovered in his room diaphoretic and non-responsive. 911 was called and Resident #1 was sent to the hospital. Staff B was remorseful for making the error and accepted responsibility for not double checking the resident's identity. According to Resident #3's (MONTH) Medication Administration Record [REDACTED] Abiraterone Acetate 1000 milligrams for malignant neoplasm of prostate Chlortialidone 25 milligrams for hypertension [MEDICATION NAME] capsule 1000 units supplement Duloxetine HCL capsule 30 milligrams for depression Losartan Potassium tablet 100 milligrams for hypertension [MEDICATION NAME] HCL capsule 5 milligrams for hypertension [MEDICATION NAME] tablet 1000 milligrams for pain Calcium [MEDICATION NAME] tablet 600 milligrams supplement [MEDICATION NAME] capsule 600 milligrams for [MEDICAL CONDITION] [MEDICATION NAME] tablet 50 milligrams for hypertension [MEDICATION NAME] tablet 5 milligrams for malignant neoplasm of prostate Senna Plus tablet 8.6-50 milligrams for constipation Progress Notes dated 12/8/19 written by Staff B indicate: 7:15 a.m. medication error occured. 7:20 a.m. Staff B notified nursing manager who directs Staff B to monitor resident every 2 hours and contact physician. 7:25 a.m. Physician notified. Attempted to provide details of error. Physician directed Staff B to just observe. 7:30 a.m. Initial vital signs taken. Temperature 97.6, oxygen saturation level 96%, heart rate 61, respirations 16 and blood pressure 130/72. Resident #1 continued to eat breakfast in dining room. 8:00 a.m. Resident returned to room, requested assistance to restroom. 8:10 a.m Resident #1 used restroom call light requested toilet paper. 8:15 a.m. Resident #1 self transfered and requested to sit in chair. 8:20 a.m. Resident #1 complained to aide that it felt chilly in his room. Room temperature adjusted. 8:25 a.m. Resident #1 still complained of room being chilly. Blankets provided. 8:55 a.m. Staff B applied [MEDICATION NAME] to back of neck. Resident denied current needs. Between 8:30 a.m. and 9:20 a.m. Resident #1 was seen intermittently, non-productive cough while sitting in chair. 9:33 a.m. Staff B entered Resident #1's room to re-assess. Resident #1 was diaphoretic, non-responsive. Sternal rub applied, no response. Temperature 95.8, oxygen saturation level 85%, heart rate 49, respirations 12 and blood pressure 72/48, pupils sluggish response. Resident #1 continued unresponsiveness. Nurse supervisor paged. 9:40 a.m. Assistance provided by nursing staff. Blood sugar 187, respirations 6 and blood pressure 50/30. Sternal rub applied, request Resident #1 opens his eyes. Resident #1 responded, I am. EMS arrived.

Based on observation, record review and staff interview, the facility failed to prevent pressure ulcers and provide complete documentation of the assessment of new pressure ulcers and failed to update the resident's care plan for four of six residents identified with pressure ulcers (Residents #22, #41, #56 and #60). The facility reported a census of 72 residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] listed [DIAGNOSES REDACTED]. The assessment documented she had a BIMS (brief interview for mental status) score of 15. The MDS recorded he required the assistance of one staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The assessment documented the resident at risk for developing pressure ulcers but without current unhealed ulcers. The assessment documented placement of a pressure reducing device on the bed and the chair. The MDS assessment defines pressure ulcer staging as follows: Stage 1 pressure ulcer: An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage 2 pressure ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage 3 pressure ulcer: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4 pressure ulcer: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and tunneling also may be associated with stage 4 pressure ulcers. The resident's care plan showed a focus area for potential for pressure ulcer development related to diabetes and obesity beginning on 5/30/17 and the goal she would have intact skin free of pressure sores. Interventions dated 5/30/17 directed staff to encourage the use of an assist bar to avoid shearing of the skin, provide a pressure relieving mattress for the bed, and to notify the nurse immediately of any new areas of skin breakdown. The care plan did not include a pressure relieving intervention for the resident's recliner or electric wheelchair and lacked any further interventions to prevent the development of pressure ulcers or to treat existing pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, dated 12/5/18 documented a mild risk for pressure ulcer development. The 2/21/19 Wound RN (Registered Nurse) Assessment sheet recorded Resident #22 had a newly acquired pressure ulcer of the right buttock measuring 0.9 cm x 1.4 cm x 0.1 cm and described the wound with red granulation tissue with a scant amount of serous (transparent, watery) drainage. A 2/21/19 Nurse Practitioner's Wound Treatment Plan recorded the new wound to the resident's right buttock and offered that Resident #22 rarely slept in his bed and reported tenderness in the buttock. During an observation on 2/25/19 at 4:17 p.m., the resident sat in his recliner without a cushion. During observations on 2/26/19 at 7:25 a.m., 7:56 a.m. and 8:48 a.m. the resident sat in his electric wheelchair without a cushion. On 2/26/19 at 10:00 a.m., Staff G LPN measured an open area with a red wound bed on the resident's right buttocks as 1 x 1 cm. Staff G then applied [MEDICATION NAME] (an ointment used to treat skin irritation) to the area. After Staff G finished, the resident sat down in his electric wheelchair without a cushion present. During observations on 2/26/19 at 12:13 p.m. and 2/27/19 at 11:45 a.m., the resident sat in his electric wheelchair without a cushion. On 2/25/19 at 4:17 p.m., Resident #56 stated he had two big areas on his bottom and stated the facility would not allow him to have a cushion in his recliner or electric wheelchair due to safety concerns. He stated he rarely slept in bed and usually slept in the recliner. During an interview on 2/27/19 at 2:06 p.m., Staff D, the facility's Wound Care nurse, stated the resident had a Stage 3 open area on his buttocks and attributed it to moisture and pressure from his recliner which he slept in often. She stated the facility did not foresee the wound and he never had a cushion in his recliner but stated she thought he should have one. She stated they needed to figure out which kind of cushion would be safe for his recliner. On 2/27/19 at 3:47 p.m., the Director of Nursing (DON) stated the resident slept in his recliner. Therapy staff advised they could not place a cushion in the resident's recliner but was not sure if they discussed alternate types of cushions as a possibility. She stated she would want the cushion addressed more and this intervention should be on the care plan. Review of the Pressure Ulcers policy, revised 1/17, revealed the following instruction: Purpose: to provide appropriate assessment and prevention of pressure ulcers, as well as treatment when necessary Policy: Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to ensure that a resident entering the location without pressure sores does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents will receive appropriate assessments and services to promote and maintain skin integrity. If a resident's clinical condition makes compromise of skin integrity clinically unavoidable, this information will be documented in the medical record. 2. The MDS assessment dated [DATE] listed [DIAGNOSES REDACTED]. The resident had a BIMS score of 15. The resident required the assistance of one staff with eating and personal hygiene and the assistance of two staff with toilet use, bed mobility, dressing and transfers. The MDS recorded the resident at risk for the development of pressure ulcers and with one Stage 4 pressure ulcer. The assessment documented use of a pressure reducing device for the chair and bed. The Braden Scale for Predicting Pressure Sore Risk, dated 12/30/18, stated the resident as at moderate risk for the development of pressure ulcers and listed an applicable intervention of a pressure reduction support surface. A care plan focus area initiated on 10/13/15 recorded Resident #41 had actual/potential impairment to skin integrity related to malnutrition, immobility, and actual pressure sores both present and in the past with the goal to have no complications related to her wounds. The care plan recorded she required a pressure relieving /reducing mattress to protect her skin but no use of a pressure relieving device for the resident's electric wheelchair. During an observation on 2/25/19 at 3:55 p.m., the resident wheeled down the hallway in an electric wheelchair. During an observation on 2/27/19 at 10:49 a.m., Staff E RN measured an open area with a pink wound bed on the resident's coccyx (tailbone) as 5 cm x 4 cm. The 1/24/19 Wound RN Assessment recorded a newly acquired partial thickness wound to the coccyx measuring 4 cm x 0.7 cm x 0.2 cm and that staff inflated the resident's Roho (pressure relieving) cushion. On 1/31/19, the wound measured 2.2 cm x 0.5 cm x 0.1 cm. On 2/20/19, the wound measured 5 x 2.8 x 0.1 cm. Progress notes revealed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. The facility lacked documentation of wound measurements from 1/31/19 to 2/6/19 and from 2/12/19 to 2/20/19. During an interview on 2/26/19 at 8:17 a.m., the resident stated her Roho cushion recently deflated and she developed two new areas on her buttock. She stated a nurse discovered the deflated cushion. During an interview on 2/27/19 at 2:13 p.m., the Staff D stated when the resident developed the sacral wound, she did some investigation and found the resident's Roho cushion in her wheelchair deflated. She stated she had no idea how long it had been deflated and stated after the discovery, she instructed the staff to inspect the cushions on a regular basis. During an interview on 2/27/19 at 3:47 p.m., the DON stated the Roho deflation could have contributed to the resident's pressure ulcer development and stated she would expect the Roho to be on the care plan. 3. Resident #60's MDS quarterly assessment completed on 1/25/19 documented [DIAGNOSES REDACTED]. The assessment documented the resident with intact memory and cognition, as evidenced by a BIMS score of 15. Resident #60 required the assistance of two staff with all activities of daily living except locomotion off their living unit and with eating. The assessment and identified as high risk for developing pressure ulcers, with MASD and with pressure reducing devices to her chair and bed. The resident's care plan identified a focus for the potential for pressure ulcer development related to reduced mobility, thin fragile skin (initiated 10/17/17 and revised 2/26/19). An intervention instructed to float her heels as she would allow with an initiation date of 2/22/19. Another intervention instructed to provide a low air loss mattress on the bed and a pressure relieving cushion on the wheelchair; both initiated on 10/17/17. A review of the physician orders [REDACTED]. Health Status Notes documented the following information: a. 2/15/19 at 10:47 a.m. - Resident #60 had an area on her right heel, a blood blister. The area was not reddened and staff sent a fax (facsimile) to her doctor's office for treatment and notified her family. The note contained no measurement or assessment of open area or the surrounding skin. b. 2/15/19 at 1:18 p.m. - Resident #60 had a new order for skin prep for the right heel twice daily until healed; family notified. c. An entry dated 2/28/19 at 9:38 a.m. documented as a late entry for 2/15/19 identified the open area on the right heel measured 3 x 3.5 cm with brownish discoloration and without redness around the wound. The Wound RN assessment dated [DATE] identified the resident with an unstageable right heel pressure ulcer with a length of 2.0 cm, width of 3.8 cm and depth of 0.1 cm. The wound showed 100% [MEDICATION NAME] tissue, a dark fluid filled blister, the peri wound was intact and blanched well. The resident denied pain and staff notified the physician. A review of the Braden Scale assessments for Pressure Ulcer development dated 10/17/17 documented the resident had a score of 12 (18 or below identified a high risk for pressure ulcer development). On 2/27/19 at 9:28 a.m., Staff D stated Resident #60 had a pressure ulcer to her right heel with 100% black eschar to the right heel approximately measuring 2.5 cm by 3.0 cm. Interventions prior to the area opening up had been to reposition the resident and to float her heels with the blue heels up cushion. After the area opened up, staff added Prafo boots which she is supposed to wear at all times except for cares and bathing. Observation on 2/26/19 at 6:42 a.m. revealed Resident #60 slept in bed on her right side. The resident's heels had been floated on a cushion and both Prafo boots sat on a wheelchair at the foot of the bed. On 2/26/19 7:26 a.m. Staff B, CNA stood by the resident's bed, turned the resident to her right side revealing a quarter-sized necrotic area on the right heel. The resident did not wear Prafo boots. Staff B and Staff H, CNA provided incontinence cares and transferred the resident to the shower chair and then Staff B took the resident to give her a shower. On 2/26/19 at 9:22 a.m. the resident slept in her wheelchair. She wore gripper socks on both feet with a foot buddy on the wheelchair foot pedals. The resident did not wear Prafo boots and had no pillow underneath her heels. On 2/26/19 10:18 a.m. Staff D entered the resident's room, closed the door, raised the bed, placed dressing supplies in plastic cup (skin prep and NS) on top of over bed table and completed wound care as ordered. A cushion had been placed underneath the resident's calves. Staff I, CNA entered room and donned gloves, held up resident's right foot while Staff D completed the ordered wound treatment. Staff D reported the ulcer may have been caused by pressure from the foot pedals on wheelchair. Staff D and Staff I removed their gloves and used alcohol hand sanitizer. Staff I then placed socks on the resident's feet and a Prafo boot only to resident's right foot and left the other Prafo boot on top of the bed and did not apply to left foot. Heels up cushion remains underneath resident's calves. After Staff D left the room, Staff I lowered resident's bed and did not apply the Prafo boot to the resident's left foot before she left the room. During an interview on 2/27/19 8:52 a.m., Staff A, CNA reported the resident had a black spot to her right heel. Interventions in place before the pressure sore developed staff were to elevate her feet by putting a pillow underneath her leg. She did not have an air mattress. After the area opened up, the new interventions added included to place a heels up cushion underneath her legs, skin prep to the area and she now had an air mattress. Staff A thought that the ulcer may have been caused by not repositioning her often and not elevating her feet. In an interview on 2/27/19 9:04 a.m., Staff B, CNA reported the resident had a pressure sore on each heel. Prafo boots should be on her feet at all times. After the areas opened, staff put a heels up cushion underneath her calves. During an interview on 2/27/19 9:04 a.m., Staff B, CNA reported the resident had a blood blister to her right heel which we started doing treatments on it a few weeks ago. The interventions in place before she developed the pressure ulcer would be to elevate her feet on a pillow and the resident wears gripper socks. She did not know if the resident had to wear boots when she's up in the chair but staff should reposition her every two hours. New interventions added after the areas opened up included boots which she is supposed to wear when she's in bed. During an interview on 2/27/19 at 9:51 a.m., Staff E, RN, reported Resident #60 had an open area to her heel and she did not know which heel. Interventions in place before she developed the ulcer included use of an air mattress and to reposition her more often. She did have boots on at the time and they were flipped upside down. The resident needs to wear the boots all the time except during cares. New interventions added after she developed the ulcer included direction to the aides to document every two hours that they repositioned her and the placement of a heels up cushion. She thought the ulcer may have been caused by the pressure of sitting on the mattress. On 2/27/19 4:14 p.m., the DON reported she expected her nurses when documenting initial assessment on new pressure ulcers would be for LPNs (Licensed Practical Nurses) to chart in the nurse's progress notes with measurements, description of the wound, put an intervention in place immediately and notify the wound nurse so she can get her documentation done then assessments should be documented every 7 days or as changes are completed. 4. Resident #56's MDS quarterly assessment completed on 1/22/19 documented [DIAGNOSES REDACTED]. The assessment documented the resident to be cognitively intact with a BIMS (brief interview for mental status) score of 14 out of 15. Resident #56 required the assistance of one staff with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #56 did not walk during the assessment period and experienced frequent incontinence of urine and occasional incontinence of bowel. The MDS identified the resident at high risk for developing pressure ulcers. He did not have a current pressure ulcer and had moisture associated skin damage (MASD). A review of the 2/19 Medication Administration and Treatment Records revealed the following information: a. 2/8/19 - Keflex (an antibiotic) 500 mg (milligrams) one capsule three times a day for wound infection for 10 days. b. 2/9/19 - [MEDICATION NAME] wound/burn dressing paste, apply to posterior sacrum wound topically every day shift every other day for wound care. Cleanse (the wound) with normal saline, apply [MEDICATION NAME], cover with [MEDICATION NAME] or Duoderm (dressings) and discontinue on 2/15/19. c. 2/16/19 - Cleanse the resident's scrotum with cleanser of choice, apply Silver Alginate rope, change daily and prn (as needed) in the morning for wound and discontinue on 2/22/19 d. 2/23/19 - Cleanse with cleanser of choice, mix collagen powder with A & D ointment, apply daily and as needed in the morning for wound A review of the care plan with the last revision date of 7/3/18 identified the resident with the potential for pressure ulcer development related to impaired mobility (date initiated 7/2/18) with the following interventions: a. 7/2/18 - Encourage, assist, supervise with use of assist bar, trapeze bar, etc for the resident to assist with turning b. 7/2/18 - Provide a pressure relieving mattress for bed and a pressure relieving cushion on the wheelchair c. 7/2/18 - Notify the nurse immediately of any new areas of skin breakdown: redness blisters, bruises, discoloration, etc., noted during his bath or daily care. The Wound RN assessment dated [DATE] recorded Resident #56 had an abscess to his scrotum area which measured 0.8 cm (centimeters) long, 0.9 cm wide and 1.3 cm deep with 100% granulation tissue and a moderate amount of serous drainage. Induration with palpation (touching) measured approximately 2.5 cm in diameter peri (around) wound is clean dry and intact resident denied pain and no documentation as to when wound opened Health Status Notes documented the following information: a. 2/7/19 at 6:51 p.m. - Resident #56 had an area on the back of his scrotum. It is not red but tender to the touch. The area had dark discoloration with some drainage and was hard in surrounding (tissue). The nurse talked to the wound nurse to look tomorrow. Resident #56 denied pain except tenderness when touched. The note contained no documentation of measurements of area. b. 2/8/19 at 12:49 p.m. - Staff received new orders for Keflex 500 mg TID x 10 day for wound infection. The Wound RN assessment dated [DATE] documented an unknown area measuring 0.7 cm x 0.7 cm x 0.3 cm, with 100% granulation tissue and a moderate amount of serous drainage noted. The resident denied pain. During an interview on 2/27/19 8:52 a.m., Staff A, CNA/CMA (certified nursing assistant/certified medication aide) reported Resident #56 had a pressure ulcer on his scrotum which opened up at the end of January. He does have a cushion in the bed and did not have an air mattress. After the area opened, the doctor ordered a powder mixed with an ointment. In an interview on 2/27/19 9:04 a.m., Staff B, CNA reported she thought the resident had pressure ulcers to the left foot and to the gluteal area and could not recall when the areas opened up. During an interview on 2/27/19 at 9:13 a.m., Staff C, CNA reported she had not been aware the resident had any open areas. In an interview on 2/27/19 at 9:28 a.m., Staff D reported the resident had a wound to the scrotum and had a history of [REDACTED]. Staff D stated when a new pressure ulcer is identified, she would expect it to be added to the care plan within 24 hours, and the initial assessment should include the size, location, the appearance of the wound bed, color, odor pain, notify the doctor and any new orders for treatment. The nurses have the tendency to document in the progress note or wound data collection. Once identified, wounds should be measured weekly by Staff D every Thursday During an interview on 2/27/19 at 9:51 a.m., Staff E, RN reported Resident #56 had a pressure ulcer on his scrotum which opened up a month ago. Staff D sees the resident every week and the possible cause would be the resident had been incontinent of urine. When new pressure ulcers developed, all nurses have the capability to update the care plan and add it to the care plan within 24 hours. When nurses first identify a pressure ulcer, she would expect them to document location, what it looks like, drainage, treatment and typically they do not measure. In an interview on 2/27/19 at 4:14 p.m., the DON reported when nurses first identify a pressure ulcer she expected them to document measurements, a description of the wound, put an intervention in place immediately and notify the wound nurse so she can get her documentation done and then assessments should be documented every seven days or as changes are completed

Based on observation, clinical record review, and staff interview staff failed to maintain an environment free of potential accident hazards by not ensuring adequate nursing supervision for Resident #4 to prevent a fall with injury. The facility staff failed to provide additional interventions after falls to prevent further falls. The residents sample included 8 residents with a census of 88 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment with the reference date of 05/31/17 identified a BIMS (Brief Interview for Mental Status) of 10 which indicated moderate cognitive impairment. The MDS indicated the resident required extensive assistance of two plus staff for activities of daily living. The resident utilized a walker and or wheelchair for mobility. The MDS indicated the resident had not been steady and could only stabilize with staff assistance and demonstrated functional limitations on the lower extremities. Review of the resident's care plan initiated 5/17/17 indicated the resident to be at risk for falls related to recent imbalance and gait impairment, pain related to pelvic fracture and history of recent fall. The care plan instructed the staff to remind the resident to not bend over and ask for help when seen reaching for out of reach objects, move the resident to a room close to the nursing station and lessen the chance of falling, when the resident is seen bending down to pick up items, redirect to ask for assistance, provide body pillow when in bed, keep call light within reach at all times when resident is in room and instruct and remind resident to use the call light when needed, physical and occupational therapy as needed for gait, transfers, strengthen, endurance, etc An Incident report dated 05/22/17 at 9:23 p.m. Staff D, LPN (Licensed Practical Nurse) documented the CNA (Certified Nurse Assistant) called nurse to Cedar, stated the resident was on the floor in the bedroom. Staff D documented entering the resident's room and observed the resident lying on the floor next to the bed with his/her head at the head of the bed and feet at the foot of the bed. Staff D documented the resident as partially under the bed. The resident stated going to my sisters. Staff D documented the resident checked for injuries, none noted, able to move all extremities independently, bends legs at knees and straightens again. No shortening of legs, no rotation. Unclear if the resident hit head, no indication of such. Neuro checks initiated and within normal limits. Staff D documented a CNA and Staff D used the Hoyer lift to get the resident off the floor and back into bed. An Incident Report dated 05/29/17 at 6:18 p.m. Staff C, LPN documented the CNA notified her Resident #4 was on the floor. Resident #4 had been in the recliner five minutes prior, when the nurse entered the room the resident was lying down on the floor in front of the recliner. The resident was wearing tennis shoes, call light in reach. The resident stated that he/she knows needed to be in the facility but doesn't want to be there. An Incident report dated 06/2/17 at 5:30 p.m. documented the resident found on floor underneath side table in front of recliner laying on left side, hands and arms above face, crying. The resident stated she/he was trying to pick something up from the floor and fell . Staff B, LPN documented she assessed Resident #4 for injury, vital signs taken, neuro checks completed, and assisted off the floor with assistance of two. Staff B documented the alarm sounded and the resident had received a left shoulder abrasion. An Incident Report dated 06/23/17 at 4:24 p.m. documented the resident had been observed lying on left side on the floor between the bed and recliner. Head resting on base of the table. Resident alert to person, situation and time. Alarm was sounding per CNA and call light was clipped to the recliner. The resident stated he/she had gotten up to walk to the bed to get the call light. Staff A, LPN documented she assessed the resident's vital signs attempted to move the resident but the resident yelled out in pain. Pillow placed under the resident's head and call placed to physician to obtain order to send the resident to the hospital to be evaluated. Resident was kept comfortable and warm waiting for transport. The staff documented the alarm sounded. The Progress notes dated 06/23/17 at 8: 01 p.m. Staff A, documented she had been called to Cedar hall by the CNA and informed the resident had been found on floor, when entering the room Staff A noted the resident to be lying on the left side with head at night stand resting on bedside table base with feet extended toward the door. Staff A documented she had asked the resident if okay. The resident replied no, I am in pain The nurse asked where and the resident said my leg. Vital signs assessed and were within normal limits. Pain was 10/10. Staff A documented she and the CNA attempted to roll the resident to back to continue the assessment and the resident yelled out in pain with the slightest move. Staff A documented when palpating the left hip area the resident voiced it hurt. The CNA remained at the resident's side as Staff A called the physician to obtain an order to send the resident to the hospital. The staff called the family member/POA, left message, notified the director of nursing and administrator. The director of nursing came to the unit to assess the resident. A call placed to transportation and no ambulance available. Staff A documented she called 911 for transport to the hospital at 4:35 p.m. The family members arrived and the resident cried that he/she hurts. The family members expressed to the nurse that has to be in pain because the resident does not cry. The nurse documented she assured the family that the ambulance was on the way and resident would be assessed at the hospital. At 4:55 p.m. the ambulance not there so Staff A called 911 again and had been advised that they could not round up enough staff so called out to another city for assistance. At 5:15 p.m. another call had been placed to see when emergency transport was as the resident in pain. Staff A documented she had been told that they had been en route for fifteen minutes and should arrive shortly. The emergency team arrived and assessed Resident #4. The resident remained alert and answered questions about pain and what happened. The emergency staff then transported Resident #4 to the hospital at 5:45 p.m. At 10:54 p.m. Staff E, LPN documented she spoke to a nurse at the hospital and Resident #4 had been admitted to the hospital with [REDACTED]. An interview on 07/13/17 at 9:20 p.m. revealed the resident was asked if he/she remembered how he/she fractured the left hip and the resident stated he/she got up to get the call light and fell . The resident stated he/she thought the call light was on the bed. On 07/17/17 at 12:22 p.m. Staff E, LPN stated she had been working on Lilac and Daisy halls when the resident had fallen. She stated when she went to Cedar, the director of nursing (DON), the family and a CNA were all in the room and they were getting the resident ready to go to the hospital. She stated she heard later the resident had a fractured left hip. Staff E stated she had gone back to Cedar to find the DON and noted the resident had been lying on the floor between the chair and bed but does not recall what position the resident was in. She stated the resident appeared calm at that time. On 07/17/17 at 3:30 p.m. Staff A, LPN stated on 06/23/17 Resident #4 had just come back from therapy. The girls went to the resident's room and placed the resident into the recliner with the call light. Staff A, stated the resident told her that he/she had been trying to get the call light. Staff stated when she entered the room the resident had been lying on the floor with his/her head beside the bedside table and feet pointed toward the door. Staff A stated the resident could not move his/her left leg at all without pain and would not move at all when the family arrived. Staff A stated the alarm had been sounding because the CNA was across the hall in another resident's room and heard it sounding. Staff A stated she did not hear the alarm because the CNA had turned it off prior to her coming to the room. Staff A stated she called the emergency transport and sat with the resident until they arrived. She stated the DON informed Staff A the family called and notified them the resident had fractured the left hip. On 07/18/17 during the exit conference the facility administrator stated that the facility failed to have a fall prevention protocol but attempted to find the root cause of falls in the facility. The facility policy on Fall Prevention and Management with a revised date of 05/16 stated: Every Rehabilitation/skilled care location will have a prevention and management program. The staff were instructed to take a Proactive approach that required identification of a potential risk and taking steps to mitigate the risk before actual harm occurs. In a fall program, a proactive approach seeks to predict what might cause a resident to fall and what action can be taken to prevent it. The policy stated a Reactive approach requires identification of actual risk factors and taking steps to prevent the fall from occurring again.

Based on record review, review of facility policy/procedures and resident and staff interviews, the facility failed to provide adequate supervision and assistive device to insure against hazards during a transfer technique (Resident #1). The sample size consisted of 13 residents and the facility reported a census of 101 residents. Resident #1 returned to the facility following a hospitalization on [DATE]. The certified nursing assistant did not receive notice the resident required 2 people for transfers instead of 1. The resident transfered with 1 staff person and no gait belt per facility policy. The resident fell and obtained femur (thigh bone) fractures. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 8/9/16. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 or more staff for bed mobility, transfer, and toilet use. The MDS dated [DATE] indicated a resident discharge with anticipated return. The MDS identified the resident transferred with extensive assistance. Record review of the facility policy, Gait (Transfer) Belt dated 5/16, directed the staff to use a gait belt to safely stabilize a transfer and or for the ambulation of a resident. The Care Plan, initiated on 11/3/16 identified a focus area with activities of daily living self-care performance deficit due to chronic obstructive pulmonary disease (COPD) and activity intolerance. The interventions included and directed the staff to assist with transferring and toilet use of 1 staff person. Review of the resident Care Plan after his/her return from the hospital, due to a fall with a fracture, documented revision dates for 10/24/16. The resident Care Plan documented the resident as non-weight bearing. The Care Plan directed 2 facility staff to assist the resident with his/her transfer with a mechanical lift (Hoyer). Review of the Physician Order Summary form dated 10/1/16-10/31/16, documented as of 10/19/16; the resident identified as non-weight bearing and for the physical and occupational therapy departments to evaluate the resident's status. Record review of the Mobilization Support Data Collection Tool, Type Re-Admission, dated 10/7/16 at 5:58 p.m. completed by Staff H, Registered Nurse, documented about the transfer between surfaces: leg Strength as in a seated position a resident could place their hands on either side of the body and push off or rise off the surface 1 to 2 inches and able to sit back down. The assessment section for ambulation mobility documented the resident could take one step forward and one step back with supervision encouragement and or cueing that required assistive devices: the gait belt, and a walker. The record review of the Nursing Admit Re-Admit Data Collection dated 10/7/16 at 5:58 p.m. documented Resident #1 had been hospitalized [DATE] to 10/7/16, for [DIAGNOSES REDACTED]. Staff H, RN, documented Resident #1 used a walker and a wheelchair. The record documented Resident #1 required physical assistance of one staff for transfers and toilet assistance. The Progress Notes documented on 10/7/16 at 7:58 p.m. revealed a readmission progress note. The Progress Notes documented the resident's return to the facility's ICF level of care from the hospital. The Progress Notes dated 10/10/16 at 7:49 p.m. documented the resident's fall, notification to the physician and the resident's family and the resident's ambulance transfer to the emergency room for evaluation and treatment. Record review of the Progress Notes documented telephone notice to the facility of the resident's admission to the hospital for a fracture to the femur (the long upper leg bone). The Incident Report dated 10/10/16 at 7:30 p.m. indicated Staff G, (Licensed Practical Nurse) as the nurse on duty had been summoned to Resident's #1 room. The report indicated Staff G found the resident on the floor of his/her room. The report documented the fall occurred when Staff E, CNA (Certified Nursing Assistant) transferred the resident from his/her wheel chair to a recliner. The resident stated he/she heard a pop in their knee and expressed inability to move their right leg. Staff G, LPN notified the physician and family and the transferred the resident via ambulance to the hospital. Review of the hospital information identified the resident as inpatient on 10/10/16-10/19/16. The hospital records identified the resident had prior right knee and right hip replacements. The Discharge [DIAGNOSES REDACTED]. The Discharge Summary included instructions for physician follow-up in 2 weeks, instructions for the facility staff to complete incision care and to maintain a non-weight bearing to the right lower extremity. Review of the Physical Therapy-Therapist Progress and Updated Plan of Care dated 9/17/2016, documented directives for Resident #1 to complete transfers (sit to stand) with the staff as a standby assistance. Record review identified the Occupational Therapy Plan of Care (Evaluation Only) completed by Staff I, OT, dated 10/24/16, documented on 10/10/16, Resident #1 fell and sustained 2 right lower extremity fractures to the femur. The record documented the resident had been assist of 2 nursing staff prior to the fall. The record documented the resident as non-weight bearing on his/her return from the hospital and would require skilled occupational therapy and a restorative program to prevent decline in their function. On 10/24/16 at 2:45 p.m. with Staff E, CNA, described he/she cared for the residents in all areas of the facility. Staff E stated she was assigned to care for the needs of Resident #1 on 10/10/16, during the shift from 2:30 p.m.-11:00 p.m. shift. Staff E, stated she did not obtain report about her assigned residents from the staff member of the prior. Staff E stated on 10/10/16 she had not been informed of any change of transfer since return from the hospital. Staff E stated she became aware of the resident's transfer change after the incident (fall) on 10/10/16. Staff E stated Resident #1 had changed from a one person transfer to needing 2 staff members since return from the hospital on [DATE]. Staff E described Resident #1 prior to his/her fall, as a one person staff assist without a gait belt as he/she transferred their own way from the wheel chair to the recliner. Staff E then demonstrated and described how the resident positioned his/her wheelchair face to face to the recliner. The resident would push themselves to stand position and use his/her hands and feet to rotate (pivot) from one surface to another. Staff E described the occurrence on 10/10/16, after 7 p.m. Staff E stated she assisted Resident #1 to transfer from his/her wheelchair into the recliner. Staff E stated in the transfer from one surface to the other, the resident voiced he/she heard a pop. Staff E explained how she had a grip on the resident's waist band, and how she slid the resident's wheelchair out of the way to reach the resident. Staff E observed the resident lower themselves to the floor from the seat of the recliner. Staff E stated she called out for assistance from Staff F, CNA, located in the shared bathroom with another resident. Staff E stated she remained with the resident and Staff F, CNA retrieved the charge nurse Staff G, LPN. Staff G assessed the resident and then the resident was transferred to the hospital for an evaluation and treatment. Staff E admitted she recalled from orientation the resident care plan could be viewed in the kardex on the kiosk if needed. Staff E expressed her responsibility to ask questions of a resident's status or changes especially after a return to the facility from the hospital. Staff E expressed the need to check the resident ' s Care Plan to provide the expected care for the resident. Staff E, CNA expressed she felt the facility's communication system failed to keep the staff alerted to the resident ' s Care Plan changes. An interview with Staff G, LPN on 10/25/16 at 7 a.m. identified awareness that the resident Care Plan did not provide accurate information. Staff G stated the facility had a changeover to implement the Safe Handling Program. The facility had not implemented the program. Staff G described the resident's transfer prior to his/her 10/7/16 return from the hospital as a 1 to 2 staff assist, with the use of a gait belt. Staff G demonstrated and described the resident's transfer from one surface to another with the use of his/her hands and feet to pivot 180 degrees to a sit down position. Staff G stated she had the inability to recall and had no report as to the resident's current transfer status since his/her return from the hospital on [DATE]. Staff G stated the expectations for the PT/OT department was to evaluate the resident's abilities on their return from the hospital and then to inform the facility Unit Managers as to the resident's status. The Unit Managers then were responsible to communicate the instructions to the facility staff; generally in the kiosk communication tab. Staff G, explained if she did not know of the resident's status, then the resident would not be transferred and instead provided care in bed until provided directions. An interview on 10/25/16, at 7:40 a.m. Staff A, CNA, and Staff B, CNA described prior to his/her fracture the transfer technique used for the resident as a one staff person assistance. Both Staff A and Staff B described how the resident stood face to face with the recliner and grabbed the recliner arms and turned until he/she could sit on the seat of the recliner. Both staff identified the recliner served purpose as the resident's bed and chair. Staff A, and Staff B stated the Care Plan for the residents were found on the kardex of the kiosk. The staff had access to the Kiosk which staff had access to. Both Staff A and Staff B confirmed the general practice is to obtained a list of the resident ' s names they are responsible for and document pertinent information received verbally from the previous shift after rounds are completed. Both staff agreed the kardex would be available however generally the kardex would be used for documentation at the end of the shift. On 10/25/16 at 11 a.m. Resident #1 was interviewed and stated his/her ability to recall the fall was like it was yesterday. The resident explained how he/she would pull up close to the recliner, in front of it, grabbed the chair arms, stood and then turned feet and arms until he/she would be able to sit down. The resident related he/she was unable to recall if the lift recliner had been in an up position or not on that day or if there had been an incontinent soak pad in the seat. When asked about the use of a gait belt, the resident stated, I haven't used one of those in a long time. The resident stated he/she turned and heard a pop sound. The resident stated from that time, he/she lowered self from the arm and seat area of the recliner to the floor. On 10/25/16 at 1:30 p.m. Staff H, ADON (Assistant Director of Nursing) was interviewed and stated she completed the resident's Readmission Assessment for 10/7/16. Staff H stated she thought the resident required 2 staff persons for assistance with a gait belt and when returned from the hospital, the resident required the same after an assessment. The staff reviewed his/her documentation in the mobilization section of the readmission assessment. The documentation revealed he/she had documented the resident's transfer as a 1 staff assist with a gait belt. The staff identified the gait belt for a transfer would be an expected standard of care practice. Staff H, ADON, revealed no knowledge of Resident #1 refusal of the gait belt or his/her nonuse of one. On 10/25/16 at 2 p.m. Staff F, CNA was interviewed and stated prior to the hospitalization , she and other staff transferred the resident with 1 to 2 staff persons. Staff F stated the transfers were completed with a gait belt. Staff F stated that on 10/10/16, she had been with another resident in the shared bathroom and heard the call from Staff E for assistance. Staff F observed Resident #1 and summoned the nurse. Staff F stated the direct care workers were not always informed of the resident changes and the care needs. Staff F, CNA, revealed the staff could obtain resident information that would include care plan information from the kiosk, Kardex. Staff F stated the therapy department would put a notice of a resident ' s change of status on the nurse ' s desk or provide information verbally. Staff F stated the facility needed better communication and updated information on the Kardex in order for the resident to received proper care. Staff D, CMA (Certified Medical Assistant), was interviewed and stated the facility needed to update the kiosk kardex timely so the staff would have current updates. Staff D identified the CNA's need for an improved report of current resident status or updated changes. The MDS Coordinator was interviewed and stated the Care Plan dated 10/12/16, directed 2 staff to assist the resident as he/she stood and moved from one surface to another. The current Care Plan dated 10/19/16, informed the facility staff of the resident's return from the hospital. The Care Plan directed and informed the facility staff, the resident status as now not able to bear any weight. The Care Plan directed 2 staff would transfer the resident with a Hoyer lift. The MDS Coordinator revealed the facility Unit Managers, charge nurses(floor nurses), the Assistant Director of Nursing, the DON and him/her self could change, update a resident's care plan and implement interventions for the resident's needs to be met. The MDS Coordinator confirmed his/her expectation for the staff to use a gait belt around the resident ' s waist when transferred. The gait belt would be an expected standard of care practice. An interview with the Director of Nursing (DON) 10/24/16 at 12:45 p.m. confirmed Resident #1 returned from the hospitalization on [DATE], and the readmission assessment had been completed on 10/8/16. The review of the assessment documented the resident as an assist of 1 staff. The Care Plan for Resident's #1 was updated on 10/8/16, and provided directions for his/her care needs. The DON (Director of Nursing) identified a document dated 10/12/16, which directed staff to use one staff person for a transfer. The documentation did not direct staff to use a gait belt for the transfer. At 3:00 p.m. on 10/24/16, the DON, stated that Staff E had been informed of the transfer change for Resident #1 and the need for 2 person assistance with transfers. The DON stated Staff E should have been informed by the nursing staff of the change in transfer when the resident returned from the hospital. The DON, provided the PT documented and explained the physical therapy documentation worded the resident required guarded assistance. The DON compared the physical therapy words to nursing's minimal assistance of 1 staff. The DON stated the care sheets or guides were not used by staff because of the availability of the resident care needs on the kiosk kardex. The staff could obtain changes for resident's needs in the communication tab, or when report completed with the previous shift staff. The DON confirmed his/her expectations for the staff to use the gait belt for resident transfers. The DON provided documentation to validate his/her expectations for all resident rooms to have a gait belt available for the staff to use.

Based on record review, staff and resident interviews and observation, the facility failed to ensure residents are free from abuse (Residents #4, #5 and #6). The sample size consisted of 19 residents and the facility reported a census of 101 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 7/1/16. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS identified the resident required supervision when walking in room and needed assistance of one staff when walking in the hallways. The MDS documented the resident's BIMS (brief interview for mental status) score of 3. A score of 3 identified the resident had a severe cognitive impairment and no behaviors. The Care Plan, initiated on 12/15/2015, had a focus area identified as impaired cognitive function and thought processes related to dementia and difficulty making decisions. The Care Plan interventions directed the staff to be aware the resident needed supervision with all decision making and required the CCDI (Chronic Confusion Dementing Illness) unit for safety. 2. Resident #6 had a quarterly MDS assessment for with a reference date of 8/5/2016. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS identified the resident as independent for walking in room and needed supervision for walking in the hallways. The MDS also documented the resident ' s BIMS score of 8. A score of 8 identified the resident had a moderate cognitive impairment. The MDS identified the resident had verbal and physical behaviors 1 to 3 days of the assessment period. The resident would wander and reject care 1-3 days of the assessment period. The Care Plan initiated on 3/11/15 identified a focus area of impaired cognitive function and thought processes related to dementia. The Care Plan interventions directed staff to cue, reorient and supervise the resident as needed. The Progress Notes dated 8/27/16 at 5:25 p.m. identified an incident dated 8/27/16 at 9:45 a.m. The note indicated a CNA (certified nursing assistant) called for the nurse. When the nurse arrived, Staff D and Staff E (CNAs) informed Staff F, License Practical Nurse (LPN), they both had been in a different resident room, came out and heard Resident #4 yelling at Resident #6. The CNAs witnessed Resident #6 in Resident #4's doorway, down on one knee with one hand on Resident#4's bed and one hand on his/her own leg. The aides helped Resident #6 back to his/her wheelchair and separated both residents. On 9/20/16 at 10:50 a.m. Staff F (licensed practical nurse) was interviewed and stated she had not been in the unit at the time of the incident between Resident #4 and #6 but she had been paged to go to the unit. Staff F explained she performed an assessment on both residents and placed Resident #6 on 15 minute checks. Staff F stated she interviewed Resident #4. Resident #4 told Staff F that Resident #6 went to her roommate ' s bed. Resident #4 told Resident #6 that was not his/her bed. At that time, Resident #6 went over to Resident #4's bed. Resident #4 grabbed Resident #6 by the shirt and Resident #6 went down. On 9/20/16 at 1:07 p.m. Staff E (certified nursing assistant) was interviewed and described Resident #4 as very protective of his/her roommate. Staff E stated once at Resident #4's room, Resident #6 held on to Resident #4 ' s bed and down on one knee. Resident #6 replied to CNAs that Resident #4 pushed him/her. Resident #4 stated Resident #6 went to roommate's bed and she/he told Resident#6 that was not his/her bed. Then, Resident #6 tried to get into Resident #4's bed and Resident #4 grabbed Resident #6's shirt sleeve to redirect and Resident #6 went down. The CNAs called for the nurse to come to the unit. On 9/20/16 at 6:30 p.m. Staff D (certified nursing assistant) was interviewed and stated she and another CNA were in a different resident's room for about 15 minutes. The other resident required assistance of 2 staff persons and the two CNAs had been the only ones in the unit at that time. Staff D stated once they exited the other resident's room and started walking down the hall they heard an argument and found Resident #6 in Resident #4's room at the end of the bed and down on one knee. 3. Resident #5 had an annual MDS assessment with a reference date of 6/24/16. The MDS indicated the resident had [DIAGNOSES REDACTED]., anxiety and depression. The MDS identified the resident as independent with walking in the room and required supervision when walking in the hallways. The MDS indicated the resident had moderate cognitive problems for daily decision making skills in new situations. The Care Plan dated 6/26/15, included a focus area for impaired cognitive function and thought processes related to dementia. The Care Plan interventions directed the staff to engage resident in simple structured activities. An Incident report dated 8/28/16 indicated the CNA called for the nurse and related information that Resident #4 observed lying on the floor and Resident #5 in Resident #4's room. The CNA re-directed Resident #5 out of the room. Resident #4 stated that Resident #5 came into his/her room and pushed him/her and he/she fell and hit head. The report identified Resident #4 laid on the floor with head towards the window and feet toward the bed and next to the table. Resident #4 complained of hitting head. The report indicated the nurse ' s assessment and observation identified no redness, bruising or swelling. An observation on 9/20/16 at 8:00 a.m. identified Resident #5 walking down the hallway and passed his/her room. The resident walked into a room at the other end of the hallway. During an observation and interview on 9/21/16 at 10:30 a.m. Staff C, Certified Medication Aide (CMA) thought Resident #5 was in his/her room. Staff C went to Resident #5's room and not there. At that time, Staff C started to look for Resident #5 and found him/her asleep in a different room. During an interview on 9/20/16 at 1:07 p.m. with Staff E, CNA, acknowledged that along with Staff I, CNA they both went into Resident #4 ' s room. Resident #4 had been yelling and found him/her on the floor on back and head next to the night stand. Resident #4 claimed Resident #5 pushed him/her down. Staff E removed Resident #5 from the room and to his/her room. An interview on 9/21/16 at 10:45 a.m. with Staff I explained that her and another CNA were the only ones on the unit at the time. Staff I stated she had just returned from break and getting report from Staff E and then started walking down the hallway. The door to Resident #4 ' s room was shut and a male voice came from inside the room. Staff I then opened the door and found Resident #4 on the floor with Resident #5 in the room. Staff I stated there to be no one else in the unit and the other CNA had been in the dining room and came down to the resident's room. At that time Staff I had been able to remove Resident #5 from Resident #4's room and left to get a nurse to come to the unit. On 9/21/16 at 8:57 a.m. Staff G LPN was interviewed and stated she had been on a different hallway when the staff person from the unit came and got her. Staff G stated the CNA reported to her that Resident #4 was on the floor and upon entering the unit and Resident #4's room, she observed Resident #4 on the floor. Staff G explained that Resident #4 voiced Resident #5 pushed him/her down. Staff G stated she knew that Resident #5 went into other resident's rooms to lie down because he/she forgets which room belongs to him/her.

Based on clinical record review, family and staff interviews and facility policy, the facility failed to assess 3 of 3 sampled residents prior to hospitalization (Residents#6, #8). Based on observation, staff and family interview, and facility policy the facility failed to assess and implement interventions for a resident with skin concerns (Resident #14). The facility reported a current census of 114. Findings include: 1. Resident #8 had an MDS (Minimum Data Set) assessment with a reference date of 11/5/15. The MDS reflected the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which reflected cognitive impairment. The resident had no signs and symptoms of [MEDICAL CONDITION] and had [DIAGNOSES REDACTED]. The MDS reflected Resident #8 was frequently incontinent of bowel and bladder. The MDS identified the resident at risk of developing pressure ulcers; however no skin concerns were identified. The 11/5/15 MDS included a current weight of 117#. The Care Plan identified a self-care deficit and included interventions which included assistance of 1 staff for activities of daily living such as bathing, dressing, toilet use and transfer/ambulation. A Progress Note dated 11/5/15 at 3:52 p.m. revealed Resident #8 had two (2) runny/watery stools with yellow mucous and very foul odor during the shift. Progress Notes revealed Resident #8 had runny/watery stools on the following dates: 11/6/15 at 8:07 a.m., 11/6/15 at 10:16 a.m., 11/7/15 at 3:00 p.m., 11/8/15 at 10:15 a.m., 11/9/15 at 1:16 a.m., 11/9/15 at 7:45 a.m., 11/11/15 at 12:59 a.m., 11/13/15 at 1:18 a.m., and 11/15/15 at 10:41 a.m. A stool sample was obtained on 11/16/15 due to continuous loose stools. laboratory results dated [DATE] indicated Resident #8 tested positive for [MEDICAL CONDITION] toxin (c diff). The physician ordered [MEDICATION NAME], an antibiotic, is administered three times daily for 10 days. Progress Notes revealed Resident #8 continued with runny/watery stools on the following dates: 11/18/15 at 4:45 a.m., 11/18/15 at 9:08 p.m., and 11/19/15 at 1:55 p.m. On 11/20/15 the facility received a physician's orders [REDACTED]. The clinical record lacked evidence of a nursing assessment related to resident complaints of nausea/vomiting. According to the Medication Administration Record [REDACTED] Progress Notes dated 11/21/15 at 1:33 p.m. the physician ordered staff to administer intravenous (IV) fluids. The clinical record lacked evidence of a nursing assessment related to a hydration concern. Progress Notes dated 11/23/15 at 10:20 a.m. revealed facility nursing staff administered Val [MEDICATION NAME], an [MEDICAL CONDITION] medication used to treat Shingles, rather than [MEDICATION NAME] on 11/21/15 at 12:00 p.m., 11/21/15 at 5:00 p.m., 11/21/15 at 8:00 p.m., 11/22/15 at 8:00 a.m., 11/22/15 at 12:00 p.m., 11/22/15 at 5:00 p.m., and 11/22/15 at 8:00 p.m. The Progress Note indicated the pharmacy was notified and would send [MEDICATION NAME]. Progress Notes dated 11/23/15 at 12:07 p.m. indicated the pharmacy was unable to fill the physician's orders [REDACTED]. On 11/23/15 the physician assessed Resident #8 regarding [MEDICAL CONDITION] and the resident's refusal to eat. According to the physician's Resident Encounter Form, Resident #8 complained of nausea and vomiting while on [MEDICATION NAME], which was discontinued on 11/20/15, and [MEDICATION NAME] ordered for treatment of [REDACTED].#8 received intravenous (IV) fluids over the weekend to assist with hydration secondary to diarrhea and refusal to eat. Resident #8 reported he/she felt weak and tired. The physician assessed Resident #8 had poor skin turgor secondary to dehydration and noted the resident's oral cavity (mouth) was dry. The physician note assessed Resident #8's skin intact. The Resident Encounter Form included [DIAGNOSES REDACTED]. The physician ordered administration of additional IV fluids due to the medication error, and discontinued two medications related to dehydration. Resident #8's nursing progress notes lacked evidence of a nursing assessment related to the concerns identified on the 11/23/15 physician's visit. Progress Notes dated 11/24/15 at 10:33 p.m. revealed antibiotics for [MEDICAL CONDITION] loose stools continued. Resident #8's family members present during the application of ACE wraps (compression wraps) and noted untraceable decubs to bilateral heels dark purple in color with resident complaints of pain when touched. The Progress Note indicated the physician observed the site and determined the area occurred as a result of foot to foot contact. Staff and family members encouraged fluids; however the resident drinks very little. Resident #8's family member requested hospitalization and facility staff informed the family member the resident can receive antibiotics at the facility also. Progress Notes dated 11/24/15 at 10:44 p.m. identified a significant weight loss of 5% over 30 days, with a current weight of 112#. The response section of the note indicated the weight loss was a result of poor appetite. Progress Notes dated 11/25/15 at 2:26 p.m. revealed lab results received with physician orders [REDACTED]. Progress Notes dated 11/25/15 at 7:10 p.m. identified a significant weight loss of 5% over 30 days with a current weight of 110.5 (a 1.5# loss over one day). Progress Notes dated 11/25/15 at 7:27 p.m. revealed antibiotics continued and loose stools have declined in amount of times throughout the day. The same note indicated a significant weight loss was due to refusal to eat or drink. The Progress Note included assessment of Resident #8's left foot as [MEDICAL CONDITION] with scattered petechiae on the inner and outer foot. The nurse assessed the area blanched, and noted the resident grimaced when dorsiflex/plantar flexion of the foot. Progress Notes dated 11/27/15 at 2:23 p.m. revealed physician notification of Resident #8's left leg. The Progress Note included an order to transfer Resident #8 to the hospital for evaluation. On 12/22/15 at 1:25 p.m. Resident #8's family member stated at the time of admission to the facility Resident #8 was up and walking around, but declined and could no longer walk. The family member indicated when the infection was diagnosed and the resident required isolation he/she spent most of the time in the chair or bed. The family member stated that around 11/16/15 the resident no longer was able to go to the dining room. The family member stated Resident #8's ankles rested on the foot of his/her recliner because staff encourages him/her to elevate his/her feet due to the [MEDICAL CONDITION], which caused the heel ulcers. Then staff made the resident lay in bed and his/her legs rested on top of each other so he/she developed 2 huge blisters around his/her legs. The family member stated Resident #8 was hospitalized with [DIAGNOSES REDACTED]. The family member voiced concerns with the resident's elevated blood sugar upon hospital admission and stated it was 700. The family member was unable to recall the diabetic medication discontinued, however thought the facility would know to assess his/her blood sugar levels due to a [DIAGNOSES REDACTED]. When asked about the medication error, the family member stated the family was informed the medication mix up was just a different antibiotic. The family member stated concerns were brought to the Director of Nursing, who confirmed Resident #8's diabetic medication was discontinued. Resident #8's family member stated Resident #8 was hospitalized and later transferred to the hospice house for comfort cares. On 12/22/15 at 6:57 p.m. Staff L, registered nurse (RN), recalled Resident #8 had open/weepy lower extremities which required Kerlix wrap to help with [MEDICAL CONDITION] that started around the time of the order for [MEDICATION NAME]. Staff L recalled Resident #8 had a raw bottom related to [MEDICAL CONDITION]. Staff L stated Resident #8 did not like to call for assistance because he/she didn't want to bother staff, so staff would check and see if he/she had been incontinent and change as needed. On 12/10/15 at 1:43 p.m. Staff B, CNA/CMA, stated she initially noted Resident #8's loose stools when she provided toilet assistance to the resident during the facility's state survey. Staff B stated she immediately recognized the odor as [MEDICAL CONDITION] and reported to the nurse. Staff B stated nothing was done for the resident for approximately 1 week. The hospital admission History and Physical, dated 11/27/15, revealed upon hospital admission Resident #8's blood sugar was 700 (normal is less than or equal to 100). The resident was mildly hypotensive, and required IV solution. Physical examination of the resident noted blistering on the lower extremities, multiple eschars on the lower extremities with some minimal surrounding [DIAGNOSES REDACTED]. The physician noted ecchymosis on the left heel with early signs of skin breakdown and superficial sacral decubitus draining some serous fluid with surrounding [DIAGNOSES REDACTED]. The resident's white blood cell count was elevated.Admitting [DIAGNOSES REDACTED]. Resident #8's clinical record lacked evidence of a nursing assessment related to skin issues identified in the hospital History and Physical. The facility policy Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements, revised 12/15, included the following: a. A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. b. If a pressure ulcer is identified, the registered nurse should record the type of wound and the degree of tissue damage on the Wound RN Assessment UDA. The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. c. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. d. Notify the resident and/or family of the pressure ulcer, orders and planned interventions. e. When a pressure ulcer is present, daily monitoring, with accompanying documentation when a complication or change is identified and include and evaluation of the ulcer and status of dressing, surrounding tissue, and presence of possible complications 2. Resident #6 had an admission date of [DATE]. On 1/4/16 nursing staff reported Resident #6 had problems with his/her hemi [MEDICAL CONDITION]. Staff AA arrived at the facility, assessed the resident's stoma, and notified the physician. Resident #6 was transferred to the hospital. Staff AA verbalized concerns with the lack of nursing assessment prior to hospitalization . Staff AA stated hospital staff phoned and requested he meets with the wound nurse for ostomy education prior to Resident #6's return to the facility. Staff AA stated Resident #6's skin is a hot mess and hospital staff were uncomfortable sending Resident #6 back to the facility without assurance Staff AA would provide wound care. Staff AA stated nursing staff did not provide communication with any wound concerns for Resident #6 while he was in the facility prior to notification on 1/4/16. A Nursing Home to Hospital Transfer Form dated 1/4/16 indicated Resident #6 was transferred to the hospital for nausea and vomiting, and decreased intake per family request. A nursing progress note dated 1/4/16 at 4:43 a.m. included a narrative note which included family requested Resident #6 be transferred for evaluation and treatment related to nausea, vomiting and weakness and noted Resident #6 had not held solid food down for a couple of days. Review of nursing progress notes lacked evidence to indicate a nursing assessment of Resident #6's nausea, vomiting or decreased intake, and lacked evidence to include documentation of skin concerns identified by the facility nursing staff. On 1/6/16 at 8:15 a.m. Staff AA stated he needed to make a late entry for Resident #6's skin concerns because he got kicked out of the electronic health record while documenting. On 1/6/16 at 2:45 p.m. the interim DON stated she would review the clinical record for additional information regarding Resident #6 and his/her intake and skin. No additional information was provided prior to the completion of the survey. The facility policy titled Nursing Documentation Guidelines/Timelines, revision date 3/15, directed: When I change in condition is identified in a resident, the nurse will use the SBAR Communication form and Progress Note to collect the data prior to communicating with the medical provider. The SBAR is the progress note and does not require the information to be rewritten. 3. Resident #14 had an MDS (Minimum Data Set) assessment with a reference date of 11/18/15. The MDS reflected the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which reflected severe cognitive impairment. [DIAGNOSES REDACTED]. The MDS reflected Resident #14 required extensive assistance of 2 or more staff for activities of daily living such as bed mobility, transfer, and toilet use. Resident #14 had a fall with injury and 2 falls with no injury since admission to the facility on [DATE]. The MDS identified the resident at risk of developing pressure ulcers; however no skin concerns were identified. The Care Plan, dated 11/7/15 and revised on 11/11/15, identified Resident #14 did not ambulate, instead crawled from chair to bed, doorway and around the room with intervention to wear knee pads, arm sleeves and hipsters for protection when crawling on carpet to prevent skin injury. The Care Plan, dated 12/3/15 and revised on 12/3/15, identified Resident #14 as potential impairment for skin integrity related to akathisia as evidenced by crawling on the floor and increased fall risk. Interventions included keep the environment free of obstacles and items with sharp edges/corners when the resident is on the floor and follow MD orders for treatment of [REDACTED]. Observation on 12/10/15 at approximately 2:40 p.m. revealed Resident #14 lying on a carpeted area of the floor dressed in pajama pants and short sleeved t-shirt with padded sleeves on his/her forearms and socks. Resident #14 rolled in slow motion about the floor. Four (4) floor mats were positioned next to the bed. Staff observed the resident and stated that's just how (he/she) is and indicated he/she is always on the floor. Observation on 12/11/15 at 8:13 a.m. revealed Resident #14 lying on the carpeted portion of floor near the door calling help me. Resident #14 rolled about the floor, reaching up with his/her right hand in attempt to sit up as he/she called help me. Resident #14 briefly sat on his/her buttocks, then gently rolled onto his/her right side. The following skin concerns were observed: a. A triangular shaped red, moist wound on Resident #14's left elbow, b. A wound with a red dried wound base with 2 scabbed areas on Resident #14's right lateral knee, c. A linear scabbed area on Resident #14's right lateral calf, d. A reddened area on Resident #14's right hip. Staff W, CNA, confirmed the area and indicated the reddened area was probably where he/she was laying. Observation on 12/16/15 at 10:30 a.m. revealed Resident #14's right elbow with a callous like appearance. Approximately half of the wound was open and half with a dried red wound base. The surrounding tissue had a dark/gray/hardened appearance. Resident #14's daughter noted the area and stated Resident #14 has had [MEDICAL CONDITION] he/she spends most of the time on the floor which was concerning to my family. Resident #8's daughter then pointed to an area on his/her forehead with a raspberry type appearance and stated upon her arrival Resident #8 was on the carpeted area rather than the mat. Resident #8's daughter stated the resident climbed out of bed while hospitalized but did not spend time on the floor as now. The clinical record lacked evidence to indicate a nursing assessment of the skin concerns identified on observations above.

Based on clinical record review, staff interview and facility policy the facility failed to ensure interventions were implemented to promote healing and prevent new sores from developing for 3 of 4 sampled residents with pressure ulcers (Resident #9, #11 and #14) The facility reported a census of 114 residents of which 5 residents currently had skin concerns. Findings include: 1. Resident #11 had a Minimum Data Set (MDS) assessment with a reference date 12/7/15 identified the resident ' s BIMS (Brief Interview for Mental Status) was 7 of 15 which indicated cognitive impairment. Resident #11 required extensive assistance from 2 or more staff for mobility, transfer, dressing, toileting and hygiene. The MDS indicated resident had no pressure ulcers but at risk of developing pressure ulcers. The MDS identified Resident #11 with moisture associated skin damage. Observation on 1/5/16 at 12:45 p.m. revealed Resident #11 lying supine on an air mattress. Resident #11 was unable to accurately state the day, month or year. On 1/5/16 at 12:57 p.m. Resident #11's physician entered and assessed the pressure area which measured 8 cm x 2 cm (centimeters). The physician noted the following areas that tunneled: a. At the 7:00 position, an area tunneled approximately 1 cm b. At the 9:00 - 3:00 position tunneled approximately 2 cm, and c. At the 4:00 position tunneled approximately 1 cm Resident #11 complained of pain to the pressure area. The physician questioned if the resident was referred to the Wound Center/Wound Nurse, the unit manager responded no, rather staff nurses complete dressing changes as ordered and a weekly skin assessment was completed each week by unit managers. The unit manager stated Resident #11 was hospitalized after lab work identified elevated white blood cell count. Hospital discharge orders dated 10/29/15 revealed the resident's primary [DIAGNOSES REDACTED]. Discharge orders included daily dressing change to the pressure ulcer and an asterisk near the order, *make sure wound care nurse follows up with patient. The clinical record lacked evidence to indicate an assessment was completed by a wound care nurse. On 1/6/16 at approximately 10:45 a.m. Resident #11's spouse stated Resident #11 developed the bed sore at the facility. The resident's spouse stated Resident #11 likes to lie on his/her back and maneuvered around in bed until he/she is on lying on his/her back. Resident #11's spouse indicated while visiting the resident, 90% of the time he/she is on his/her back and added the air mattress was implemented after Resident #11 was hospitalized . Resident #11's spouse stated he/she was notified that the physician ordered a consult with the Wound Center. At the time of the interview, Resident #11 was lying on his/her back on an air mattress. Observation on 1/6/16 at approximately 7:00 a.m. revealed Resident #11 lying supine on his/her air mattress with his/her left leg slightly propped upon a pillow near the mid-thigh/knee. Resident #11 complained of nausea and pain in the abdominal right upper quadrant. An assessment was completed by the nurse at this time. Review of the skin sheets revealed the following: a. On 12/22/15 Resident #11's coccyx wound measured 3.7 x 0.9 x 0.3 cm with no tunneling identified. A physician's orders [REDACTED]. b. On 12/29/15 Resident #11's coccyx wound measured 3.9 x 1.0 x 0.4 cm with no tunneling identified. The Wound Data sheet noted a wound culture from the resident's hospitalization showed infection. c. Wound documentation on 1/3/16 and 1/4/16 lacked evidence of a wound measurement. On 1/5/16 at 3:30 p.m. the interim DON provided information that identified the pressure area was initially observed on 9/26/15, however no RN assessment was completed until the following Tuesday. The interim DON stated she would have expected an RN to assess when identified, and if on the weekend, the on call unit manager should have assessed the wound. The interim DON stated her facility has a wound nurse on staff, but was not aware of how this facility handled wound nurse referrals, and then confirmed no referral documentation or assessment was located. The facility policy Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements, revised 12/15, directed the following: When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified) should include the following: * An evaluation of the ulcer, if no dressing is present *An evaluation of the status of the dressing: if present * The status of the area surrounding the ulcer *The presence of possible complications, such as signs of increasing area or ulceration or soft tissue infection *Whether pain, if present, is being adequately controlled If the pressure ulcer is not determined to be clinically unavoidable, the ulcer should show signs of improvement within two to four weeks. The Pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment UDA and include measurements (length, width and depth), characteristics of the ulcer, and presence of pain and current treatments. 2. Resident #14 had an MDS (Minimum Data Set) assessment with a reference date of 11/18/15. The MDS reflected the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which reflected severe cognitive impairment. [DIAGNOSES REDACTED]. The MDS reflected Resident #14 required extensive assistance of 2 or more staff for activities of daily living such as bed mobility, transfer, and toilet use. Resident #14 had a fall with injury and 2 falls with no injury since admission to the facility on [DATE]. The MDS identified the resident at risk of developing pressure ulcers; however no skin concerns were identified. The Care Plan, dated 11/7/15 and revised on 11/11/15, identified Resident #14 did not ambulate, instead crawled from chair to bed, doorway and around the room with intervention to wear knee pads, arm sleeves and hipsters for protection when crawling on carpet to prevent skin injury. The Care Plan, dated 12/3/15 and revised on 12/3/15, identified Resident #14 as potential impairment for skin integrity related to akathisia as evidenced by crawling on the floor and increased fall risk. Interventions included keep the environment free of obstacles and items with sharp edges/corners when the resident is on the floor and follow MD orders for treatment of [REDACTED]. Observation on 12/10/15 at approximately 2:40 p.m. revealed Resident #14 lying on a carpeted area of the floor dressed in pajama pants and short sleeved t-shirt with padded sleeves on his/her forearms and socks. Resident #14 rolled in slow motion about the floor. Four (4) floor mats were positioned next to the bed. Staff observed the resident and stated that's just how (he/she) is and indicated he/she is always on the floor. Observation on 12/11/15 at 8:13 a.m. revealed Resident #14 lying on the carpeted portion of floor near the door calling help me. Resident #14 rolled about the floor, reaching up with his/her right hand in attempt to sit up as he/she called help me. Resident #14 briefly sat on his/her buttocks, then gently rolled onto his/her right side. The following skin concerns were observed: a. A triangular shaped red, moist wound on Resident #14's left elbow, b. A wound with a red dried wound base with 2 scabbed areas on Resident #14's right lateral knee, c. A linear scabbed area on Resident #14's right lateral calf, d. A reddened area on Resident #14's right hip. Staff W, CNA, confirmed the area and indicated the reddened area was probably where he/she was laying. Observation on 12/16/15 at 10:30 a.m. revealed Resident #14's right elbow with a callous like appearance. Approximately half of the wound was open and half with a dried red wound base. The surrounding tissue had a dark/gray/hardened appearance. Resident #14's daughter noted the area and stated Resident #14 has had [MEDICAL CONDITION] he/she spends most of the time on the floor which was concerning to my family. Resident #8's daughter then pointed to an area on his/her forehead with a raspberry type appearance and stated upon her arrival Resident #8 was on the carpeted area rather than the mat. Resident #8's daughter stated the resident climbed out of bed while hospitalized but did not spend time on the floor as now. The clinical record lacked evidence to indicate a nursing assessment of the skin concerns identified on observations above. 3. Resident #9 had a Minimum Data Set (MDS) assessment with a reference date 12/7/15 identified the resident ' s BIMS (Brief Interview for Mental Status) was 7 of 15 which indicated cognitive impairment. Resident #9 required extensive assistance from 2 or more staff for mobility, transfer, dressing, toileting and hygiene. The MDS indicated resident had no pressure ulcers but at risk of developing pressure ulcers. The MDS identified Resident # with moisture associated skin damage. The Care Plan dated 11/30/15, identified the problem ADL self-care performance deficit and directed: a. Staff turn the resident from side to side using one staff and total lift with large full body sling, and assist of 2 staff for mobility to move up in bed b. Allow resident preference to be in bed only during hours of sleep. He/she prefers to rest in his/her recliner during daytime hours. When in recliner prefers to be reclined with legs stretched out on leg rest. The Care Plan also identified Resident #9 at risk for impairment to skin integrity related to impaired mobility and directed: a. Staff assists with routine repositioning. b. Resident needs pressure relieving mattress. c. Avoid scratching and keep hands and body parts from excessive moisture and fingernails short. d. Elevate heels off bed. e. Follow physician orders [REDACTED]. On 1/5/16 at 1:25 p.m. Resident #9's spouse stated Resident #9 recently returned from the hospital with a heel wound acquired while hospitalized . Resident #9's spouse stated she noticed the purple area that was the approximate size of a quarter. Air boots were initiated while the resident was hospitalized for [REDACTED]. Observation of Resident #9 at this time revealed the resident resting in bed with his/her right knee resting on his/her left knee. The resident's spouse stated he/she had been in bed approximately 30 minutes. Resident #9's spouse stated usually air boots were utilized while he/she is in bed however they were not applied when he/she was positioned in bed after the noon meal. Resident #9's heel was exposed at this time by his/her spouse and revealed a dark purple circular area that measured approximately 1.5 - 2 inches in diameter. On 1/5/15 at 3:30 p.m. the interim Director of Nursing stated she would look for skin assessment sheets for the heel wound. She confirmed the Care Plan lacked evidence to indicate the heel ulcer and felt a dark purple area indicated deep tissue damage, and confirmed interventions should be implemented to protect the area from decline.

Based on clinical record review and staff interviews the facility failed to ensure resident safety for 4 of 6 sampled residents identified as fall risk (Residents #2, #4, #5, and #12). The facility reported a current census of 114. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had [DIAGNOSES REDACTED]. The resident had impaired cognitive ability with a BIMS (Brief Interview for Mental Status) score of 8 that indicated moderate cognitive impairment. Resident #2 required extensive assistance of 1 staff for locomotion, toileting, dressing and bathing, and limited assistance of 1 person for bed mobility, transfer, and hygiene. A balance during transitions and walking test identified the resident as not steady only to stabilize with staff assistance when moving from seated to standing, walking, turning around while walking, moving on and off the toilet and surface to surface transfers. The resident utilized a walker and wheelchair for mobility. The MDS revealed Resident #2 had falls prior to admission. Additionally, Resident #2 had a fall since his/her admission on [DATE]. The facility form titled Falls Tool; dated [DATE] identified Resident #2 as high risk for fall. Risk factors identified included one of more falls in the last 3 months, more than two medications, moderately impaired cognition, and dizziness/postural hypotension. Additional risk factors and interventions included observed impulsive/risk-taking behavior, restlessness, confusion, and poor memory. Review of the Care Plan, dated [DATE], identified Resident #2 at risk for falls related to weakness and previous falls. Interventions included but not limited to the following: a. Remind the resident not to bend over to pick up dropped items/encourage use of a grabber or request assistance. b. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility. c. Avoid clothing that is falls risk (i.e. too lose, slippery, etc.) d. Review and modify environmental hazards (i.e. tubing, electrical supply cords, etc.) that could cause or contribute to a fall. The same Care Plan identified Resident #2 had an activities of daily living (ADLs) deficit and directed staff to provide stand by assistance of one staff member for ambulation to the toilet, and personal hygiene. Incident Reports revealed the following: a. On [DATE] at 11:20 p.m. Resident #2 was found on the bathroom floor, and was incontinent of urine. The resident's call light was not on. Resident #2 stated he/she was trying to get to the toilet. The Incident Report identified the intervention implemented on [DATE] staff education for increased frequency of visual checks on routine rounds. The resident's Care Plan lacked evidence of an intervention immediately implemented to prevent falls. b. On [DATE] at 7:03 p.m. Resident #2 was found sitting beside the bathroom door. Resident #2 reported he/she fell during self -transfer. The Incident Report lacked evidence to indicate a new fall intervention immediately implemented to prevent falls. Resident #2's Care Plan revealed an intervention, created [DATE] and initiated [DATE], directed a pressure alarm utilized on the resident's bed and chair to alert staff to resident's movement and ensure appropriate footwear such as rubber soled shoes, gripper socks, etc. c On [DATE] at 12:30 a.m. Resident #2 was found sitting on the lower portion of his/her electric scooter. Resident #2 reported he/she attempted to reach an item under the bed. The Incident Report identified an intervention removal of the electric wheelchair and a room change for the resident to allow closer visualization of the resident in addition to routine rounds. d. On [DATE] at 3:20 p.m. staff responded to Resident #2 yelling from his/her room. Resident #2 was found sitting on the floor of his/her bathroom with socks on his/her feet. Resident #2 reported he/she self- transferred to the toilet and fell . The Incident Report lacked evidence to indicate a new fall intervention immediately implemented for fall prevention. A Care Plan intervention, created [DATE] and initiated [DATE], directed staff move Resident #2 to a room closer to the nurses station and the electric wheelchair to be sent home. e. On [DATE] at 11:25 a.m. staff responded to Resident #2's call for help and found the resident on the floor lying on his/her right side. Resident #2 was incontinent of bowel and bladder. Resident #2 reported he/she had to have a bowel movement. The resident sustained [REDACTED]. The Incident Report identified an intervention staff education provided regarding alarm placement and checking placement/function during routine rounds. The Care Plan lacked evidence of a new fall intervention implemented to prevent future falls. f. On [DATE] at 7:12 p.m. staff responded to Resident #2's verbal call for help and found Resident #2 on the floor in his/her bathroom. Staff noted a head injury which was bleeding. According to the Incident Report, a bandage was applied to the resident's head and oxygen applied. No additional information was documented on the Incident Report. Report failed to identify if alarms sounded. Staff interviews as follows: a. On [DATE] at 2:11 p.m. Staff E, registered nurse (RN), stated at approximately 6:00 p.m. change of shift, she provided report to Staff D, RN. Resident #2 was in his/her wheelchair and yelled for assistance. Staff E propelled him/her into his/her room and attempted to apply his/her oxygen. Resident #2 pulled the oxygen off and yelled that he/she had to go to the bathroom. Staff E stated she felt unsafe to transfer Resident #2 alone. The RN did not transfer Resident #2 and left him/her in the wheelchair because additional staff was not immediately present. Staff E turned Resident #2's call light on and returned to the nurse's station to complete report. Staff E was not aware Resident #2 required an alarm. At approximately 6:15 p.m. Staff E confirmed she heard Resident #2 yelling he/she had to go to the bathroom from his/her wheelchair and indicated the resident did not utilize the call light, instead yelled for assistance. Staff E stated at approximately 6:30 - 6:45 p.m. following report, she noted Resident #2 was no longer yelling. She administered another resident's medication. After the medication was administered, Staff E observed Resident #2's call light on. Upon entry to his/her room she observed Resident #2 on the toilet, alone, with his/her overalls down around his/her ankles. Resident #2 requested assistance off the toilet. Staff E stated no staff was present to assist, and left him/her on the toilet with his/her call light on and proceeded to pass medications. Staff E stated she thought the aides would see the call light on and provided transfers assistance. Staff E stated [DATE] was her 4th shift in the same unit, and confirmed she was aware Resident #2 had a fall history, however she felt there was no way 1:1 could be provided. Staff E admitted she probably should not have left Resident #2 alone on the toilet because she knew he/she was a fall risk. Staff E stated she did not hear an alarm sound, and did not observe an alarm in Resident #2's chair or wheelchair. Staff E stated Resident #2 did not have oxygen on, which probably resulted in increased confusion. Staff E learned Resident #2 had fallen and died after she returned from passing medications. She estimated the time frame was approximately 20 minutes from the time she last saw Resident #2 on the toilet to the time she observed the resident on the floor deceased . b. On [DATE] at 3:30 p.m. Staff F, certified nursing assistant (CNA), indicated she at approximately 7:00 p.m. observed Resident #2 when she took the dinner tray into his/her room. Upon entry to Resident #2's room, she observed Resident #2's wheelchair in the bathroom and Resident #2 on the toilet. Staff F noted the resident's bib overalls were around his/her ankles and he/she held a piece of toilet paper on his/her elbow. Resident #2 reported he/she picked a scab which caused bleeding. Staff F stated she did not observe an alarm and did not hear an alarm. Staff F stated she observed the call light string hanging near the toilet. Staff F left Resident #2 on the toilet, then provided dining assistance to a resident in his/her room down the hall. At approximately 7:30 p.m. Staff F returned to the floor and observed Resident #2 deceased on the floor. Staff F stated she was not aware Resident #2 required an alarm in his/her wheelchair but did observe an alarm in his/her recliner. c. On [DATE] at 2:24 p.m. Staff A, certified nursing assistant (CNA), stated between 6:45 p.m. and 7:00 p. m. she arrived to the unit. Upon entry to the unit Staff A heard a resident yelling. She was unable to recall or understand what the resident yelled. Staff A began reviewing resident information at the nurse's station, and then went into the med room to make copies. The nurse's station is directly across from Resident #2's room. At approximately 6:55 p.m. - 7:00 p.m. Staff AA, RN, directed Staff A check Resident #2 and see why he/she was hollering. Staff A stated upon entry to the room, she observed Resident #2 lying on the bathroom floor bleeding. Resident #2 was screaming however she was unable to make sense of what he/she was saying. Staff A immediately notified the Assistant Director of Nursing (ADON) and Staff AA, both at the nurse's station. The ADON reached Resident #2 first and directed Staff AA call 911. Staff A attempted to get the resident's blood pressure while the ADON assessed his/her head injury in attempt to determine the source of bleeding. Staff A stated his/her blood pressure was low but Resident #2 continued to yell, then began to turn blue. Staff A observed the oxygen tubing on the floor and applied it as the ADON did a sternal rub. Staff A stated Resident #2's respirations ceased after Staff AA called 911. Staff A confirmed knowledge Resident #2 had a fall history and required an alarm for safety, however no alarms were observed or heard at the time of Resident #2's fall. Staff A stated only agency staff were present for the evening shift, and no one admitted they provided transfer assistance and were unaware of how Resident #2 got on the toilet. d. On [DATE] at 1:45 p.m. Staff B, CNA/CMA (Certified Medication Assistant), stated she provided cares for Resident #2 and most of the time the resident utilized personal alarms while in bed, chair (recliner) and wheelchair. Staff B stated Resident #2 was moved to a room in closer proximity to the nurse's station for increased visualization and ability to hear him/her. Staff B stated if Resident #2 required assistance with toileting, he/she would 'holler out or sit in the doorway and wait for staff to provide transfer/toilet assistance. Staff B recalled at times Resident #2 was inpatient to toilet but if they assisted him/her before and after meals he/she would rest in the recliner. e. On [DATE] at 5:35 a.m. Staff C LPN (Licensed Practical Nurse), recalled Resident #2 had alarms because he/she would self- transfer. Staff C stated his/her alarm sounded at night when he/she sat at the edge of the bed and yelled help me, help me because he/she had to go to the bathroom. f. On [DATE] at 10:46 a.m. Staff K, RN, indicated awareness upon Resident #2's entry to the facility he/she was a high fall risk because he/she had falls at home. Staff K indicated frustration because it took 3 days to determine Resident #2 was able to use a call light. Staff K indicated the MDS nurse said the facility does not automatically implement personal alarms for residents at risk for falls. Resident #2 sustained a fall on [DATE] and Staff K advised the unit manager she felt Resident #2 should be placed in closer proximity to the nurse's station for closer supervision. Staff K stated Resident #2 refused to wear oxygen which caused hypoxia and increased confusion. Staff K stated she directed staff to offer toileting assistance to Resident #2 frequently offer toileting assistance with each encounter due to his/her complaints of urinary urgency however a toileting plan was not officially implemented. g. On [DATE] at 6:57 p.m. Staff L, RN, recalled Resident #2 noncompliant with his/her call light and frequently self -transferred. Staff L felt Resident #2 had increased strength upon admission, however around the time Resident #2 was moved to the room in closer proximity to the nurse's station his/her lower extremities became edematous and required Lasix. (Lasix is a diuretic medication which causes increased urination and urgency.) h. On [DATE] at 1:15 p.m. Staff AA, RN, stated at approximately 6:15 - 6:30 p.m. in the midst of providing cares to a resident, he heard Resident #2 yelling he/she had to pee. Staff AA stated three agency staff was in the unit at this time. After cares were completed, Staff AA and the ADON were at the nurse's station reviewing paperwork for a newly admitted resident. Staff AA continued to hear Resident #2 yelling and requested Staff A check him/her. Staff A entered and reported Resident #2 was on the floor bleeding all over. Staff AA and the ADON entered, and the ADON began to assess the resident. Staff AA stated Resident #2 repeated stated he/she had to pee. The ADON noted the bleeding was from an injury to the resident's head, verbalized neurological concerns and directed Staff AA call 911. Staff AA stated he left the resident's room, gathered supplies for the wound as he called 911. Upon return to the resident's room, he noted Resident #2 had had a drastic change as evidenced by muffled speech, which then became mumbled. Resident #2's mouth and extremities became cyanotic. Within approximately 3 minutes he/she went from mumbled speech to deceased . Staff AA stated he notified the Director of Nursing by phone. Staff AA reported the DON responded doesn ' t tell me that and advised no one move the resident's body until the paramedics arrived and take photos of the resident and environment. Staff AA confirmed Resident #2 had a fall history and required an alarm. Resident #2 could not ambulate without assistance, however indicated awareness he/she attempted to self -transfer. Staff AA stated he did not observe an alarm and did not hear an alarm sounding around the time of the fall. i. O [DATE] at 2:30 p.m. Staff M, CNA, indicated she heard Resident #2 call out hey for toileting assistance. The resident rarely utilized his/her call light, rather yelled loudly to request staff assistance. Staff M stated the resident's room was across from the nurse's station and that Resident #2 was easily heard calling for help. Staff M provided cares for Resident #2 on the day shift [DATE] and noted he/she was very confused. Staff M stated only agency/temporary staff was staffed for the evening shift. Staff M stated Resident #2 required personal alarms because he/she had so many falls and required assistance of one staff because he/she was unsteady for transfers. Staff M was directed by the Director of Nursing (DON) to hide it and make it look like he/she did not utilize alarms which was a big lie. j. On [DATE] at 8:40 a.m. the Assistant Director of Nursing (ADON) stated just before 7:00 p.m. Resident #2 was heard yelling and Staff AA requested Staff A check him/her. Staff A checked Resident #2 and reported he/she had fallen. The ADON stated Resident #2 was lying on the floor and bleeding from his/her head. The ADON stated Staff AA went to get supplies for the wound which appeared as a skin tear. The ADON stated almost instantly the resident's respirations became shallow, and then was gone. The ADON stated the resident was not moved until paramedics arrived. The ADON stated no staff present prior to the resident's fall admitted they provided transfer assistance to him/her. The ADON stated she did not hear an alarm sound and did not observe an alarm near Resident #2. The ADON stated she was newly hired and was not able to provide information regarding the resident's fall history. k. On [DATE] at 3:02 p.m. the Director of Nursing (DON) stated Staff AA or the ADON notified her that Resident #2 had fallen. The DON stated Resident #2 was in distress and collapsed and was deceased within minutes. The DON confirmed Resident #2 had fallen quite a bit and attempted to self- transfer. The DON stated no alarms were utilized for Resident #2 because they agitated him/her, so they moved him/her to a room closer to the nurse's station. The DON confirmed Resident #2 was a high fall risk however with every fall and intervention was implemented to help the resident. The DON stated staff was not required to remain with Resident #2 while in the bathroom because alarm were not utilized. The DON printed the resident's Care Plan, and confirmed an alarm was implemented following a fall. The DON then stated he/she should not have been left alone in the bathroom. Interview on [DATE] at 1:00 p.m. with the Medical Examiner revealed Resident #2 died and Emergency medical services identified a bandage area to Resident #2 ' s head. The Medical Examiner requested the funeral director notify for anything noticed out of the ordinary. 2. According to the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had [DIAGNOSES REDACTED]. The resident had impaired cognitive ability with a score of 11 on the BIMS (Brief Interview for Mental Status). Resident #4 had impaired vision. Resident #4 required extensive assistance of 2 or more staff for mobility, transfer, toilet use and personal hygiene. The resident was non-ambulatory and had impaired range of motion on one side of his/her upper and lower extremities. A balance during transitions and walking test identified the resident as not steady but able to stabilize without staff assistance when moving from seated to standing, moving on and off the toilet and surface to surface transfers. The MDS revealed Resident #1 had a fall with injury since his/her admission to the facility on [DATE]. The facility form titled Falls Tool; dated [DATE] identified Resident #4 as high risk for fall. Risk factors identified included mild psychological impairment (i.e. decreased judgment especially related to mobility), mildly impaired cognition, and a recent change in condition and/or medications affecting safe mobility. Resident #4's Care Plan, dated [DATE], identified Resident #4 had an activities of daily living (ADLs) deficit and identified the resident was non-ambulatory and unable to bear weight on his/her left side. The Care Plan directed 2 staff provide assistance to stand/pivot to the wheelchair and 2 staff assist with total lift to the toilet or commode. An Incident Report, dated [DATE] at 9:05 p.m., revealed staff reported she lowered Resident #4 to the floor during transfer in his/her bathroom. Resident #4 reported his/her leg gave out. Resident #4 initially complained of pain to his/her left leg and was transferred out of the bathroom by four staff. Resident #4 then complained of severe pain to his/her left knee. A History and Physical, dated [DATE], revealed Resident #4's leg became twisted during transfer and an audible crack was heard. Resident #4 reported he/she experienced immediate pain and was unable to bear any weight on the left leg. The History and Physical noted Resident #4 had not been able to walk since a stroke in 2011, however was able to bear weight. A CT revealed a comminuted, impacted fracture of the distal left femur with displacement and angulation. On [DATE] at 12:50 p.m. Resident #4 confirmed recollection of the fall. Resident #4 stated he/she held the towel rack while a new staff member provided assistance. Resident #4 informed the staff member his/her left leg was going to give out, and then went down. The resident stated only 1 staff person provided assistance at the time of his/her fall, but prior to the fall two staff provided transfer assistance. Resident #4 had a stroke and his/her left side gives out at times. Resident #4 stated he/she entered the facility on [DATE] and fell [DATE], one day after his/her birthday. The resident reported the physician said the fracture could not be surgically repaired because everything was crushed and the bone, wouldn't hold a screw. Resident #4 admitted he/she did not inform the staff member prior to transfer assistance that his/her left leg gives out because they knew he/she had a stroke. At the time of interview, Resident #4 correctly identified the current day, month/date and President. On [DATE] at 3:05 p.m. Staff R, CNA, confirmed she provided transfer assistance to Resident #4 at the time of the fall. Staff R stated she became a CNA in July, 2015 and that Resident #4's fall occurred on her first shift working independently as a CNA. Staff R stated she was not aware Resident #4 required 2 staff for assistance and that she had never seen a disc thing (referring to a pivot disc). Staff R stated after Resident #4 stood up from the toilet, she applied a gait belt. Staff R stood behind Resident #4 thought Resident #4 would place his/her foot on the pivot disc and instead went down onto the floor. Staff R stated she heard the resident's bone crack and that was the worst part of it, I can still picture it happen. Staff R stated Resident #4 was screaming in pain and it was terrible. Staff R stated she was too shaken up to provide assistance to Resident #4 after the fall. Staff R stated resident Care Plan information is on the Kardex and should be checked every day but she remembers specific resident information. Staff R indicated day shift (nurse or aide) report if a change is made on the resident's Care Plan. Staff R stated at first the DON said Resident #4 fell because he/she didn't have shoes on. Staff R indicated while on the toilet, Resident #4 complained of sore feet and requested his/her shoes be removed and she complied and removed his/her shoes prior to providing transfer assistance. On [DATE] at 4:53 p.m. Staff I, LPN, stated Staff R notified her Resident #4 was lowered to the floor after his/her leg gave out. Staff I stated Staff R was a new CNA. Staff R indicated at report she was directed Resident #4 utilized a pivot disc for transfer in the bathroom. Staff I stated upon review of Resident #4's Care Plan did not include a pivot disc be utilized, instead directed staff utilize a lift. Staff I provided education to Staff R regarding review of the Kardex at the beginning of her shift. 3. According to the Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had [DIAGNOSES REDACTED]. The resident had impaired cognitive impairment and was unable to complete the BIMS (Brief Interview for Mental Status). Resident #12 required extensive assistance of 1 staff for bed mobility, locomotion on the unit, and personal hygiene and extensive assistance of 2 staff for transfer, dressing, and toilet use. Resident #12 did not ambulate. A balance during transitions and walking test identified the resident as not steady only able to stabilize with staff assistance when moving from seated to standing, walking (with assistive device), moving on and off the toilet and surface to surface transfers. The MDS revealed Resident #12 did not have a fall since his/her assessment. Resident #12's Care Plan, dated [DATE] and revised on [DATE], identified a problem of self-care performance deficit and included, but not limited to, the following interventions: a. 2 staff assist transfer from lying to sitting and utilize a total lift with large full body sling, b. 2 staff assist transfer between surfaces as the resident can ' t pull self to stand c. The resident was non-ambulatory. The Care plan identified Resident #12 a problem of fall risk related to confusion and a history of falls, and gait/balance problems and directed staff to remind the resident not to bend over to pick up dropped items/lay baby down, and ensure appropriate footwear (non-skid socks/shoes/slippers) when up mobilizing in his/her wheelchair. An Incident Report dated [DATE] at 8:06 p.m. revealed Resident #12 leaned forward and fell forward out of his/her wheelchair as staff attempted to reposition the resident. On [DATE] at 1:20 p.m. Staff U, CNA/CMA, stated on the [DATE] evening shift she and Staff V were responsible to provide all cares and medications to the 17 residents in the locked dementia unit, and administer medications to the 12 residents who reside outside of the locked unit. Staff U stated, it was crazy. Staff U stated Resident #12 screamed for staff to assist him/her out of bed. Resident #12 was placed in his/her wheelchair in the television room. Staff U indicated Resident #12 leaned forward in his/her wheelchair and fell forward, out of his/her wheelchair. Staff U stated when the dementia unit is staff with 2 CNA/CMAs and responsible to assist residents and administer medications to residents, 1 staff has to leave the locked dementia unit to administer medications to the 12 residents outside the locked unit which leaves 1 staff member to supervise 18 residents in the locked dementia unit. Staff U indicated she felt that was an unsafe practice. During a follow up interview on [DATE] at 7:45 a.m., Staff U admitted she provided transfer assistance to Resident #12 alone because Staff V was at lunch break and Resident #12 attempted to self-transfer. Staff U confirmed knowledge Resident #12 required 2 staff to provide transfer assistance however was afraid Resident #12 would fall if she did not intervene and provide transfer assistance. On 1//16 at 1:34 p.m. Staff V, CNA/CMA, confirmed after 6:00 p.m. she and Staff U were responsible to provide cares and medications to residents in the locked dementia unit and administer medications to residents outside the dementia unit. Staff V stated when she returned from her break, she observed Resident #12 leaning forward in his/her wheelchair. Staff V stated she attempted to push Resident #12's wheelchair to Staff U to provide assistance and reposition him/her in his/her wheelchair. Staff V stated as she pushed the wheelchair Resident #12 put his/her feet down, leaned forward and fell forward out of the wheelchair onto the floor. Staff V admitted the wheelchair foot pedals must have been up along the side of the wheelchair legs when she pushed the wheelchair, and indicated awareness staffs are not to propel a resident in their wheelchair with foot pedals up. 4. According to the Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had [DIAGNOSES REDACTED]. The resident had no impaired cognitive impairment and scored 15 on the BIMS (Brief Interview for Mental Status). Resident #5 required supervision of 2 staff for bed mobility, and required extensive assistance of 1 staff for transfer, locomotion on and off the unit, and limited assistance of 1 staff for dressing, toilet use and personal hygiene. A balance during transitions and walking test identified the resident as not steady only able to stabilize with staff assistance when moving from seated to standing, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfers. The MDS revealed Resident #1 did not have a fall since his/her admission to the facility on [DATE]. Resident #5's Care Plan, dated [DATE], identified Resident #5 had an activities of daily living (ADLs) deficit and directed 1 staff provide assistance ambulate, bathe, dress, personal hygiene and transfer on and off the toilet. The Care Plan also identified Resident #5 at fall risk related to hemiparesis and obesity as evidenced by the need for assistance with transfers and directed staff to remind the resident not to bend over to pick up dropped items, remind him/her to ask for assistance and ensure appropriate footwear such as gripper socks or non-slip shoes when up. Observation on [DATE] at 8:03 a.m. revealed Resident #5 in his/her wheelchair near the public restroom. Resident #5 requested the surveyor unlock and open the public restroom door near the dining room so he/she could use the restroom. The surveyor advised Resident #5 she would inform nursing staff he/she requested assistance, and entered the dining room. Upon the surveyor's return to check Resident #5 observation revealed Staff S, payroll staff, unlocked the public restroom door for Resident #5 and Resident #5 propelled his/her wheelchair into the bathroom. Staff S stated she could not provide assistance because she was not nursing staff, however Resident #5 informed her he/she did not require staff assistance to toilet. Staff T, RN, approached Resident #5 and Staff S, observed Resident #5's name on his/her wheelchair then stated she thought Resident #5 could self -transfer. Upon review of Resident #5's MDS and Care Plan the interim DON confirmed Resident #5's Care Plan directed 1 staff provide assistance to toilet and stated she would remind Staff S about providing assistance to residents.

Based on record review, staff and physician interviews and review of facility policy/procedures, the facility failed to administer the correct medication as ordered by the physician to Resident #8 which resulted in a significant medication error. As a result of the significant medication error, the resident developed dehydration and wound infection and required hospitalization . The facility reported a census of 114 residents. Findings include: On 12/10/15 at 1:15 p.m. Staff AA, registered nurse (RN) reported concerns that a critical medication error occurred which resulted in the death of a resident (Resident #8). A physician's orders [REDACTED]. Staff AA stated the resident received Val [MEDICATION NAME] for 2-3 days and was later sent to the hospital/hospice and passed away. Staff AA stated he completed an Incident Report to include photos of the medication label and reported to the Director of Nursing. Staff AA stated the Incident Report and photos are now missing. 1. Resident #8 had an MDS (Minimum Data Set) assessment with a reference date of 11/5/15. The MDS reflected the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which reflected cognitive impairment. The resident had no signs and symptoms of [MEDICAL CONDITION] and had [DIAGNOSES REDACTED]. The MDS reflected Resident #8 was frequently incontinent of bowel and bladder. The MDS identified the resident at risk of developing pressure ulcers; however no skin concerns were identified. The 11/5/15 MDS included a current weight of 117#. The Care Plan identified a self-care deficit and included interventions which included assistance of 1 staff for activities of daily living such as bathing, dressing, toilet use and transfer/ambulation. A Progress Note dated 11/5/15 at 3:52 p.m. revealed Resident #8 had two (2) runny/watery stools with yellow mucous and very foul odor during the shift. Progress Notes revealed Resident #8 had runny/watery stools on the following dates: 11/6/15 at 8:07 a.m., 11/6/15 at 10:16 a.m., 11/7/15 at 3:00 p.m., 11/8/15 at 10:15 a.m., 11/9/15 at 1:16 a.m., 11/9/15 at 7:45 a.m., 11/11/15 at 12:59 a.m., 11/13/15 at 1:18 a.m., and 11/15/15 at 10:41 a.m. A stool sample was obtained on 11/16/15 due to continuous loose stools. laboratory results dated [DATE] indicated Resident #8 tested positive for [MEDICAL CONDITION] toxin (c diff). The physician ordered [MEDICATION NAME], an antibiotic, is administered three times daily for 10 days. Progress Notes revealed Resident #8 continued with runny/watery stools on the following dates: 11/18/15 at 4:45 a.m., 11/18/15 at 9:08 p.m., and 11/19/15 at 1:55 p.m. On 11/20/15 the facility received a physician's orders [REDACTED]. According to the Medication Administration Record [REDACTED] Progress Notes dated 11/21/15 at 1:33 p.m. the physician ordered staff to administer intravenous (IV) fluids. Progress Notes dated 11/23/15 at 10:20 a.m. revealed facility nursing staff administered Val [MEDICATION NAME], an [MEDICAL CONDITION] medication used to treat Shingles, rather than [MEDICATION NAME] on 11/21/15 at 12:00 p.m., 11/21/15 at 5:00 p.m., 11/21/15 at 8:00 p.m., 11/22/15 at 8:00 a.m., 11/22/15 at 12:00 p.m., 11/22/15 at 5:00 p.m., and 11/22/15 at 8:00 p.m. The Progress Note indicated the pharmacy was notified and would send [MEDICATION NAME]. Progress Notes dated 11/23/15 at 12:07 p.m. indicated the pharmacy was unable to fill the physician's orders [REDACTED]. On 11/23/15 the physician assessed Resident #8 regarding [MEDICAL CONDITION] and the resident's refusal to eat. According to the physician's Resident Encounter Form, Resident #8 complained of nausea and vomiting while on [MEDICATION NAME], which was discontinued on 11/20/15, and [MEDICATION NAME] ordered for treatment of [REDACTED].#8 received intravenous (IV) fluids over the weekend to assist with hydration secondary to diarrhea and refusal to eat. Resident #8 reported he/she felt weak and tired. The physician assessed Resident #8 had poor skin turgor secondary to dehydration and noted the resident's oral cavity (mouth) was dry. The physician note assessed Resident #8's skin intact. The Resident Encounter Form included [DIAGNOSES REDACTED]. The physician ordered administration of additional IV fluids due to the medication error, and discontinued two medications related to dehydration. Progress Notes dated 11/24/15 at 10:33 p.m. revealed antibiotics for [MEDICAL CONDITION] loose stools continued. Resident #8's family members present during the application of ACE wraps (compression wraps) and noted untraceable decubs to bilateral heels dark purple in color with resident complaints of pain when touched. The Progress Note indicated the physician observed the site and determined the area occurred as a result of foot to foot contact. Staff and family members encouraged fluids; however the resident drinks very little. Resident #8's family member requested hospitalization and facility staff informed the family member the resident can receive antibiotics at the facility also. Progress Notes dated 11/24/15 at 10:44 p.m. identified a significant weight loss of 5% over 30 days, with a current weight of 112#. The response section of the note indicated the weight loss was a result of poor appetite. Progress Notes dated 11/25/15 at 2:26 p.m. revealed lab results received with physician orders [REDACTED]. Progress Notes dated 11/25/15 at 7:10 p.m. identified a significant weight loss of 5% over 30 days with a current weight of 110.5 (a 1.5# loss over one day). Progress Notes dated 11/25/15 at 7:27 p.m. revealed antibiotics continued and loose stools have declined in amount of times throughout the day. The same note indicated a significant weight loss was due to refusal to eat or drink. The Progress Note included assessment of Resident #8's left foot as [MEDICAL CONDITION] with scattered petechiae on the inner and outer foot. The nurse assessed the area blanched, and noted the resident grimaced when dorsiflex/plantar flexion of the foot. Progress Notes dated 11/27/15 at 2:23 p.m. revealed physician notification of Resident #8's left leg. The Progress Note included an order to transfer Resident #8 to the hospital for evaluation. On 12/22/15 at 1:25 p.m. Resident #8's family member stated at the time of admission to the facility Resident #8 was up and walking around, but declined and could no longer walk. The family member indicated when the infection was diagnosed and the resident required isolation he/she spent most of the time in the chair or bed. The family member stated that around 11/16/15 the resident no longer was able to go to the dining room. The family member stated Resident #8's ankles rested on the foot of his/her recliner because staff encourages him/her to elevate his/her feet due to the [MEDICAL CONDITION], which caused the heel ulcers. Then staff made the resident lay in bed and his/her legs rested on top of each other so he/she developed 2 huge blisters around his/her legs. The family member stated Resident #8 was hospitalized with [DIAGNOSES REDACTED]. The family member voiced concerns with the resident's elevated blood sugar upon hospital admission and stated it was 700. The family member was unable to recall the diabetic medication discontinued, however thought the facility would know to assess his/her blood sugar levels due to a [DIAGNOSES REDACTED]. When asked about the medication error, the family member stated the family was informed the medication mix up was just a different antibiotic. The family member stated concerns were brought to the Director of Nursing, who confirmed Resident #8's diabetic medication was discontinued. On 12/22/15 at 6:57 p.m. Staff L, registered nurse (RN), confirmed she administered the wrong medication. Staff L stated she thought Val [MEDICATION NAME] was an off brand of [MEDICATION NAME]. Staff L stated she did not complete an Incident Report. Staff L recalled Resident #8 had open/weepy lower extremities which required Kerlix wrap to help with [MEDICAL CONDITION] that started around the time of the [MEDICATION NAME]. Staff L also recalled the resident had a raw bottom due to [MEDICAL CONDITION]. Staff L stated Resident #8 did not like to call for assistance because he/she didn't want to bother staff, so staff would check and see if he/she had been incontinent and change as needed. On 12/23/15 at 10:46 a.m. Staff K, RN, confirmed she administered the wrong medication. Staff K stated everyone saw VA and didn't see the difference in Val [MEDICATION NAME] and [MEDICATION NAME], so it was confusion on everyone's part. Staff K stated she did not complete an Incident Report. On 12/10/15 at 1:43 p.m. Staff B, CNA/CMA, stated she initially noted Resident #8's loose stools when she provided toilet assistance to the resident during the facility's state survey. Staff B stated she immediately recognized the odor as [MEDICAL CONDITION] and reported to the nurse. Staff B stated nothing was done for the resident for approximately 1 week. On 12/21/15 at 11:23 a.m. the pharmacist confirmed on 11/21/15 the pharmacy received an order for [REDACTED]. The pharmacist stated she spoke with the facility Director of Nursing in early December but was unable to recall the exact date. The DON confirmed Resident #8 received 6 doses of Val [MEDICATION NAME] rather than [MEDICATION NAME]. On 12/21/15 at 12:01 p.m. Resident #8's physician/facility Medical Director stated he assumed the medication error was directly related to the resident's hospitalization . The physician indicated the resident did not respond to IV fluids, continued to decline which required hospitalization . The hospital admission History and Physical, dated 11/27/15, revealed upon hospital admission Resident #8's blood sugar was 700 (normal is less than or equal to 100). The resident was mildly hypotensive, and required IV solution. Physical examination of the resident noted blistering on the lower extremities, multiple eschars on the lower extremities with some minimal surrounding [DIAGNOSES REDACTED]. The physician noted ecchymosis on the left heel with early signs of skin breakdown and superficial sacral decubitus draining some serous fluid with surrounding [DIAGNOSES REDACTED]. The resident's white blood cell count was elevated.Admitting [DIAGNOSES REDACTED]. The undated facility policy Medication Errors-Remedial Intervention revealed an algorithm. The policy noted: a. If the medication error is a Level 2 occurrence and resulted in the need for increased resident monitoring by licensed nurse or medication aide and no patient harm, report to the DON or designee within 24 hours and follow directives, consult with the physician, contact family, document in the medical record and complete a medication report/Incident Report. b. If the medication error is a Level 3 occurrence and resulted in the need for increased monitoring with a change in vital signs but no ultimate resident harm, or any occurrence that resulted in the need for licensed nurse monitoring, report to the DON or designee within 24 hours and follow directives, consult with the physician, contact family, document in the medical record and complete a medication report/Incident Report. c. If the medication error is a Level 4 occurrence resulted in the need for treatment with another drug or change in physician orders, nurse monitoring and or intervention but resident was able to remain in the facility, report immediately to the DON or designee, and follow orders. d. If the medication error is a Level 5 occurrence resulted in the need for resident to be transferred temporarily to the hospital (emergency room , outpatient), report immediately to the DON or designee, follow orders. If Level 5, staff providing direct care to the involved resident will be drug tested , contact physician and family, complete incident report and medication form, document in medical record, report to state agency if regulations require. e. If the medication error is a Level 6 occurrence and resulted in resident being transferred to a higher level of care (admitted ) the occurrence is classified as a Significant Event. f. If the medication error is a Level 7 and resulted in resident death, the occurrence is classified as a significant even. Facility action for a Level 6 or Level 7 directed report immediately to the DON or designee, staff providing direct care to the involved resident will be drug tested , licensed nurse contact physician/follow orders, contact family. Complete an incident report and Medication Error Report Form, document in medical record. Report incident immediately via the Critical Incident Notification Hotline and report to State Agency and coroner if regulations require.

Based on record review, staff interviews, observation and review of facility documents, the facility failed to provide adequate supervision to ensure against hazards to self and others and failed to plan for and direct the nursing care in order that the residents remain safe in the CCDI (Chronic Confusion or a Dementing Illness) unit. Interviews with staff identified Resident #2 as physically fit, moved quickly and displayed physical behaviors towards staff and other residents. The facility had determined noise (from alarms, doors, other residents) to be a contributing factor which led Resident #2 to escalate. Although staff attended to the noises and attempted to obtain clues that triggered behaviors, the facility still lacked interventions needed to increase supervision for Resident #2 in order to prevent other residents from injury. Resident #2 had physical altercations (hit, slapped, punched and pushed) with 3 residents (4 times) and 4 staff members. The sample consisted of 11 residents and a total of 13 residents resided in the CCDI unit. Findings include: 1. Resident #2 had an admission MDS (Minimum Data Set Assessment) with a reference date of 1/2/14. The MDS identified Resident #2 had [DIAGNOSES REDACTED]. The facility documented the resident as unable to complete the Brief Interview for Mental Status and identified the resident with both short and long term memory impairment and severely impaired cognitive function related to daily decision making skills. The MDS reflected the resident had inattention and disorganized thinking at times. The MDS identified the resident with the following moods present on a daily basis or more than half of the days: feeling down or depressed, trouble falling or staying asleep, trouble concentrating on things, and being short tempered or easily annoyed. The MDS also identified the resident with the following behaviors exhibited on average of 4-6 days of physical and verbal behaviors directed toward others. The MDS identified the resident demonstrated behaviors such as scratching, pacing, hitting, or making disruptive sounds on an average of 1-3 days. The MDS identified symptoms which put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, put others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and the resident significantly disrupted care or the living environment. The MDS revealed the resident rejected cares on an average of 1-3 days and demonstrated wandering on a daily basis. The MDS identified the wandering behavior placed the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy or activities of others. The MDS reflected preferences for customary routine and activities. The facility identified the resident enjoyed snacks between meals, family or significant other involvement in care discussions, listening to music, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. The MDS identified the resident required supervision with bed mobility, dressing, and eating. The resident required limited staff assistance with toileting needs, personal hygiene, and bathing. The MDS revealed the resident as independent with transfers, ambulation both in and out of the resident's room, and locomotion both on and off of the unit. The resident had no pain present and no fall history. The Resident Care Area Assessment for Cognitive Loss/Dementia dated 2/11/14, the summary reflected the resident continued to adjust to the new environment but became very aggressive and combative toward staff and other residents and had multiple altercations with staff and other residents. The summary revealed the resident remained at high risk for elopement due to the tendency to wander throughout the facility and into other resident rooms. The assessment reflected the resident as very mobile and independent. The assessment identified at times the resident verbalized needs/wants but at other times demonstrated difficulty understanding communication and simple directives. The summary also noted the resident ' s moods and behaviors tended to fluctuate related to the [DIAGNOSES REDACTED]. Under Resident Care Area Assessment for Falls, the facility identified the resident can be very pleasant and can become combative seconds later with the behavior being unpredictable. The summary reflected the resident easily redirected at times and refused care at other times. Under Resident Care Area Assessment with Psychotropic Drug Use, the summary reflected the resident became combative at times, behavior unpredictable though could be pleasant at times and without any reason become agitated. The physician admission orders [REDACTED]. The admission medications orders included Sertraline ( Zoloft - medication for the treatment of [REDACTED]. The Care Plan identified the residentas independent with mobility throughout the facility. The Care Plan identified depression and forgetfulness as problems so this directed staff to monitor moods and behaviors and record on the behavior documentation sheets, use redirection and distraction, and administer medications as ordered. The Care Plan also directed staff to ask simple questions, allow time to respond, and to face the resident when speaking. An incident Investigation form dated 12/27/13 at 9:15 p.m. revealed Resident #2 demonstrated increased anxiety when he/she heard Resident #3 screaming in the hallway. The MDS reflected Resident #3 demonstrated physical and verbal behaviors 1-3 days a week and other behavioral symptoms such as screaming or crying uncontrollably 4-6 days per week.) Resident #2 grabbed Resident #3 by the shoulders and pushed the resident down. Resident #3 did not sustain a fall or any injuries. The Investigation Form revealed the corrective actions to be taken in order to prevent recurrence were to reproach the resident, use lavender oil, distraction, and medication as a last resort. Nursing documentation did not address this incident however Staff C sent a facsimile (fax) to the resident's attending physician regarding the incident. The physician responded to the fax on 12/30/13 with the directive to observe (the resident). Nursing documentation on 12/28/13 at 1:15 a.m. revealed the resident roaming in the hallways. Resident #2 wandered into another resident's room. Staff on duty entered the room and informed Resident #2 that the resident in bed was sleeping. The resident then raised both fists, walked toward the CNA, and slammed the room door. The nurse then attempted to get the resident to come down the hall to his/her room but the resident became agitated, shoved the nurse in the chest, and broke her name tag and then put it in his/her pocket. The resident then stated " Now get out of here." The resident then walked over to the resident in bed, touched Resident #3 's shoulder, and began speaking. The staff asked the resident if he/she felt hungry or wanted a snack. At which time the resident replied " No. I want you out of this room" and slammed the door. The staff again opened the door and told the resident "Why don't we go down the hall and find a place for you to relax" to which the resident replied "You are killing these people. I want you out of my wife's room now" and backed the nurse up against the wall. The staff left the room and came back to check on the resident who sat in an easy chair next to Resident #3 who slept in bed. The staff left the resident to sit in the chair and did visual checks on both residents. The staff entered the room again when Resident #2 attempted to remove the blankets from Resident #3. The staff stated "Let ' s go find your blankets" and the resident became agitated shaking fists at the staff and pointed toward the door and said "Out now!" Staff B then placed a call to the East Building and requested additional help. Two nurses from the East building came to the CCDI Unit and approached the resident. Resident #2 told them to get out of the room and slapped one nurse on the back of the head and stomped on her foot. A physician order [REDACTED]. The December MAR (Medication Administration Record) identified Resident #2 received Ativan 1 mg orally at 11:20 p.m. on 12/30/13 due to combative behaviors demonstrated. At 12:00 a.m. the resident appeared to be sleeping. Nursing documentation dated 12/31/13 at 9:30 p.m. revealed the resident demonstrated exit seeking behaviors out of the room all shift with staff attempting to offer redirection but the resident held up a clenched fist as if going to hit someone. At 11:00 p.m. nursing documentation noted the resident entered into Resident #3 ' s room, stated was going to sleep, and laid down on the floor. Staff E, LPN, and Staff F, CNA, donned a gait belt around the resident' waist and began to assist the resident up off of the floor to take the resident back to own room. The resident turned with a closed fist and punched Staff F in the face. The resident continued to take swings at both Staff E and Staff F as they assisted the resident to own room. An incident Investigation form completed on 12/31/13 at 10:25 p.m. documented the above episode. The corrective action taken following the incident directed staff to monitor the resident's where abouts every 15 minutes for the remainder of the shift. The nurse sent a fax to the physician to inform the physician of the resident punching the CNA in the face with a closed fist. The physician responded on 1/2/14 with O.K. (alright) and thanks. Nursing documentation on 1/3/14 at 9:30 p.m. revealed the resident's physician there to make a visit. The physician noted the resident affect and mood as anxious. The physician ordered to check a CBC (Complete Blood Count), BMP (Basic Metabolic Blood Panel), B-12, and TSH (Thyroid Stimulating Hormone) levels. All labs returned within normal levels. Nursing documentation dated 1/4/14 at 10:00 a.m. revealed the resident wandering the hall. Staff G, CNA, asked the resident to go to his/her room to change clothing when the resident punched her in the chin. The staff sent a fax to the resident's physician regarding the incident. The fax was returned on 1/6/14, with no new orders. Nursing documentation dated 1/6/14 at 8:30 p.m. revealed the resident showed increasing behaviors after supper. Resident #2 entered another resident's room and used the bathroom. This awakened the resident who set off the bed alarm while attempting to get up to check on the cause of the commotion in the bathroom. Resident #2 exited the bathroom, approached the resident and Staff G, and pushed both of them onto the bed before exiting the room. Staff F attempted to administer an Ativan to the resident who refused to take it and knocked the medication out of her hand. At 7:30 p.m. Staff F administer the Ativan, then mixed in pudding. The resident hit Staff F in the arm as she obtained vital signs and continued to attempt to hit staff during any attempts to complete an assessment. The incident report completed on 1/6/14 by Staff E directed staff to watch the resident with frequent checks to make sure he/she didn't enter into other resident rooms. The physician responded to the fax with no new orders at this time. Nursing documentation dated 1/7/14 at 5:45 a.m. revealed the resident rested quietly in bed all night and up this a.m. for cares. The Resident became upset and punched Staff G in the neck and shoulder and attempted to also punch Staff D. The Incident Details asked what immediate interventions have been put in place to prevent this incident from happening again. The form reflected staff separated both residents. Nursing documentation at 9:00 p.m. revealed the resident made a fist several times this shift, staff just walked away with no incidents. At 11:00 p.m. Staff E in the med room and heard a resident yell " Ouch". Staff E exited the med room and saw Resident #2 push Resident #4 into the wall with open hands on the chest. Staff E attempted to assess Resident #2 but unable to do so as the resident continued to swing at the staff and exhibit combative behaviors. An Investigation form completed on 1/7/14 at 9:50 p.m. revealed intervention put into place to keep these residents apart, prevent residents from congregating at the nurse's station, placed resident's name on room door for ease of location. The Incident Details form asked what immediate interventions have been put in place to prevent this incident from happening again. The form reflected the physician notified and ordered 2 milligrams of Ativan. Nursing documentation on 1/8/14 at 11:00 a.m. revealed a fax sent to the physician regarding the increased night behaviors. The physician returned the fax on 1/8/14 with no new orders received. Nursing documentation on 1/8/14 at 11:00 p.m. revealed the resident wandering the halls with another resident all shift. At 9:30 p.m. Staff E heard a resident yelling to get out. Staff E entered room 109 and saw 3 residents in the room and the occupant of the room yelling for them all to get out. Staff E assisted the first 2 residents out of the room and then returned to assist the 3rd resident when Resident #2 grabbed Staff E by the back of her hair and threw her into the wall knocking the picture off of the wall and proceeded to punch at Staff E in the back of the head and back. Staff H, CNA entered the room and grabbed Resident #2 arm to stop the punching of the nurse or other residents in proximity. Resident #2 continued to have another altercation in the hallway when the resident heard another resident scream. The resident again grabbed Staff E and threw her up against the wall causing the nurse to hit back against the wall. Staff E grabbed the resident shirt sleeve to prevent any more punches while Staff H summoned more staff assistance. Staff E telephoned the physician on call and received an order to administer Ativan 2 mg/ 1 ml intramuscularly and requested the resident's attending physician be notified of the incident the following day. Nursing documentation on 1/9/14 at 9:00 p.m. reflected the Physician Assistant at the facility to see the resident. The Encounter Form dated 1/9/14 under psychiatric assessment category identified observations of the resident's behaviors included: aggression, hitting, uncooperative, refusals to take medication(s), and slapping. The Physician Assistant ordered to discontinue Aricept and to begin Exelon patch 4.6 mg/24 hours daily as directed and to start Trazadone 50 mg 1/2 tablet every p.m. for restlessness and sun-downing effect. The Encounter Form noted Resident #2 appeared to be distressed around residents in distress as the resident seemed to respond to the distress in the immediate environment. The Physician Assistant stated the current behaviors likely due to new surroundings and disease progression. The nursing interventions also initiated to prevent another incident, directed staff to redirect the resident away from other residents that also wandered, keep resident busy by giving different tasks, and observe what is going on and re-approach or ask resident to help you. Nursing documentation on 1/10/14 at 7:00 p.m. revealed the resident as agitated whenever Resident #1 screamed in the dining room. Staff C arrived in the dining room and saw Resident #2 holding Resident #1 right hand very firmly. The Resident refused to allow the application of the Exelon patch until the 3rd try. When the nurse and CNA attempted to talk with the resident, the resident became agitated, went into another resident room, and locked the door. The CNA went to the room and the resident opened the door and appeared anxious. The Incident Details report asked what immediate interventions have been put in place to prevent this incident from happening again. The form reflected the resident started on Exelon Patch and Trazadone and the resident returned to his/her room and shut the door. An Investigation Report dated 1/10/14 at 4:30 p.m. revealed Resident #4 screaming and very upset. Resident #3 voiced " This is not good ", when Resident #2 approached. The Daily Huddle report directed staff to keep Resident #2 busy. Nursing documentation dated 1/12/14 at 5:30 a.m. revealed Staff D ambulated in the hallway toward the nurse's station when Resident #2 walked out of room door. The nurse greeted the resident by name and the resident proceeded to punch the nurse in the chest, pointed a finger at her, and yelled "Get out of here!" Resident #2 then pushed Staff D up against the wall and slapped the nurse across the face. Staff D then asked the resident what is wrong and the resident placed both hands on her chest and shoved her against the wall. Staff F came up the hall and offered reassurance to the resident that everything was okay. The resident then pointed a finger at her and yelled " you get out of here." As Staff F turned to go down the hallway, Resident #2 walked back into room and shut the room door. The nursing interventions put in place following the incident included when resident gets up at night try to determine the resident's mood before talking to the resident as the resident is very unpredictable and had aggressive behaviors with no known cause. The Physician Assistant responded to the fax sent on 1/12/14 regarding the incident with an order to increase the Trazadone to 75 mg at bedtime and begin 25 mg every morning. Nursing documentation dated 1/15/14 at 10:30 p.m. revealed the resident on edge at the beginning of the shift and continued to be on edge with increased anxiety. The resident had been attempting to lift a dining room chair up when Staff E requested it be put back down. The resident then shoved the chair into the table and held up a fist as the nurse walked away. After supper the resident walked up to Resident #3, who at the time conversed with another resident. Resident #2 put his/her arms around the resident as if he/she was going to give Resident #3 a hug but instead threw the resident into the nurse's station before walking away down the hall. Resident #3 hit the back of head and upper back on the wall and then slid down the wall onto the floor. Staff E notified the physician on call who gave an order to administer Ativan 2 mg/ 1 ml intramuscularly. The Incident Details asked what immediate interventions have been put in place to prevent this incident from happening again and directed staff to update the Care Plan. The form reflected the physician had been notified and Resident #2 kept away from others. The nursing documentation on 1/15/14 at 9:15 p.m. reflected Resident #2 attempted to pull another resident out of bed. Resident #2 then began swinging at the staff whenever he/she got close to anyone. Staff E again telephoned the physician on call and received an order for [REDACTED]. The resident received 1.25 mg at 9:40 p.m. The resident continued to roam up and down the halls and in and out of other resident rooms until 11:00 p.m. Nursing documentation on 1/21/14 at 4:00 a.m. revealed staff heard a loud bang and found the resident on the floor in room. The resident remained combative and resistive to any care offered and yelled "Stay away from me." Staff I notified the resident's physician who ordered the resident be transported to an area hospital for evaluation. The resident returned to the facility at 11:20 a.m. The ambulance EMT (Emergency Medical Technician) reported to the staff the resident received 5 mg of Haldol and 2 mg of Ativan while at the hospital. The resident remained lethargic at the time of return to the facility. The Incident Details form asked what immediate interventions have been put in place to prevent this incident from happening again and put on Care Plan. The document reflected staff notified of the fall status and the physician and paramedic notified. Close supervision of the resident until the paramedics arrive. The facility Daily Huddle report dated 1/21/14 directed staff to perform frequent checks of the resident. The Daily Huddle report dated 1/22/14 directed staff to check the resident frequently and assist with all activities of daily living due to had fallen and very lethargic. The nursing note on 1/25/14 at 7:10 p.m. revealed a resident to resident altercation occurred when Resident #2 walked up to Resident #1, who had been yelling out at the nurse in a high pitched voice, and with a closed fist, hit the resident directly in the face. The nursing documentation revealed the staff immediately separated the residents and tended to the resident's injuries. Resident #2 sustained a skin tear to the right knuckle and Resident #1 sustained an injury to the upper lip. Resident #1 went to the emergency room for treatment and sutures to the lip. The documentation revealed prior to the incident, Resident #2 had not demonstrated any aggressive, resistive, or combative behaviors and had been pleasant toward staff and other residents. The Incident Details report revealed the immediate intervention to prevent this from happening again was to separate the residents. A History and Physical report obtained on 1/26/14 from a local hospital revealed Resident presented to the emergency room with agitation, assaulted another resident at the facility, resulting in a cut to the lip (Resident#1), and sent to the ER ( emergency room ) for placement. Character of symptoms angry, anxious, and agitated. The resident admitted to the hospital on [DATE] and remained there until discharge to another area facility on 2/12/14. An interview conducted with Staff M (Licensed Practical Nurse) on 2/12/14 at 3:45 p.m. revealed the resident to resident altercation occurred on her 3rd day of orientation working in the CCDI Unit. She explained she didn't know Resident #2 prior to this and had heard from other staff conversations that this resident had been aggressive with other residents. Staff M stated she and the CNAs were assisting residents into the dining room for supper and she noticed Resident #1 seated in the wheelchair in the dining room. Staff M pulled down the resident ' s shirt. She stated initially Resident #1 yelled out and then began conversing with Staff M. Staff M stated she had her back turned and Resident #2 must have come up from behind her and around her back and punched Resident #1 directly in the face. Staff M stated the resident's lip bled profusely and required being sent to the hospital. An interview conducted on 2/12/14 at 4:00 p.m. revealed Staff A, CNA, had worked quite often with Resident #2 on the evening shift. When asked what a safe, non-threatening environment meant to her, Staff A stated to make sure the residents were comfortable in this environment and to make sure they didn't get hurt by another resident. She stated it is difficult to keep a constant eye on every resident. She stated Resident #2 proved difficult to take care of and felt it impossible to meet all of his/her needs. Staff A stated she did not feel Resident #2 was a good fit for the CCDI Unit. Staff A stated the staff needed to figure out what made the resident upset and try to hit with clues. The resident did not like the sounds of alarms or being told what to do. An interview conducted on 2/11/14 at 2:00 p.m. with the ADON who verified she also currently acted as the CCDI Unit Coordinator. The ADON stated she couldn't determine if Resident #2 pushed a resident down due to anger or if just trying to protect the resident. The ADON stated after this incident she informed the staff that Resident #2 seemed to be sensitive to any type of commotion. The ADON explained the first roommate Resident #2 had, used a pressure pad alarm on the bed and whenever the alarm sounded Resident #2 became quite upset to the point that she moved Resident #2 to another room. The ADON stated the resident continued to have more and more incidents of aggression. She stated the management staff began to discuss Resident #2 on a daily basis and she reviewed every incident and reenacted each one with the staff involved to determine what actually happened and what circumstances might have set off the behaviors. She explained the resident really didn't seem to demonstrate many behaviors on the day shift but tended to show sundowners syndrome on the evening shift with increased restlessness, agitation, and combativeness. The ADON stated the resident's moods seemed to change very quickly so she directed the staff to keep the resident busy. She explained the physician also often checked the resident's labs which were generally normal. The ADON explained just prior to the resident to resident altercation, she had conversed with the consulting pharmacist regarding Resident #2 current medications and continued behaviors. The Pharmacist recommended increasing the Exelon patch and ordering the Ativan on a routine basis. She explained by the time she received these recommendations Resident #2 remained hospitalized . The ADON stated she began to become concerned with Resident #2's behaviors after the incident with Resident #3 being pushed into the nurse's station. She stated she did not necessarily believe that the resident "Slammed " Resident #3 as the nurse documented in the incident report. She stated the resident to resident altercation with Resident #1 occurred with a new nurse on orientation. The ADON stated she wondered if the outcome would have been different if somehow the staff could have controlled the noise levels and commotion. She stated Resident #2 never seemed to bother any other residents except those who constantly wandered. She stated evenings were definitely the worst time for the resident which was why the physician ordered the additional Trazadone at bedtime. She stated she did have concerns about the episode with Resident #4 when Resident #2 pushed him/her in the chest into the wall. The ADON stated she began to wonder what Resident #2 would do to more disabled residents who are unable to defend themselves. On 2/12/14 at 2:40 p.m. the DON (Director of Nursing) was interviewed and stated the management team had daily discussions about this resident and as the incidents continued to occur. She stated she eventually held a meeting with the CCDI Unit nurses and discussed with them of any and all interventions tried or successful in the management of the behaviors. The DON stated she felt the resident remained in a transition period and realized that evenings were the worst time for the resident who exhibited symptoms typical of sun-downing. The DON described the resident as very physically fit and would actually jog down the halls especially when hearing noises. She stated she never believed the resident would go to this extreme with the behaviors and she stated when she became aware of the resident to resident altercation that occurred on 1/25/14, she felt the resident needed to be hospitalized and she became fearful after this incident as to what else the resident could be capable of doing. She stated this incident seemed to be different from the previous ones as it seemed to be unprovoked. The DON stated the Administrator made the decision not to readmit the resident to the facility that weekend. The Admission Criteria Guidelines for the CCDI Unit (revised on 3/12) listed the following: Individuals who are considered for admission will exhibit some or all of the following characteristics: Significant memory impairment Short attention span Difficulty communicating own needs Ability to perform Activities of daily living independently or with one-person assistance Impaired judgment requiring protection from self and/or others Some degree of disorientation to person, place, or time. Inappropriate behavior (e.g. physical or verbal aggression, agitation, combativeness, call out, pacing, wandering, elopement etc.) which may disrupt the environment but can be altered or redirected through the use of interventions by unit staff. Needs a secure environment for safety Guide Lines for Criteria for Discharge from the CCDI Unit listed the following: The resident exhibits continued, unmanageable, combative behavior or excessive noise toward self or others. The behaviors are not altered by programming or other interventions and the individual becomes a danger to self. Note: At the time of the complaint investigation, the complaint was coded at a " K " immediate and serious jeopardy. By 2/14/14, the facility had addressed the jeopardy and the grid placement was lowered to the " E " level. The facility Administrator had presented information that would direct an increase in resident supervision by 1 staff member until the resident is stable and aggressive behavior subsides if other interventions are unsuccessful. The CCDI staff received training for aggressive behaviors. The Medical Director/attending physician would be asked to identify options for medical care, psychiatric care, or inpatient treatment for [REDACTED]. The Director of Nursing would provide education regarding behavioral management guidelines. As of the 2/19/14 exit conference, the facility continued to need to: .Finish in-servicing all employees regarding aggressive behaviors and behavioral management guidelines. .Continue to provide adequate staff in the CCDI unit to ensure safety for residents, when residents display aggressive behaviors and are not stable. .Continue to monitor aggressive behaviors with proper treatment and adequate supervision in order to maintain a safe unit for the residents and staff.

Based on clinical record review and staff and physician interviews, the facility failed to perform assessments and timely intervention for one resident ' s bowel needs which resulted in the resident hospitalized for [REDACTED]. The sample consisted of 17 residents and the facility identified a census of 96 residents. Findings include: 1. Resident #5 had an Minimum Data Set (MDS) assessment dated [DATE] that identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident as fully dependent on staff for activities of daily living, required an indwelling bladder catheter and experienced frequent episodes of bowel incontinence. The Comprehensive Care Plan dated 2/27/13 identified a problem with altered elimination and listed a goal for the resident to have a bowel movement every three days. The Bowel Movement Concern and Interventions protocol listed the following procedure: 10:00 p.m. - 6:00 a.m. evaluate the bowel movement record and offer prune juice. Day 2 6:00 a.m. - 2:00 p.m. follow up with interventions and offer prune juice and administer milk of magnesia 2:00 p.m. - 10:00 p.m. ensure any results and offer prune juice 10:00 p.m. - 6:00 a.m. evaluate for results and give [MEDICATION NAME] suppository Day 3 notify the unit manger if no results. If no bowel movement after 2 days, document bowel sounds, nausea, vomiting, and other gastrointestinal concerns in the clinical record. According to the bowel movement report the resident had no bowel movement 2/12/13 until 2/16/13. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR for February 2013 revealed the resident received a suppository on 2/16/13. The clinical record lacked documentation the effectiveness of the interventions. The interdisciplinary notes documented the resident had a bowel movement on 2/16/13. According to the bowel movement report the resident had no bowel movement 2/26/13 until 3/2/13. Review of the MAR for February 2013 revealed the resident received milk of magnesia on 2/27/13 and 2/28/13. The interdisciplinary notes document the resident had no results from the milk of magnesia Review of the MAR for March 2013 revealed the resident received Milk of Magnesia and prune juice on 3/1/13 and a [MEDICATION NAME] suppository on 3/2/13. The interdisciplinary notes documented the resident had no results from the Milk of Magnesia. Subsequent interdisciplinary notes dated 2/27/13 and 2/28/13 lacked documentation of a bowel assessment. The interdisciplinary notes dated 3/1/13 at 3:00 p.m. documented the resident had no nausea or vomiting and had active bowel sounds. The Interdisciplinary Progress Notes (IPN) dated 3/1/13 at 10:00 p.m. documented the resident had vomited, had bowel sounds, and the abdomen had distention. The interdisciplinary notes documented the resident had no results from the bowel interventions. The IPN dated 3/2/13 at 4:30 a.m. reflected the resident vomited. Staff removed a small hard amount of stool from the resident's rectum. The IPN on 3/2/13 at 2:00 p.m. documented the resident had vomited three times that shift. Staff removed a small amount of firm stool from the resident's rectum. The IPN on 3/2/13 at 2:30 p.m. documented the resident continued to vomit and staff sent the resident to the hospital. On 8/7/13 at 1:37 p.m. Staff P, Registered Nurse, was interviewed and stated on the 3/2/13 she worked the 6:00 a.m. to 2:00 p.m. shift. Staff P stated received in report the resident had constipation. She administered a suppository and did a rectal check revealing soft stool in the rectum. At the change of shift at 2:00 p.m. the resident vomited fecal matter and she sent the resident to the emergency room (ER). The History and Physical from the hospital dated 3/3/13 documented the resident had abdominal pain and vomited fecal matter. In the ER, staff disimpacted the resident with some success. The History and Physical documented [DIAGNOSES REDACTED]. On 8/7/13 at 10:58 a.m., Staff O, Registered Nurse was interviewed and stated the resident had no bowel movement for 5 days and felt the resident had an impaction. After two days without a bowel movement, she expected staff to administer Milk of Magnesia and complete a bowel assessment. After three days without a bowel movement, she expected staff to notify the physician for direction. On 9/4/13 at 11:06 a.m., the resident ' s attending physician was interviewed and stated he would have expected staff to call about the resident by day 4 without a bowel movement and would have ordered an enema and a flat abdominal x-ray based on the results of the enema. The physician certainly would have expected a call by day 5 without a bowel movement.

Based on record review, observations, and interviews, the facility failed to ensure Resident #2 received adequate supervision to prevent accidents. The staff failed to properly transfer Resident #2 who sustained fractured ribs. Observation showed the staff failed to use the proper sling size when transferring Resident #2 with the mechanical lift. The facility reported a census of 104. Findings include: 1. According to the [DIAGNOSES REDACTED]. The Care Plan updated on 4/25/12 identified Resident #2 at risk for major injury related to fall. The care plan directed staff provide transfers with the assistance of two (staff) or EZ stand. The Care Plan updated on 5/23/12 identified Resident #2 at risk for major injury related to fall. The care plan directed staff provide transfers with the assistance of 1-2 (staff) with gait belt. A typed document used by the aides to provide cares called West Group 2, dated 6/20/12 identified Resident #2 transferred with 1-2 staff and a gait belt. The Care Plan dated 6/28/12 identified Resident #2 at risk for major injury related to fall due to dementia, debility, and required assistance with transfers as he/she had unsteady balance. The care plan directed staff to transfer Resident #2 with assistance of two staff or with the E-Z stand (sit to stand lift). The care plan also directed staff to use tabs alarm when in bed and ensure the resident's bed was positioned at the lowest setting. According to the Incident Details report dated 7/4/12 at 7 p.m., a certified nurse aide (CNA) observed bruising to the resident's left lateral and top breast area and alerted the nurse. The bruise measured 7.4 centermeters (cm) by 14.5 cm and 7 cm by 14.5 cm. The resident complained the area hurting. The physician and family received notification, and the facility had been unable to determine how the bruise occurred. (The clinical record lacked any documentation of X-ray). According to the Incident Details report dated 7/27/12, staff observed a bruise area purple in color to the resident's left breast/chest, left shoulder and upper arm area. The bruise area measured 36 cm by 25 cm and had been raised. The facility documented the source of the injury was unknown. A typed document called Investigation, dated 7/27/12 identified the following: On 7/5/12 the resident had an incident of bruising on the left side area. After investigating the facility determined it was related to the sling used for the EZ stand transfers. After this incident staff had been directed to use the two staff when transferring the resident or pad the EZ stand if used until a new type of sling arrived. The report documented the PA had seen the resident and had no new orders. The report documented another incident of bruising appeared on 7/27/12. The facility questioned staff and it was discovered that one staff member had transferred the resident by herself on 2-10 shift on 7/27/12. With the new bruising (7/27/12) the PA ordered an X-ray which showed old rib fractures. The X-Ray report dated 7/27/12 revealed Resident #2 had a multiple nondisplaced left posterior rib fractures (6th, 7th, 8th and 9th posterior lateral ribs per x-ray 7/27/12) . The Physician's Visit sheet dated 7/31/12 revealed Resident #2 had a large bruise earlier in the month on the left chest and breast area. The facility attributed the bruise to the harness on the EZ stand (sit to stand lift) and ordered a new sling. The bruise slowly improved over several weeks. On 7/27/12 the staff noticed a new lump and significant purple bruising on the left anterior chest and left upper arm. It was first noted at 4:30 a.m. when staff turned Resident #2 in bed. No known source of injury. The rib fractures appear to be old as Resident #2 had no tenderness or bruising in that area. Resident #2 continues on Aspirin and Prednisone which caused increased bleeding. During an interview on 8/1/12 at 12:32 p.m., Staff A reported he/she started an investigation on 7/27/12. Staff A talked to the staff that worked the evening on 7/26/12. The staff that transferred Resident #2 before supper had to change his/her shirt. They noticed the bruising had faded and had a yellow color. Staff D transferred Resident #2 after supper by him/her(self). Staff D reported he/she used a gait belt and lifted Resident #2 up under the arms without incident. Staff A found that Staff B and Staff E transferred Resident #2 to the shower chair the morning of 7/27/12 without a gait belt. Staff A reported all three staff received a written counseling. During an interview on 8/1/12 at 10:20 a.m. Staff B verified he/she transferred Resident #2 with Staff E without using a gait belt. Staff B reported he/she knew better and made a mistake. Staff B observed the bruising on 7/26/12 and it had faded. Staff B reported the bruising on 7/27/12 had worsened and had a black and gray color with an apple size lump. During an interview on 8/1/12 at 2:32 p.m. Staff E verified he/she assisted Staff B to transfer Resident #2 without the gait belt. During an interview on 8/1/12 at 2:46 p.m., Staff D reported he/she thought Resident #2 required assistance of 1 - 2 staff with a gait belt or the sit to stand lift. Staff D looked for help and could not find anyone. Resident #2 attempted to get into bed unassisted. Staff D reported he/she transferred Resident #2 with a gait belt to the bed without other staff assistance. The Care Plan copy received on 7/31/12 and updated on 7/27/12 directed the staff to transfer Resident #2 with the Hoyer (total mechanical lift) only. Observation on 7/31/12 at 4:33 p.m. revealed Staff D and Staff H transferred Resident #2 from the bed to the wheelchair with the total mechanical lift. The staff checked the tag on the sling and reported it had size extra-large printed on it. The Care Plan copy received on 8/1/12 and updated on 7/27/12 directed the staff to use an size large sling. According to the MDS dated [DATE], Resident #2 weighed 143 pounds and was 64 inches tall. Observation on 8/1/12 at 11:56 a.m. revealed Staff B and Staff E transferred Resident #2 from the bed to the wheelchair with a size large sling. The staff reported they generally do not use the total mechanical lift on the unit. The staff indicated they go by the weight of the individual to determine what size sling to use. Staff A present during the transfer reported Resident #2's weight borders between a size Large and Extra Large. Observation of the 200 Hall Linen Closet on 8/1/12 at 12:15 p.m. revealed 3 bins for the mechanical lift slings: a. 100 to 175 pounds - Medium b. 150 to 275 pounds - Large c. 200 to 400 pounds - X Large The Transfer Lift Assessment for Residents dated 7/27/12 revealed a Hoyer (total mechanical lift) required and to use a size Large - Green sling. The Patient Sling Reference Guide sheet received on 8/1/12 revealed the bins were labeled with the correct size and weight guidelines. The sheet revealed the sling size can vary significantly depending on the patient weight and girth and are general guidelines.

Based on observation, and record review, and staff interviews, the facility failed to provide consideration, respect, and treat Resident #8 with dignity for his/her personal needs. Reasonable people in our culture would feel undignified if they asked for assistance to use the bathroom and instead had to use an incontinent brief. The facility identified a census of 110 residents. Findings include: 1. A [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment tool dated 5/23/12, documented Resident #8 sometimes had the ability to make themselves understood and understood others, demonstrated a fluctuating attention span, required extensive assistance of staff with bed mobility, transfers, walking in his/her room, dressing, toilet use and personal hygiene. The MDS documented the resident as occasionally incontinent of urine. A Care Plan dated 2/15/12, documented the resident had a problem with alteration in elimination related to urinary dribble, wore a pad for dignity and security, had the awareness of the need to go to the bathroom (urinate) and would frequently yell help when he/she needed to toilet between the toileting schedule. The Care Plan directed staff to provide prompt toileting before and after meals, at bedtime and as needed. A hospital Discharge and Transfer form dated 5/14/12 documented the resident did not bear weight on his/her left leg and transferred from bed to chair only with assistance. An observation 5/18/12 at 9:35 a.m, revealed the resident lying in his/her bed calling to staff for staff toileting assistance and stated, oh please, oh please, I need to go to the bathroom. Staff F, Licensed Practical Nurse, confirmed he/she was in the resident's room just prior to the observation and the resident requested to go to the bathroom, so Staff F called staff to assist the resident. An observation 5/18/12 at 9:45 a.m., revealed Staff G, Certified Nursing Assistant (CNA) entered the resident's room and begun to set up equipment. During the equipment set up, the resident continued to state, " oh please, oh please, I have to go to the bathroom. " At 9:47 a.m., Staff H, CNA and Staff D, RN also entered the room. Staff G, Certified Nursing Assistant asked the RN if the resident was a, "check and change" or if staff took the resident to the toilet. The RN did not respond. Staff G left the room briefly and returned to confirm the resident was a "check and change." Staff G and Staff H then removed the resident ' s brief, which was soiled with urine and provided incontinence care for the resident and replaced the residents brief. During the incontinence care, staff positioned the resident back and forth on his/her fractured left hip. During an interview 5/18/12 at approximately 10:15 a.m., the Director of Nursing confirmed staff should have toileted and/or used a fracture bedpan for the resident based on physical therapy and/or physician recommendations. The Good Samaritan Society Procedure for Resident Dignity form dated 4/05, documented the policy promoted, encouraged, supported and enhanced the resident's self esteem and self-worth and assisted with respecting and abiding by the resident's rights. The procedures included the following: a. Grooming residents as they wished to be groomed. b. Refraining from practices demeaning to the residents such as refusing to comply with the resident's request for toileting assistance.

Based on record review, staff interviews, observation, and policy review, the facility failed to provide adequate supervision against hazard; and accurate assessment in response to Resident #8's symptoms. Resident #8 fell when staff left him/her unattended on the edge of the bed and immediately following the fall, staff failed to accurate assess the resident's symptoms and instead lifted the resident back into bed. Staff interviews identified the resident complained of hip pain after the fall and while being transferred back into bed and record review identified the resident sustained [REDACTED].#10's safety. Concerns were identified for two of five residents reviewed with a facility census of 110 residents. Findings include: 1. A Minimum Data Set (MDS) assessment with the assessment reference dated of 5/2/12, documented Resident #8 sometimes had the ability to make themselves understood and understand others with fluctuating inattention. The assessment revealed Resident #8 had active [DIAGNOSES REDACTED]. The assessment identified Resident #8 required two (2) staff physical assistance with bed mobility, transfers, ambulation in his/her room, dressing, toilet use and personal hygiene. The assessment determined Resident #8 required stabilization from staff when moving from a seated to standing position, when walking, during surface to surface transfer (transfer between bed and chair or wheelchair) and when moving on and off the toilet. The MDS assessment documented the resident had impairments on both sides of his/her upper and lower extremities and had one fall with injury since admission and/or his/her last assessment. A Care Plan dated 2/15/12, documented the resident had been at risk for injury from falls related to arthritis, of joints, impaired circulation, edema of his/her lower extremities and legally blind. The resident had fluctuating balance and gait, memory loss with impaired safety awareness (may transfer/ambulate without assistance). The approach's included the following: a. Transfer with the assistance of a walker, gait belt and 1 assist. b. Be aware he/she may have transferred herself/himself (dated 2/25/12) c. Pressure alarm to bed at all times (dated 3/15/12) Resident #8 ' s Falls Data Collection Tool form dated 5/10/12 revealed he/she scored 28. A score of 12 or more indicated the resident was at high risk for falls. The Incident Detail forms revealed the resident had fallen on 3/15/12(no injury) and also on 2/23/12 with a reddened area to his/her back. A Transfer Lift Assessment for Residents form dated 3/22/12, documented the resident transferred and ambulated with limited to extensive assistance of one staff member and utilized a walker. An Interdisciplinary Progress Note entry dated 5/10/12 at 6:15 a.m., revealed Staff A, Licensed Practical Nurse documented she had heard the resident from the nurse ' s station hollering out. Staff A entered Resident #8's room and documented she noted the resident lying on his/her buttocks on the floor beside his/her bed. The alarm was sounding. Staff A documented the resident' s vital signs (a temperature of 95.8 degrees, blood pressure of 81/43, pulse at 24 and respirations at 20). Staff A documented the resident complained of severe left hip pain with no other injuries noted, and no redness or bruising. Staff A documented the resident had been assisted back to bed and the physician notified of the incident and she was awaiting a return call. An Interdisciplinary Progress Note entry dated 5/10/12 at 6:30 a.m., revealed Staff A, Licensed Practical Nurse documented a new order had been received and noted, see physician's order [REDACTED]. An Interdisciplinary Progress Note entry dated 5/10/12 at 7 a.m., revealed Staff A, Licensed Practical Nurse documented the ambulance had been at the facility for pick up, paperwork sent and the resident left the facility in stable condition, he/she had not hit his/her head and the resident's fall had been witnessed by the CNA. The report had been called to the hospital. The progress notes entry at 1 PM on 5/10/12, documented the family member informed the facility staff Resident #8 had been admitted to the hospital and sustained a hip fracture. An Interdisciplinary Progress Note entry dated 5/10/12 at 12:45 a.m., documented the resident had been in surgery now for repair of a left hip fracture. An Incident Details form dated 5/10/12, revealed Staff A, Licensed Practical Nurse documented the fall had occurred on 5/10/12 at 6:15 in the resident's room. The resident had slipped and fell on buttocks beside his/her bed. The nurse documented Staff B, Certified Nursing Assistant had been present and went to get resident up for routine cares per the resident's norm. The CNA had assisted the resident to sit up on the side of the bed per usual routine and get the resident's clothing for the day. The CNA told the resident she had been getting his/her clothes and he/she would be right back to wait there (on the side of the bed). Staff A, Licensed Practical Nurse documented the part of the resident's body allegedly injured had been his/he left hip, that the resident complained of left hip pain and that his/her vitals had been as stated above. The nurse documented the type of assessment/evaluation and/or medical treatment that had been performed as a result of the incident had been a fall assessment skin check, vital signs and a pain assessment (there was no further details documentation). The immediate intervention had been to assist the resident off the floor to his/her bed. The nurse documented under the comments section that the resident's bedside table had been at the resident ' s bedside next to the dresser, the wheelchair at bedside at the foot of the bed and the walker by the closet. The resident had last been seen during shift change rounds and the resident had a history of [REDACTED]. The nurse documented the Administrator, Physician and family had been notified. Staff A, Licensed Practical Nurse, documented the fall had been a repeat incident and the resident had fallen in the past 31-180 days and had medical conditions that included Alzheimer' s with behavioral disturbances, peripheral vascular disease, glaucoma and increased anxiety. The nurse summarized the factors that may have contributed to the incident as based on the information gained the resident had been doing his/her usual activity at the time with the usual staff. The resident had attempted to self transfer which resulted in a fall and the resident had yelled out after the fall. Staff A, Licensed Practical Nurse documented the results of the investigation as the resident had been getting up the usual time, with the usual activity and the usual staff. The CNA had spoken to the resident after the resident had been positioned on the side of the bed and told the resident to hold on he/she would have been right back, she had been going to get the resident ' s clothes for the day out of the closet. The resident self transferred and fell . The Staff B, Certified Nursing Assistant told the nurse the resident had not hit her head or say anything to the staff member prior to his/her self transfer. The resident had a history of [REDACTED]. The resident complained of severe hip pain with no other injuries noted. The resident had slippers on his/her feet, no incontinent episodes and/or requests for toileting. During an interview 5/18/12 at 12:40 p.m., Staff A, Licensed Practical Nurse, stated he/she had heard the resident yell from the nurse's station so she went to the resident's room and found Resident #8 on the floor with his/her head up against the bedside stand with Staff B holding the resident's head. Staff A stated she assessed Resident #8, did vitals and checked his/her hips for bruising and redness. When Staff A was asked if the resident's legs/feet had been rotated, she responded by saying, " you have to understand the resident had club feet" and you cannot tell but he/she had on slippers. " Staff A acknowledged Resident #8 had complained of pain to his/her hip and back but basically all over. Staff B stated the resident wanted to get up and the CNA already had the gait belt around him/her and the resident's knees were bent so with the CNA on the resident ' s right side and herself on the resident's left side they stood Resident #8 up with the gait belt. Staff A stated the resident took a few steps and the staff sat him/her on the bed. Staff A stated the CNA supported the resident's upper torso while she supported the resident's legs and they positioned the resident in bed all the while Resident #8 complained of pain throughout the entire process. Staff A stated it was hard to know what had been going on but she thought Resident #8 was not hurt. When asked if she performed range of motion, checked for any deformity and or rotations she stated yes and she did a fall assessment and documented that on the incident report. When asked what the fall assessment entailed she stated, vitals, range of motion and stuff. When asked where that information was documented she stated," just where she wrote the fall assessment, on the incident report. " Staff A stated she then went to the nurse ' s station, called the resident's family member, physician, and got him/her outta there which took about 30-35 minutes. Staff A stated the resident was usually up and down and an anxious person. When asked if she was sure the resident had been transferred back to bed after the fall with a 2 person assist, (verse a 3/4 person assist), Staff A stated she thought the transfer was with 2 people. During an interview 5/18/12 at 12:25 p.m., Staff B, Certified Nursing Assistant, confirmed she had gone into Resident #8's room to awaken him/her for a bath. Staff B stated she sat Resident #8 on the edge of the bed, went to the closet to get clothes and when/he she turned around she heard a "curplunk" sound. The staff member turned around and Resident #8 was on the floor at the side of the bed with his/her bottom on the ground and with his/her legs slightly bent. Staff B, Certified Nursing Assistant then ran to make sure the resident had not hit his/her head and yelled for the nurse who had been at the nurse ' s station. When Staff B was asked if the resident ' s leg had been rotated in any way, she confirmed she thought the resident's leg had been internally rotated. Staff B, Certified Nursing Assistant stated when the nurse arrived she assessed the resident and then they transferred the resident to his/her bed utilizing 3 staff members. Staff B stated she along with the nurse had supported the resident's upper torso utilizing a gait belt while another staff (unknown staff) member supported the resident's lower body and the resident had been positioned in bed. Staff B, Certified Nursing Assistant confirmed the resident had complained of pain throughout the entire process. When Staff B was asked if she felt it was appropriate to sit a fall risk resident on the edge of the bed unattended even if the resident had been alarmed and responded, no probably not, she should not have done that. During an interview 5/18/12 at 10:42 a.m., Staff C, Certified Nursing Assistant, confirmed the resident had been a 1 to 2 person assist prior to the fall and that staff should have never leave a resident at risk for falls, unattended on the edge of their bed. During an interview 5/18/12 at 10:50 a.m., Staff D, Registered Nurse, confirmed that if a resident had fallen he/she would have first assessed them and if the resident complained of pain or severe pain they would not have moved the resident. During an interview 5/18/12 at 11 a.m., Staff E, Registered Nurse, confirmed that if a resident had fallen he/she would have assessed the resident and call a physician but it would have depended if the resident had complained of hip pain. If the resident had complained of hip pain he/she would not have moved the resident and/or expect the resident to have been moved. The staff member confirmed he/she had not felt it had been an acceptable practice to sit a resident at fall risk, unattended on the edge of the bed even if the staff member had just been across the room. During an interview 5/18/12 at 12:10 p.m., Staff J, Registered Nurse, confirmed it had not been appropriate for nursing assistants to set residents who had been at a fall risk on the edge of the bed unattended even if the resident had been alarmed. The staff member also confirmed it was not appropriate to transfer a resident after a fall if they complained of hip pain. During an interview 5/18/12 at 11:45 a.m., Staff H, Certified Nursing Assistant, confirmed he/she would not set a resident at a fall risk, even if alarmed, up on the edge of the bed unattended even if he/she had been in the same room. During an interview 5/18/12 at 2:30 p.m., the Administrator confirmed there had been no staff counseled following the residents fall. Review of the facilities Procedure for a Fallen or Injured Resident form dated 4/11, documented the purpose had been to give prompt treatment, prevent further injury and to make staff aware of required and optional documentation related to falls. The procedures included the following: a. DO NOT MOVE THE RESIDENT. b. The charge nurse needed to observe the resident and perform a full body exam to determine if there had been any suspected fractures and direct whether to move the resident. Use a lift if a resident had been transferred. Do not attempt to move the resident if a spinal or hip fracture had been suspected. Review of the facilities Fallen or Injured Resident Job Aid form, documented the staff were to assess and document the following information post a fall when the resident had not hit their head: a. Do not move until the primary and secondary evaluation had been complete. b. Call for assistance. c. Complete a primary assessment: 1. airway 2. breathing 3. circulation - control bleeding if present. d. Complete a secondary assessment: 1. level of consciousness (loc). 2. neuro checks if altered loc. 3. vital signs. 4. full body exam. 5. stabilize and stranger as indicated (mechanical lift, ambulance). e. Observations: 1. vitals every 4 hours or more if change of loc or condition. 2. monitor response to interventions implemented. 3. monitor for new symptoms and/or pain. f. Notify physician, family and others as indicated. g. Documented per procedures. A Good Samaritan Society Job Description form for a Charge Nurse - LPN/LVN dated 3/10, documented the nurse's responsibility had been to provide care to assigned residents in a caring, safe and efficient manner; and was responsible to perform the following according to the Good Samaritan mission, center/campus standards, procedures and individualized resident care plans. a. Safety: Responded appropriately to emergency needs in the center which included falls. b. Documents incidents or accidents in resident record and all necessary forms. 2. A [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], documented Resident #10 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The assessment revealed the resident required two person physical assistance with bed mobility, transfers, ambulation in the corridor, dressing, toilet use and personal hygiene. The MDS assessment documented the resident had impairment on one side of his lower extremities and had one fall without injury since admission to the facility and/or his/her prior assessment. A Care Plan dated 3/14/12, documented the resident had a problem with impaired mobility related to a fall with a right acetabular fracture, cognitive impairment with fluctuating mental status and impaired safety awareness. The approaches directed staff to use a pressure alarm oh his/her bed and chair and for staff to check placement and functioning every shift. A Falls Data Collection Tool dated 2/25/12, documented the resident had a fall risk score of 30. A score of 12 or above equals high risk. An Incident Detail form dated 2/25/12 at 3:40 a.m., documented the resident had been found on the floor with no injury. An observation 5/18/12 at 8:25 a.m., revealed the resident had been positioned in his/her wheelchair in the hallway outside of the activity room at the end of the 200 hallway without his/her pressure alarm appropriately attached. The resident had been sitting on the pressure mat, the alarm box had been attached to the back rest of the wheelchair and the connecting wire had been hanging to the right of his/her wheelchair not attached. During the observation Staff K, housekeeping, Staff C, Certified Nursing Assistant and Staff L, Social Services Assistant walked right by the resident without attempting to re-attach the alarm. During an interview 5/18/12 at 8:32 a.m., the Director of Nursing confirmed the alarm had not been attached and checked to see if the connecting wire had been tangled which it had not.

Based on record review, and staff and family interviews, the facility failed to provide consideration, respect, and privacy for 1 of 26 reviewed residents (Resident #10) who had fallen and was left lying on the floor, uncovered, and unattended, with the door open, for an hour while waiting for the ambulance to arrive. Reasonable people in our culture would feel degraded and undignified lying on the floor, after a fall with injuries, with no blanket covering them, and the door to their room left open so anyone going down the hallway could observe the person laying on the floor. The facility identified a census of 114 residents. Findings include: According to the quarterly Minimum Data Set ((MDS) dated [DATE], Resident #10 had [DIAGNOSES REDACTED]. The assessment indicated the resident's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The resident relied totally on two staff for bed mobility, transfers, and toilet use. The resident's care plan dated 3/9/11 directed staff to transfer him/her with assist of two staff and a hoyer lift (mechanical lift). An Incident Report, dated 4/16/11 at 4:20 p.m., indicated the resident fell from the hoyer lift during a transfer, resulting in a [MEDICAL CONDITION] and left hip pain (later diagnosed as a [MEDICAL CONDITION]). During an interview on 5/4/2011 at 11:15 a.m., Staff U, Registered Nurse (RN), stated she was called to Resident #10's room on 4/16/11 by walkie talkie. When she entered the room, the resident was lying on the floor with a pillow underneath his/her head. No blankets covered the resident. She further stated she did not put any blankets on the resident from the time of the fall up to when the ambulance arrived to transport the resident to the hospital. During an interview on 4/27/11 at 1:00 p.m., Staff T, certified nursing assistant (CNA), stated she was in and out of Resident #10's room from the time of the his/her fall at 4:20 p.m. until she left the room for her supper break at 4:30 p.m. The last time she saw Resident #10, he/she was lying on the floor, and Staff T stated she was almost positive there was a pillow under her head, but the resident did not have any blankets covering his/her body. Later, when she was walking down the hall she glanced into the resident's room and again noted no blankets covered the resident. Staff V, R.N., for the hallway where Resident #10 resided, stated during an interview on 5/4/11 at 12:30 p.m. that she had placed 2 pillows under Resident #10's head after the fall on 4/16/11, but did not observe or direct any staff member to place blankets over the resident. Staff V further stated that a resident's family member arrived at the facility at approximately 5:00 p.m. and stayed in the resident's room with the resident until the ambulance arrived to transport him/her to the emergency room . During a subsequent interview on 5/25/11 at 3:45 p.m., Staff V indicated the resident had been wearing slacks and a shirt at the time of the fall and that the resident's bedroom door had remained open during that hour between the time the resident fell and when the ambulance crew arrived. Staff W, CNA, stated during an interview on 5/4/11 at 3:30 p.m. that she was in the resident's room when the fall from a Hoyer occurred at 4: 20 p.m. and she remained there until she was told to go to the dining room to assist with feeding residents. She proceeded to the dining room before 4:50 p.m. During this time no blankets were placed over the resident. On 4/27/2011 at 1:30 p.m., the Director of Nursing stated she had counseled the nurses about providing pillows and blankets for residents who have fallen and staying with them with them until an emergency crew arrives. During an interview on 5/4/11 at 10:30 a.m., the resident's family member stated she arrived at the facility after being notified of the resident's fall on 4/16/11. She entered the facility and saw 3 nurses at the nurses' station who stated they were checking on the resident at various intervals. The family member proceeded to the resident's room and found the resident alone in the room, lying on the floor, and bleeding from a [MEDICAL CONDITION]. There were no blankets covering the resident. She stayed with the resident until the ambulance crew arrived at the facility.

Based on record review and staff interviews, the facility failed to assess and provide interventions for one resident (Resident #16) who complained of severe pain secondary to a pressure sore, and failed to continuously monitor one resident (Resident #10), who had fallen out of a hoyer lift and hit his/her head, while the resident laid on the floor waiting for the ambulance to arrive. The sample consisted of 26 residents and the facility reported its census as 114 residents. Findings include: 1. According to a Minimum Data Set (MDS) significant change assessment, with a reference date of 1/19/11, Resident #16 had moderately impaired cognition, relied extensively on staff for bed mobility and transfers, did not walk, and had an unstageable pressure ulcer with suspected deep tissue injury (an unstageable ulcer cannot be staged due to the presence of necrotic tissue covering the wound) . The assessment reflected the resident experienced almost constant pain on a daily basis which interfered with his/her day-to-day activities. The resident rated his/her pain as a "5" on a scale of 0-10, with 10 being the worst pain imaginable. See F314. The resident's care plan dated 9/16/10 with a goal date of 2/16/11 did not address the resident's pain related to his/her left heel ulcer. The care plan instructed staff to observe/listen for complaints of pain, administer [MEDICATION NAME] as ordered, observe for effectiveness, and notfify the physician if the resident's pain was uncontrolled. The care plan advised staff that "mood" may be a pain indicator. According to the resident's January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also had an order for [REDACTED]. 1/6/11 at 1:45 a.m. 1/9/11 at 12:45 a.m.-helpful 1/12/11 at 4:00 p.m.- "+" 1/15/11 at 12:00 p.m. 1/17/11 at 4:00 a.m.-"+" The MAR indicated [REDACTED]. Facility staff documented on a pain management review sheet the following entries: 1/3/11-[MEDICATION NAME] 5 mg prn for left leg spasms 1/10/11-Had left heel open area, has [MEDICATION NAME] prn 1/20/11-discontinue [MEDICATION NAME]/add [MEDICATION NAME] prn for leg spasms. Has left heel open with black eschar (necrotic) tissue. The resident's wound flow sheet attachments contained the following entries: a) On 1/15/11 (no time documented), the nurse documented the resident repeatedly pulled his/her heel along a pillow even without a dressing in place. The resident stated he/she couldn't control (this action) due to the pain. b) On 1/16/11 (no time documented), the nurse documented that he/she didn't change the dressing that had been changed on the night shift to decrease the resident's chance of pain. c) On 1/18/11 (no time documented), the nurse documented the resident's left heel had a black eschar center, and that the resident reported severe pain and often tore the bandage off (the heel). d) On 1/19/11 (no time documented), the nurse documented the resident reported severe left heel/ankle pain. The interdisciplinary progress notes contained the following entries: a) On 1/17/11 at 1:30 p.m., the nurse documented the resident refused to leave his/her legs elevated; that the resident pulled his/her left leg up to his/her chest, and that the resident was fidgeting with everything in reach. b) On 1/17/11 at 8:00 p.m., the nurse documented the resident kept his/her leg drawn up in the fetal position, and "bothered" the wrap to his/her left heel. c) On 1/18/11 at 4:00 a.m., the nurse documented the resident had been awake most of the shift, that he/she had removed the dressing, sock, and foam boot to the left foot, and pulled the leg up to his/her chest. d) On 1/19/11 at 8:00 p.m., the nurse documented the resident ripped off the dressing to his/her left heel. e) On 1/20/11 at 5:30 (p.m.), the nurse documented a late entry which stated that during the mood assessment interview, the resident indicated that he/she felt he/she would be better off dead, and thought about it more than half of the days. f) 1/23/11 at 8:00 a.m., the nurse documented the resident's heel had a foul odor, and that the resident stated he/she wanted to go the the hospital because, "I can't take the pain anymore." According to the note, the nurse made arrangements to transfer the resident to the hospital where, according to a hospital discharge form dated 1/31/11, he/she underwent an above-the-knee amputation of his/her left leg due to left heel osteo[DIAGNOSES REDACTED] (bone infection). During an interview on 5/27/11 at 8:40 a.m., Staff D acknowledged the resident had been in a lot of pain prior to his/her above-the-knee amputation of his/her left leg, that [MEDICATION NAME] reduce his/her pain, and that the resident also received [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 5/27/11 at 8:15 a.m., the resident stated the pain in his/her left foot had been, "Bad, real bad" prior to his/her surgery. When asked what the staff did for his/her pain (prior to the surgery) he/she shook his/her head, and said, "I came to the wrong place." 2. According to the quarterly Minimum Data Set (MDS) assessment tool dated 3/2/2011, Resident #10 had [DIAGNOSES REDACTED]. The MDS further indicated the resident had severely impaired cognitive skills and as totally dependent on two persons for bed mobility, transfers, and toilet use. The resident's care plan dated 3/21/11 directed 2 staff members to transfer the resident using a hoyer lift (mechanical lift). According to an incident report dated 4/16/11 at 4:20 p.m., one staff member attempted to transfer the resident in the hoyer lift which resulted in the resident falling out of the lift's sling onto the floor. The incident reported indicated Staff V performed a skin, pain, and fracture check assessment after the resident's fall and documented the resident hit his/her head resulting in a 2.5 centimeter (cm) laceration to the parietal head, and complained of left hip pain. The resident's vital signs were as follows: blood pressure-152/88, temperature -96.5 degrees Fahrenheit, respirations-16 (per minute) and pulse-67 beats per minute. During an interview on 5/4/11 at 11:15 a.m., Staff U, R.N., stated she was called to Resident 10's room (on 4/16/11) via her walkie talkie. Upon entering the room, Staff U stated Staff V, R.N., was already in the resident's room. The resident lay on the floor with a pillow under his/her head and no blanket covered the resident. During an interview on 5/4/11 at 12:30 p.m., Staff V stated that she did not recall entering the resident's room again (after her initial assessment) until the ambulance crewed arrived at 5:35 p.m. Staff V indicated the resident's daughter arrived at the facility at around 5:00 p.m. and remained with her parent until the ambulance crew arrived. Staff V stated she and Staff U sat at the nurses' station when the resident's daughter arrived. During a second interview on 5/25/11 at 3:45 p.m., Staff V estimated the resident's blood loss from his/her [MEDICAL CONDITION] to be between 15-30 cubic centimeters (cc) after the resident's fall on 4/16/11. Staff V stated staff was not always with the resident from his/her fall (at 4:20 p.m.) until the ambulance arrived. According to interdisiplinary progress notes dated 4/16/11, the ambulance departed with the resident at 5:30 p.m. During an interview on 5/4/11 at 12:00 p.m., the resident's daughter stated she arrived at the facility around 5:00 p.m. on 4/16/11 and noted 2 nurses at the nurses' station. The nurses told the family member they were checking on the resident at various times. The family member proceeded to the resident's room and found him/her along in the room, lying on the floor bleeding from a [MEDICAL CONDITION]. The family member stayed with the resident until the ambulance arrived at 5:35 p.m. and stated during this time period no staff member entered the room to check on the resident or provided any cares or services. During an interview on 4/27/11 at 1:00 p.m., Staff T, certified nursing assistant, stated she was in and out of the resident's room from the time he/she fell at 4:20 p.m. until she left the room for her supper break at 4:30 p.m. The last time she saw the resident, he/she was lying on the floor. Later, when she was walking down the hall, she glanced into the resident's room but did not enter the room. Staff W, certified nursing assistant, interviewed on 5/4/11 at 3:30 p.m. stated she was in Resident #10's room when he/she fell from the hoyer sling at 4:20 p.m. She stayed with the resident until she was told by the nurse to go to the dining room to assist with feeding other residents. She left for the dining room before 4:50 p.m. According to the Hospital Admitting Form Resident #10 was treated in the emergency room where the [MEDICAL CONDITION] was stapled. The hospital then admitted the resident for inpatient care for surgery to treat the resident's left [MEDICAL CONDITION] and [MEDICAL CONDITION]. Corporate policy for Fallen or Injured Resident directs staff as follows: 1. Do not move the resident. 2. Remain calm and reassure and comfort the resident. 3. Summon charge nurse or other help. 4. If the resident is bleeding, locate the injured area and apply continuous, firm pressure to the area. 5. Do not remove any blood soaked dressings or clothing, but instead add more layers to absorb the blood. 6. Cover the resident and have him or her lay quiet until help arrives. 7. Take the resident's blood pressure, pulse and respiration to help assess the resident's condition. 8. The charge nurse needs to observe the resident and direct whether to move the resident, 9. If a head injury is suspected, the charge nurse needs to initiate a Neuro-Check Flow Sheet. 10. Notify the physician and follow any orders as directed. Document physician's response in the Interdisciplinary Progress Notes. 11. Notify the family or responsible party of the incident. An interview on 4/27/11 at 1:20 p.m. with the Director of Nursing revealed that she had counseled Staff V to remain with residents who have fallen and sustained a head injury until the emergency crew arrives.

Based on clinical record review and interviews, the facility failed to assess and provide interventions to avoid the development of a non-stageable pressure sore to one resident's left heel (Resident #16) which resulted in an above-the-knee amputation of the resident's leg (Resident #16). The facility reported 8 residents with pressure sores, four of which were reviewed. The facility reported a census of 114 residents. Findings include: According to face sheet and [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment tool, with an assessment reference date of 1/19/11, indicated the resident had moderately impaired cognition, required extensive assistance of 2 persons for transfers, toilet use, and bathing, and did not walk. The MDS assessment documented the resident had one unstageable pressure ulcer (unstageable due to coverage of the wound bed with slough and/or eschar). The resident's care plan identified on 12/13/10 that the resident wore a Bledsoe boot to the left foot-on in a.m., off at night. The care plan also identified the resident had a blister to his/her left heel on 12/25/10. The care plan approaches regarding the left heel specifically were: Foam heel protector to the left foot-ace wrap to the left foot, on in a.m./off at night. These interventions were handwritten and not dated. The care plan did not direct staff to check the resident's foot daily for pressure areas and to suspend the resident's heel to prevent pressure sores from developing. An incident report dated 11/30/10 indicated the resident had sustained a fall during a transfer to the toilet; interdisciplinary (IDT) notes dated 12/3/10 at 12:30 p.m. revealed resident had sustained a fracture to his/her left foot. An IDT note dated 12/3/10 at 2:00 p.m. revealed an order had been received for the resident to wear a Cam boot (walking boot, also referred to as Bledsoe boot) to his/her left foot and leg. An IDT note dated 12/6/10 at 9:00 a.m. revealed the resident had received [MEDICATION NAME] (over the counter pain reliever) for left foot pain and that the resident had an appointment to see an orthopedist that day. The IDT note dated 12/6/10 at 3:15 p.m. stated the resident had returned from the orthopedist's office with orders to continue wearing an ace wrap and Cam boot, and to elevate his/her leg. An IDT note dated 12/7/10 at 8:00 a.m. revealed the facility had called the physician's assistant regarding the resident's complaints of increased pain in his/her left foot. At that time, the facility received an order for [REDACTED]. The actual physician's orders [REDACTED]. On 12/11/10 at 8:00 a.m., the facility documented the resident's left anterior ankle had a red indentation from the Bledsoe boot and that the resident's heel was also red and irritated. The note also stated the resident complained the boot was bothersome all night and he/she couldn't sleep. On 12/13/10 at 8:00 a.m., the nurse documented the resident's left foot had red areas to the side of his/her foot, the left heel appeared dark purple, and the resident complained about the Bledsoe boot. At 9:00 a.m., the nurse called the orthopedist and left a message. An IDT note dated 12/13/11 at 2:00 p.m. stated a new order had been received from the orthopedist for the resident to not wear the Bledsoe boot at night. On 12/14/10 at 2:15 a.m., the nurse documented the boot and wrap were off the resident's foot per order, and that the resident's heel remained red in color. The nurse also documented the resident had his/her "legs elevated, resident removes often." On 12/17/10 at 1:00 p.m., the nurse documented the resident's left ankle continued to be swollen and bruised, and that the left dry was dry. On 12/22/10 at 10:00 a.m., the nurse documented the resident's left heel as dry. On 12/25/10 at 8:00 a.m., the nurse documented the resident's left heel had an open blister and a small abrasion. The nurse called the resident's primary care physician and received an order to apply skin prep (provides a protective film) to the area. According to a wound flow sheet dated 12/25/10, the wound measured 7 centimeters (cm) long by 4 cm wide, and was superficially open. The remaining measurements on the wound flow sheet were as follows: 12/27/10-3.4 cm by 2 cm-skin prep treatment 1/3/11----3.4 cm by 3.7 cm with 100 % eschar (necrotic tissue)-wound gel treatment (wound gel provides a moist environment intended to promote healing) 1/10/11--4.0 cm by 3.6 cm with 75% black eschar-Santyl treatment (chemically removes eschar) 1/17/11--5.0 cm by 4.1 cm, unable to measure depth, 100 % eschar The wound flow sheet attachment notes contained the following entries (not all entries): 12/30/10, no time noted-Left heel blister open-yellow drainage, tissue red, [MEDICATION NAME] applied, faxed update to physician. 12/31/10, no time noted-Left heel bleeding, dark green center, called for new orders, received orders for wound gel and culture of left heel. (laboratory results dated [DATE] of wound culture were positive for staphyloccoccus aureus.) 1/1/11, no time noted-left heel dark center, no change noted. 1/3/11, no time noted-left heel dark purple to black in color, measures 3.4 by 3.7 cm., surrounding area slightly reddened, no drainage noted, no complaints of pain, treatment to area continues. 1/4/11, no time noted-left heel black tissue, called for Santyl order. 1/5/11, no time noted-left heel black, firm tissue with white edges, Santyl to black area on heel. Has redness around outer wound also. Continues on [MEDICATION NAME] for left heel wound infection. 1/17/11, no time noted-Area to left heel measured 5 by 4.1 cm with black eschar in place, wound margins beefy red with scant amount serosanguinous drainage. 1/18/11, no time noted-left heel has black eschar center with small red, beefy border, no warmth, no drainage, resident reports severe pain and often tearing bandage off (See F309 regarding resident's pain) 1/20/11, no time noted-Left heel eschar black, pink edges. Called physician's assistant for new orders-soak with [MEDICATION NAME] (topical antiseptic) and hold Santyl. 1/22/11-Left heel black eschar/foul odor, soft tissue center of black eschar-skin peeling. 1/23/11-left heel black eschar with white edges soft center. Foul odor. Has [MEDICAL CONDITION] 2+ of left foot. Unable to determine depth of wound on heel. No drainage from heel wound. 1/23/11, no time noted-Resident wants hospital today-sent to hospital at family request. On 1/7/11, the orthopedist examed the resident and wrote the following orders: discontinue Bledsoe boot, refer to wound center for treatment of [REDACTED].! (foam heel protectors do not provide pressure relief) According to an IDT note written on 1/10/11 at 9:30 a.m., the facility contacted the VA wound clinic to set up an appointment for the resident. The facility called the VA wound clinic again on 1/12/11 at 9:30 a.m. regarding an appointment and was told the VA would call when they had an appointment set up. An IDT note dated 1/20/11 at 10:00 a.m. indicated the facility had called the physician's assistant to report an update about the resident's heel wound. The facility also called the wound clinic again regarding an appointment for the resident. A progress note dated 1/27/11, late entry for 1/20/11, stated that a call had been received from the VA wound clinic stating that the resident had an appointment on 1/24/11. On 1/23/11 at 8:00 a.m., the nurse documented the resident told him, "I want to go to the hospital, I can't take the pain anymore." The facility made arrangements to send the resident to the hospital that day. According to a discharge summary from the hospital dated 1/31/11, the resident had been admitted with a gangrenous left foot ulcer requiring a left, above-the-knee amputation. The facility readmitted the resident on 1/31/11. Staff D, L.P.N., indicated during an interview on 5/26/11 at 10:00 a.m. that she knew the resident well and had cared for him often after he/she fractured his/her ankle and ended up wearing the Bledsoe boot. Staff D stated she hated those Bledsoe boots because the elderly couldn't tolerate them and developed pressure sores from wearing them. When asked if there had been any discussion about changing the Bledsoe boot to another boot that suspended the heel once the heel appeared reddened, she stated "no." Staff D indicated the Bledsoe boot had been discontinued and the resident had then worn a foam boot. Staff D had been the nurse on duty who documented the presence of a foul odor from the resident's heel wound on 1/22 and 1/23/11. When asked why she didn't call the physician to report this finding she stated she didn't because the wound didn't appear any differently to her. Staff D indicated the resident had told her on that Sunday (1/23/11) that he couldn't take the pain anymore and needed to be sent to the hospital. She felt she had done everything she could for him/her and was surprised when she found out the resident had osteo[DIAGNOSES REDACTED] and they had to take his/her leg. An interview with the assistant director of nursing on 5/25/11 at 2:30 p.m. revealed that it was the unit manager's responsibility to monitor the resident's skin conditions on his/her unit, and that the unit manager who was responsible for the resident's care in December and January 2011 no longer worked at the facility. When asked why there were no skin sheets regarding the resident's left heel beginning on 12/11/11 when the heel first appeared reddened, she replied that the redness was considered to be an abrasion, not a pressure area.

Based on record review, observation, and staff interviews, the facility failed to assess and implement interventions intended to prevent serious injury for one resident (Resident #2) who fell out of his/her lift chair four times; the last fall resulted in a fractured left clavicle. The facility also failed to follow care plan interventions for one resident (Resident #20) who experienced numerous falls. The standard sample consisted of 26 residents and the facility reported its census as 114 residents. Findings include: 1. According to the comprehensive care plan dated 3/23/11, Resident #2 had [DIAGNOSES REDACTED]. The facility admitted the resident on 12/14/2010. The Minimum Data Set (MDS) assessment with a reference date of 3/19/11 reflected the resident as cognitively intact, and as exhibiting frequent verbally abusive behaviors directed towards others. The assessment further indicated the resident required extensive assistance of 2 staff for bed mobility, transferring, and toilet use. The resident's comprehensive care plan dated 3/23/11 identified the resident at risk for injury from falls due to [DIAGNOSES REDACTED] (one-sided weakness) and a fall history from home. The care plan directed staff to transfer the resident using an EZ stand (mechanical lift that requires resident have some weight-bearing ability) and 2 staff members. The care plan also directed staff to offer to place the resident in his/her recliner chair when he/she returned from dialysis (to treat end-stage renal disease). The care plan did not state the resident preferred to sleep in his/her lift chair at night. The care plan also identified the resident at risk for chronic confusion related to mild memory loss, inappropriate decision making ability, demanding and inpatient behaviors, non-compliance with fluid restrictions and treatments, and yelling out "help" and cursing behaviors. The planned approaches included allowing the resident to make many of his/her own decisions. An interdisiplinary progress (IDT) note dated 3/16/11 at 3:00 p.m. stated the resident slept in a recliner in his/her room. An incident report dated 3/15/11 at 10:30 p.m. indicated staff had found the resident sitting on his/her buttocks on the floor of the bedroom. The resident stated he/she had slipped out of the lift chair on to the floor when he/she leaned forward in the chair while sleeping. The resident sustained [REDACTED]. Interventions listed on the report were as follows: Put up feet in recliner and ask him/her to please leave them that way. These interventions were not written on the resident's care plan. According to an IDT progress note dated 4/24/11 at 4:30 a.m., the nurse had heard the resident yelling for help from his/her room; the nurse found the resident lying on the bedroom floor on his/her left side. The resident stated he/she had fallen out of the recliner. The nurse documented staff had educated the resident several times that shift to lean back in the chair and keep it in the reclined position. The note stated the resident had agreed to sleep in a bed and that the maintenance man had been contacted (to place a bed in the room). The resident sustained [REDACTED]. The incident report dated 4/24/11 stated the resident would not comply with staff requests to sit back in the recliner and keep the chair reclined. An IDT note dated 4/27/11 at 1:15 a.m. reflected the resident had fallen asleep in the recliner in the "up" position and had fallen out of the chair onto the floor. The resident sustained [REDACTED]. The care plan had a notation dated 4/28/11 which read: Floor mat when in bed/recliner. An IDT note dated 5/11/11 at 2:15 a.m. indicated that at 1:15 a.m. that same day the nurse heard a noise from the resident's room, and the resident yelling for help. The nurse found the resident lying on the floor and complaining of pain to his/her left shoulder, neck, and left hip. The nurse documented she and a certified medication aide had been in the resident's room at 12:45 a.m.; at that time the resident was playing with the chair's remote control and the chair was in the up high position. Staff encouraged the resident to quit playing with the remote. Staff had to lower the chair's height because the resident's attempts to do so were unsuccessful. According to the same note, staff assessed the resident and made arrangements for the resident to be transferred to the emergency room for evaluation and treatment at 1:55 a.m. The resident returned to the facility later that morning at 5:55 a.m. with a fractured clavicle (that was treated by the resident wearing a sling). An interview on 5/26/11 at 9:40 a.m. with Staff X, the registered nurse on duty when the resident fell on [DATE], revealed the chair had been in the "up" position when she came into the resident's room and found him/her on the floor. Staff X stated she and a certified nurses' assistant had been in the resident's room multiple times that night, encouraging him/her to lie back in the chair with his/her feet up, but that the resident refused to remain seated that way. Staff X acknowledged trying to convince the resident to transfer from the recliner to the bed, but that he/she refused to do so. An interview with Staff B, nurse manager, on 5/26/11 at 9:30 a.m. revealed a bed had been placed in the resident's room after his/her fall on 4/24/11, but that the recliner had not been removed from the room. Staff B stated the resident complained of discomfort after lying in the bed after an hour or so and would then demand to be transferred into the recliner. Staff B stated that after the fall on 5/11/11, the resident and his/her spouse agreed to have the recliner removed from the bedroom. When asked if the resident continued to complain of discomfort after lying in the bed, Staff B stated that he/she no longer complained and seemed to be used to the bed. Further review of the resident's record revealed only one instance in which staff documented the resident refused to be transferred to the bed and that occurred on 4/28/11 at 9:00 p.m. The resident's care plan had notations dated 5/11/11 which included: remove recliner-high-low bed to be in the lowest position when resident in bed; transfer resident with hoyer lift instead of EZ stand. Observation of the resident's room on 5/26/11 at 8:30 a.m. revealed the presence of 2 beds and no chairs. 2. The MDS (Minimum Data Set) assessment tool dated 4/28/11 documented Resident #20 had [DIAGNOSES REDACTED]. According to the MDS, the resident required extensive assistance of one person with bed mobility and transfers. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive loss. The assessment identified the resident experienced falls without injury. Review of facility incident reports revealed falls on the following dates: 12/30/10 at 4:35 AM 12/30/10 at 7:40 PM 12/31/10 at 10:45 PM 1/5/11 at 8:10 PM 1/29/11 at 2:15 PM 2/20/11 at 7:15 PM 4/9/11 at 6:35 PM 4/24/11- no time indicated A Falls Data Collection Tool dated: 2/20/11 scored 22 4/8/11 scored 28 4/24/11 scored 27. According to the Falls Data Collection Tool, a score of 12 or more equals high risk and instructed to proceed to care plan approaches. A care plan dated 2/24/11 identified a concern with a risk for injury from falls related to dementia with impaired safety awareness, acute and chronic conditions with generalized weakness/debility, impaired balance, tremors, Hospice care with terminal prognosis. The same care plan instructed the staff to apply a pressure alarm to the bed and chair at all times. Observation on 4/27/11 at 3:35 PM revealed Staff H, certified nursing assistant (CNA) entered the resident's room to take the resident to the bathroom. Staff B, registered nurse (RN) and unit manager observed the care along with the surveyor. Observation revealed the resident sat in a recliner in the room facing the doorway into the hall. Staff H applied a gait belt and assisted the resident to stand to begin ambulating (walking) with staff and a walker. Observation revealed the resident with severe extremity tremors. Observation revealed no alarm sounded as the resident stood from the chair. Staff H assisted the resident into the bathroom. The CNA washed her hands and gloved, then checked the resident's brief. The CNA removed the brief stating the brief contained a bowel movement (BM) smear. The CNA performed pericare for the resident after taking him/her to the bathroom and assisted the resident with ambulation back to the recliner. The CNA sanitized her hands, placed the resident's oxygen on per nasal cannula and gave the resident his/her call light. The CNA exited the room and walked up the hall to get water for the resident's humidifier on the oxygen concentrator. The CNA returned to the resident's room and filled the humidifier. The surveyor inquired of the CNA if she could show the surveyor the alarm on the resident's recliner. The CNA stated at this time that the alarm was not on the chair. The CNA walked behind a room curtain and located the pressure alarm from the seat of the resident's wheelchair. She then assisted the resident up and placed the alarm under the resident in the recliner, activating the alarm. Review of a facility policy dated October 2008 entitled Prevention and Management of Falls Practice Guidelines conveyed the following guidelines to the staff: 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 the national Campus support. A successful Falls Prevention program consists of the program operationalization, providing motivation/incentives to celebrate success and ongoing evaluation of staff skill sets related to the program.

Based on clinical record review and staff interviews, the facility failed to assess Resident #2' s bowel status for 1 of 5 residents reviewed for constipation. The facility reported a census of 112 residents. Findings include: The facility procedure titled Bowel Elimination indicated the night nurse is responsible for checking and evaluating the daily elimination records and the nurse will make a list of residents that need further monitoring or assessments. The information will be given to the oncoming shift and will need to be communicated during the report between shifts. The guidelines identified in the procedure are as follows: Day 2 if no bowel movement, offer prune juice or encourage fluids. Day 3-administer a prn laxative as ordered by the physical Day 4-assess the resident's bowel sounds, assess abdominal distention and do rectal check for the presence of stool and administer a prn rectal laxative as ordered. According to the Minimum Data Set ((MDS) dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. The assessment identified the resident made poor decisions and required cues and supervision. The assessment revealed the resident sometimes made him/her(self) understood and sometimes adequately responded to simple communication. Resident #2 had physically abusive behavior and resisted cares daily. The resident required extensive assistance of 1 staff for bed mobility, eating, dressing, and personal hygiene and required extensive assistance of 2 staff for transfers and toilet use. Resident #2 had occasional bowel incontinence. Review of the Comprehensive Care Plan dated 9/23/10, Resident #2 had [DIAGNOSES REDACTED]. 1. Provide management of bowel and bladder incontinence. 2. To observe the resident from scratching or digging at their peri-rectal area. 3. Encourage fluid intake between meals to decrease risk of urinary tract infections or constipation. 4. Observe stool/urine for changes in color, clarity and odor, report hard/loose stool or dark odorous urine to charge nurse. Review of Resident #2's September 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #2's Bowel record, the resident did not have bowel movements for the following dates: 9/2-9/6/10 (4 days); 9/17-9/21/10 (4 days) and 9/30-10/3/10 4 days). Review of the Interdisciplinary Progress Notes from 9/1/10 to 9/24/10, showed no bowel assessment completed or communication with the staff regarding the resident ' s bowel status. Review of the Interdisciplinary Progress Notes dated 9/23/10 revealed the resident had an episode of vomiting and had a pale skin tone. The resident had a very loose, watery, light brown stool. The staff called the Physician's Assistant to report and obtain orders. The PA ordered the resident to have a medication to stop the vomiting and loose stools. The notes revealed the resident's condition continued to decline, noting lethargy and refusal to consume fluids or food. The staff obtained an order for [REDACTED]. Review of computerized tomography (CT) scan of Resident #2 ' s abdomen and pelvis with contrast performed on 9/25/10 reveled the resident had a probable fecal impaction. The report determined a large amount of rectal stool measuring up to 7 centimeters in diameter. The preliminary report dated 9/27/10 documented the finding from the inpatient hospital stay. The report indicated the resident's bowel gas pattern was non-obstructive with no evidence of free air and there was no [MEDICATION NAME] distention to suggest ileus (obstruction of the intestine due to paralysis of the intestinal muscles) at this time. Review of the Patient Discharge and Transfer Form dated 9/29/10 indicated Resident #2 had discharge [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress Notes from when the resident returned from the hospital on [DATE] to 10/3/10, showed only two occasions when the nurse assess for bowel sounds (9/29/10 and 9/30/10). Interview with Staff A on 10/13/10 revealed Resident #2 is dependent on staff for his/her toilet needs. During an interview with the Director of Nurses on 10/13/10 at 8:05 a.m., the interview revealed no further information regarding the bowel elimination status for Resident #2 in September, 2010. The Director of Nurses stated the night nurse will run a report from the data imported from the aides hand held devices, the information is passed along in report. The Director of Nurses stated she could not find any 24 hour reports with bowel information on them for Resident #2. As of the exit, the facility did not submit any additional information on Resident #2. According to the American College of [MEDICATION NAME] (ACG) in 2005 a task force defined constipation as an unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. Difficult stool passage includes straining, a sense of difficulty passing stools, incomplete evacuation, hard/lumpy stools, prolong time to pass stool, or need for manual maneuvers to pass stool. According to an article titled " [MEDICATION NAME]: Constipation and Fecal Impaction," in the University of Iowa Family Practice Handbook, 4th Edition, Chapter 5, a fecal impaction is a firm, immobile mass of stool most often in the rectum. The article identified in the present of symptoms of fecal impaction, the facility is obligated to determine whether or not the resident is in fact, impacted and to provide appropriate treatment.