Every finding on record at Good Samaritan - Ottumwa

Based on clinical record review, hospital records, interviews, and policy review the facility failed to provide a hospital receiving one of their residents for care with adequate information about the resident at the time of the transfer (Resident #2). The facility reported a census of 97 residents.Findings include:The Minimum Data Set (MDS) for Resident #2 dated 07/02/2026 documented diagnoses of orthostatic hypotension (sudden drop in blood pressure when standing from a sitting or lying position), non-Alzheimer's dementia, and chronic congestive heart failure (the heart can not pump blood well). The Brief Interview for Mental Status (BIMS) assessment indicated a moderate cognitive impairment score of 10/15.A Progress Note titled Health Status dated 07/11/2026 at 2:13 PM indicated Resident #2's family asked Staff B, Licensed Practical Nurse (LPN) to come to the resident's room at 1:57 PM because he was not breathing well and had purple lips. Staff B entered the room to check on the resident and adjusted the head of the bed. The resident's family member did not let the nurse conduct further assessment of the resident and Staff B called 911 around 2:07 PM.A document titled ED (Emergency Department) Physician Record dated 07/11/2026, page 1 of 7, documented that all of the information obtained regarding the resident was obtained from prior medical charts and EMS (Emergency Medical Services). Per EMS there was no staff around to help the resident when they arrived. The Electronic Health Record for Resident #2 did not include documentation regarding the information sent with the resident to the hospital about his health status, medications, reason for the transfer, or resident demographics.During an interview with Staff B on 08/04/2026 at 9:54 AM she stated that when a resident had a change in condition nurses should go check on the resident, assess vital signs, ask questions, and follow up based on what they said or needed. She stated she completed vitals on Resident #2 that morning with no concerns noted. After lunch the resident was tired and the Certified Nurses Aides (CNAs) helped him to bed. Staff B stated the resident's family came in and soon after came to get her because 'something was wrong'. She raised the head of the resident's bed further and left to call the weekend nurse manager. The family member would not let her back in the room to complete an assessment, but Staff A, Registered Nurse (RN) from 2nd shift was able to do it and informed EMS of the resident's blood pressure and oxygen saturation when they arrived. Staff B confirmed she called 911. She stated she did not give a report to EMS because the family did not want her in the room. Staff B stated they usually sent the face sheet to the hospital but she didn't print it that day. She confirmed she did not call the hospital about the resident.During an interview with Staff A on 08/05/2026 at 10:14 AM she stated she provided EMS with a report that included 77% oxygen saturation, 80/50 blood pressure, and pulse (she was unable to recall the number). She said EMS was confused about why they did not get a full report from Staff B. Staff A confirmed she did not print paperwork for EMS to take to the hospital and thought Staff B printed a face sheet and medication list. Staff A reported she did not call the hospital. The hospital called the facility later and asked who the morning nurse was, but Staff A did not provide information about the resident during that call.During an interview with Staff C, LPN/weekend nurse manager on 08/05/2026 at 9:05 AM she stated she told Staff B to do an assessment and get the resident to the hospital. Staff C expected nurses to send information regarding the resident's change in condition, the Medication Administration Record (MAR), and demographic information at least. Staff C thought the transfer information was sent to the hospital later that day by Staff B, but she did not know if that was done and stated Staff B should have done it with the transfer.A policy titled Discharge and Transfer reviewed/revised 01/15/2026 page 2 documented the following:Information provided to the receiving facility must include at a minimum: 1. Contact information of the practitioner responsible for the care of the resident. 2. Resident representative information including contact information. 3. Advance directive information. 4. All special instructions or precautions for ongoing care. 5. Comprehensive care plan goals. 6. All other necessary information including a copy of the discharge summary to ensure a safe and effective transition of care.

Based on observation, resident interview, staff interviews, the resident council notes, and the facility policy, the facility failed to routinely offer fresh water to residents for extended amounts of time for 2 of 4 residents (Resident #15 and Resident #11) reviewed for hydration. The facility reported a census of 95 residents. Findings include: 1. The Resident Council Meeting Notes dated 4/21/26 revealed no fresh ice water, and fresh water at nights is an issue. The Resident Council Meeting Notes dated 5/19/26 revealed ice water was better than it was, not every day. During a continuous observation on 6/2/26 at 6:01 AM to 10:37 AM, no water pass completed on the 200 Hall. Multiple residents sat in the common area, in their wheelchairs with no tables within reaching distance. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated that cognition severely impaired. The MDS indicated the resident needed set up/clean up assistance with eating. The diagnoses list included Alzheimer's dementia, renal insufficiency, and diabetes mellitus. The MDS indicated resident took a diuretic, antidepressant, and antipsychotic. The Task Intake (for fluids outside of meals) for Resident #15 revealed no data found for type of fluid (do not include supplements) for the last 30 days. During a continuous observation on 6/2/26 from 6:01 AM to 10:35 AM, fluid not readily available to Resident #15 while he sat in the recliner in the common area. A table was not placed near the resident. Resident given fluids during medication administration and breakfast. During an interview on 6/1/26 at 4:59 PM, Staff A, Certified Nurse Aide (CNA), stated during the day shift, water pass was hard to get to, but the evening shift CNAs did it. Staff A stated some of the residents will ask for water and the staff used a pitcher on the medication cart. Staff A stated if the staff passed water to the rooms, the water would not be cold when they went back to their rooms anyway. Staff A stated Resident #11 and Resident #15 should have been given fresh water. During an interview on 6/2/26 at 2:21 PM, Staff B, Registered Nurse (RN) asked about water pass and Staff B stated the evening CNAs did it. Staff B stated a lot of the residents couldn't have it independently so she gave it from the medication cart. During an interview on 6/2/26 at 3:40 PM, Staff C, CNA, queried on water pass and Staff C stated they were supposed to do water pass, but quite a few days the staff didn't have time to do water pass. During an interview on 6/2/26 at 5:25 PM, the Director of Nursing (DON) queried on water pass and she stated once a shift water should be passed and with the residents in the 200 hall, a pitcher should be set beside them in the common area and the staff should try to push as much fluids as they can. The DON stated the elderly don't drink unless you give it to them. 3. The MDS assessment tool, dated 4/30/26, listed diagnoses for Resident #11 which included urinary incontinence, arthritis, and diabetes. The MDS stated the resident was occasionally incontinent of urine and required the assistance of 1 staff for toileting hygiene. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. Observations on 6/1/26 revealed the following: At 8:32 AM, Resident #11 sat in her wheelchair in the dining room. The resident remained in the dining room while she ate breakfast and the DON wheeled her out to the common area at 9:09 AM. The resident remained in the common area until 9:42 AM when Staff O, Activities Assistant wheeled the resident to the chapel. The resident remained in the chapel until 11:03 AM. when Staff N, RN Case Manager wheeled her back to the common area. The resident remained in the common area until 11:18 AM when Staff K, CNA wheeled her to the dining room. During this observation staff did not offer the resident fluids from 9:09 AM. until 11:18 AM On 6/2/26 at 2:18 PM, Staff R, CNA stated staff usually passed water each shift. She stated on the day shift they tried to pass water after breakfast. She stated there were definitely days this was not completed due to staff being too busy. On 6/3/26 at 2:34 PM, the DON stated staff were assigned each shift to distribute fresh water and this was listed on the schedule. Review of the facility policy titled Nutrition and Hydration-Food and Nutrition Policy dated 4/27/26, Hydration section revealed, in part: 2. Offer sufficient fluid intake to maintain proper hydration and health. a. A goal of 1,500 mls (milliliters) of liquids per day is often recommended. Estimated fluid needs may vary depending on each individual resident. 3. Employees will monitor residents' intake of drinks and other fluids at meals through observation, offer alternative fluids and make changes as necessary. Fluids at meals may be recorded in [brand name redacted, electronic health record] per location process. 4. Fresh water will be available to the residents at bedside unless contraindicated.

Based on observation, record review, staff interviews, and the facility policy, the facility failed to maintain appropriate infection control practices during medication administration when staff handled pills with bare hands for 3 of 3 residents (Resident #2, Resident #10 and Resident #15), failed to perform hand hygiene after glove removal, and failed to ensure hairbrushes were used for a single resident, and failed to cover and label toothbrushing supplies stored in a common bathroom. The facility reported a census of 95 residents. Findings include:1. During an observation on 5/27/26 at 4:24 PM, a CNA (Certified Nurse Aide) used the same hairbrush in the common area in the 200 Hall on 3 different residents. Then at 4:26 PM, the CNA brushed another resident's hair with the same hairbrush. During an observation on 6/1/26 at 9:11 AM, two hairbrushes (one pink and one teal wet brush) sat on the ledge in the common area in the 200 Hall. During an interview on 6/1/26 at 4:59 PM, Staff A, CNA queried on using the same hairbrush for the residents and Staff A stated yes, the hairbrushes were for communal use. Staff A stated she knew they shouldn't use them for multiple residents.During an interview on 6/2/26 at 3:40 PM, Staff C, CNA queried on the hairbrushes used on multiple residents and she stated when they used single hairbrushes, staff couldn't find them in their room. Staff C stated if they had a designated area, the facility could have one brush for everyone. During an interview on 6/2/26 at 5:25 PM, the Director of Nursing (DON) queried on using the same hairbrush for multiple residents and she stated each resident should have their own hairbrush. 2. On 6/2/26 at 9:51 AM, in the common bathroom (the use of common bathroom is meant to describe a larger bathroom with a shower on the 200 hall that is available to all residents with a room on the hallway) observed multiple resident denture cups and multiple gray basins with toothbrushes/toothpaste tubes on a cart. The toothpaste and toothbrushes in the gray basins were not covered, or labeled to identify which basin belonged to which resident. During an interview on 6/2/26 at 3:13 PM, Staff G, CNA asked where the residents toothbrushes and toothpaste stored and she stated the dentures and toothpaste were in the common bathroom and the staff had a cart with the denture cups and toothpaste/toothbrush. Staff G stated she took the resident's supplies to their rooms in the morning to get them ready. During an interview on 6/2/26 at 3:40 PM, Staff C, CNA queried where the residents toothbrushes and toothpaste stored and she stated the staff left some of the residents' products in the common bathroom. Staff C stated they left the dentures in the common area so when they bring the residents down the hall, they can do their dentures. During an interview on 6/2/26 at 5:25 PM, the DON queried on storing the toothbrushes and toothpaste in the common bathroom and the DON stated the common bathroom was bigger and the DON not sure how the staff stored the items. The DON stated the items could be stored in the common bathroom if covered, labeled, secured from someone else, and where splashes couldn't get on their personal belongings. 3. During an observation on 6/2/26 at 6:34 AM, Staff B, Registered Nurse (RN) prepared Resident #10's medications. Staff B poured pills into the lid of the medication bottle and picked out the extra pills that fell in the lid with her ungloved finger and then put the extra pill back into the bottle. When Staff B popped the pills from the bubble packs, Staff B used her ungloved fingers to guide the pills into the medication cups. After Staff B finished preparing the pills, Staff B walked over to Resident #10 and administered the medications.4. Review of electronic health record revealed Resident #15 had Physician Orders for:a. Lantus Solostar (long acting insulin) subcutaneous solution pen-injector 100 unit/ml (milliliters)- Inject 60 unitsb. Accu check (measure blood sugar) twice a dayc. Vitamin D3 tablet 25 mcg (micrograms)During an observation on 6/2/26 at 8:15 AM, Staff B, RN prepared Resident #15 morning medications. Staff B cleaned off the bedside table, removed gloves and placed a barrier on the bedside table. Staff B placed new gloves, alcohol pads, and medication cups on the barrier. She then took keys out of her pocket and without completing hand hygiene started to prepare the medications. Staff B popped Resident #15 medications out of the bubble packs, and primed an insulin pen. Staff B then took a bottle of Vitamin D3 25 mcg from the medication cart, opened it and dropped 2pills into the lid of the bottle. Staff B touched one pill with an ungloved finger and dropped it into the medication cup and put the second pill back into the bottle. During an observation on 6/2/26 at 8:23 AM, without completing hand hygiene or putting on gloves, Staff B, RN walked over to Resident #15 and re-positioned him in the electric recliner, prepared a cup of water, and then applied gloves (without first completing hand hygiene). Staff B used a lancet on the resident's right ring finger to measure blood glucose. Staff B unable to obtain an adequate blood droplet. Without a change of gloves or completing hand hygiene, she obtained a new lancet from the medication cart and again poked Resident 15's finger. Staff B wiped away the first drop of blood and then used the glucometer to get a blood sugar reading. Without a change of gloves or hand hygiene, Staff B picked up the medication cup and placed it to the resident's mouth. Staff B removed gloves, and without completing hand hygiene gave Resident #15 a Boost drink. Staff B then picked up the used supplies and threw them in the trash. Without completing hand hygiene, Staff B put on new gloves, opened the window blinds and proceeded to administer an injection of insulin in Resident #15 right arm. Staff B applied new glove and cleaned the accu-check machine before placing it back in the cart. 5. Review of electronic health record revealed Resident #2 had Physician Orders for, in part:a. Tylenol (acetaminophen) oral tablet 650 mg (milligrams) - give 650 mg (1 tab or 2 tabs of 325 mg) by mouth three times a day. b. Magnesium Oxide oral tablet 400 mg - give 400 mg by mouth in the morning.During an observation on 6/2/26 at 8:59 AM, Staff B, RN prepared Resident #2 medications. Staff B popped several medications from bubble packs into a medication cup. She then pulled a bottle of acetaminophen 325 mg tablets from a med cart drawer, opened the bottle and dropped 4 pills into the lid. Staff B held her ungloved finger on two pills, dropped the other 2 pills into med cup and put the other 2 pills back into the bottle. After Staff B popped several more medications from bubble packs into the med cup, she took a bottle of magnesium oxide 400 mg from the med cart, opened it and dropped 2 pills into the lid of the bottle. Staff B held one pill in her ungloved fingers, dropped the 2nd pill back into the bottle and placed the 1st pill in the med cup. Staff B popped the remaining medications out of bubble packs into the med cup, and then administered the medications to Resident #2. During an interview on 6/2/26 at 2:21 PM. Staff B, RN queried on touching the pills during medication administration and Staff B stated she would guide the pills with her fingers into the medication cup because Staff B wasn't very good at getting the pills from the bubble packs into the cups. Staff B stated she didn't directly touch the pills until 6 Tylenol tablets come out of the bottle. Staff B asked about glove use and Staff B stated use hand sanitizer after removing gloves. Staff queried on Resident #15 medication administration and Staff B stated if it was all the same resident she did not use hand sanitizer in between glove use. During an interview on 6/2/26 at 5:25 PM, the DON asked about touching the pills during medication administration and the DON stated the staff should not touch the pills. The DON confirmed staff should sanitize after removing gloves. Review of the facility policy titled Hand Hygiene Policy dated 11/13/25 directed staff to complete hand hygiene after glove removal.

Based on observation, menu review, facility policy review, resident representative and staff interviews, the facility failed to follow the breakfast menu when fruit was not served for 2 of 2 breakfast meals. The facility reported a census of 95 residents. Findings include: Review of the breakfast menu for 5/28/26 revealed the meal to be served included french toast, sausage patty, mixed fruit cup, choice of hot or cold cereal, assorted juice, milk/beverageDuring an observation on 5/28/26 at 6:57 AM, Staff H, Dietary [NAME] conducted the pre temperatures for breakfast service. All the hot foods, milk, and juice temped for service. No fruit cup observed.During an interview on 5/28/26 at 9:10 AM, Staff H queried about the fruit cup and Staff H stated they put the fruit in dishes and she didn't know it wasn't done. Staff H stated the fruit usually came out of the can and put into dishes and she didn't know what happened. During an interview on 5/28/26 at 2:03 PM, Resident #2 resident representative stated the residents didn't always get fruit and vegetables with meals.During an observation 6/1/26 at 9:00 AM, residents ate in the dining room. No fruit cups observed in front of residents in the dining room.Review of the breakfast menu for 6/1/26 revealed the meal to be served included ancakes, bacon, mixed fruit cup, choice of hot/cold cereal, assorted juice, and milk/beverage.During an interview on 6/1/26 at 9:15 AM, Dietary Manager queried if fruit cups offered and the Dietary Manager asked Staff I, Dietary Aide if she gave fruit. Staff I stated she didn't know they had it and no one asked for it. The Dietary Manager stated they usually offered it, and it was stored in the back.During an interview on 6/2/26 at 1:00 PM, Staff I, Dietary Aide stated she told the residents in the dining room what they were having and if fruit on the menu it was dished up in the tulip dishes ready to go. Staff I stated she didn't see fruit on any of the room trays and the 100 hall didn't take fruit up.During an interview on 6/2/26 at 1:04 PM, the Dietary Manager informed of the 2 breakfast meals that did not serve fruit as indicated on the menu and the Dietary Manager stated she worked in the kitchen this week, so she knew what was being dished up. The Dietary Manager stated they usually had fruit on the cart every morning. The Dietary Manager stated she would start watching more.During an interview on 6/2/26 at 6:17 PM, the Administrator informed of the 2 breakfasts without fruit cups offered and the Administrator stated the facility should follow the menu or offer a substitution.Review of the facility policy titled, Menu Requirements- Food and Nutrition Services dated 11/18/25 revealed menus were prepared to meet the balanced nutritional needs of the residents in accordance with established national standards.

Based on record review, resident representative interview, staff interviews, and the facility policy, the facility failed to treat a resident in a dignified manner by placing him on a mattress in the common area when he is acting out for 1 of 3 residents (Resident #2) reviewed for dignity. The facility reported a census of 95 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognition. The MDS indicated no behaviors exhibited verbal, physical, utilized a manual wheelchair, and required substantial/maximal assistance to roll right and left, lying to sitting on side on side of bed, and chair/bed-to-chair transfer. The diagnoses list included depression, heart failure, repeated falls, and polyarthritis (arthritis in multiple locations). Review of Resident #2's Care Plan dated 4/7/26 revealed a Focus area to address The resident has behavior symptoms; calling the nurses station, the front desk, SS (Social Services) for every need he has. He is very tearful. He calls his wife frequently and then she calls the facility. Resident also yells out and uses profanity when he is not getting the attention he desires. Resident will also threaten to put himself on the floor. Interventions included, in part:a. When resident is trying to put self on floor, assist him so he does not fall. Allow him to be on the floor until he is ready to get up and sit in chair or go to bed. Allow him to lay on mattress if he will on the floor. Allow to sit on floor when he becomes belligerent, aggressive, and tries to hit. He will try to get out of chair when he is upset and is a harm to self or others. Revised: 5/10/26.During an interview on 5/28/26 at 2:03 PM, Resident #2's family member stated the facility puts Resident #2 on a mattress on the floor in the common area when Resident #2 had behaviors. The family member stated she didn't think it was right to keep the resident in the common area because the resident did have some pride left.Review of the electronic health record (EHR) revealed:a. Other Progress Note dated 5/10/26 at 3:35 PM: Resident behavior starting to yell out, states come on lets go. Using Hoyer (name brand of a mechanical body lift) assist 2 transferred to the floor with no difficulties, mattress on the floor to lay on. Yelling out lets go.b. Other Progress Note dated 5/10/26 at 8:00 PM: Resident sleeping on the floor. Using Hoyer assist of 2 transferred to w/c (wheelchair) bed, then into the recliner to eat and ate 25%. Taking medications without any problem. Transferred to floor using a hoyer when resident slapping a workers glasses out and states you will get tired of doing this.c. Other Progress Note dated 5/10/26 at 11:17 PM: Res (resident) remains laying on mattress in common area. Sleeping soundly without any signs of discomfort. Staff monitoring closely.d. Health Status Note dated 5/11/26 at 12:51 AM: Resident laying on mattress on floor in common area under direct supervision. Is asleep. Has been very confused this noc (night shift). Staff is worried to put resident in bed due to behaviors and worried about his safety so he is under one-on-one direct supervision. Monitoring resident closely. Remains total care with hygiene and incontinent care. Turning and repo resident.During an interview on 6/1/26 at 4:59 PM, Staff A, Certified Nurse Aide (CNA) queried on Resident #2 behaviors and being placed on a mattress in the common area and she stated never placed Resident #2 on a mattress in the common area because she thought it was a dignity issue. Staff A stated when the resident had behaviors, staff had helped him to the floor for safety concerns but if they gave the resident 15 minutes to calm down, the resident usually got back up.During an interview on 6/2/26 at 2:21 PM, Staff B, Registered Nurse (RN) asked about Resident #2 behaviors and the resident being placed on a mattress in the common area and Staff B stated she was not at the facility when it happened and she didn't think putting Resident #2 on a mattress in the common area was okay. Staff B stated she went to the case manager about it and stated the mattress should be in his room, not the common area.During an interview on 6/2/26 at 3:40 PM, Staff C, CNA queried on Resident #2 being placed on a mattress in the common area and Staff C stated she didn't think it was appropriate because a bunch of people were around. Staff C stated she would have hoyered Resident #2 to his room and if he wanted to be on the mattress in his room that would be better. During an interview on 6/2/26 at 4:00 PM, Staff D, Licensed Practical Nurse (LPN) stated she had put Resident #2 on a mattress in the common area 3 times when Resident #2 had behaviors until the resident calmed down. Staff D confirmed other residents were in the common area when this happened.During an interview on 6/2/26 at 4:16 PM, Staff E, LPN queried about Resident #2 being placed on a mattress in the common area and Staff E stated even if it was Care Planned Staff E didn't feel like it was appropriate and is a dignity issue. Staff E stated family and other people would know Resident #2 and he was well known in the community and it wouldn't be dignified.During an interview on 6/2/26 at 4:51 PM, Staff F, LPN stated she placed Resident #2 on the mattress in the common area because she thought it was more dignified than laying on the floor. Staff F stated Resident #2 would relax and fall asleep. Staff F stated the core team came together and decided to keep the mattress in the resident's room and if the resident was more comfortable on the floor, he could be on the floor in his room.During an interview on 6/2/26 at 5:04 PM, Staff J, LPN queried about Resident #2 laying on a mattress in the common area and Staff J stated she didn't agree with it and at times Staff J understood they couldn't take Resident #2 to his room but when he fell asleep, Staff J was told not to move him. Staff J stated she would come in at 6:00 PM and Resident #2 would be asleep on the mattress. Staff J stated she felt it was a dignity issue and verbalized it, but she was overridden. Staff J stated keeping Resident #2 in the common area would cause some of the other residents to stay up or have behaviors.During an interview on 6/2/26 at 5:25 PM, the Director of Nursing (DON) queried on Resident #2 being placed on the mattress in the common area and the DON stated when she heard about the situation, the DON got the feeling staff were desperate and worried about safety. The DON stated the common area can be congested and having a resident on the floor in the common area can also cause a safety concern for other residents and some residents might even try to help. The DON stated the facility didn't want anyone to feel they were not treated with dignity, and they wanted to keep them safe and provide cares like they were adults.Review of the facility policy titled Resident Dignity-Rehab/Skilled Policy dated 12/18/25 indicated the facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The procedure revealed treating residents with respect.

Based on clinical record review, policy review, and staff interview, the facility failed to notify the physician of a weight loss for 1 of 4 residents (Resident #4) reviewed for a change in condition. The facility reported a census of 95 residents.Findings included:The Minimum Data Set (MDS) assessment tool, dated 4/15/26, listed diagnoses for Resident #4 which included Alzheimer's disease, non-Alzheimer's dementia, and muscle weakness. The Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicated a severe cognitive impairment. Care Plan entries, dated 3/28/25, stated the resident met the criteria for malnutrition and directed staff to monitor for weight loss. The facility policy Nutrition and Hydration-Food and Nutrition, dated 4/27/26, stated the facility would routinely assess the resident's nutritional status and monitor nutritional risk. The facility carried out a systematic method for obtaining, verifying, and interpreting data to identify nutrition related problems. The facility notified the physician as appropriate in evaluating and managing causes of the resident's nutritional risks. Resident #4's Weight Summary included the following weights during the period of 12/6/26 to 5/15/26:a. 11/03/25 - 121.0 lbs (pounds)b. 1/05/26 - 122.2 lbsc. 2/04/26 -123.8 lbsd. 3/04/26 -125.0 lbse. 3/27/26 -126.0 lbsf. 4/07/26 - 124.4 lbsg. 4/19/26 - 125.2 lbsh. 5/01/26 - 127.6 lbsi. 5/15/26 - 128.0 lbsj. 5/22/26 -118.8 lbsStaff U, Licensed Practical Nurse (LPN) documented the resident's 5/22/26 weight.The resident experienced a weight loss of 9.2 lbs. during the 7-day period between 5/15/26 and 5/22/26, calculated as a loss of 7.9%.The facility lacked documentation of physician notification of the weight loss during the period of 5/22/26 to 6/2/26.On 6/2/26 at approximately 12:00 p.m., when queried regarding Resident 4's weight loss between the dates of 5/15/26 and 5/22/26, Staff U, LPN stated she did not report the loss to the physician because she did not believe it was a true weight loss. Shortly after the interview, Staff U stated staff reweighed the resident and she currently weighed 122.2 lbs. On 6/3/26 at 9:42 a.m., during a phone interview, the Staff S, Physician stated if there was a large weight loss, staff should reweigh the resident. He stated he would like staff to inform him of significant losses.On 6/3/26 at 12:05 p.m., Staff T, Registered Nurse (RN) Case Manager stated if there was a 10 lbs. weight loss in one week, staff should contact the physician.On 6/3/26 at approximately 4:00 p.m., the Director of Nursing (DON) stated they reweighed the resident's wheelchair today and this was the reason for the weight discrepancy.

Based on observation, record review, staff interviews, and the facility policy, the facility failed to perform weekly skin observations for residents at risk of pressure ulcers and ensure a physician order in place prior to completing a wound dressing change for 2 of 5 residents (Resident #2 and Resident #15) reviewed for assessment and intervention. The facility reported a census of 95 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognition. The diagnoses list included depression, heart failure, repeated falls, and polyarthritis (arthritis in multiple locations). The assessment identified the resident at risk of pressure ulcer development. The MDS indicated Resident #2 without pressure ulcers, venous and arterial ulcers, or other wounds and skin issues. The MDS identified 9/27/25 as the admission date for Resident #2.Review of Resident #2's Care Plan dated 4/23/26 revealed a Focus area to address The resident has potential for pressure development r/t (related to) obesity, impaired mobility, incontinence of bladder. Interventions included, in part: Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc, noted during baths and daily care. During an observation on 5/26/26 at 11:28 AM, Resident #2 sat in his wheelchair next to the nurse's station in the 200 hall. Multiple bruises noted on his left arm, bandages on his knees and on his left elbow.A review of the electronic health record (EHR) revealed a Physician Order dated 5/3/36 to Review of EHR Physician Orders Dated 5/3/26- Cleanse open area to left buttock with wound cleaner soaked 4x4s, pat dry with clean 4x4s, apply triad paste and cover with a mepilex daily and PRN until healed- one time a day for open area AND every 1 hours as needed.Review of May 2026 N Adv Skin Check notes in the EHR revealed;a. Note dated 5/1/26 assessed: Skin Issues: #001.Location: Right outer wrist. Issue type: Puncture; #002: Location: Left Dorsum Left Hand. Issue type: Skin tear; #003: Location: Left Dorsum Left Hand. Issue type: Skin tear.b. Note dated 5/5/26 assessed: Skin Issues: #001.Location: Right outer wrist. Issue type: Puncture; #002: Location: Left Dorsum Left Hand. Issue type: Skin tear; #003: Location: Left Dorsum Left Hand. Issue type: Skin tear.c. Note dated 5/19/26 assessed: Skin Issues: #001.Location: Right outer wrist. Issue type: Puncture; #002: Location: Left Dorsum Left Hand. Issue type: Skin tear; #003: Location: Left Dorsum Left Hand. Issue type: Skin tear.During an interview on 6/2/26 at 2:21 PM, Staff B, Registered Nurse (RN) queried Resident #2 orders for the wound on his bottom and Staff B stated she thought it was healed, but didn't look at it today. Staff B explained the Assistant Director of Nursing (ADON) completed the skin assessments.During an interview on 6/2/26 at 6:08 PM, the ADON stated she did not do the weekly skin assessments, the floor nurses were supposed to. The ADON stated schedules placed in each med room for mornings and evenings to do. The ADON queried about Resident #2 order for a wound on his bottom but the skin assessment not addressing the wound and the ADON stated she didn't know why it was not addressed on the skin assessment unless Resident #2 had the wound prior to being at the facility.2. Review of Resident #15 MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, which indicated a severe cognitive impairment. The diagnoses listed included Alzheimer's dementia, renal insufficiency, and diabetes mellitus. Review of Resident #15 Care Plan dated 9/12/23 revealed a Focus area to address The resident has potential for pressure ulcer development r/t dementia. Interventions included, in part: Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc, noted during baths and daily care.During an observation on 6/2/26 at 10:00 AM, while Resident #15 sat in the common area Staff B, RN completed a dressing change on Resident #15 lower right arm. Review of the EHR Assessment page revealed the skin assessments, labeled V3 Skin Observation entered in 2026 on the following dates: 1/03/26, 1/10/26, 1/17/26, 1/25/26, 2/01/26, 2/08/26, and 2/15/26. Review of the EHR Physician Orders found no Physician Orders for wound care/dressing changes on Resident #15 right lower arm. During an interview on 6/2/26 at 2:21 PM, Staff B, RN queried about the dressing change for Resident #15 and Staff B stated she thought there was an order, and after Staff B reviewed Resident #15 chart, confirmed there was no order on the EHR. Staff B stated Resident #15 had a skin tear and she didn't know how it happened. Staff B stated the facility had a skin protocol, where they would put in the dressing change and the doctor would review and order it.During an interview on 6/2/26 at 4:00 PM, Staff D, Licensed Practical Nurse (LPN) queried on who did the skin assessments and Staff D stated they did them on the day shift. During an interview on 6/2/26 at 5:25 PM, the Director of Nursing queried on skin assessments, and the DON stated the skin assessments were done weekly. The DON stated the floor nurses were supposed to do the skin assessments. The DON stated residents had a skin protocol and staff followed the standing order and put the order in the chart. Review of the facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation Requirements - Rehab/Skilled Therapy and Rehab dated 3/30/26 revealed a Purpose section which declared: To systematically assess residents regarding risk of skin breakdown; To accurately document observations and assessments of residents; and To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers.Review of the facility policy titled Physician/Practitioner Orders Policy dated 4/6/25, revealed, in part: Wounds: Orders must be obtained for wound care including product to be used, when to change and when to reassess. A licensed nurse must provide wound care.

Based on clinical record review, resident representative interview, and staff interviews, the facility failed to provide adequate supervision for 1 of 4 residents (Resident #2) reviewed for safety when staff left a resident with a history of falls unattended in the bathroom/shower room. The facility reported a census of 95 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognition. The MDS indicated Resident #2 utilized a manual wheelchair, required substantial/maximal assistance to roll right and left, lying to sitting on side on side of bed, and chair/bed-to-chair transfer. The diagnoses list included depression, heart failure, repeated falls, and polyarthritis (arthritis in multiple locations). The MDS indicated resident had 2 falls with no injury since the last assessment (01/01/26).A review SAFE Resident Event documents revealed in 2026 Resident #2 had falls on: 2/6/26, 2/8/26, 2/17/26, 2/26/26, 2/28/26, 3/13/26, 3/23/26, 3/28/26, 4/3/26, 4/7/26, 4/8/26, 4/27/26, 5/1/26, and 5/6/26. Review of Resident #2 Care Plan dated 5/11/26 revealed Focus areas to address:a. The resident is at risk for falls r/t (related to) poor safety awareness, noncompliant with asking for assist, falls are unavoidable, impaired balance. Res will put himself out on the floor. Res will use recliner remote to raise and fall floor on purpose. Interventions included, in part: Educate resident/family/IDT (interdisciplinary team) as to causes of fall. DO NOT LEAVE IN SHOWER HOUSE UNATTENDED. Date Initiated: 4/3/26.b. The resident has an ADL (activities of daily living) self-care performance deficit r/t impaired mobility. Interventions included, in part: BATHING: Resident requires reclining shower chair 1 x assist: cueing, etc. Date Initiated: 9/26/25. TOILET USE: Resident requires (1x staff assist, cueing, etc). Date Initiated: 9/26/25.During an interview on 5/28/26 at 2:03 PM, resident representative stated Resident #2 left in the shower room alone and he tried to stand up and fell and staff should have stayed in the shower room with him. Resident Representative stated Resident #2 thinks he can stand, but he can't. Review of document titled SAFE Resident Event revealed, in part: Resident Name: [Name redacted, Resident #2]. Date: 4/3/26. Location of Event: Public Bathroom. Description of Event: This nurse overheard yelling from 400 hall shower room. [Name redacted] medication aide opened the door resident observed to be laying on the floor in front of toilet on right side. Resident yelling Get me off of this god damn floor. Stand aid next to resident Residents pants appeared to be up and BM on sink next to toilet. Full ROM noted. No injuries noted. Resident assisted x3 from floor to WC. Resident brought into common area resident yelling I'm gonna throw myself on the god damn floor. Increased behaviors noted this AM. Resident yelling at staff. Describe the immediate intervention: Resident not to be left alone in shower room. Was there an injury of unknown origin: Not at this time. Type of Injury: No Injury Noted.During an interview on 6/1/26 at 4:59 PM, Staff A, CNA asked if she ever been with him when Resident #2 had a fall and Staff A stated on the 400 hall Resident #2 fell in the shower room. Staff A stated someone put the stand aide in front of him and locked it and went to get a brief, and Staff A didn't realize they left him alone. Staff A stated she knew not to leave Resident #2 alone and to keep Resident #2 where you can see him. Staff A stated she opened the door to the shower room and Resident #2 had pushed the stand aide out of the way and fell on the floor.During an interview on 6/2/26 at 2:21 PM, Staff B, Registered Nurse (RN)asked if ever here when Resident #2 fall in the shower room and Staff B stated no. Staff B stated she heard about it happening and heard it a couple of different ways, but if the stand aide was locked in front of the resident and they try to get up, that creates a safety barrier because they can get hung up on the stand.During an interview on 6/2/26 at 4:16 PM, Staff E, Licensed Practical Nurse (LPN) queried on leaving Resident #2 in the bathroom alone and Staff E stated no, Resident #2 shouldn't be left unattended at this point. Staff E asked if a resident with a BIMS of 9 should be left alone in the bathroom and Staff E stated no.During an interview on 6/2/26 at 5:25 PM, the Director of Nursing (DON) queried on Resident #2 fall on 4/3/26 and the DON stated she would have to review his chart because the DON didn't think Resident #2 was ever left alone in the shower room. The DON stated some days Resident #2 had good days and other days forgetful and it would depend on the day he was having. The DON stated with that being said, just knowing Resident #2, the DON would yell out for a brief and that was what staff usually did.Review of a facility policy titled Fall Prevention and Management Policy dated 6/2/26 included a Purpose section which declared, in part: To identify risk factors and implement interventions before a fall occurs. The Proactive Approach before a Fall Occurs section directed, in part: Care Plan the appropriate interventions, including personalizing all (SPECIFY)' areas.

Based on clinical record review, policy review and staff interview, the facility failed to ensure residents received ordered medications for 2 of 5 residents reviewed for the provision of medications(Residents #1 and #8). The facility reported a census of 95 residents.Findings included: 1. The Minimum Data Set (MDS) assessment tool for Resident #1, dated 2/18/26, list diagnoses included pain, cancer, and constipation. The Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicated intact cognition. The MDS identified 2/12/26 as the admission date for Resident #1. Review of a hospital Active Outpatient Medications dated 2/10/26 list documented an active order for buprenorphine (a potent, long-acting narcotic pain medication) 7.5 micrograms (mcg)/hour (hr) 1 patch to the skin every 7 days. Review of an eAdmin Record noted entered in the electronic health record (EHR) on 2/16/26 at 7:58 PM revealed the buprenorphine patch did not arrive from the pharmacy. Review of a History and Physical dated 2/17/26 revealed, in part: Assessment: Cholangiocarcinoma, currently on hospice care. Cancer-related pain. Plan:.continue Butrans (buprenorphine) patch 7.5 mcg per hour, changed weekly. The February 2026 Medication Administration Record (MAR) listed a 2/13/26 order for buprenorphine patch 7.5 mcg/hr one time per day every 7 days for 7 days. The 2/13/26 entry contained the numeral 4 to indicate the medication was not available. The February 2026 MAR lacked documentation the resident received the medication during the month of February 2026. Review of the March 2026 MAR did not include an order for the buprenorphine patch and lacked documentation the resident received the medication during the month of March 2026. During an interview on 6/2/26 at 12:41 p.m., the Director of Nursing (DON) stated the resident's buprenorphine was put into the computer incorrectly for only 7 days instead of every 7 days. During an interview on 6/3/26 at 2:52 p.m., Staff Q Lead Administrative Assistant [company name redacted] Hospice Agency stated the only reason she knew that the resident did not receive his patch was because the hospital called and informed them (after he discharged ). Staff Q stated she then spoke to a couple of facility nurses and found out he didn't get the patch he was supposed to. On 6/3/26 at 1:42 p.m., Staff N Registered Nurse (RN) Case Manager stated she erred when she input the resident's patch into the computer. She stated though that the nurses should confirm the orders once placed into the computer. 2. The MDS dated [DATE] revealed Resident #8 scored a 15 out of 15 on BIMS exam, which indicated cognition intact. The MDS revealed medical diagnosis for chronic obstructive pulmonary disease (often referred to as COPD, a chronic respiratory condition that makes breathing difficult) with acute exacerbation. The Care Plan revealed a focus area dated 2/3/26 for shortness of breath related to COPD. Review of the EHR revealed a Physician Order for Trelegy Ellipta Inhalation powder breath activated 100-62/5-25 mcg/act (micrograms per actuation) The Review of the April 2026 MAR revealed resident's Trelegy Ellipta Inhalation powder breath activated was not available for 4 days (April 4th-April 7th). Review of the EHR revealed the following eAdmin Record notes: a. Dated 4/4/26 at 9:07 AM, revealed Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT- 1 inhalation inhale orally in the morning. Ordered from pharmacy. b. Dated 4/5/26 at 8:28 AM, revealed Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT1 inhalation inhale orally in the morning.Ordered from pharmacy During an interview on 6/2/26 at 1:33 PM, Staff P, Pharmacy Technician asked when a refill made for Resident #8 Trelegy and Staff P stated the first fax the pharmacy received from the facility was on 4/7/26. Staff P stated the pharmacy received 2 faxes that day for the Trelegy one on 4/7/26 at 9:53 AM and the other one on 4/7/26 at 10:01 AM. During an interview on 6/2/26 at 4:16 PM, Staff E, Licensed Practical Nurse (LPN) queried on the process of reordering an inhaler and Staff E stated the inhalers usually had meters and showed when they got low and when the inhaler at 8,9, or 10. Staff E confirmed they faxed the pharmacy for refills and pharmacy was usually pretty good about refilling medications. During an interview on 6/2/26 at 5:25 PM, the DON asked about Resident #8 Trelegy inhaler being out for 4 days and the DON stated the pharmacy usually pretty good about refilling medication and Resident #8 inhaler might of been delayed because of the cost and would need to look into that. Per an email exchange 6/3/26 at 12:02 PM, the State Agency (SA) asked the DON about the process when a resident's medications runs low. At 12:23 PM, the DON responded It gets reordered. Review of the facility policy titled Local Pharmacy Medication Ordering Policy dated 8/29/25 revealed the following: a. If the medication is not available in the emergency/contingency kit and the pharmacy has not delivered the drug by the scheduled med pass time, call the pharmacy, and speak to a pharmacist to determine why the medication was not delivered. Document details in EMR. b. If the medication is not available, notify the ordering physician immediately to determine whether the order should be changed or starting the medication can wait until the medication is available from the pharmacy. Document in the PN – Communication with Pharmacy or PN – Communication/Visit with Physician/EMR as appropriate. c. Please follow the procedures in the local pharmacy's procedure manual, if available, from your local pharmacy for routine ordering and reordering. Note: Remember, if you wait to re-order a medication until you are out, you need to communicate to the pharmacy that you are out of the medication. Review of the facility policy titled Facility Physician/Practitioner Orders Policy dated 4/6/25 revealed, in part: Following Hospitalization: When a resident returns from the hospital, physician/practitioner orders must be updated to reflect the resident's current needs. Drug regimen review is required following any return from hospital.

Based on observation, resident representative interview, resident interview, staff interviews, and the facility policy, the facility failed to maintain appropriate food temperatures for a breakfast room tray. The facility reported a census of 95 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 scored a 15 out of 15 on the Brief Interview for Mental Status, which indicated cognition intact. During an interview on 5/26/26 at 4:01 PM, Resident #8 when asked about the food at the facility stated she didn't like the food. Resident #8 explained sometimes the food was hot and the meat can be cold on the outside and warm on the inside. Resident #8 stated the meat could partially cooked, or partially frozen. Review of the breakfast menu for 5/28/26 revealed the meal to be served included french toast, sausage patty, mixed fruit cup, choice of hot or cold cereal, assorted juice, milk/beverageDuring an observation on 5/28/26 at 6:57 AM, Staff H, Dietary [NAME] conducted the pre temperatures before breakfast service and received the following temperatures: a. French toast- 164.1 F (degrees in Fahrenheit)b. Sausage 196.1 Fc. Cream of wheat- 180.1 FDuring an observation on 5/28/26 at 8:46 AM, Staff H, Dietary [NAME] prepared the last room tray, which had a mechanical texture. At 8:50 AM, the cart prepared with one room tray and a test tray for the State Agency (SA) and waiting to be picked up by a staff. At 8:53 AM, the Dietary Manager took the cart with the room tray to the 400 Hall. At 8:55 AM, temperatures taken for the food items on the SA test tray. Temperatures completed by a staff member, with the following results: a. Cream of Wheat- 130.2 Fb. French toast - 113.1 Fc. Sausage link- 131.2 FAt 8:57 AM, the SA taste-tested the Cream of Wheat, sausage and French toast. The Cream of Wheat and sausage tasted warm, while the French toast tasted lukewarm.During an interview on 5/28/26 at 2:03 PM, Resident #2 resident representative stated the food was terrible and it was usually cold if the residents stayed in their room.During an interview on 6/2/26 at 1:04 PM, the Dietary Manager informed of the temperatures on the test tray and the Dietary Manager stated all the temperatures were low. The Dietary Manager stated she didn't know what she was going to do, the French toast sticks cool so fast and she even took the cart back to the unit. The Dietary Manager stated that was something she would have to figure out and the temperatures shouldn't be below 140 degreesDuring an interview on 6/2/26 at 6:17 PM, the Administrator informed of the test tray for breakfast temperature and the Administrator stated they temped to low, and stated we will have to look into it. Review of the facility policy titled Food Temperature Monitoring-Food and Nutrition Services revised on 3/23/26 revealed, in part:a. TCS (Temperature Control for Safety) hot foods should be served at 135 degrees Fahrenheit or higher. b. Test tray monitoring occurs as a part of quality assurance monitoring to ensure temperatures are acceptable when the location uses room trays or satellite dining rooms. Temperatures for test trays are based on proper serving temperature not tray line holding temperatures based on food safety.

Based on observations, facility policy review, resident and staff interviews, the facility failed to maintain a homelike environment due to dry wall tape falling from the ceiling in the sunroom, drywall scuffed off in 2 residents' rooms and the heat baseboard coming off the wall leaving a large crack for 2 of 3 residents reviewed for homelike environment (Resident #8 and Resident #13). The facility reported a census of 95 residents. Findings include:1. During an observation on 5/26/26 at 12:18 PM, a piece of drywall tape hung from the ceiling in the facility sunroom; and the drywall had a wet spot with bubbling from water damage. This observation remained unchanged on 5/27/26 at 9:46 AM, 5/28/26 at 1:04 PM, and 6/1/26 at 4:39 PM. 2. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition.During an observation on 5/26/26 at 4:01 PM, the drywall in Resident #8 room scuffed by her recliner with multiple scratches.During an interview on 5/26/26 at 4:01 PM, Resident #8 stated the drywall tape hanging in the sunroom was due to leaks when it rained. Resident #8 stated maintenance wanted to cut out the scuffed drywall in her room out and put up a hard plastic piece rather than replaster it. Resident #8 stated maintenance was supposed to fix it a few months ago and Resident #8 didn't know when they were going to do it. Resident #8 stated it bothered her the way the wall looked when she had visitors.During an observation on 6/1/26 at 4:37 PM, Resident #8 wall near her recliner is still scuffed and has drywall powder on the floor near the wall. 3. Review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of15 out of 15, which indicated intact cognition. During an interview on 5/28/26 at 8:13 AM, Resident #13 stated he hoped maintenance would fix his electric baseboard heater because it was falling off the wall. Resident #13 said he told maintenance a month ago and maintenance said they would get to it, but they haven't yet.During an observation on 5/28/26 at 10:15 AM, Resident #13 baseboard was coming off the wall and the paint above the baseboard scuffed off in an approximately 1-foot x 1-foot section.During an interview on 6/2/26 at 10:50 AM, the Maintenance Supervisor queried on the ceiling in the 300-400 hall and the Maintenance Supervisor stated the roof got replaced a month ago. The Maintenance Supervisor stated it was on his list and they would do in house to save money. The Maintenance Supervisor stated the ceiling needed fixed for 8 months but they needed to fix the roof first.During an interview on 6/2/26 at 10:50 AM, the Maintenance Supervisor stated the goal was to fix Resident #8 wall with a plastic peel and stick made out of vinyl and he still needed to order it. The Maintenance Supervisor stated Resident #8 had brought it to his attention a couple of times in the last couple of months ago.During an interview on 6/2/26 at 10:50 AM, the Maintenance Supervisor stated he was aware of Resident #13 heat register and it needed specialty order and needed to order it. The Maintenance Supervisor stated he knew about it for about the last 6 months. The Maintenance Supervisor had a lot going on and something fell down the list and were forgotten about for a while.During an interview on 6/2/26 at 6:17 PM, the Administrator queried about the drywall tape in the sunroom hanging and the Administrator stated she was not aware of the drywall tape hanging. The Administrator stated the roof got fixed and the facility had water damage but only the bubbling. The Administrator queried about Resident #8 wall and the Administrator stated she would look into it. The Administrator asked about Resident #13 heating register and she thought maintenance ordered one because the heating registers were custom and she would look into it. The Administrator queried on when repairs needed completed and the Administrator stated it depended if they needed a contractor, and repairs need done timely.Review of the facility policy titled Resident Environment- R/S (Rehab/Skilled) Policy dated 12/29/25 revealed the center will provide a safe, clean, comfortable and homelike environment that allows the resident use of some personal belongings to the extent possible. Resident rooms will be designed and equipped for adequate nursing care, safety and comfort, as well as the following: Housekeeping and maintenance services.

Based on observation, clinical record review, resident and staff interviews, the facility failed to check incontinent residents and change as needed every 2 hours for 2 of 4 residents (Resident #11 and Resident #15) reviewed for incontinent care; and failed to perform morning oral hygiene for 1 of 3 residents (Resident #11) for residents reviewed for oral hygiene. The facility reported a census of 95 residents. Findings include: 1. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3 out of 15, which indicated a severe cognitive impairment. The MDS indicated Resident #15 dependent with toileting hygiene, required substantial/maximal assistance with toilet transfer, and always incontinent of urine and frequently incontinent of bowel. The diagnoses list included Alzheimer's disease, renal insufficiency, and anxiety disorder. The MDS indicated the resident took a diuretic (commonly known as a water pill, medication that helps the kidney flush excess salt and water). Review of Resident #15's Care Plan revised 3/23/23, revealed a Focus area to address resident had an ADL (Activity of Daily Living) self-care performance deficit related to dementia. Interventions included, in part: TRANSFER: Resident is stand aid with assist x 1, TOILET USE: Resident requires stand aid with assist x1. During a continuous observation on 6/2/26 at 6:01 AM, Resident #15 sat in the common area, in a recliner. At 8:45 AM, Staff B, Registered Nurse (RN) came over and administered his morning medications. At 9:36 AM, Resident #15 served his breakfast. At 9:48 AM, Staff G, Certified Nurse Aide (CNA) asked the resident if he was still eating his breakfast. At 10:00 AM, Staff B completed a dressing change on Resident #15 arm. At 10:29 AM, the State Agency (SA) asked Staff C, CNA when the staff would get Resident #8 up and the Staff C stated pretty quick. At 10:32 AM, Staff C asked Resident #15 if he was ready to get up and Resident #15 said yes. At 10:37 AM, Staff C took Resident #15 into the shower room and when resident was being placed on the toilet, Resident #15 incontinent brief was saturated. Resident #15 sat in the recliner for a total of 2 hours and 26 minutes. During an interview on 6/2/26 at 3:13 PM, Staff G, CNA asked about incontinence cares for Resident #15 and Staff G stated incontinence cares needed done every 2 hours. Staff G stated night shift said Resident #15 was up late so they didn't bother him until he was ready to get up. Staff G stated Resident #15 urinates large volumes. During an interview on 6/2/26 at 3:40 PM, Staff C, CNA queried on incontinence cares for Resident #15 and she stated every 2 hours. Staff C stated Resident #15 had been up late last night and sometimes get mad when asked, but today she didn't have any problems. Staff C stated Resident #15 won't tell you if he has to go to the bathroom, Staff C would just ask if he wanted to go to the bathroom. Staff C confirmed his incontinent brief was full. During an interview on 6/2/26 at 4:00 PM, Staff D, Licensed Practical Nurse (LPN) stated residents needed taken to the bathroom or checked and changed every time they got up or at least every 2 hours. During an interview on 6/2/26 at 5:25 PM, the Director of Nursing (DON) informed Resident #15 not asked or checked and changed for over 4 hours and the DON stated Resident #15 needed toileting every 2 hours and every 2 hours was the standard for the facility. 2. Review of Resident #11's MDS assessment tool dated 4/30/26, diagnoses listed included urinary incontinence, arthritis, and diabetes. The MDS listed the resident's BIMS score as 14 out of 15, which indicated intact cognition. The MDS indicated the resident dependent for toilet hygiene, and required substantial to maximal assistance with oral hygiene. The MDS also documented Resident #11 occasionally incontinent. Review of Resident #11 Care Plan dated 4/24/26 revealed the following: a. A Focus area to address the resident has bladder incontinence. Intervention: BRIEF USE: Resident uses incontinence products. Check & change before & after meals & HS (bedtime) & PRN (as needed). b. A Focus area to address The resident has an ADL self-care performance deficit r/t decrease mobility and spinal stenosis. Intervention included, in part: ORAL CARE: Resident has her own teeth. PERSONAL HYGIENE: Resident requires assist x 1. During observations on 6/1/26: At 8:32 AM, Resident #11 sat in her wheelchair while in the dining room. The resident remained in the dining room while she ate breakfast and the DON wheeled her out to the common area at 9:09 AM. Resident #11 remained in the common area until 9:42 AM when Staff O, Activities Assistant wheeled the resident to the chapel. Resident #11remained in the chapel until 11:03AM when Staff N, RN Case Manager wheeled her back to the common area. The resident remained in the common area until 11:18 AM when Staff K, CNA wheeled her to the dining room. The resident ate lunch and remained in the dining room until 12:25 PM. when Staff C, CNA asked her if she wanted to lie down and wheeled her out to the common area. At 12:29 PM, Staff C wheeled the resident into her room and she and Staff K, CNA transferred the resident to bed at 12:33 PM. The staff unfastened the resident's brief and it was heavily soaked with urine. Both sides of the resident's buttocks and the back of both of her thighs were covered with deep red indentations. Staff completed incontinence cares and applied a new incontinent brief. Continuous observation revealed staff did not offer to assist the resident to lie down or complete incontinence cares from 8:32 AM until 12:33 PM, a total of 4 hours and 1 minute. On 6/2/26 at 7:02 AM, Staff M CNA stated she would check the resident's incontinent brief because at times she was confused and staff needed to ask her if she needed assistance with incontinence cares. During an interview on 6/1/26 at approximately 12:40 PM, Resident #11 stated staff did not brush her teeth. Observations on 6/2/26 revealed at 6:40 AM, Resident #11 laid in bed. Staff L, CNA and Staff M, CNA changed the resident's clothes and transferred her into the wheelchair. Staff M combed the resident's hair and then wheeled her out of the room into the day room. Staff L and Staff M did not complete oral cares while they assisted the resident to get ready for the day. At 7:40 AM, a staff member wheeled the resident to the dining room where she remained until 9:33 AM, when a staff wheeled her back to the common area. At 9:37 AM, staff wheeled the resident into the therapy room. As of 9:37 AM, staff had not offered to assist the resident with oral cares. During an interview on 6/2/26 at 9:44 AM, Staff L, CNA stated that she did not brush the resident's teeth today as she wasn't sure if she had real teeth or dentures. During an interview on 6/3/26 at 1:42 PM, Staff N, RN Case Manager stated staff should check and change Resident #11. Staff N explained that due to Resident #11 having had a stroke, she could not always recognize that she was wet. Staff N stated the resident was incontinent even prior to admission when she was in assisted living. She stated staff should toilet residents in between meals. Staff N stated staff should complete oral cares in the morning. During an interview on 6/3/26 at 2:34 PM, the DON stated staff should check and change residents every 2 hours. She stated staff should complete oral cares when they get up and before bed. Review of the facility policy Perineal Care, dated 7/30/25, stated the purpose of perineal cares included the prevention of infection and odors. The policy directed staff regarding the method of performing incontinence care but did not provide a frequency with which staff should carry this out. The facility policy Denture and Oral Care, Dental Health Assessment, Dental Services, dated 3/30/26, instructed staff to assist residents with oral hygiene if they could not complete it themselves.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure a call light within the reach of 1 out of 21 dependent residents (Resident #95) in the sample. The facility reported a census of 101. Findings include: The Minimum Data Set (MDS) for Resident #95, dated 10/24/2025, list of diagnoses included atrial fibrillation or other dysrhythmias (irregular heart rhythm) diabetes mellitus, Non-Alzheimer's dementia, anxiety disorder, depression, and respiratory failure. The MDS identified Resident #95 dependent on staff for transfers and could not walk. The Care Plan for Resident #95, date initiated: 10/03/25, included a Focus area to address The resident has an ADL (activities of daily living) self-care performance deficit R/T (related to) copd (chronic obstructive pulmonary disease). Interventions included, in part: TRANSFER - Transfer Between Surfaces: assist x 2 with sit to stand with large harness if weak use the total lift high back large sling. Date Initiated: 11/7/25. During an observation on 12/02/2025 at 10:39 AM, Resident #95 sat in a recliner in her room. The resident called for help. The resident stated no one answered her and she needed help. The resident's call light observed tied to her bed with multiple knots, and outside the reach of the resident. The resident bed positioned across the room from the recliner. In an interview on 12/04/2025 at 11:20 AM, Staff A, Certified Nursing Assistant (CNA), stated call light buttons must be within reach of a resident at all times when they are in their rooms. She explained this is so they can call for help if they needed it. She stated it was unacceptable to have a call light in a resident's room and not within the residents reach when that resident is dependent on staff for mobility. During an interview on 12/04/2025 at 11:29 AM, Staff C, CNA, stated call lights are to be set up within reach of a resident when they are in their rooms. She stated it can be clipped to a number of surfaces, including their clothing, to ensure they have it within reach at all times. She then stated if they can't reach it they can't use it. During an interview on 12/04/2025 at 11:33 AM, Staff B, CNA, stated call lights staff are required to make sure a resident can reach their call light regardless of where they are in their room. He stated call lights should be handy, so that any time the resident needs help they can use it. During an interview on 12/04/2025 at 11:46 AM, the Director of Nursing (DON) acknowledged call lights should be within reach of a resident at all times. Review of a facility policy titled Call Light- R/S, LTC, Therapy & Rehab, dated 7/08/2025, included a Purpose section which included:a. To ensure a resident always has a method of calling for assistance.b. To promptly answer resident's call light. The Procedure section of the policy included, in part, the direction to #4. When leaving the room, place call light in easy reach of resident.

Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to respond to a weight loss in timely manner for 1 of 2 residents (Resident #104) reviewed for weight change. The facility failed to notify the physician of a weight loss in a timely manner which delayed the implementation of dietician recommended interventions. The facility reported a census of 101 residents. Findings include:Review of Resident 104's Minimum Data Set (MDS) assessment dated [DATE] revealed a diagnoses list which included hyperlipidemia, anxiety, depression, dementia, pain, and hypokalemia. A Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicated severely impaired cognition. The MDS indicated Resident #104 required set up assistance with eating.Review of the Care Plan, initiated on 12/23/22, revealed a Focus area to address The resident has potential for nutrition issues r/t (related to) dementia, hx (history) surgical wound, anxiety d/o (disorder), muscle wasting increasing risk for malnutrition. Weight gain may occur given previous wt (weight) loss, and wound healed. Interventions, included, in part:a. Weight per orders. Date Initiated: 4/22/24b. Provide supplement as ordered. May eat meals on the wing if Res I'd over stimulate. Date Initiated: 3/15/24c. Monitor for poor intake at meals, meal refusals. Provide cueing at meals as needed. Resident noted for liking grilled cheese and cheerios. Meal Alternatives offered. Previously attempted assisting dining to encourage meal intakes, resident did not accept. Date Initiated: 4/10/24.d. Monitor for significant weight change, RD (Registered Dietitian) to f/u (follow up) prn (as needed). Date Initiated: 12/23/22. Review of the Weight Summary in the electronic health record (EHR) revealed a weight of 153.8 Lbs (pounds) recorded for Resident #104 on 10/6/25. On 11/10/25 a weight of 133.0 Lbs recorded. On 11/19/25 a weight of 132.8 Lbs recorded. During a phone interview on 12/3/25 at 1:09 PM, Staff L, Restorative Nurse Aide (RNA) stated the restorative nurse aides were responsible for weighing the residents monthly. Staff L stated she noted Resident #104 weight loss when she weighed her before breakfast on 11/10/25. Staff L stated she re-weighted the resident on 11/10/25 and confirmed the loss. Staff L stated she informed Staff G, Registered Nurse (RN) of the weight loss. Staff L stated on 11/19/25, the Director of Nursing (DON) asked her to re-weight Resident #104. Review of a document titled Dining RD Consultant Report for Diet Change PCP (primary care provider) FAX Report, dated 11/18/25, addressed to [name redacted, Medical Director of facility]. Resident: [name redacted, Resident #104]. Assessment: Weight Loss Progress Note. Summary: RD Weight Eval: CBW (current body weight) 133.0 # (pounds). BMI (body weight index). Resident's wt showing significant wt loss -13.52% x 30 d (times 30 days)/-13.52% x 90 d/-1250%x 180d observations. Intake of Regular diet. 7 Regular texture, 0 Thin consistency diet inconsistent avg (average) 50% with 5 meals refused x 30 d hx. No documented edema over 14d hx. Recommend adding house supplement 4 oz (ounce) BID (twice daily) at AM and HS (night time) snack time Dietary add fortification to breakfast foods as appropriate. RD to monitor intakes, weight status and reassess with monthly weight collection or PRN. Consultant Recommendation/Intervention: Fortified Foods: Fortified cereal/oatmeal. Nutritional Supplement: House supplement 4 oz BID at AM and PM snack time. The fax signed by Primary Care Physician on 12/2/25 with the Approve Recommendation box checked. Review of the EHR revealed a Communication with Resident/Family note, entered on 11/19/25 at 10:51 AM, Who did you talk to/notify: daughter [name redacted]. Summary of discussion/notification and any education provided: Called & informed of recent loss down approx (approximately) 20lbs & dietician to make recommendations. Very thankful for info. Was consent needed? No documentation added.On 12/2/25 at 12:50 PM, a Communication/Visit with Physician note entered Dr. [name redacted] here on rounds, reviewed communication fax from dietician, agree with house supplement 4 OZ BID. noted. Review of the December 2025 Medication Administration Record (MAR) revealed an order for House Supplement two times a day for Weight loss, poor appetite/Intake Amount to serve: 4 OZ. Start Date: 12/2/25. Scheduled for AM and PM. The MAR documented House Supplement started on 12/2/25 during PM scheduled time. During an observation on 12/3/25 starting at 8:29 AM, Resident #104 assisted with wheelchair transport to the dining room. At 8:36 AM, Staff G, Registered Nurse prepared and offered a 4 oz nutritional supplement to the resident. Resident #104 consumed 100% of the supplement. At 8:39 AM, a Certified Nursing Assistant (CNA) encouraged Resident #104 to eat her breakfast. During an interview on 12/3/25 at 8:47 AM, Staff I, Manager of Nutrition and Food Services (MNFS), stated Resident #104's weight had fluctuated up and down in the past and was not too concerned right now with the resident's nutritional status.During an interview on 12/3/25 at 8:52 AM, the Consultant RD stated she would expect the recommendations she made for weight loss be implemented as soon as the resident's physician reviewed and approved the recommendations. The RD explained she visited the facility weekly to assist with the provider's nutrition and food services. She stated she communicated with the facility with the use of a document titled Nutrition Care Report. The RD stated the report gave a summary of her nutritional assessment for each resident reviewed during the weekly visit, and included recommendations. She stated if recommendations required physician approval she would send a document titled Consultant Request for Diet Change PCP FAX Report. The RD added Resident #104 was on her priority list due to the significant weight loss. During an interview on 12/3/25 at 10:39 AM, Staff G, RN Case Manager stated she is responsible for the residents on the 100, 200, and 300 wings which included the MDS assessments and coordination of Care Plans. Staff G stated that Resident #104's weight loss of 20 Lbs from 10/6/2025 to 11/10/25 was not addressed until nine days later, on 11/19/25. Staff G stated Resident #104 had been reweighted and the weight loss confirmed. Staff G stated the facility had a weekly At-Risk Committee meeting on Wednesdays. Staff G explained residents who were clinically at risk where discussed, which included significant weight changes. Staff G stated she could not recall if Resident #104's significant weight loss had been discussed at the 11/12/25 ARC meeting. She stated on 11/19/25, she had notified Resident #104's family of the significant weight loss. Staff G stated that nine days was a little lengthy to address a significant weight change and agreed that the facility had not promptly identified Resident #104's significant weight loss.Review of the facility's At-Risk Committee (ARC) meeting minutes revealed during the 11/12/25 no dietary staff had attended the meeting and Resident #104's significant weight loss had not been noted. On 11/19/25 Activities, Nursing, Social Services, Dietary staff and Consultant RD attended the ARC meeting and Resident #104's weight loss noted as having been discussed.During an interview on 12/4/25 at 8:15 AM, the Administrator stated the facility needed to develop a formalized protocol to address resident weight loss.During an interview on 12/4/25 at 10:14 AM, the DON stated on 11/10/25, when Resident #104's significant weight loss was identified, the nursing staff failed to notify the resident's physician and the RN Case Managers relied on the Consultant RD to complete her assessment and provide her recommendations to the resident's physician. The DON stated at the 11/12/25 ARC meeting she could not recall that Resident #104's weight loss had been discussed. The DON stated that at the 11/19/25 ARC meeting, Resident #104's significant weight loss of twenty-pounds had been discussed and she had asked RNA, Staff L, to re-weigh Resident #104 after that meeting ended. The DON stated she could not answer why Resident #104's significant weight loss had not been addressed immediately. Review of the facility policy titled Weight and Height, reviewed date of 9/30/25, included a Purpose section which included, in part: To report changes in a resident's clinical condition (significant weight change) to physician and family and/or resident. The Procedure section revealed in part:8. The licensed nurse should notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. Significant weight change is defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. 9. The licensed nurse should immediately notify the medical provider regarding any significant weight change as defined in step 8.

Based on observations, clinical record review, and staff interviews, the facility failed to use proper hand hygiene techniques during the administration of an insulin injection and eye drops for 1 of 3 residents (Resident #3) reviewed during medication administration observation. The facility reported a census of 101 residents. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #3's diagnoses included type 2 diabetes Mellitus. A Brief Interview for Mental Status documented a score of 07 out of 15, which indicated severely impaired cognition. This MDS documented that Resident #3 received insulin injections 7 of the past 7 days of the review period. Review of the Medication Administration Record (MAR) for the month of December 2025, directed Humulin KwikPen Suspension Pen-injector (Insulin) 10 units be administered in the AM and PM. Staff A , Licensed Practical Nurse (LPN) signed the MAR on 12/3/25 to indicate the AM dose administered. Review of the MAR for the month of December 2025, directed Polyvinyl Ophthalmic Solution be administered 1 drop in both eyes four times a day for dry eyes, be instilled. Staff A, LPN signed the MAR on 12/3/25 to indicate the 8:00 AM dose administered. On 12/3/25 an observation of Staff A, LPN started a medication pass began at 7:39 AM. During this observation it was noted that both Resident #3's insulin and eye drops were given without Staff A donning gloves. On 12:3/25 at 8:20 AM, Staff A, LPN acknowledged that she should have put on gloves prior to administering Resident #3's eye drops and prior to administering Resident #3's insulin. On 12/3/25 at 9:27 AM, the Administrator acknowledged not wearing gloves during the administration of an insulin injection and eye drops is a concern.A review of the facility's medication administration policies revealed that the policies did not include wearing gloves specifically for insulin pen injection nor for eye drop administration. On 12/4/25 at 11:50 a.m., the Director of Nurse (DON) stated she was surprised to hear that donning of gloves for insulin pen injections and for eye drop administration was not mentioned in their policies. This DON stated that normally she would say they would follow the policies, but stated she would wear gloves while administering both the insulin and the eye drops. She stated gloves should be worn for infection control purposes and that it is a standard of practice.

Based on observation, clinical record review and staff interview, the facility failed to use enhanced barrier precautions (EBP) during peri care for 1 of 3 residents who required EBP (Resident #6). The facility reported a census of 92 residents. Findings include: According to a Minimum Data Set (MDS) with a reference date of 6/17/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score 14 out of 15, indicating intact cognitive status. Resident #6 required moderate assistance with transfers, mobility and dependent assistance with dressing, toilet use and personal hygiene needs and determined as having a catheter and occasional incontinence of bowel. Resident #6's diagnoses included Parkinson's, coronary artery disease, gastroesophageal reflux disease, malnutrition, benign prostatic hypertrophy, and a right femur neck fracture. The Care Plan initiated 7/1/25, revised on 7/22/25, revealed the following: The resident requires Enhanced Barrier Precautions (EBP) R/T (related to) indwelling catheter. The Intervention dated 7/22/25 revealed, [NAME] gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. Observation on 8/28/25 at 9:00 a.m. revealed upon entrance to Resident #6's room, Staff U, Certified Nurse Aide, was in the process of resident care. Staff U was observed at Resident #6's bedside, and only wore gloves and no gown per EBP protocols. Resident #6's brief was open as to appear she was preparing to complete peri care. A new brief sat at the foot of the bed. Staff U stopped what she was doing and left the room to get a supervisor. Upon returning to the room, Staff U donned gloves and a gown and stated she needed to empty the catheter bag. Staff U then stated there was no graduate and asked her supervisor to get one. Upon returning with the graduate, Staff U then stated she had no alcohol wipes and again asked her supervisor to get her some. Staff U then proceeded with emptying the catheter bag properly using aseptic technique. Staff U then doffed her gloves and gown and re-gloved. She pulled Resident #6's brief open, stated he was clean, and she had completed catheter care prior to this surveyor entering the room. Staff #6 left the old brief on and reattached it, continued to dress Resident #6, then transferred him into his wheelchair and to the dining room for breakfast.According to the facilities Enhanced Barrier Precaution policy, Enhanced Barrier Precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff, hands and clothing.Enhanced barrier precautions are used for residents with chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers) and residents with indwelling medical devices (i.e., central lines, hemodialysis catheters, indwelling urinary catheters, feeding tubes, and tracheostomies), even if the resident is not known to be infected or colonized with an MDRO (Multidrug resistant organisms).

Based on observation, clinical record review, and staff and resident interview, the facility failed to implement and follow physician orders for application of an ace wrap for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 92 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS revealed the resident had a diagnosis of heart failure. Clinical record review revealed an order dated 6/18/25 for an ace wrap to be applied to Resident #8's lower extremities in the morning and discontinued in the evening. Review of June, July and August 2025 Medication Administration Records found no documentation of ace wrap or compression stockings being used as ordered. Observation on 9/3/25 at 10:45 a.m. noted Resident #8 sat in his recliner with his feet elevated. Resident #8 wore socks and shoes, but no ace wrap or compression stockings as ordered. Resident #8 was queried about using ace wrap on his legs and he stated they did it once, but it hurt so bad that he had them remove it. In an interview on 9/3/25 at 10:50 a.m. Staff W, Registered Nurse, was queried whether the computer showed Resident #8 was to have ace wraps applied daily. Staff W brought up her computer and searched, but was unable to find it as a nursing task. In an interview on 9/3/25 at 11:00 a.m. the Director of Nursing (DON), was questioned whether Resident #8 was to have ace wrap applied to his lower extremities daily. The DON searched her computer and noted he had an order for it, but was uncertain where it would be documented as completed. In an interview on 9/3/25 at 11:15 a.m. the Assistant Director of Nursing (ADON) brought her computer in and was able to show where aides documented the task of putting on an taking off the ace wrap.

Based on observation, clinical record review and staff interviews, facility staff failed to ensure prompt intervention to ensure supplemental oxygen was administered in accordance with physician orders and each resident's individual care plan for 2 of 3 residents reviewed (Resident #6, #7). The facility reported census of 92 residents. Findings include: 1.According to a Minimum Data Set (MDS) assessment with reference date 6/17/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score 14 out of 15, which indicated intact cognitive status. Resident #6 required moderate assistance with transfers, mobility and dependent assistance with dressing, toilet use and personal hygiene needs and determined as having a catheter and occasional incontinence of bowel. Resident #6's diagnosis included Parkinson's, coronary artery disease, gastroesophageal reflux disease, malnutrition, benign prostatic hypertrophy, and a right femur neck fracture. According to physician orders, Resident #6 was to receive oxygen at 2-3 liters per minute for shortness of breath as needed to keep his oxygen saturation levels greater than 90%.During an observation on 8/21/25 at 11:40 a.m. Resident #6 sat in his wheelchair in the dining room waiting for lunch. He had an oxygen tank and wore a nasal cannula. The oxygen tank was either empty or near empty as the needle was in the red range on the tank gauge.During an observation on 8/21/25 at 3:20 p.m. Resident #6 attended an activity and remained in his wheelchair with oxygen on per nasal cannula, however his tank remained empty as the needle remained in the red range on the tank gauge.In an interview on 8/21/25 at 3:30 p.m. Staff L, Licensed Practical Nurse, was queried who was responsible to change out empty oxygen tanks. Staff L stated the nurses would change them out and typically relied on the aides to let them know when they were low or empty.In an interview on 8/21/25 at 3:40 p.m. the Director of Nursing (DON) was queried regarding whose responsibility it was to ensure residents oxygen tanks were kept full. The DON stated it was everyone's, noting if a tank was observed low or empty, nurses or aides could exchange the tank.2. According to a MDS with reference date 7/12/25, Resident #7 had a BIMS score 14 out of 15, which indicated intact cognitive status. Resident #7 required maximal to dependent assistance with transfers, mobility and dependent assistance with dressing, toilet use and personal hygiene needs and was determined as always incontinent of bladder and bowel. Resident #7's diagnosis included rheumatoid arthritis and gastroesophageal reflux disease.According to Resident #7's Plan of Care dated 10/8/24, Resident #7 required oxygen therapy related to hypoxia. Interventions initiated 10/8/24 included to monitor signs and symptoms of respiratory distress and report to the health care provider as needed, prevent abdomen compression and respiratory distress by routinely checking the resident's position so she does not slide down in bed, and oxygen therapy at 1-4 liters per minute per nasal cannula. According to physician orders, Resident #7 was to receive supplemental oxygen 1-4 liters per minute as needed to keep oxygen saturation levels great than 90%.During an observation on 8/21/25 at 11:40 a.m. Resident #7 sat in a wheelchair in the dining room waiting for lunch. She had an oxygen tank and was not wearing her nasal cannula. The oxygen tank was empty as the needle was in the red on the tank gauge.During an observation on 8/21/25 at 1:15 p.m. Resident #7 was propelled back to 200 unit and sat at a table. Resident #7's tank was exchanged and now had half full tank and she wore her nasal cannula.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to provide adequate supervision or provide timely care in order to prevent a fall with major injury. The facility also failed to implement new interventions to reduce falls from the wheelchair for 1 of 3 residents reviewed (Resident #2) for falls. The facility failed to ensure safe wheelchair transport and proper use of foot pedals during a general observation of Resident #67. The facility reported a census of 111. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/5/24, listed diagnoses for Resident #2 which included intellectual disabilities, seizure disorder, and pain. The MDS stated the resident was dependent on staff for chair to bed transfers, shower transfers, and toilet transfers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating moderately impaired cognition. The Slipped or fell report dated 8/11/24 at 11:00 am documented staff getting residents up for lunch when a resident yelled out that someone was on the floor. Resident #2 found on the floor face flat on the floor. Resident stated the wheelchair hurts her back and when asked how she fell she stated from the side of the wheelchair. The Care Plan initiated 5/10/2016 documented the resident is at risk for falls related to debility, impaired mobility, seizures and intellectual disability. The Care Plan documented a goal that the resident will not sustain serious injury through the review date. On 8/11/24 the Care Plan was updated with an entry directing staff to ensure the resident was in a proper sitting position in her wheelchair with her hips and back secured in the back of the chair and in good alignment with foot pedals on her chair. An 8/18/24 Mood/Behavior note stated the resident leaned forward in her wheelchair. The resident was very close to falling forward out of her chair and (staff) assisted her to sit back in her chair multiple times. Staff then used a Hoyer (a type of mechanical lift) to transfer her to a recliner to assist with safety. A 9/6/24 Other Progress note stated the resident colored at the counter slumped over and sliding out of her wheelchair. Staff manually lifted her back to a properly seated position. The Slipped or fell report dated 9/23/24 at 7:39 pm documented the resident was yelling bed. Resident then leaned forward, screamed, and fell forward out of the wheelchair onto the floor. The nurse did not see if she hit her head due to partial wall in the way. The wheelchair was in the reclined position. The resident sustained a bruise to the front of the right shoulder. A 9/24/24 Communication/Visit with Physician stated the resident complained of pain in the right leg, did not want to move the leg, and yelled when touched. Tylenol did not help with the pain. The facility submitted a request for an x-ray of the right leg. An undated handwritten note by Staff A Licensed Practical Nurse (LPN) stated she heard the resident yell bed and heard Staff K Certified Nursing Assistant (CNA) tell the resident she would finish another resident and help Resident #2 next. Staff A then walked down the hall to assist another resident. Staff A observed the resident lean forward as she normally did to color. The resident screamed and fell forward out of her wheelchair, which was in a reclined position. A 9/24/24 Care Plan entry directed staff to remind the resident not to lean forward in the wheelchair and offer an earlier time to go to bed. The Care Plan lacked documentation to address the resident's wheelchair positioning concerns on 8/18/24 and 9/6/24 and lacked a related intervention prior to 9/24/24. A 9/25/24 Communication/Visit with Physician stated the resident was in pain. The facility received an order for Tramadol (a narcotic pain medication every 4 hours as needed). A 9/25/24 Final Radiology Report stated the resident had right fibular (referring to the long, lower leg bone) and tibial (referring to the shin bone) fractures. A 10/1/24 Health Status note stated the resident reported pain to the right lower extremity. On 10/9/24 at 9:51 a.m. Staff L and Staff M (CNAs) transferred Resident #2 from the wheelchair to the bed using a mechanical lift. When the resident rolled over to the right side she stated ow. On 10/10/24 at 8:24 a.m. via phone Staff A stated she was present when Resident #2 fell . She stated the resident yelled bed three times earlier that night from the time she returned from the dining room around 6:00 p.m. She stated a CNA trained another CNA and told the resident she would be right with her. She stated she heard a crash and a scream and the resident laid on her left side. She stated she did not see the fall due to the presence of a partial wall. She said the fall occurred between 7:00 p.m. and 8:00 p.m. and the resident initially did not appear to have an injury. On 10/10/24 at 8:49 a.m. Staff F CNA stated there was an occurrence when the resident tried to bend over and slide out of her wheelchair. She stated the resident liked to toss herself out of her wheelchair and if she yelled bed, she would prioritize assisting her. On 10/10/24 at 8:55 a.m., Staff G Certified Medication Assistant (CMA) stated the resident had been close to falling when she sat way up in her wheelchair. On 10/10/24 at 9:13 a.m. Staff H Registered Nurse (RN) stated the resident was impulsive and when pushed in her wheelchair, she immediately moved forward. On 10/10/24 at 9:24 a.m., Staff I CMA stated the resident threw herself around in her chair and it terrified her. On 10/10/24 at 11:20 a.m., Staff J RN Case Manager stated the resident did not try to get out of her chair any other times. She stated staff did not report to her that the resident almost fell out of her wheelchair prior to the 9/23/24 fall. She stated if the resident voiced that she wanted to go to bed, staff should have assisted her sooner. On 10/10/24 at 12:06 p.m., the Director of Nursing (DON) stated if a resident yelled bed, staff should ask her what was wrong and meet her needs. On 10/10/24 at 1:10 p.m., via phone, Staff K CNA stated on the night of the fall, she did not get on the floor until 6:30 p.m. She stated Resident #2 said bed but she had another resident that she needed to take care of who she could not leave. She went down and took care of the other resident for 10-15 minutes and then heard that the nurse needed her because Resident #2 was on the floor. Staff K stated there should have been another CNA on the floor and she did the best she could. She did not want the other resident to fall. The facility policy Fall Prevention and Management reviewed 7/29/24, stated the facility would have a fall prevention and management program and stated the facility would identify the causes of a problem so solutions could be identified and put into place. The policy directed staff to include appropriate interventions on the Care Plan. 46513 2. The MDS assessment dated [DATE] for Resident # 67 included medical diagnoses for Parkinson's disease and respiratory disease. The MDS revealed the resident required partial/moderate assist with chair/bed transfers, sit to stand, lying to sitting and scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The Care Plan revealed a focus area initiated on 8/27/24 for Resident #67, documented limited physical mobility related to weakness. Interventions included use of a wheelchair for locomotion and foot rest use. During an observation on 10/7/24 at 12:28 PM, Staff E, CNA (Certified Nurse Aide) pushed Resident #67 down the hall after lunch and the left foot was off the foot pedal and dragged on the floor. During an interview on 10/7/24 at 5:00 PM, the DON (Director of Nursing) acknowledged awareness of possibilities of falls and injuries if feet are not on the wheel chair when pushed. Facility memo provided, DON relayed was made available to staff and directed, do not push any resident that is in a wheel chair without pedals. Serious injury can result, please make sure pedals are in place before you push a resident.

Based on observation, staff interviews, and policy review, the facility failed to ensure dignity to residents in the main dining room. Resident with soiled shirt of spilt drink and processed food propelled self near other residents eating thorough the dining area (Resident #71). The facility reported a census of 111 residents. Findings include: The Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #71 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition was severely impaired. Diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, dysphagia (indicates difficulty swallowing) and pain. The MDS revealed resident required supervision or touching assistance with eating and required a mechanically altered diet. The Care Plan revealed a focus area initiated 5/31/24 for ADL (Activities of Daily Living) self care performance deficit related to Alzheimer's disease. The intervention dated 5/31/24 revealed resident required assistance of one. The intervention dated 9/15/24 revealed Resident #71 wore a food protector at meals to protect clothing per family request. During an observation on 10/9/24 at 5:20 PM in the main dining room, the dining room filled with residents enjoying dinner meal. Resident #71 eating independently, spilled liquid down his shirt and had pureed food going down his shirt with food in residents beard as well, began to exit self in his wheelchair through the dining room. In an interview on 10/9/24 at 5:22 PM with Certified Nursing Assistant, (CNA) Staff C stated the resident usually does wear a clothing protector, they are no longer available in the dining room. Stock is normally in another hall and there are not many. A staff must remember to bring it with the resident. Relayed resident wants to try to feed himself. In an interview on 10/9/24 at 5:24 PM with the Director of Nurses, (DON) relayed we have done away with using clothing protectors, only use if family wants them and the family would have to provide them. Relayed would reach out to the family. Policy provided titled Resident Dignity-Rehab, Skilled revised 11/16/23 documented would promote care for residents in a manner and in an environment that maintains or enhances each residents dignity and respect in full recognition of his or her individuality.

Based on observation, interview, record review and policy review the facility failed to implement interventions to prevent the development of multiple pressure injuries. Facility also failed to follow physician treatment, using an incorrect medicated treatment on an open pressure injury and further failed to prevent contamination of pressure injuries while performing wound care for 1 of 3 residents (Resident #96) observed for wound care. Facility reported a census of 113 residents. Findings include: Review of Resident #96 Admission Assessment Record, dated 2/17/23, revealed resident was determined at risk for pressure ulcer development related to immobility. According to assessment, wounds present on admission included a right trochanter surgical wound and a pressure wound to coccyx. Admission assessment indicated resident had anomaly to feet and informed that resident was not able to ambulate independently, with one assist, or with device (e.g. cane/walker/wheelchair) upon admission. Daily Skilled Progress Note, dated 2/20/23, at 10:38 AM documented that Resident #96 refused to leave her bed, refused to get up and transfer to wheelchair or recliner. Dietitian Note, dated 2/22/23 at 11:10 AM, revealed Resident #96 intakes were sporadic and nutritional supplement 4 ounces to be initiated twice per day. Documentation that Resident #96 required feeding assistance in bed. Summary of Skilled Services Note, dated 3/04/23 at 12:28 PM, revealed Resident #96 required assistance of 2 staff with a mechanical (Hoyer) lift for transfer and staff assistance with eating. Skin assessment dated [DATE] revealed initial assessment of pressure ulcer to right heel, not present on admission. Assessment indicated Diabetes Mellitus and pressure ulcer as the complications present. A second skin assessment for right heel, dated 3/20/23, revealed pressure injury presented as an intact blister, measured 3cmx3cm, and classified as a Stage 2 pressure injury. Assessment indicated a club foot deformity as a present complication. Skin assessment, dated 3/18/23, revealed pressure ulcer to left heel, not present on admission. Skin assessment, dated 4/01/23, revealed initial assessment of a pressure wound to Resident #96's left foot bony prominence. Assessment indicated the following interventions to be implemented: repositioning, support surfaces, wound care treatment, and pain management. Documentation informed physician notification of new ulcer. Skin assessment, dated 4/02/23, revealed pressure areas noted on Resident #96's left heel, left ankle, and top of left foot. Assessment documentation indicated cause of pressure areas from orthopedic abnormalities and pressure to the areas. Skin assessment revealed that resident had pain related to the pressure areas. Interventions to be implemented included: medications, padded wound dressing, positioning, and padded moon boots. Skin assessment, dated 4/14/23, revealed suspected deep tissue injury of left toes, not present on admission. Indicated Diabetes Mellitus and pressure as complications present. Skin assessment, dated 5/08/23, revealed right outer foot pressure ulcer, not present on admission. Assessment indicated 100% of wound covered in eschar (black, necrotic) tissue. Right outer foot pressure ulcer measured 0.6cmx0.1cm and classified as an unstageable pressure wound. Progress note, dated 5/24/23, revealed notification to Provider of maintaining unstageable pressure areas to bilateral feet. Review of Resident #96 most recent Minimum Data Set (MDS) assessment (Quarterly) completed on 5/30/23 listed Diabetes Mellitus (DM) as an active diagnosis. MDS revealed the Brief Interview for Mental Status (BIMS) score to be 11, indicating moderate cognitive impairment. The Braden scale, used to assess for the risk of pressure injury development, indicated resident is at risk. The MDS revealed Resident #96 had one or more unstageable deep tissue injuries that were not present upon admission. MDS revealed that Resident #96 received pressure ulcer/injury care and the application of non-surgical dressings with or without topical medications. Progress note, dated 8/10/23, revealed wound on left foot appeared to be deteriorating. Indicated notification to Wound Care Nurse for reassessment. The Resident's Care Plan lacked focus areas, goals, and interventions for prevention of skin issues to include development of pressure areas until 2/17/23. Review of current Care Plan, review date started on 08/10/23, revealed the focus area for an unstageable pressure ulcer to right heel and the potential for pressure ulcer development related to immobility. The Care Plan indicated the goal that Resident #96's pressure ulcer would show signs of healing and remain free from infection through the review date. The Care Plan interventions related to pressure ulcers on the feet listed as follows: Encourage, assist, supervise with use of assist bar, etc., for resident to assist with turning, initiated on 2/17/23. Float heels when supine and apply moon boots as appropriate, initiated on 3/22/23. Monitor/remind/assist to turn/reposition at least every two hours, initiated on 4/03/23. Provide pressure relieving device air mattress with boulders, initiated on 4/03/23. Review of current Medication Administration Record (MAR) listed the treatment order for Santyl External Ointment 250 Units/GM (Collaginase), to be applied to left inner ankle ulcer topically one time a day for healing. Directions included to cleanse area with wound cleanser soaked 4 x 4 s (gauze), pat dry with clean 4 x 4 s (gauze), apply Santyl, cover with Xerofoam, cover with foam and wrap with rolled gauze, secure with tape. Order for Santyl ointment initiated date of 08/11/23. MAR also indicated skin [NAME] barrier film to be applied to bony prominence's of feet and cover with padded gauze wrapped dressing. On 08/21/23 at 11:00 AM, Resident #96 wore gauze wraps to both feet and padded boots on both feet. On 08/22/23 at 01:05 PM observed wound care treatment and wound dressing change performed by Staff T, Registered Nurse (RN), for Resident #96: On 08/22/23 at 01:05 PM Staff T, Registered Nurse (RN) used hand sanitizer prior to putting on gloves, then removed the old gauze wrap dressing from Resident #96's left foot. Staff T used scissors from the top of the treatment cart to aid in the removal of the dressing. Staff T failed to sanitize the scissors after use. Staff T then opened several packets of skin [NAME] barrier film and applied to pressure areas on left heel and left bunion, wound cleanser spray used on gauze 4x4 to clean the open pressure injury on left inner foot. Staff T did not perform hand hygiene or change gloves between removal of soiled dressing and beginning of wound cleaning. Staff T then opened a package of calcium arginate wound treatment and cut off a square piece of treatment using the same scissors. The treatment was applied to the left inner foot open wound. The same scissors were again used to cut a square piece of foam which was placed on top of the left inner foot wound, scissors were never sanitized. During the treatment observation an open area on the left inner ankle with raised, dark purple/red colored skin surrounding the open area, the wound bed appeared white, yellow in color was observed. Resident reported the area felt sore during wound cleaning. Staff T then wrapped the Left foot wrapped with gauze bandaging. Staff T continued to wear the same gloves throughout entire procedure. Staff T next removed the soiled wound dressing from right foot using the same scissors and applied skin [NAME] film barrier to resident's right heel, right inner bunion, and right outer foot, same gloves continued to be worn. The observation included the following; a. black scab with pink surrounding skin to right outer foot wound, resident complained that area felt sore when touched. b. black scab with red surrounding skin to right inner foot wound. c. large black scab that covered almost entirety of right heel, surrounding skin appeared pink, dry, and flaky. With continued observation Staff T placed padding on resident's right heel and right inner foot, secured with gauze bandaging wrap. The new dressings applied to Resident #96's feet were not labeled with the RN initials or the date performed. Staff T's gloves were removed at the end of procedure and hand hygiene performed only after finishing wound care and dressing change for multiple pressure areas on Resident #96's feet. On 08/21/23 at 11:00 AM Resident #96 reported that she had quite a bit of pain in her ankles. Resident #96 stated that she had sores on her ankles and heels, she also reported not having any sores when she came here. Staff T, RN reported on 8/2/23 at 1:22 PM the times she should wash hands and change gloves during a wound care procedure as when she were to leave or come back into a resident room, and when she had visible blood on her gloves. RN confirmed that Santyl was not used on left ankle ulcer and stated that since the scab fell off the wound they now do the calcium on the open area. Staff T indicated that wound care and dressing changes are completed daily and that a Wound Nurse performs skin assessment weekly. On 08/22/23 at 01:43 PM, the Director of Nursing (DON) reported that Nursing staff were expected to follow facility policies and the standard of practice when performing wound care and dressing changes. DON confirmed the expectation that hand hygiene and glove changes would be performed during the dressing change between removal of soiled dressing and application of a clean dressing or before wound cleaning to prevent contamination. The DON indicated that the Nursing staff receive training from Wound Nurse/Infection Preventionist, Staff Q, and reported that Staff T would be receiving further education on infection control/wound care if that is what is needed. On 08/23/23 Staff Q, Wound Nurse/Infection Preventionist at 11:20 AM, confirmed that she is responsible for Nursing staff wound care training and facility infection control program. Staff Q confirmed the expectation of Nursing staff to perform hand hygiene and change gloves during dressing change between removal of soiled dressings and application of a clean dressing or before wound cleaning to prevent contamination. On 08/24/23 at 10:02 AM. Staff R, RN reported Resident #96 had some red areas to feet upon admission but no open areas, she confirmed that resident's feet have a congenital disorder and turn inwards. Staff R stated Resident #96 had worn padded moon boots for a while but could not recall for how long. Staff R reported that Residents #96's wounds have stayed static but did identify a concern for reddened left inner foot open ulcer and stated she reported concern to Wound Nurse. On 08/24/23 at 11:15 AM, Staff P, Case Manager Nurse, indicated that she would update a resident Care Plan when a new order started, therapy made changes, or when staff report changes. Staff P confirmed the first pressure ulcer documentation and assessment of feet was for the left heel on 3/13/23. Case Manager confirmed that padded moon boots intervention was initiated in Care Plan on 3/13/23, following the left heel pressure ulcer development. Staff P also confirmed the interventions to float heels and reposition every 2 hours were initiated in the Care Plan on 4/03/23 following the development of a pressure ulcer. On 08/24/23 at 11:22 AM, Staff S, Certified Nursing Assistant (CNA), reported the resident had worn the padded moon boots for the last couple of months. On 08/24/23 at 11:30 AM, Resident #96, reported the wounds on her feet started with one then spread to both feet. Resident #96 was unable to recall how long padded moon boots had been in place, she stated before the boots they would put a pillow at the crook of her knees. On 08/24/23 at 11:55 AM, the Director of Nursing (DON), reported the Nurses complete a full head to toe assessment on all residents upon admission. The DON reported the Braden Scale was used to determine resident risk for pressure injury and the expectation that interventions would be initiated if a resident was determined at risk for pressure ulcer development. The DON confirmed that Resident #96 developed pressure wounds to her feet after admission and reported that resident condition, not being mobile, and anomaly of feet may have contributed to pressure ulcer development. The DON stated she was not aware of any interventions that were in place for Resident #96 prior to pressure ulcer development to her feet. Review of facility policy titled Pressure Ulcers- R/S, LTC, Therapy & Rehab, dated 2/10/23, revealed that 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 ulcers 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.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out fall interventions in order to prevent a major injury for 1 of 3 residents reviewed for falls (Resident #312) and failed to safely assist a resident with wheelchair locomotion for 1 resident during a general observation (Resident #84). The facility reported a census of 113 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment tool, dated 11/17/22, listed diagnoses for Resident #312 which included arthritis (inflammation of the joints), disorder of bone density, and pain. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene, dressing, and bathing, depended completely on 1 staff for bed mobility and toilet use, and depend completely on 2 staff for transfers. The MDS stated the resident did not transfer or walk during the review period and listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, which indicated intact cognition. The facility policy Fall Prevention and Management-Rehab/Skilled, Therapy and Rehab, reviewed 3/29/23, stated the facility would identify risk factors and implement interventions before a fall occurred. The policy stated the facility would carry out a root cause analysis to identify the causes of a problem so that solutions could be identified and put in to place. A 12/27/22 document entitled Found on Floor stated the resident's family found her on the floor on the right side of the bed lying on the right side of her body. The family member called 911. A 12/27/22 10:50 p.m. Health Status Note stated the resident returned to the facility. A 12/28/22 Care Plan Change note listed an intervention for the 12/27/22 fall was for staff to ensure the correct bed height was in low position before leaving the room. A 12/28/22 Care Plan entry directed staff to ensure the correct bed high was in the low position before leaving the room. A 12/30/22 document entitled Found on Floor stated dietary staff reported the resident was on the floor and laid between the bathroom door and the bed. Her left knee showed deformity with bone protruding underneath the skin. The left foot and ankle were purple in color and the bed was in the up position. The resident transferred to the hospital. A 12/30/22 hospital Patient Visit Information document stated the resident had a right tibial plateau (shin bone) fracture. A 12/31/22 Other Progress Note stated the resident had a tibia (shin bone) fracture to the left leg. On 8/24/23 at 8:33 a.m., Staff U Registered Nurse (RN) stated someone in the dietary department informed her the resident was on the floor. She stated when the resident was on the floor, her bed was in the regular height position, not the low position. Staff U stated she found out after the fall that a low bed was the intervention from her previous fall. She stated the resident reported she was trying to get up and was sick and confused. On 8/24/23 at 9:37 a.m., Staff P RN Case Manager stated staff should carry out care plan changes. She stated the resident should have had a low bed with a scoop mattress at the time of the fall. She stated the care plan directed staff to make sure the bed was in low position before exiting the room. On 8/24/23 at 9:45 a.m. the Director of Nursing(DON) stated after a resident fell , they came up with interventions and staff should follow through with those interventions. She stated she expected staff to carry out the low bed intervention. 46513 2. The Quarterly Minimum Data Set (MDS) for Resident #84 dated 7/19/23 revealed resident scored 09 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderate cognitive impairment. The MDS revealed the resident required limited assistance of one (1) person for transfers and used a wheelchair for mobility. The medical diagnoses included peripheral vascular disease, diabetes and dementia. The Care plan completed 7/23/23 for Resident #84 revealed a focus problem of limited physical mobility related to debility, required staff assist of one (1) and used a wheelchair for locomotion with the foot rest. On 08/22/22 at 2:03 PM observation of resident #84 in his room in wheelchair yelled out repeatedly, wanted out of the room. Certified Nursing Assistant (CNA) Staff #B approached resident and started pushing resident from his room swiftly down the hallway to the common area, about 50 feet. The wheel chair did not have foot pedals, residents' feet hung in front of the wheel chair. On 8/22/22 at 2:05 PM Interview with Registered Nurse (RN) Staff A who was present in the hall relayed resident did not use his feet to move the wheel chair. Staff A confirmed Resident #84 did not like the foot pedals so they were taken off. Staff A acknowledged seeing the resident being pushed by Staff B and stated it appears she will need to educate Staff B not to push the resident without the foot pedals. On 8/22/23 at 4:00 PM the Director of Nurses reported that she believed staff are educated during their CNA training about safety transport and education is also provided with facility compliance checks. The DON relayed the expectation is that staff are aware of the potential dangers and use foot pedals on wheelchairs when pushing a resident. The DON reported on 8/23/23 at 9:00 AM that the facility did not have a specific policy regarding resident's transfers with wheelchairs.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions in order to prevent a fall with major injury for 1 of 6 residents reviewed for falls (Resident #68). The facility reported a census of 102 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated 4/25/22, listed diagnoses for Resident #68 which included [CONDITION(S)], intellectual disabilities, and pain. The MDS stated the resident required extensive assistance of 2 staff for bed mobility and dressing, and depended completely on 2 staff for transfers, toilet use, personal hygiene, and bathing. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 6 out of 15, indicating severely impaired cognition. A 5/10/16 Care Plan entry stated the resident required the assistance of 2 staff to roll side to side. An untitled 5/20/18 incident report stated the resident was jerking and thrashing and turned in bed over the edge and staff lowered the resident to the ground. A 12/19/19 3:10 a.m. Progress Note stated staff told the resident to roll to her right in order to check her brief and the resident rolled too far off the bed and onto the floor to her knees. The resident had a bruise to the right ankle and a 3 cm(centimeter) laceration to the left great toe. The facility obtained an order to send the resident to the hospital. A 12/19/19 7:07 a.m. Progress Note stated the resident returned from the hospital. A 12/19/19 7:09 a.m. Progress Note stated the facility would implement the following interventions with relation to the resident's fall: scooped bariatric mattress, assist of 2 with 1 person on each side of the bed. A 3/8/2021 7:00 a.m. Progress Note stated staff changed the resident when she grabbed the grab bar on the side of her bed, sat herself up on the edge of the bed, and threw herself off the side of bed. Staff was unable to stop the resident. A 5/1/22 2:53 a.m. Progress Note stated a CNA(Certified Nursing Assistant) asked the resident to assist with repositioning and the resident used too much force rolling onto the left side and rolled out of bed. A 5/1/22 7:41 a.m. Progress Note stated the resident transferred to the ER for evaluation. A 5/2/22 hospital History and Physical stated the resident had a right distal femoral(upper leg bone) fracture and would proceed with surgery. A 5/4/22 Progress Note stated the resident returned from the hospital. During an observation on 6/6/22 at 1:13 p.m., the left side of the resident's bed was pushed up against the wall. Staff J CNA and Staff C CNA transferred the resident to the bed utilizing the stand lift. Staff assisted the resident to roll over on the left side in order to complete perineal cares and change the resident's brief. Staff J and Staff C were both in close proximity to the bed while providing assistance to the resident. The facility policy Care Plan-R/S, LTC, Therapy and Rehab revised 5/3/22, stated the care plan would ensure residents received the appropriate care and services. During an interview on 6/13/22 at 2:22 p.m., Staff L CNA stated she was changing the resident in the middle of the night and she went to roll too fast and rolled out of the bed. She said at the time, she was in a different room with a different bed than normal due to her regular room receiving a treatment for bed bugs. She stated her normal bed was wider and the bed she was in at the time of the fall was open on one side(not against the wall). She stated the resident currently required the assistance of 2 staff for bed mobility but she didn't know what the requirement was at the time of the fall. She stated they had a Kardex for staff to review with regard to resident's care requirements. During an interview on 6/13/22 at 2:31 p.m., Staff N CNA stated the resident had always required the assistance of 2 staff for bed mobility. She stated when she rolled she used to just fly over. During an interview on 6/13/22 at 3:02 p.m., Staff C CNA stated prior to the resident's fall, staff would utilize 2 people while in bed. She stated if the resident was too far to one side, she could roll off. During in an interview on 6/14/22 at 1:07 p.m. Staff M CNA stated she would utilize 2 staff for the resident when assisting her with cares in bed for backup. She stated she had always required the assistance of 2 staff members. During an interview on 6/15/22 at 11:28 a.m., Staff I RN (Registered Nurse) Case Manager stated staff should look at the Kardex every day. She stated the resident should have 2 staff to assist with bed mobility and this was not the first time she rolled out of bed. She stated the resident was quick and impulsive and not very safe. She stated when she rolled out of bed, the staff member was alone and this was why she had the care plan intervention of the assistance of 2. During an interview on 6/15/22 at 1:27 p.m., the DON (Director of Nursing) stated the resident's care plan directed staff to utilize 2 staff for assistance in bed and stated this was her expectation.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions in order to prevent a pressure ulcer for 1 of 4 residents reviewed with a pressure ulcer(Resident #77). The facility reported a census of 102 residents. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 2/16/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for eating, and depended completely on 2 staff for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS stated the resident did not walk and only transferred from surface to surface once or twice during the review period. The MDS stated the resident was at risk of developing pressure ulcers but had no current unhealed ulcers. The MDS stated the resident was not on a turning/repositioning program and listed the resident's BIMS(Brief Interview form Mental Status) score as 10 out of 15, indicating moderately impaired cognition. A 2/6/22 Progress Note stated the resident transferred to the hospital. A 2/14/22 Progress Note stated the resident was in the hospital due to kidney failure. A 2/14/22 Nursing Admit Re-Admit Data Collection report stated the resident returned from hospital leave. The assessment did not state the resident had a current pressure ulcer but stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/14/22 Braden Scale for Predicting Pressure Sore Risk stated the resident was at risk for developing pressure sores due to factors which included very limited mobility, chairfast status, and inadequate nutrition. A 2/15/22 DNP(Doctor of Nursing Practice) Progress Note stated the resident had [CONDITION(S)] affecting the left side. A 3/2/22 Progress Note stated (staff) noted an unstageable(known but not stageable due to coverage of the wound bed by slough[dead tissue] and/or eschar[a dry, dark scab]) wound to the resident's left heel. The skin was darkened and hard and did not blanch with drainage and had a 3 cm(centimeter) slit. A 3/2/22 Wound Data Collection report stated the resident had an unstageable pressure area to the left outer heel measuring 7 x 7 (in cm length x width). Subsequent Wound Data Collection reports listed the following measurements: 3/8/22 7 x 7 3/15/22 7 x 7 3/24/22 7 x 7 3/29/22 7 x 7 4/5/22 7 x 7 4/12/22 7 x 7 4/19/22 6.8 x 7 4/26/22 6 x 6.2 5/3/22 6 x 6 5/10/22 6 x 5 5/17/22 8 x 8 5/24/22 8 x 8 5/31/22 6 x 2 6/7/22 6 x 8 6/14/22 6 x 8 The facility lacked documentation of a skin assessment completed between 2/14/22 and the discovery of the wound on 3/2/22. The 5/18/22 MDS stated the resident had 1 unstageable pressure ulcer. Care Plan entries, dated 3/2/22, stated the resident had an unstageable pressure area to the left outer heel and directed staff to apply moon boots and offload bilateral heels while lying in the supine(on the back) position. The Care Plan lacked documentation of the initiation of boots and heel offloading prior to 3/2/22. The facility policy Pressure Ulcers-R/S, LTC, Therapy and Rehab, revised 6/3/22, stated the facility would utilize prevention and assessment interventions to ensure a resident without a pressure ulcer did not develop a pressure ulcer. During a joint interview on 6/9/22 at 1:09 p.m., Staff F Nurse Manager stated the facility did not carry out skin checks on residents without current skin issues. The DON(Director of Nursing)stated there were no skin checks on paper. During a phone interview on 6/14/22 at 10:24 a.m., Staff G LPN(Licensed Practical Nurse) stated when he first saw the resident's wound, it was a dark spot and he informed the Wound Nurse. He stated he was not sure if staff floated the resident's heels prior to the development of the wound but stated he did wear boots after the discovery. During an interview on 6/14/22 at 12:58 p.m., Staff H CMA(Certified Medication Aide) stated she did not see the resident with boots prior to the development of the wound. She stated he currently wore a boot and staff floated his heels while in bed and these interventions started after the wound developed. During an interview on 6/15/22 at 10:01 a.m., Staff I RN(Registered Nurse) Case Manager stated the facility completed skin checks on existing wounds only. She stated the resident was totally dependent on staff for assistance and had one side affected by a stroke. She stated the resident had a wedge to keep his heels off the bed and a boot. She stated these were implemented because of the discovery of the wound. During an interview on 6/15/22 at 10:11 a.m., Staff A Facility Wound Nurse stated the facility had documentation of the interventions of heel offloading and boots starting from 3/2/22. During an interview on 6/15/22 at 1:27 p.m., the DON(Director of Nursing) stated the CNAs should complete daily skin checks and report any changes to the nurses. She stated if a resident had risk factors, she would expect staff to float the resident's heels and utilize boots. Observation on 06/08/22 at 08:43 AM of Staff A, RN/wound nurse, did a dressing change to the unstageable left outer ankle/heel wound. The wound cart top was sanitized and equipment gathered. Resident #77 laid in bed with lower legs elevated and heels up off of the mattress. The left lower leg/foot had a padded boot on. The nurse washed her hands, applied gloves and removed the boot. She removed gloves, used hand sanitizer and put on new gloves. She set up a clean barrier and a dirty site with plastic garbage bags. Supplies were placed on a clean site. The dressings were removed. The moderate amount of tan thin drainage had no odor. The nurse changed her gloves and her hands were sanitized. The nurse cleansed the wound with Dermal wound cleanser and gauze pads. It was dried with gauze pads. Santyl ointment applied to the wound bed. Xeroform dressing applied, then non- adhesive dressing applied. Gauze roll wrap applied and was taped in place. The date written on the tape. The wound measured 4 x 3.5 centimeters by the wound nurse. There is non- pigmented healed tissue around the black eschar.

Based on observations, record review and staff interviews, the facility failed to provide adequate supervision, appropriate assistance in accordance with the plan of care, implement interventions to prevent further falls and failed to safely transfer residents for 3 of 3 sampled (Resident #1, #4, #5) for falls. The facility failed to provide supervision and assistance in accordance with the plan of care for Resident #1 who fell and sustained a left [CONDITION(S)], multiple pelvic fractures and a hematoma. The facility failed to implement interventions for Resident #4 who had multiple falls and sustained a golf ball size swelling to the head after a fall and sustained a contusion of right hip, right rib fracture after further falls. The facility failed to safely transfer Resident #5 who fell out of a mechanical lift resulting in a fractured right tibia and fibula. The facility reported a census of 106. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had short and long term memory deficits and moderately impaired cognitive status for daily decision making. Resident #1 requires limited assistance with transfers and mobility and extensive assistance with dressing, toilet use and personal hygiene needs. Resident #1's diagnosis includes Non-Alzheimer's dementia. According to Resident #1's Care Plan, Resident 1 at risk for falls and directed staff to ensure wearing proper foot wear, remind not to bend over to pick up items, low bed, and assistance of 1 staff when walking. According to the Fall Tool dated 5/27/21, Resident #1 had a high risk for falls. During an interview on 10/29/21 at 10:00 a.m., Staff A (Director of Environmental Services) stated on the afternoon of 6/7/21 she entered the memory care unit and observed two residents in the hallway. Within a moment of Staff A entering the unit, Resident #1 lost her balance and fell to the floor striking her head. Staff A stated no staff were in the vicinity of Resident #1 at the time of her fall. During an interview on 10/29/21 at 12:50 p.m., Staff B (Certified Nurse Aide) stated she passed supper trays on 6/7/21 when she heard a boom and responded to the hall and found Resident #1 on the floor. Staff B stated several residents in the hall and she did not recall where the other staff were at the time of the fall. Staff B stated Resident #1 independently mobile prior to her fall. During an interview on 10/29/21 at 12:45 p.m., Staff C (Certified Nurse Aide) stated she is not familiar with the residents on the memory care unit and 6/7/21 was the first shift she worked the unit. Staff C was in the lobby when Resident #1 had the fall. Staff C stated Resident #1 required assistance of one staff when ambulating and staff are to be with her when she is up. During an interview on 10/29/21 at 1:15 p.m., Staff D (Case Manager) stated Resident #1 required assistance of one staff with ambulation when first admitted . Staff D expected staff to be by Resident #1's side when she is up moving. During an interview on 11/2/21 at 1:23 p.m., Staff E (Certified Nurse Aide) stated Resident #1 is often up and walked independently prior to her fall. Staff E states she remembers when Resident #1 is first admitted on the memory care unit, she is told Resident #1 liked to walk a lot and believed had independence with mobility. According to the facilities Incident Report dated 6/7/21 at 4:30 p.m. Resident #1 got up on her own and started walking in the hallway beside another resident. Staff entering the hallway through the double doors of the unit witnessed Resident #1 loose her balance and fall to the ground. Staff unable to get to Resident #1 before the falls. Resident #1 hit her head on the wall and complained of pain in her left hip and had external rotation of the leg. Resident #1 had a bump on the back of her head after the fall. Resident #1 remained on the floor and the staff obtained orders to send her to the emergency room for evaluation. According to a Progress Note dated 6/8/21 at 12:30 a.m., the staff called the hospital for an update and informed Resident #1 admitted for observation, had a left [CONDITION(S)], multiple pelvic fractures and a hematoma. According to a Hospital Progress Note dated 6/9/21, Resident #1 sustained a pelvic fracture involving the sacral ala and pubic rami, nondisplaced and a retroperitoneal hematoma. According to a Progress Note dated 6/8/21 at 8:42 a.m., Staff D documented a reviewed of the 6/7/21 fall. Resident #1 had severe dementia and no safety awareness. Resident #1 had multiple falls at home prior to admission and unable to communicate her needs. Will address further interventions when resident returns from the hospital. 2. According to the MDS assessment dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score 5 indicating a severely impaired cognitive status. Resident #4 required extensive assistance with transfers and mobility, dressing, toilet use and personal hygiene needs. Resident #4 had diagnoses of dementia, diabetes mellitus, and anxiety. According to the Care Plan, Resident #4 had limited physical mobility related to dementia and directed staff to provide assist of one staff with mobility, assistance of one staff when ambulating and with toilet use, educate resident to ask for help when needed to use the restroom, ensure appropriate foot wear, when restless place in solarium for better supervision, and to leave the bathroom light on at night to maximize resident safety. According to Resident #4's Kardex, Resident #4 required assistance of one staff when ambulating and with toilet use, ensure appropriate foot wear or gripper socks when ambulating or mobilizing in her wheelchair, gripper socks while in bed, remind resident to pick up feet when ambulating, assist with toilet use, if resident is restless bring her to the solarium for better supervision, do not leave resident sitting in her wheelchair. Leave bathroom light on at night to maximize resident safety. Review and modify environmental hazards that could cause or contribute to falls. Review of Resident #4's Incident Reports from 8/29/21 through 11/1/21 noted six recorded falls: a. On 8/29/21 at 10:05 p.m., the nurse is up front and hears a loud thud and immediately responds room to room. Resident #4 is discovered outside her bathroom door and has fallen backwards, hitting her head on the door/wall. Resident #4 has a golf ball size swelling on the right side of her head. No other injuries noted. b. On 9/1/21 at 8:00 a.m., staff alerted nurse to Resident #4's bedroom where resident is discovered on the floor. Resident #4 is sitting in a plastic tote with her pants pulled down as if using the bathroom. Urine is present in the tote. No injuries noted at this time. c. On 9/11/21 at 2:15 p.m., Resident #4 went into front bathroom by dining room and then is heard saying help me. Resident #4 is discovered on her knees on the floor with her hand on the door knob, then rolls onto her bottom next to the toilet. No noted injuries. d. On 9/15/21 at 12:30 a.m., a tapping heard up front and when the nurse searches room to room, Resident #4 is discovered on the floor at the entryway into her bathroom. Resident #4 states she was going to the bathroom. Resident #4 complains of hip and pelvis pain. Orders obtained to send her to the emergency room for evaluation. e. On 9/16/21 at 4:40 a.m., Resident #4 discovered on the floor with her back up against the bathroom door, leaning to the left with her legs folded towards her. No noted injuries. f. On 10/18/21 at 9:40 p.m., Resident #4 discovered on her bedroom floor near the bathroom door with her head raised, yelling for get me off the floor. No injuries noted. During an interview on 11/2/21 at 1:19 p.m., Staff F (Registered Nurse) stated on 9/11/21 Resident #4 observed entering the front bathroom, unassisted. Moments later Staff F heard Resident #4 asking for help. The door is opened and Resident #4 is on her knees, grabbing the door knob. Resident #4 then releases the door knob and rolls onto her buttocks. Staff F states Resident #4 at that time is independently mobile and used the toilet independently and is not an assist of one. Staff F states residents who require assistance of one or two staff for mobility or ambulation require staff to be next to them with that resident is up and moving. According to a Progress Note dated 9/15/21 at 11:52 a.m. Resident #4 diagnosed at emergency room visit with contusion of right hip, right rib fracture and is at high risk for falls. During an interview on 11/2/21 at 1:00 p.m., Staff D, (Case Manager) stated when she arrives to work in the morning she reviews the risk management log to determine who fell , who is working and the fall details. Staff D stated she may interview staff and then presents the information at the morning meeting. Interventions are then discussed, changed or added to the care plan and kardex. Staff D stated she also puts in a progress note regarding the fall and interventions. Staff D stated she is the one who updates care plans and ensures updates are added to the kardex. Staff D provided six fall incident reports for Resident #4 from 8/29/21 to 10/18/21 and state Resident #4 is receiving physical therapy to improve strength and balance, but otherwise no additional interventions implemented to address increased supervision and monitoring during the 60 days which resulted in six falls. Staff D reported she notes changes and updates on the care plan. Staff D provided the current kardex for Resident #4 which had the same interventions as the Care Plan and had no new interventions for the falls. Review of Progress Notes associated with Staff D's review of falls and actions taken include: a. On 8/30/21 at 7:06 a.m., Resident #4 with increased shuffling of feet. Resident has an order for Physical Therapy will follow up whether resident is receiving PT or not. b. On 9/2/21 at 7:03 a.m., will continue working with PT. c. On 9/13/21 at 7:06 a.m., instructed staff Resident #4 requires assist of one with toileting. d. On 9/15/21 at 7:00 a.m., will have physician assess for falls and possible [CONDITION(S)] and have labs drawn. e. On 9/16/21 at 5:21 a.m., Review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls. f. On 10/19/21 at 6:57 a.m., will continue with therapy which frequency increased last week. 3. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #5 had a (BIMS) score of 11, indicating a moderately impaired cognitive status. Resident #5 required extensive assistance with transfers and mobility, dressing, toilet use and personal hygiene needs. Resident #5 had diagnoses of diabetes mellitus, [CONDITION(S)] and [CONDITION(S)]. According to the Care Plan Resident #5 had activities of daily living (ADL) performance deficits with interventions which include requiring two staff assistance, total lift and large full body sling with transfers. According to an Incident Report dated 11/11/21 at 8:46 a.m., staff assisting Resident #5 with a mechanical lift and Resident #5 slid out of the sling and onto the floor. The aides left her night gown (silk) on for breakfast because they were going to shower her after breakfast and the resident agreed with this. Resident #5 complained of her right leg hurting and transferred to the emergency room for evaluation and treatment. According to Radiology Reports Resident #5 sustained an acute proximal right tibia, right tibial plateau and acute distal right tibia and fibula fractures and acute impacted left tibial plateau and acute proximal left fibular fractures. During an interview on 11/15/21 at 3:50 p.m., Staff H (Certified Nurse Aide) described and demonstrated Resident #5's transfer on the morning of 11/11/21. Staff H stated she provided perineal care and a clean brief, and positioned the full body sling under Resident #5. Staff H then waited for Staff I to assist with the transfer. Staff I arrived and they attached the sling straps to the mechanical lift. Staff H positioned on the left side of Resident #5. Staff I positioned on the right side of Resident #5 in bed. The staff attached the upper black strap on the lift arm and the bottom burgundy strap on the lift arm. Staff H stated she used the mechanical lift controls and lifted Resident #5 a few inches off of her bed. Staff H checked the sling straps to ensure they are secure. Staff H pulled the lift out from the bed and noted Staff H had physical contact with Resident #5's legs. Staff H moved the wheel chair next to the mechanical lift and at that time Resident #5 slid forward out of the sling. Staff H unable to stop Resident #5's head and shoulders. Resident #5's bottom hit the floor and her legs get caught the left base of the lift. This forced Resident #5's knees to bend. Staff H stated Resident #5's baseline as legs contracted and unable to bend at the knees much. During an interview on 11/15/21 at 4:05 p.m., Staff I (Certified Nurse Aide) described and demonstrated Resident #5's transfer on the morning of 11/11/21. Staff I states the sling is already under Resident #5 when she arrives. Staff I is on the left side or Resident #5, who is in bed and Staff H is on the right side. Staff I states she attaches the top black strap onto the lift arm and the bottom burgundy strap on the lift arm as Staff H is doing the same. Staff H is in control of the lift and lifts Resident #5 off of the bed and pulls the lift out away from the bed. Staff I states she follows Resident #5 from around the bed. Staff H then stops and positions the wheel chair to the left of Resident #5. As Staff H returns to the lift, she begins to move the lift and Resident #5 slides out of the sling quickly, landing on her bottom with her legs bent on the frame of the lift. Staff I states she grabs Resident #5's arm and Staff H is able to catch her head and shoulders. Staff I states she was not in physical contact with Resident #5 during the transfer or at the time she slides out of the sling. Staff I also states she did not check the sling straps to ensure the straps were attached and the sling properly fitted. During an interview on 11/16/21 at 9:40 a.m., Staff J (Certified Trainer) states he teaches staff the proper use of mechanical lifts and sling placement. Staff J describes and demonstrates the use of a mesh full body sling, noting it is used for showers and amputees. Staff J states the sling is also being used for Resident #5, noting the other sling type caused discomfort when she had a catheter. Resident #5 has since had her catheter removed and should have been switched back to the old sling. Staff J demonstrates the use of the mesh sling Resident #5 is using, folding the legs over and bottom straps through the leg loop, then attaching the black upper strap and bottom burgundy strap to the lift arm. Staff J also demonstrates the standard sling protocols. Staff J's demonstration and explanation is consistent with Staff H and Staff I's use of the mesh full body sling. During an interview on 11/18/21 at 10:23 a.m., Resident #5 immediately became tearful when asked about the fall. Resident #5 stated they just let me drop and it hurt so badly. Resident #5 continued to repeat how horrible the event was and how painful, but unable to provide details of the transfer.

Based on observation, record review, and staff interview, the facility failed to provide adequate nursing supervision and assistive devices to protect against hazards from self, others, or elements in the environment during transfers and ambulation (walking) for one of one of four residents reviewed. Resident #113 required assistance of one staff to go to the bathroom. One CNA ambulated with the resident to the bathroom with physical assistance, but no gait belt. When the CNA saw a wheelchair blocked the bathroom entrance, she let go of the resident's arm and walked to the wheelchair to remove it. When the CNA stepped away, the resident then fell and fractured his hip. The facility reported a census of 143 residents. Findings include: According to the quarterly Minimum Data Set (MDS) Assessment Tool dated 11/24/18, Resident #113 had [DIAGNOSES REDACTED]. The MDS documented Resident #113 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, revealing the resident displayed severe cognitive impairment. The MDS also documented the resident required extensive to total assist of 1-2 staff for all activities of daily living (ADLs). Balance during transitions and walking, moving on and off toilet and with surface to surface transfer (transfers between bed and chair or wheelchair) showed resident not steady and only able to stabilize with staff assistance. The MDS identified Resident #113 had a history of [REDACTED]. The care plan contained the following information: a. A revision dated 12/20/17 directed staff to transfer the resident with assist of 1 staff b. A revision dated 5/18/17 documented the resident as at risk for falls related to weakness, history of falls, dementia, and impaired mobility. c. A revision dated 12/26/18 directed staff to review and modify environmental hazards (e.g. tubing, electrical supply cords, etc.) that could cause or contribute to fall. Don't leave wheelchair in resident bathroom. A progress note dated 12/23/18 completed by Staff E, Licensed Practical Nurse (LPN) showed Resident #113 was being assisted by Certified Nursing Assistant (CNA) ambulating with wheeled walker into bathroom. When CNA noticed wheelchair blocking bathroom entrance, CNA attempted to move wheelchair out of the way. At that time, the resident lost balance and fell in the room. Resident complaint of pain to Left hip, so physician notified. Staff received new order to send the resident to the emergency room for evaluation. A Diagnostic Report dated 12/24/18 at 1:05 AM revealed radiograph of right hip; 2 views with frontal pelvis, 3 images. Findings: Acute non-displaced right intertrochanteric femoral fracture. In an observation on 02/13/19 at 9:50 AM, Staff I, CNA transferred Resident #113 from wheelchair with stand aide non-mechanical lift. Staff encouraged the resident to pull himself up without using a gait belt around the resident's waist and CNA's hand under left arm. Staff H, Registered Nurse (RN) case manager intervened. The resident's oxygen saturation was 88% at that time. O2 reapplied and resident rested. Resident stated too tired to pull himself up with stand lift moved in wheelchair closer to recliner. Staff I, CNA and Staff H, RN attempted another transfer and lifted the resident's feet and placed in stand aid. The resident stood up with minimal assist and seat placed under buttocks. Staff turned the resident and positioned them in recliner. Staff H, RN removed chair from lounge and placed it in resident's room. In an interview 02/13/19 at 5:09 AM, Staff E, LPN stated she was the nurse on duty the night of Resident #113's fall with [MEDICAL CONDITION]. It was fairly late in the shift and Staff F, CNA reported the resident was in his room in his recliner when Staff F, Certified Nursing Assistant (CNA) transferred him with assist of one from the recliner and assisted him to walk to the bathroom. En route, Staff F found a wheelchair in pathway to bathroom. Staff F went to move the wheelchair and Resident #113 fell . Staff E stated not aware if Staff F let go of the resident when fall occurred, but thought staff might have had a gait belt on the resident. Staff E reported the resident complained of hip pain, went to the hospital, and returned with a right [MEDICAL CONDITION]. On 2/13/19 at 5:43 AM, Staff F, CNA reported in an interview that she transferred Resident #113 the night he fell and broke his hip. She stated the resident was yelling so she went into his room to take him to the bathroom. The resident stated he could not go in because it was occupied (bathroom.) Staff F stated the wheelchair was in front of the bathroom blocking the door. Staff F added she was hurrying because he had to go really bad, and she had to let go of him to step in front of him about 3 feet to get the wheelchair out of the way. Staff F reported the resident fell right after she moved the wheelchair; she turned around but was unable to try and stop the fall. She added it happened too fast, within seconds. Staff F stated the resident was to ambulate with gait belt and walker to bathroom as needed and transfer with one assist according to the kardex. Staff F, CNA verified she did not have a gait belt around Resident #113's waist when she was transferring him. She reported she was not sure why she did not use a gait belt, because she normally always used a gait belt. She said the facility policy was to use a gait belt for residents who required assist of one staff. In an interview on 02/13/19 at 9:45 AM, Staff G, CNA stated staff is to always use a gait belt and check the kardex for directions regarding resident assistance required for transfers with resident. Staff G stated staff should always be touching the resident if they need physical assist according to the resident transfer status on the care plan kardex which is in P[NAME] (computer documentation). On 02/13/19 at 3:02 PM, the Director of Nursing, DON stated the outside door of Resident #113's room shuts against the bathroom door and that is when the CNA discovered the wheelchair. She stated a CNA should use gait belt at all times when physical assist is required for resident transfers. The DON confirmed awareness that Staff F, CNA did not use a gait belt and she physically let go of resident to move the wheelchair. Her expectation would be for staff to 58.28(3)e 58.19(2)j 481-58.28(135C) Safety. The licensee of a nursing facility shall be responsible for the provision and maintenance of a safe environment for residents and personnel. (III) 58.28(3) Resident safety e. Each resident shall receive adequate supervision to protect against hazards from self, others, or elements in the environment. (I, II, III) 481-58.19(135C) Required nursing services for residents. The resident shall receive and the facility shall provide, as appropriate, the following required nursing services under the 24-hour direction of qualified nurses with ancillary coverage as set forth in these rules: 58.19(1) Activities of daily living g. Ambulation with equipment if applicable, or transferring, or positioning; (I, II, III) DESCRIPTION: Based on observation, record review, and staff interview, the facility failed to provide adequate nursing supervision and assistive devices to protect against hazards from self, others, or elements in the environment during transfers and ambulation (walking) for one of one of four residents reviewed. Resident #113 required assistance of one staff to go to the bathroom. One CNA ambulated with the resident to the bathroom with physical assistance, but no gait belt. When the CNA saw a wheelchair blocked the bathroom entrance, she let go of the resident's arm and walked to the wheelchair to remove it. When the CNA stepped away, the resident then fell and fractured his hip. The facility reported a census of 143 residents. Findings include: According to the quarterly Minimum Data Set (MDS) Assessment Tool dated 11/24/18, Resident #113 had [DIAGNOSES REDACTED]. The MDS documented Resident #113 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, revealing the resident displayed severe cognitive impairment. The MDS also documented the resident required extensive to total assist of 1-2 staff for all activities of daily living (ADLs). Balance during transitions and walking, moving on and off toilet and with surface to surface transfer (transfers between bed and chair or wheelchair) showed resident not steady and only able to stabilize with staff assistance. The MDS identified Resident #113 had a history of [REDACTED]. The care plan contained the following information: a. A revision dated 12/20/17 directed staff to transfer the resident with assist of 1 staff b. A revision dated 5/18/17 documented the resident as at risk for falls related to weakness, history of falls, dementia, and impaired mobility. c. A revision dated 12/26/18 directed staff to review and modify environmental hazards (e.g. tubing, electrical supply cords, etc.) that could cause or contribute to fall. Don't leave wheelchair in resident bathroom. A progress note dated 12/23/18 completed by Staff E, Licensed Practical Nurse (LPN) showed Resident #113 was being assisted by Certified Nursing Assistant (CNA) ambulating with wheeled walker into bathroom. When CNA noticed wheelchair blocking bathroom entrance, CNA attempted to move wheelchair out of the way. At that time, the resident lost balance and fell in the room. Resident complaint of pain to Left hip, so physician notified. Staff received new order to send the resident to the emergency room for evaluation. A Diagnostic Report dated 12/24/18 at 1:05 AM revealed radiograph of right hip; 2 views with frontal pelvis, 3 images. Findings: Acute non-displaced right intertrochanteric femoral fracture. In an observation on 02/13/19 at 9:50 AM, Staff I, CNA transferred Resident #113 from wheelchair with stand aide non-mechanical lift. Staff encouraged the resident to pull himself up without using a gait belt around the resident's waist and CNA's hand under left arm. Staff H, Registered Nurse (RN) case manager intervened. The resident's oxygen saturation was 88% at that time. O2 reapplied and resident rested. Resident stated too tired to pull himself up with stand lift moved in wheelchair closer to recliner. Staff I, CNA and Staff H, RN attempted another transfer and lifted the resident's feet and placed in stand aid. The resident stood up with minimal assist and seat placed under buttocks. Staff turned the resident and positioned them in recliner. Staff H, RN removed chair from lounge and placed it in resident's room. In an interview 02/13/19 at 5:09 AM, Staff E, LPN stated she was the nurse on duty the night of Resident #113's fall with [MEDICAL CONDITION]. It was fairly late in the shift and Staff F, CNA reported the resident was in his room in his recliner when Staff F, Certified Nursing Assistant (CNA) transferred him with assist of one from the recliner and assisted him to walk to the bathroom. En route, Staff F found a wheelchair in pathway to bathroom. Staff F went to move the wheelchair and Resident #113 fell . Staff E stated not aware if Staff F let go of the resident when fall occurred, but thought staff might have had a gait belt on the resident. Staff E reported the resident complained of hip pain, went to the hospital, and returned with a right [MEDICAL CONDITION]. On 2/13/19 at 5:43 AM, Staff F, CNA reported in an interview that she transferred Resident #113 the night he fell and broke his hip. She stated the resident was yelling so she went into his room to take him to the bathroom. The resident stated he could not go in because it was occupied (bathroom.) Staff F stated the wheelchair was in front of the bathroom blocking the door. Staff F added she was hurrying because he had to go really bad, and she had to let go of him to step in front of him about 3 feet to get the wheelchair out of the way. Staff F reported the resident fell right after she moved the wheelchair; she turned around but was unable to try and stop the fall. She added it happened too fast, within seconds. Staff F stated the resident was to ambulate with gait belt and walker to bathroom as needed and transfer with one assist according to the kardex. Staff F, CNA verified she did not have a gait belt around Resident #113's waist when she was transferring him. She reported she was not sure why she did not use a gait belt, because she normally always used a gait belt. She said the facility policy was to use a gait belt for residents who required assist of one staff. In an interview on 02/13/19 at 9:45 AM, Staff G, CNA stated staff is to always use a gait belt and check the kardex for directions regarding resident assistance required for transfers with resident. Staff G stated staff should always be touching the resident if they need physical assist according to the resident transfer status on the care plan kardex which is in P[NAME] (computer documentation). On 02/13/19 at 3:02 PM, the Director of Nursing, DON stated the outside door of Resident #113's room shuts against the bathroom door and that is when the CNA discovered the wheelchair. She stated a CNA should use gait belt at all times when physical assist is required for resident transfers. The DON confirmed awareness that Staff F, CNA did not use a gait belt and she physically let go of resident to move the wheelchair. Her expectation would be for staff to use the gait belt and if resident allows request assist, or have the resident back down and move the wheelchair. The DON stated staff should not let go of the resident during a transfer. The facility policy Mobility Support and Positioning provided by the facility dated (MONTH) 2013 and last revised 10/18 directed the staff for Assist with Ambulation: Gait belt, unless contraindicated. A gait belt should be used for all residents who require assistance with ambulation. The caregiver would typically walk on the resident's affected side. The caregiver assisting should walk in step with the resident holding on to the gait belt, grasping the belt with palm up. The opposite hand should rest on the resident's shoulder. Care must be taken not to interfere with the resident's sense of balance by pulling.

Based on record review and staff interviews, the facility failed to ensure Resident #2 received adequate supervision to mitigate the risk for falls and injury. The facility reported a census of 137 residents and the sample consisted of 4 residents. The facility identified Resident #2 to be at risk for falls due to a history of a [MEDICAL CONDITION] (stroke), anxiety and previous fall. Due to the risk, the facility planned to not leave the resident alone in the resident's room alone and in a wheelchair. The plan directed staff to place the resident at the nurse's station. The staff did not know this and pushed the resident in the wheelchair to her room and left her alone. The resident rose from the chair and fell . The fall resulted in a [MEDICAL CONDITION] and a change in level of care to hospice care. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 11/1/17. Resident #2 had a Brief Interview for Mental Status score of 11. A score of 11 identified the resident had a moderately impaired cognitive status. The MDS indicated the resident required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS indicated the resident had [DIAGNOSES REDACTED]. The Care Plan identified Resident #2 at a risk for falls related to the [MEDICAL CONDITION] and a history of fall. The interventions included and directed the staff to not bend over to pick up dropped items, encourage resident to use grabber, ensure resident is wearing appropriate footwear. On 11/16/17, the interventions initiated included resident is to be positioned at the nurse's station when spouse not visiting and do not leave resident in wheelchair when in room. The Progress Notes dated 1/5/18 at 6:10 p.m. written by Staff A, Licensed Practical Nurse stated: CNA (certified nursing assistant) called the attention of the nurse to the resident's room. Resident #2 was found on floor in front of the dresser on her right side. Resident #2 assessed and reported pain to right elbow. Upon examination, a bruise was noted on lateral aspect of right forearm measuring 3 centimeters by 1 centimeters and a reddened area on the back lateral right arm measuring 9 centimeters by 3 centimeters. Resident #2 stated she was going to see her folks and then fell . Resident #3 assessed and she reported pain on the right elbow and could not rate her level of pain. The vital signs checked and all within normal limits. Staff lifted the resident off the floor with the help of a Hoyer lift and transferred into bed. Once in bed, the nurse noted the right leg was rotated outwardly. The nurse notified the physician and received orders to transfer to the hospital (emergency room ). On 1/16/18 at 2:00 p.m. Staff B, case manager, was interviewed and stated following Resident #2's fall on 1/5/18, she amended Resident #2's Care Plan to include not leaving Resident #2 unattended while in her wheelchair in her room. Staff B insisted she was certain she made the change under the fall risk section of the Care Plan and documented the revision in the progress notes 1/8/18. On 1/16/18 at 2:20 p.m. Staff C, case manager skilled unit, stated Resident #2 was initially on the skilled unit and following a second fall on 11/15/17, she added interventions to include having Resident #2 up at the nurse's station after her spouse leaves and to not leave Resident #2 in her wheelchair while in her room. These interventions were added on 11/16/17 and remained in place when Resident #2 was moved off of the skilled unit. Progress Notes dated 11/16/17 at 6:33 a.m. Care Plan Change, written by Staff C states: Intervention: ensure/provide a safe environment: Resident up to nurse's station after spouse leaves. Don't leave in wheelchair in room. Note Text: Review of resident fall. Resident stated she was getting ready for breakfast when she was found on the bathroom floor. Spouse had just left. Resident does not remember to use call light. Staff to bring resident up to nurse's station when spouse leaves. Staff instructed not to leave resident sitting up in wheelchair in her room. On 1/16/18 at 12:52 p.m. Staff D, certified nurse aide, stated he worked the 2:00 p.m. to 10:00 p.m. shift on the afternoon of 1/5/18. Sometime around shift change and after supper, he was involved with laying residents down. Resident #2's spouse and son visited and left 15-30 minutes earlier. Staff D stated he checked on Resident #2 shortly after the family had left and she was in her room, in her wheelchair with a bedside table in front of her. Staff D stated he had a conversation with his co-worker, Staff E, unrelated to Resident #2 and went about assisting other residents. Within a few minutes, Resident #2's roommate came out into the hall and alerted them Resident #2 had fallen. Staff D and Staff A responded and assessed Resident #2. Initially Resident #2 complained of right arm pain. Resident #2 was confused, stating she needed to meet her folks. They put a Hoyer sling under Resident #2 and lifted her into bed. At that time Resident #2 complained of hip pain and her right leg was turned outward. They called emergency medical services and had Resident #2 transported to the hospital. Staff D stated he was not aware that Resident #2 was not to be left alone in her wheelchair when in her room. Staff D stated that information would be in the Kardex (electronic Care Plan). On 1/16/18 at 1:26 p.m. Staff E, certified nurse aide, stated she worked a 10:00 a.m. to 6:00 p.m. shift on 1/5/18. Staff E stated after supper she assisted resident back to their rooms and thought she had propelled Resident #2 back to her room, placed the bedside table next to her and gave her the call light. Staff E stated she then left to assist other residents. At around 5:50 p.m. Resident #2's roommate entered the hallway and alerted staff Resident #2 had fallen. Staff E and Staff D responded to the room and found Resident #2 on the floor. Staff E stated she was not aware Resident #2 was not to be left unattended in her room while in her wheelchair. Staff E stated that information should be in the Kardex (electronic Care Plan), but didn't recall seeing it.

The following deficiency relates to facility reported incident -I: Based on record review and staff interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 4 residents identified at risk for falls (Resident #1). The facility reported a census of 139 residents. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 4/12/16. The assessment identified Resident #1 with a Brief Interview for Mental Status score of 5 indicating severely impaired cognitive skills for daily decision making. Resident #1 required extensive assistance of 2 staff with transfers and toilet use. Resident #1's [DIAGNOSES REDACTED]. The Care Plan dated 2/16/16 documented Resident #1 had the risk for falls related to a recent fall and hip fracture with interventions which included a bed alarm to alert staff of the resident ' s movement and to assist staff in monitoring movement. The care plan also called for Resident #1 to wear appropriate footwear when ambulating or mobilizing in wheelchair. On 3/23/16 the bed alarm was discontinued. On 4/6/16 the facility added to assist or offer toileting assistance every two hours. On 4/12/16 the care plan identified review the resident ' s history of recent falls or recurrent falls. On 5/5/16 the resident ' s care plan had been modified to include a low bed, a floor mat beside the bed, and a scooped mattress. Progress Notes reviewed from March through April 5, 2016 indicated multiple entries in which Resident #1 was confused and did not utilize the call light to summon staff, but instead would holler, Yoo-hoo to get staffs attention. Progress notes also noted Resident #1 was not getting up unassisted. Progress Notes dated 3/23/16 indicated alarms removed as resident not attempted to get up unassisted. Progress Notes dated 4/4/16 at 9:27 a.m. indicated Resident #1 does attempt to self transfer at night. Progress Notes dated 4/5/16 at 2:30 p.m. indicated Resident #1's catheter was discontinued. Progress Notes dated 4/6/16 at 3:30 a.m. indicated Resident #1's was found sitting on the floor next to his/her bed. Resident was incontinent of bowel. Progress Notes dated 4/6/16 at 3:30 a.m. indicated Resident #1's was found sitting on the floor next to his/her bed. Resident was incontinent of bowel. Facility incident report dated 4/6/16 at 3:20 a.m. indicated staff heard sounds coming from Resident #1's room. Resident #1 was found sitting on the floor beside the foot of the bed. Resident #1 stated he/she was getting up. No injuries noted. Progress Notes dated 4/6/16 at 7:40 a.m. written by Staff A under the Care Plan Change note, stated Resident #1 to be checked frequently and toileted routinely. Intervention was to review the bowel and bladder continence status and establish and/or review toileting plan based on the resident's needs. Assist/offer every two hours. Progress Notes dated 4/11/16 at 5:35 p.m. indicated Resident #1's was not using his/her call light. Facility incident report dated 4/12/16 at 2:20 a.m. indicated staff heard Resident #1 holler out. Resident #1 was found lying on the bathroom floor. Resident #1 had been awaken earlier to use the bathroom and refused. He/she later decided he/she needed to go and got up unassisted. Resident #1 sustained a skin tear on his right hand. Progress Notes dated 4/12/16 at 7:17 a.m. written by Staff A under the Care Plan Change note, stated Staff educated to get the nurse during the night if Resident 31 refuse to get up. Resident #1 noted to have been refusing to get up when aides are doing rounds, but gets up on his/her own when they leave the room. Resident #1 to wear gripper socks at night. Requesting a touch call light to be clipped to Resident #1's gown. Progress Notes dated 4/13/16 at 1:38 a.m. indicated Resident #1 self transferred to the bathroom during the night shift. Progress Notes dated 4/13/16 at 9:33 a.m. indicated Resident #1 continues to self transfer while in his/her room. Resident educated on how to use the call light. Progress Notes dated 4/15/16 at 8:08 a.m. indicated Resident #1 continues to self transfer at times. Resident educated on how to use the call light. Progress Notes dated 4/16/16 at 5:23 p.m. indicated call light within reach while in room, but Resident #1 does not use. Progress Notes dated 4/17/16 at 5:14 p.m. indicated call light within reach while in room, but Resident #1 never uses it. Progress Notes dated 4/22/16 at 5:52 p.m. indicated Resident #1 does not use call light. Yells out yoohoo for assistance. Encouraged to use call light many times. Progress Notes dated 4/23/16 at 11:12 a.m. indicated Resident #1 self transfers at times and is educated on how to use the call light. Facility incident report dated 4/25/16 at 1:00 a.m. indicated Resident #1 was found on the floor next to his/her bed. Resident #1 stated he/she was getting up to use the restroom. Resident #1 sustained a bruise to his/her left knee. Progress Notes dated 4/25/16 at 8:09 a.m. written by Staff A under the Care Plan Change note, stated staff to continue to do frequent checks at night and assist Resident #1 with toileting. Resident #1 noted not using the call light at night and continues to try and toilet him/herself. Progress Notes dated 4/26/16 at 3:22 a.m. indicated Resident #1 does not use his/her call light. Progress Notes dated 4/27/16 at 11:23 a.m. indicated Resident #1 has had numerous falls noted at night. Will continue to check frequently and toilet resident. Progress Notes dated 4/28/16 at 9:41 a.m. indicated care plan to continue to monitor Resident #1 for safety. Facility incident report dated 4/30/16 at 11:40 p.m. indicated staff heard Resident yell, Woo-hoo. Resident #1 was found lying on his/her back. Urine noted on bathroom floor and suspected Resident #1 had gotten up to the bathroom and fell while returning to bed. Resident #1 assessed and noted right lower extremity shorter than left and rotated outward. Resident also sustained a skin tear on his left anticubital. Resident #1 was sent to the emergency room for further evaluation and treatment. Radiology report dated 5/1/16 indicated Resident #1 with an acute fractured right femoral neck. In an interview on 6/15/16 at 1:35 p.m. Staff A, case manager, indicated Resident #1 was admitted from assisted living following a fall which resulted in fracturing his/her left hip. Resident #1 received skilled services to recover from his/her fracture. Resident #1 had been initially care planned for a bed alarm. After several weeks of Resident #1 not attempting to get up unassisted, the bed alarm was discontinued. On 4/6/16 Resident #1 had his/her first fall while at the facility. It occurred in the middle of the night while Resident #1 had been attempting to go to the bathroom. They decided to implement an every two hour toileting schedule and frequent checks throughout the night. On 4/12/16 and 4/25/16, Resident #1 had additional falls related to getting up and needing to use the bathroom. Staff A stated staff were frequently checking on and offering toileting assistance, but Resident #1 would refuse and then get up after staff had left. Staff A stated there were no additional interventions attempted. On 4/30/16 Resident #1 fell again while attempting to go to the bathroom, this time fracturing his/her right hip. Staff A stated each morning during the week there is a core meeting involving department heads and the Administrator. Falls are discussed and interventions considered. There are also Fall huddles during a shift in which falls are reviewed and intervention strategies discussed. Staff A indicated the facility was going alarm free and therefore an alarm was not considered for Resident #1. In an interview on 6/15/16 at 10:20 p.m. Staff B, certified nurse aide, stated she typically works the overnight shift on the rehab unit and was familiar with Resident #1. Staff B stated Resident #1 was often confused and would get up unassisted during the night. Staff were checking on him/her more frequently and it was not uncommon (2-3x a week) to find Resident #1 in the bathroom or sitting up on the side of his/her bed. Staff B stated she couldn't recall Resident #1 getting up too often when he/she had a bed alarm as Resident #1 hated the alarm sounding whenever he/she moved. In an interview on 6/15/16 at 4:05 p.m., Staff C, Registered Nurse reported Resident #1 was often in his/her wheelchair or recliner at the nurse's station during the day. Staff C reported Resident #1 did not like to be in his/her room alone and in the evening, the resident had visitors or self-propelled up and down the halls to the common areas. In an interview on 6/15/16 at 1:50 p.m. the Director of Nursing stated the facility had been considering to go alarm free for the last couple of years. When the new Administrator started in March 2016 the facility began to actively reduce alarm use. The DON stated they tried increasing the frequency of checks on Resident #1 following his/her falls, but often Resident #1 would refuse assistance and get up a few minutes later unassisted.

The following deficiency relates to complaint # -C: Based on record review and staff interviews, the facility failed to meet professional standards of quality for medication administration when staff failed to administer medications in accordance to a resident's physician order [REDACTED].#1). The facility reported census is 138. Findings include: A Minimum Data Set (MDS) with an assessment reference date of 8/1/15 indicated Resident #1 was admitted to the facility on [DATE]. Resident #1's cognitive status had not been assessed on the MDS. Resident #1 required extensive assistance with physical assist of one to two staff members with bed mobility, dressing, toilet use and personal hygiene. Resident #1 was assessed with [REDACTED]. He/she was admitted with a feeding tube. Resident #1's [DIAGNOSES REDACTED]. physician's orders [REDACTED].#1 was on aspiration precautions, was NPO (nothing by mouth) and HOB (head of bed) to be elevated at 30 to 45 degrees. The physician orders [REDACTED].#1 ' s feedings and medications through his/her PEG tube (tube inserted directly into the stomach) and was to be provided water swabs as needed to moisten the oral cavity. Resident #1's plan of care indicated he/she requires tube feeding related to dysphasia with interventions to maintain the HOB at 30 -45 degrees during and up to 30 to 40 minutes after feedings, no pitcher at bedside due to NPO status and monitor and report any signs or symptoms of complications of tube feeding, coughing or choking. Hospital Physician B ordered a diagnostic imaging swallow study 7/22/15 that indicated Resident #1 experienced aspiration and pooling of various consistencies of liquids in the valleculla (area located in the back of the throat). According to Hospital Physician B ' s Progress note dated 7/24/15 Resident #1 is unable to take food/fluids orally will initiate NPO status and start PEG tube feeding. Hospital Physician B Progress note dated 7/30/15 indicated Resident #1 has significant dysphasia and is now on a PEG tube feeding and tolerating well. Plan included comment that Resident #1 has deteriorated in his/her physical stability and could be due to nutritional problem, age, senility or heart failure. Admitting History and Physical indicated Resident #1 had a swallow study done which demonstrated aspiration with all consistencies and a PEG tube was placed at that time. Resident #1 is now getting all his/her nutritional needs via the PEG tube. Resident #1 has clinical and radiological documentation of left lower pneumonia due to aspiration. He/she has ongoing problems with shortness of breath, but his/her cough is gradually getting better. Resident #1 continues to be very weak. Respiratory assessment noted Resident #1 with upper respiratory rhonchi, dyspnea and slightly increased respiratory effort when talking. Progress Notes dated 7/31/15 noted Resident #1 was NPO at this time. Nursing Admit Data Collection form indicated Resident #1 with clear, but diminished breath sounds. Medication Administration Record [REDACTED]. In an interview on 8/20/15 at 3:55 p.m. the Director of Nursing (DON) indicated Staff A Licensed Practical Nurse (LPN) was hired on 6/1/15 and it was her first nursing job. Staff A LPN received 4 weeks of orientation training, including medication administration via PEG tubes. The DON stated there is no clinical demonstration in the training for PEG tubes. In interviews on 8/20/15 at 11:37 a.m. and 8/24/15 at 4:40 p.m. Staff A LPN, stated on the morning of 8/1/15 she prepared medications for Resident #1. Staff A LPN stated she crushed aspirin, [MEDICATION NAME] and [MEDICATION NAME] and put them in a teaspoon of applesauce. Staff A LPN then administered the medications orally to Resident #1. Resident #1 took the medications without incident. Staff A LPN stated Resident #1 lacked noticeable gurgling choking or signs of aspiration and indicated he/she was fine afterwards. Staff A LPN stated an aide in the room told her Resident #1 was NPO, but she also knew Resident #1 was allowed sucks of water as needed. Staff A LPN admitted that this confused her somewhat and she didn't think it through. Staff A LPN admitted she did not carefully read the Medication Administration Record [REDACTED]. Following the incident Staff A LPN reported her error to Staff E Registered Nurse (RN) who confirmed Staff A LPN shouldn't have given the medications orally. Staff A LPN stated she assessed Resident #1 and monitored him/her throughout the day and noted no significant change in his/her condition. Staff A LPN stated she felt horrible about what she did and the risk to Resident #1. In an interview on 8/20/15 at 12:50 p.m. Staff B certified nurse aide (CNA), indicated she was in the room of Resident #1 on the morning of 8/1/15. According to Staff B, CNA that morning Resident #1 was having labored breathing and she informed Staff A LPN of his/her condition. Staff B, CNA returned to the room and assisted Resident #1 to get dressed. Staff B CNA was putting on Resident #1's socks when Staff A LPN entered the room. Staff B CNA heard Resident #1 mildly cough and she looked up and saw a spoon in the hand of Staff A LPN. Staff B CNA asked Staff A LPN if she had given Resident #1 medication and she stated, Yes. Staff B CNA stated Resident #1 is NPO and Staff A LPN then had a troubled look on her face. Staff A LPN then left the room. Staff B CNA stated Resident #1 seemed fine and did not appear to have any adverse effects, gurgling, choking or gasping. Staff B CNA stated Resident #1 seemed fine that day and remained in bed with the HOB at 30-40 degrees. In an interview on 8/20/15 at 1:22 p.m. Staff C, CNA indicated she was working the morning of 8/1/15 and in the room of Resident #1. Resident #1 was having labored breathing and Staff B CNA informed Staff A LPN. While Staff C CNA was in the room, Staff A LPN entered the room and administered Resident #1 ' s medication orally and with a drink of water. Resident #1 coughed lightly and attempted to clear his/her throat. Staff A LPN was informed Resident #1 was NPO and she left to inform Staff E RN. Staff C CNA indicated Resident #1 seemed fine and had no apparent adverse effects from getting his/her medication orally. Resident #1 remained in bed that day with the HOB at 30-45 degrees. In an interview on 8/20/15 at 1:08 p.m. Staff D, CNA indicated she was working on the morning of 8/1/15 and saw Resident #1. Resident #1 had labored breathing and Staff E RN was informed. Later that morning Staff D CNA heard of the incident in which Staff A LPN administered Resident #1 ' s medications orally when he/she was NPO. Staff D CNA stated Staff A LPN told her Resident #1 coughed when given the pills orally. In an interview on 8/20/15 at 12:09 p.m. Staff E RN indicated on the morning of 8/1/15 she assessed Resident #1 prior to initiating his/her bolus feeding. Resident #1's respirations were uneven and labored that morning and there was no air movement in his/her left lower lobes. Staff E RN stated Resident #1 was clammy and anxious and his/her lungs sounded terrible. Staff E RN contacted Physician A who stated Resident #1 had aspiration pneumonia. Physician A ordered medication to reduce Resident #1's dyspnea (difficulty breathing). Later that same morning, Staff A LPN approached Staff E RN, asking how to administer liquid medications via the PEG tube. Staff E RN told Staff A LPN to crush the pills and she would show her how. Staff A LPN stated she had already crushed the pills in applesauce and given it to Resident #1 orally. Staff E RN informed Staff A LPN that Resident #1 is NPO and shouldn't receive oral medication. Staff E RN instructed Staff A LPN to fill out a medication error report. Staff E RN stated she did not see Resident #1 the rest of the day, but according to Staff A LPN he was doing okay. In an interview on 8/27/15 at 10:00 a.m. the DON indicated on the morning of 8/1/15 she was informed of the medication error involving Resident #1 and Staff A LPN. Staff A LPN informed the DON that Resident #1 seemed to tolerate the crushed medications in applesauce well with no indication of aspiration or distress. Staff A LPN self-identified the error and was very remorseful. On Monday, 8/3/15 the DON discussed the incident with Administrative staff and decided to discipline Staff A LPN. Staff A LPN was pulled off the floor and received counseling as well as informed she would need to be re-trained in medication administration before returning to her work duties. After retraining, Staff A LPN was assigned to the north hall with another nurse to mentor and monitor during medication passes and treatments. The nurse then reported to the ADON (Assistant Director of Nursing) daily. The ADON was also involved in medication pass audits. Following an additional week, Staff A LPN was called in for follow up counseling and at that time decided to resign. Progress Notes dated 8/1/15 at 9:02 a.m. written by Staff E RN documented Resident #1 was assessed, respirations uneven and labored at 32 beats a minute. No air movement to left lower lobe, resident clammy and anxious. Physician A notified and received new order. Physician order [REDACTED]. Clarified at 2:40 p.m. as 5mg via PEG tube every hour as needed for dyspnea. Progress Notes dated 8/1/15 at 10:47 a.m. written by Staff A LPN identified a facsimile (fax) sent to Physician A regarding medication error related to Resident #1. Progress Notes dated 8/1/15 at 11:07 a.m. written by Staff A LPN stated resident #1's family notified of medication error. Family voiced concern of Resident #1 choking. Family reassured Resident #1 showed no signs of choking. Progress Notes dated 8/1/15 at 2:32 p.m. written by Staff A LPN documented Resident #1 stayed in bed this shift. Tolerates activities of daily living with moderate amount of assist. PEG site dry and intact. No coughing or gurgling voice. Compliant with weight bearing restrictions. No chills or complaints of flank pain. No change in health status. In interviews on 8/20/15 at 3:00 p.m. and 8/24/15 at 2:30 p.m. Staff F RN indicated her first encounter with Resident #1 was on the evening shift on 8/1/15. Staff F RN was informed of the medication error earlier that day. Staff F RN indicated Resident #1 was congested with diminished lung sounds initially on her shift and continued to worsen as the evening went on. Staff F RN contacted the Advanced Registered Nurse Practitioner (ARNP) as the secretions increased and obtained an order to suction as needed. Staff F stated she suctioned Resident #1 several times during the evening with minimal secretions. Resident #1 ' s lung sounds remained coarse and she again notified the ARNP who ordered oxygen at 2-4 liters per minute to keep oxygen saturation levels above 90%, to check oxygen levels every shift and hold feedings. Staff F RN stated she was in Resident #1's room several times during her shift in attempts to keep him/her comfortable. Staff F RN stated the HOB was always greater than 30 degrees, Family remained at Resident #1's bedside and towards the end of the evening shift requested that Hospice services be provided. Arrangements were being made to initiate Hospice services when the evening shift ended. Progress Notes dated 8/1/15 at 3:40 p.m. written by Staff F RN indicated ARNP contacted due to Resident #1's family concerned with increased secretions and wondering if Resident #1 could be suctioned. ARNP gave an order. ARNP order by phone on 8/1/15 at 3:40 p.m. may suction oral cavity as needed for increased secretions. Progress Notes dated 8/1/15 at 5:55 p.m. written by Staff F RN indicated Resident #1 remained in bed this evening. Resident #1 has congested cough and able to bring up some sputum. Oral suction twice with minimal effect. Lung sounds coarse, tolerating feedings. [MEDICAL CONDITION] noted in left arm. Arm elevated. Progress Notes dated 8/1/15 at 8:45 p.m. written by Staff F RN indicated ARNP notified and updated on Resident #1's condition. Resident #1 ' s lung sounds remains gurgly even after suctioning. Oxygen level at 78 with room air. New orders received. ARNP order by phone on 8/1/15 at 8:45 p.m. hold scheduled feeding and water flush one time, keep HOB at at least 30 degrees, oxygen at 2-4 liters per minute to keep oxygen saturation levels above 90%. Check oxygen saturation levels every shift for dyspnea. Progress Notes dated 8/1/15 at 10:00 p.m. written by Staff F RN indicated numerous family members are at Resident #1's bedside and requested Hospice services due to decline in condition. ARNP notified and informed. New orders received. ARNP order by phone on 8/1/15 at 10:00 p.m. Resident #1 may have Hospice services related to aspiration pneumonia. In an interview on 8/25/15 at 2:30 p.m. a Speech Pathologist familiar with Resident #1's swallow study stated Resident #1 had difficulty swallowing all consistencies of food or fluid and that her recommendations were that he/she received nothing by mouth. The Speech Pathologist noted Resident #1 was alert and able to communicate when having swallowing difficulty and whether food or fluid was getting stuck in his/her throat. The Speech Pathologist did not know what factors led up to him/her having aspiration problems. The Speech Pathologist stated Resident #1 was susceptible to aspiration of saliva as well as any intake orally. Diagnostic Imaging Report dated 7/22/15 (Modified [MEDICATION NAME] swallow) indicated [MEDICATION NAME] swallow performed using different consistencies of [MEDICATION NAME]. Impression: Aspiration seen with thin, nectar and honey consistencies of [MEDICATION NAME]. General [MEDICATION NAME] pooling in the pyriform recesses from valleculla with aspiration. Follow the recommendations of the Speech Pathologist. Note: At the time of the onsite investigation the deficiency was coded at a J level for immediate and serious jeopardy. By August 3, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an D level. The facility provided a staff training plan regarding administration or medications orally and by gastric tube for residents. Additional training was completed related to the facility policy for resident in NPO status and on PEG tubes.

The following deficiency relates to Self Report # -I. Based on record review, observations, and staff and resident interviews; the facility failed to plan for and direct the nursing care to meet the resident ' s needs by provision of assessments and timely interventions to prevent falls from the wheelchair (Resident #1). Four residents were reviewed. The facility reported a census of 142 residents. 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 4/26/2011 which revealed a BIMS (Brief Interview for Mental Status) score of 6. A score of 6 reflected the resident had a severe cognitive impairment. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS documented the resident required assist of two staff members for bed mobility, dressing and assist of one staff member for personal hygiene, transfer, ambulation, dressing, toilet use, and personal hygiene. The MDS identified the resident as using a wheelchair for mobility. The assessment coded the resident as having one fall with injury since prior assessment, not steady with balance, and having impairments of functional motion on both lower extremity and impairment of one side to the upper extremity which places the resident at risk for injury. The Care Plan dated 12/1/11 identified a problem with potential for injury related to a seizure disorder due to head trauma, unsteady gait, history of falls and the resident as noncompliant and refused to ask for assistance from staff. The approaches directed staff to: a) Encourage resident to use call light for assistance. b) Uses wheelchair for long distance. c) Bed, chair alarms and personal alarm to alert staff if the resident attempts to self transfer or ambulate. d) Reacher provided for picking items up off the floor. The document identified as Incident Details dated 5/12/11 at 11:25 p.m. revealed the resident had been found on floor in room with his back against the dresser. The resident stated he leaned to far forward in his wheel chair and fell out of the wheelchair. No alarms sounded. resident sustained [REDACTED]. An immediate intervention implemented had been to remind staff to check that all fall precautions such as wheelchair alarms are in place and functioning. The document titled Incident Details dated 7/2/11 10:40 p.m. revealed the resident slipped out of the wheelchair in room hitting right shoulder against the wall and heating unit. The wheelchair alarm sounded, no injury noted. The immediate interventions implemented had been to remind the resident to not lean forward in the wheelchair. The Incident Details dated 7/19/11 at 12:30 a.m. revealed the resident had been leaning forward in the wheelchair and fell forward. The chair alarm had not sounded. The resident had a visible abrasion/laceration injury to the posterior trunk and complaints of pain to the lower leg. The immediate interventions implemented had been to counsel resident to use call light and on wheel chair safety. Staff advised to check chair alarm and personal alarm. The Incident Details dated 8/24/11 at 10:00 p.m. revealed resident found on the floor lying on his right side inside his/her room by the door calling out for help. The Incident report lacked indications that any alarms were in place or immediate interventions implemented. Review of the Incident Details dated 12/7/11 at 10:05 p.m. revealed the resident had slipped out of his wheelchair as a staff member attempted to move him closer to the bed. The resident received abrasion to his back. The incident report lacked indications of alarms being in place and sounding prior to fall or of any further interventions implemented by the facility. Review of the Incident Details dated 12/14/11 at 8:45 p.m. revealed the resident found in a sitting positron between the dresser and wheelchair in room. No alarm on wheelchair. Resident states he slipped out of his wheelchair. Resident received a laceration to left elbow and left hip. The immediate interventions implemented had been to place a personal alarm on the wheelchair. Review of the Incident Details dated 1/14/12 at 8:00 p.m. revealed two staff members assisting the resident to transfer to bed from wheelchair. One staff member adjusted the resident's feet while the other had been moving the wheelchair and resident leaned forward and fell out of wheelchair to floor hitting his/her head on the heating vent. The resident was sent to the emergency room for further evaluation and treatment. Review of the Physician Clinical Report dated 1/4/2012 revealed the resident had a fall at facility and sustained an injury to the head and neck from falling out of a wheelchair. The resident sustained [REDACTED]. The resident discharge back to the facility with orders for ice to be applied to areas of injury and to follow-up with the resident's physician. Review of Physician order [REDACTED]. On 1/25/12 at 3:30 p.m., Staff E (Certified Nursing Assistant) was interviewed and reported he/she had been in Resident #1 room on 1/4/12 around 8:00 p.m. along with Staff B preparing to transfer the resident from his wheelchair to bed. Staff E reported the resident had been sitting in the wheelchair at the end of the bed when Staff E removed the foot pedals and straightened out the resident's feet as they were under the wheelchair. Staff B and then moved to the right side of the bed to wait for the resident to be positioned at side of bed for transfer. Staff E states he/she had been watching the resident's feet and Staff B had been behind the wheelchair, I didn't see Staff B pushing the wheelchair or the resident self propelling the wheelchair. The resident then went forward and to the right landing on floor and hitting his head on the heating vent. Staff E stated Staff B went and called for the nurse. Staff E indicated the resident falls a lot from his/her wheelchair from leaning forward too far. Review of Staff E's written statement dated 1/5/11 at 4:40 p.m. revealed Staff B had been maneuvering the resident's wheelchair around the corner of the bed and the dresser and Staff E believed the wheelchair caught the corner of the bed or the handle of the dresser but not positive as Staff E had not been pushing the wheelchair. At this point the resident fell out of wheelchair and landed on his head on the heater vent and on right side. On 1/24/12 at 4:20 p.m., Staff B (Certified Nursing Assistant) was interviewed and stated on 1/4/12 around 8:00 p.m. he/she had been in Resident's #1 room along with Staff E to transfer the resident from his wheelchair to his bed. Staff B stated she had been behind the resident with hands on the wheelchair and Staff E had a hold of the resident's feet and were at the foot of the resident's bed. Staff B indicated that the resident had been propelling the wheelchair with his hand when the resident slid out of the wheelchair, bottom first, then went onto right side with head hitting the heat vent. Staff B reported he/she did not know if the resident's bottom or head hit first. Staff B stated the resident used a right foot pedal only as he uses the left to propel wheelchair, the right foot pedal had been up but not removed at time of fall. Staff B reported the resident is known to lean forward in his wheelchair often and has fallen from leaning forward in the wheelchair. Staff B reported the resident has alarms in place and do activate if resident is leaning to far forward and staff is able to get to resident before a fall occurs. Staff B stated the resident would have had a lot more falls if the alarm had not been in place. Staff B reported that staffs check for alarm placement and activation on each shift and during the shift. Staff B indicated she summoned for the nurse after the resident's fall. Review of a verbal statement from Staff B to the facility dated 1/9/12 indicated Staff B reported he/she had been behind the resident's wheelchair with hands on wheelchair and had started to slowly pushing the wheelchair forward when the resident leaned too far forward and fell out of the chair. Staff B reported he/she reached for the resident to try and stop him from falling but wasn't quick enough. Staff B reported he/she never lifted the resident's wheelchair in anyway. On 1/24/12 at 3:35 p.m., Staff D (Licensed Practical Nurse) was interviewed and stated he/she had been the nurse assigned to care for Resident #1 on 1/4/12. Staff indicated around 8:00 p.m. he/she had been in the hall preparing to pass medications when heard a noise coming from the resident's room. Staff D reported Staff B summoned her for help stating the resident had fallen. Staff D went and assessed the resident, contacted the resident's physician and sent the resident to the emergency department for further evaluation and treatment. Staff D stated the resident was known to lean forward in the wheelchair and has had falls out of wheel chair before. Staff D indicated the resident had a fall on 12/14/11. The resident had been found on the floor after falling out of his wheelchair. Staff D indicated the resident had no alarm in place at the time of the fall and Staff D placed a personal alarm on the resident at that time. Staff D stated it is the staff responsibility to ensure on each shift that alarms are in place and on. Staff D reported the resident now has alarms, anti-tip bars to the wheelchair and a belt to prevent sliding or falls. Staff D reported the resident told him/her that he/she likes the belt in place and no further incidents occurred since 1/4/12. On 1/25/12 at 12:00 noon, Staff A ( Nurse Case Manager) was interviewed and stated the resident had been care planned since 10/6/10 to have pressure alarm in place. On 12/14/11 the pressure alarm or the personal alarm had not been in place prior to the resident's fall and Staff A did not know why it had not been in place. On 1/25/12 2:14 p.m., Staff G (Occupational Therapist), stated she did not know of the falls Resident #1 has had from leaning forward in the wheelchair. Staff G stated that if she had been aware she would have recommended an evaluation for wheelchair positioning. Staff G stated she did do a wheelchair evaluation for the resident on 1/10/12 and recommended front anti-tippers on the wheelchair and a positioning belt to prevent sliding/falling from the wheelchair. Staff G stated the resident demonstrated the ability to release the belt on his/her own. The facility has not reported any further incidents of falls from the wheelchair since these interventions were implemented at the time of this interview. On 1/24/12 at 11:30 a.m., the DON (Director of Nursing) stated Resident #1 is well known by staff to lean forward in the wheelchair to pick up items and has fallen from the wheelchair. The facility had been aware of the resident leaning forward and falling from the chair and the facility did not assess for alterative measures to keep the resident safe.

The following deficiency relates to complaint -I: Based on clinical record review and staff interviews, the facility failed to plan for and direct nursing care and services to ensure a resident received adequate supervision from hazards. The staff found Resident #2 on the bathroom floor face down after he/she had been left unattended on the toilet for approximately 15-20 minutes. Staff interviews revealed some staff had also left the resident unattended in the bathroom prior to the fall; while some staff would remain with the resident due to his/her inability to balance and cognitive impairments. The facility and or the director of nursing failed to plan for and direct services to ensure Resident #2 received assistance to and from the bathroom safely. The facility reported a census of 141 residents with 4 residents reviewed. Findings include: According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 11/9/11, Resident #2 had short and long term memory deficits. The assessment identified Resident #2 had moderate impaired cognitive skills for daily decision making, which meant his/her daily decision making skills were poor; and he/she required supervision/cues. The assessment determined Resident #2 rarely or never had the ability to express his/her ideas or wants; and rarely or never had the ability to understand others. Resident #2 required extensive assistance with physical assist of two staff with bed mobility, transfers, locomotion, dressing, personal hygiene, toilet use and bathing. Resident #2 was determined as not steady moving on and off the toilet and was only able to stabilize on the toilet with physical assistance. Resident #2's [DIAGNOSES REDACTED]. The Incident Details dated 5/9/11 at 3:05 p.m. identified Resident #2's alarm sounding, and staff found resident on his/her knees next to bed. The notes documented the resident stated,"where's my baby." No injuries were noted. A low bed intervention was implemented after the fall. Resident #2's Incident Details identified another fall on 5/29/11 with no injury when the resident was found on the floor. Staff documented the resident was going to get up from bed and the bed alarm sounded. Resident #2's plan of care identified a goal in which resident will not sustain a serious injury related to falls with approaches which included: a. Low bed with scoop mattress and floor mat at bedside. b. Bed alarm The care plan noted on 12/11//11, send to ER for evaluation. On 12/12/11, the care plan inventions indicated, do not leave unattended in wheelchair. On 12/12/11, the care plan directed staff to use PA (personal alarm) at all times. The Incident Details dated 12/11/11, documented Resident #2 was found on the floor "face first " lying in an unusually manner. The nurse did not complete an assessment, and a CNA sat with the resident until the ambulance arrived. The nurse checked all of the following on the incident report for alleged injuries: right arm, right side of face, nose, and he/she hit his/her head. The note documented the resident was sent to the ER for an evaluation. The interdisciplinary progress notes dated 12/11/11 at 10 a.m., documented the ER still evaluating the resident; at 1:30 p.m., the nurse documented she called again and the ER nurse stated the resident went back to radiology for a CT scan of his/her head due to complaints of headache. The nurse documented a chest x-ray would also be completed and due to multiple injuries will most likely admit resident unless they called back. The notes dated 12/11/11 at 4:30 p.m., documented the resident's family member wanted to know if the resident had really fallen in the bathroom. The notes identified the family member reported Resident #2 had a big gash on his/her head. The progress notes documented the resident's been admitted to the hospital for pneumonia and returned to the nursing home on 12/13/11. The resident had a laceration (one inch) on his/her forehead. The full extent of the resident's injuries was unknown until the radiology reports identified no fractures: The radiology reports dated 12/11/11 identified Resident #2 had a head CT done for possible head injury. The CT showed no evidence of acute hemorrhage or acute infarctions. Additional radiology reports revealed, Resident #2 had shoulder pain & knee pain, with X-rays showing no injury to these areas. In an interview on 12/29/11 at 12:50 p.m. Staff A indicated she and Staff B were getting residents up for breakfast on the morning of 12/11/11. Staff A and Staff B assisted Resident #2 to the bathroom and placed him/her onto the toilet. While waiting, a personal alarm sounded from the room across the hall (for Resident #5) and Staff A responded to that room. Staff B followed Staff A and together they provided cares for that resident (Resident #5). Upon exiting the room, Staff A indicated Staff B was not around. Staff A stopped outside of Resident #2's door to let him/her know she would be right back. Staff A found Staff B in another resident's room (Resident #6). The resident was upset and Staff A remained with Resident #6 to help calm him/her. Staff A and Staff B then went to Resident #2's room where they found Resident #2 on the bathroom floor. (The nurse was called after they found Resident #2 on the bathroom floor to assess for injuries.) Staff A indicated it appeared as if Resident #2 had leaned forward to wipe him/her(self) and fell forward. Staff A indicated the facility policy regarding leaving a resident unattended on the toilet was if a resident has a personal alarm, they are not to be left unattended. Staff A indicated Resident #2 did not have a personal alarm and he/she has left Resident #2 unattended on the toilet before and Resident #2 had always used the call light when finished. Staff A believed Resident #2 would be safe if left unattended on the toilet that day. Staff A stated Resident #2 had been left on the toilet for about 15 minutes. In an interview on 12/29/11 at 12:15 p.m. Staff B indicated she and Staff A were getting residents up on the morning of 12/11/11. Staff A and Staff B had assisted Resident #2 to the bathroom and placed him/her onto the toilet, when they then heard a personal alarm sounding. Staff B and Staff A responded to the room and the resident (Resident #5) was agitated, combative and because he/she was a fall risk, they both got him/her ready. Staff B and Staff A got the resident up and Staff A took the resident to the nurse's station. Staff B then heard another resident screaming and responded to that room where she found that resident (Resident #6) attempting to get out of bed with his/her feet tangled up in his/her covers. Staff A then arrived into the room and together they got that resident calmed down, ready and into a safe area. Staff B and Staff A then went back to Resident #2's room and found Resident #2 lying on the bathroom floor. Staff B indicated the facility policy was to not leave a resident unattended on the toilet if they had a personal alarm. Staff B indicated Resident #2 did not have a personal alarm and believed Resident #2 was stable and safe on the toilet without supervision. Staff B indicated Resident #2 was left on the toilet unsupervised for no longer than 20 minutes. (Resident #2's MDS dated [DATE], documented he/she required extensive assistance with physical assist of two staff for transfers, personal hygiene and toilet use. The same MDS also identified the resident only able to stabilize on the toilet with physical assistance.) In an interview on 1/3/12 at 11:10 a.m. Staff C indicated she was the charge nurse on 12/11/11 when Resident #2 had his/her fall. Staff C indicated facility protocol when determining whether a resident can be left unattended on the toilet is based on the resident having no previous history of attempting to get up unassisted or personal alarm. Staff C indicated Resident #2 had no history of getting up without assist and at that time believed Resident #2 would be safe to be left unattended. Staff C indicated residents should not be left alone for more than a few minutes(5 minutes). In an interview on 12/29/11 at 1:35 p.m. Staff D indicated he would never leave anyone alone on the toilet if he felt the resident was unsafe or unstable. Staff D stated he did not work on the east hall often, but when he did, he would not leave Resident #2 alone on the toilet. In an interview on 1/3/12 at 2:43 p.m. Staff E indicated on the evening shift Resident #2 was not being left unattended in the bathroom because he/she did not have a good sense of balance or awareness. In an interview on 1/3/12 at 2:25 p.m. Staff F indicated she would not feel comfortable leaving Resident #2 on the toilet. Noting on second shift, Resident #2 was not very steady and sometimes leans while on the toilet. Staff F indicated one staff would always remain with Resident #2 when he/she was on the toilet. In an interview on 1/3/12 at 2:10 p.m. Staff G indicated she would not leave any resident on the toilet unattended if she felt it would be unsafe. Staff G indicated she believed Resident #2 was not safe to be left alone on the toilet before or after the fall incident. In an interview on 1/3/12 at 2:53 p.m. Staff H, RN (Registered Nurse) indicated her criteria when determining whether a resident could be left unattended on the toilet was whether they could walk independently and pull up their pants independently. Staff H indicated during the day shift Resident #2 did not wear a personal alarm, but on the evening shift staff were instructed to place a personal alarm on Resident #2 because of his/her behaviors. Staff H she did not feel it was safe to leave Resident #2 on the toilet unattended and instructed her staff to always remain with Resident #2. The care plan did not identify that Resident #2 utilized a personal alarm at night. In an interview on 1/3/12 at 1:25 p.m. Staff I indicated Resident #2 had no prior history of attempting to get up unassisted from his/her wheel chair or toilet. Since the incident, Resident #2 now has a personal alarm and any resident that is confused or has physically impaired mobility are not to be left alone on the toilet. In an interview on 12/29/11 at 2:00 p.m. the Director of Nursing indicated Staff A and Staff B followed facility protocol when they allowed Resident #2 to remain on the toilet without supervision. Facility protocol requires residents with personal alarms to be supervised when on the toilet. Resident #2 was not care planned for a personal alarm and had no history of attempting to get out of his/her wheelchair without assistance. Nevertheless Staff A and Staff B were given "written counseling" regarding the incident. Following the incident, staff have been educated on the facilities new protocol in which residents with impaired mobility and impaired cognitive abilities are also not to be left unattended or unsupervised when on the toilet.

Based on record review and interviews, the facility failed to plan nursing services with provisions of care and services, assessments or interventions for one (1) of seven (7) residents reviewed (Resident #6). The facility reported a census of 135 residents. Finding included: 1. The initial Minimum Data Set (MDS) with an assessment reference date of 8/17/10 documented Resident #6 had impaired cognitive skills for daily decision making skills and long and short term memory loss. The MDS indicated the resident required extensive assistance from staff for transfers, bed mobility, toilet use, bathing and personal hygiene. The MDS indicated the resident to be occasional bladder incontinence. The MDS showed the resident had no skin impairments. According to the MDS, the resident had [DIAGNOSES REDACTED]. Resident #6 ' s initial temporary care plan dated 8/13/10 indicated the resident demonstrated self care deficits and required assistance for bathing, dressing, grooming, oral care and toileting. The preadmission case management data sheet dated 8/11/10 noted the resident required physical assistance for dressing, toilet use, personal hygiene, and bathing. The document indicated the resident to be incontinent of bowel and bladder. According to the Physical Nursing Data Sheet completed within 24 hours of the resident ' s admission, Resident #6 had no comprised skin areas (skin intact) with the exception of the following: a). 4 x 4 centimeter bruise to left shin b). bruise to right arm c.) an ingrown toe nail to the left great toe that had been removed. The assessment form noted the resident had been incontinent with dark yellow urine upon admission and would require the use of an incontinent brief at all times. The form identified the resident ' s admitted as 8/13/10, and did not contain an employee signature or date when completed. The Braden scale dated 08/13/10 documented a score of 18 which indicated the resident to be at mild risk for skin breakdown. A seven day observation tool with dates that ranged from 08/13/10 through 8/22/10 indicated the resident totally dependent on staff for personal hygiene. The bathing record indicated the resident received a shower on 08/16/10 and 08/19/10. On 08/22/10 at 2:10 p.m. the interdisciplinary progress notes indicated the resident had been taken from the facility for a family outing. On 08/23/10 at 10:00 a.m. the interdisciplinary progress notes indicated the resident's family had decided to remove the resident from the facility because of concerns regarding the quality of care that the resident had received from the facility staff. On 09/08/10 at 11:20 a.m. a family member stated the resident had been picked up on 8/22/10 for a home visit and she noticed body odor that smelled like feces. The family member stated when assisting their loved one in the bathroom, it was noted the resident's left and right groin areas to be reddened, excoriated and seeping blood. The family member stated their loved one had no such skin breakdowns upon admission to the facility. The family member stated she had taken the photographs of her loved on 8/22/10 after she had discovered the areas. The family member stated her parent had just been at the nursing home for about 10 days (admitted on [DATE]), and then they did not let him/her return to the nursing home. The family member stated they did not want anyone else to go through what their parent had and s(he) did not get the necessary care at the nursing home. On 09/09/10 at 12:20 p.m. Staff A (Director of Nursing) and Staff B (assistant Director of Nursing) acknowledged that they were aware of the concerns regarding Resident #6's skin problems discovered by the family. Staff A stated the facility did investigate the concern but not in a formal manner. Staff B stated when talking with the staff it was the consensus from the nursing staff interviewed that the resident was independent. Both Staff A and Staff B acknowledge the resident did not receive appropriate care for his/her physical and mental level. Staff B stated she felt the staff might have been confused as to the residents required level of care. Staff A acknowledged that any resident in the facility should have accurate assessments in order to receive the level of care that they actually required. Resident #6's clinical record did not contain documentation on any skin breakdown, rashes, redness, abrasions, dryness, flaking, or any other type of compromised skin areas on the resident ' s groin areas. The facility had no assessment or intervention in place to address the skin breakdown. Staff interviews identified the nursing home staff had no knowledge of the compromised skin/skin breakdown until discovered on 8/22/10 by the resident ' s family.