Every finding on record at Heartland Care Center

Based on facility record review, staff interviews, and facility policy, the facility failed to provide nutritional assessments for Resident's #4, #14, #17, #20, #26, #32. The facility reported a census of 27 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Resident #4's diagnoses include gastro-esophageal reflux disease (GERD), type 2 diabetes mellitus (DM), and congestive heart failure (CHF). The MDS identified Resident #4 was on a regular diet and needed supervision or touching with eating. The MDS also identified Resident #4 admitted to the facility on [DATE] with a Stage 2 and Stage 3 pressure ulcer. Review of the clinical assessments revealed the facility failed to do an nutritional admission assessment on Resident #4. 2. Resident #14's MDS dated for 3/2/26 assessment identified a BIMS score of 10 indicating moderately impaired cognition. The MDS documented diagnosis of stroke, anxiety disorder, diabetes mellitus and hypertension. The MDS identified Resident #14 was on a regular diet and needed supervision or touching assistance with eating. The MDS indicated Resident #14 admitted to the facility on [DATE]. Review of the clinical assessment revealed the facility failed to do an nutritional admission assessment on Resident #14. 3. Resident #17's MDS dated for 4/30/26 assessment identified a BIMS score of 6 indicating severe impaired cognition. The MDS documented a diagnosis of cerebrovascular accident (CVA), anxiety disorder, hypertension (high blood pressure). The MDS identified Resident #17 was on a general diet and is independent with eating. Review of the Progress Notes on 4/30/26 indicated Resident #17 had a choking episode. Review of the clinical assessment revealed Resident #17 had a nutritional assessment completed on 12/30/25 and 12/13/24. The clinical assessment lacked nutritional assessments between these two assessments and after her choking incident on 4/30/26. 4. Resident #20 MDS dated for 4/27/26 assessment identified a BIMS score of 15 indicating intact cognition. The MDS documented a diagnosis of dysphagia(difficulty swallowing), coronary artery disease (CAD), hypertension(high blood pressure), and Diabetes Mellitus (DM). The MDS identified Resident #20 was on a regular diet and independent of eating. The MDS indicated Resident #20 admitted to the facility on [DATE]. Review of the clinical assessments revealed the facility failed to do an nutritional admission assessment on Resident #20. 5. Resident #32 MDS dated for 4/9/26 assessment identified a BIMS score of 15 indicating intact cognition. The MDS documented a diagnosis of stroke, hemiplegia, hemiparesis, anxiety and depression. The MDS identified Resident #32 was on a mechanically altered diet and needed supervision or touching assistance with eating. Review of Progress Notes revealed Resident #32 had a choking episode on 4/11/26, the progress notes also showed Resident #32 has a hx of choking with an episode on 4/16/25, which also stated has had choking episodes in the past. Review of the clinical assessments revealed the facility completed a nutritional assessment on 1/29/25 and 10/29/25. Interview on 5/6/2026 at 5:06 pm with Staff G, Registered Dietician, stated that she comes to the facility once a month and tries to participate in the care conferences and stated sometimes they have been cancelled. Staff G stated there is not a good process when it comes to communication between her and the facility. Staff G stated that she pulls reports from the electronic health record to see who has been admitted /discharged or if there had been a change with a resident. Staff G stated that she reviews section K on the MDS, but does not always sign it off. Staff G stated that the MDS coordinator completes section K and signs it off. Staff G stated that she was not notified of the weight loss with Resident #26, or the pressure area with Resident #4. Staff G stated Resident #26 slipped through the cracks. Staff G stated she was not notified of the choking episodes for Resident #17 or Resident #32. Staff G stated that she is playing catch up on her assessments due to other responsibilities. Staff G stated the expectation would be to have all new admissions or residents with a change have an assessment and also quarterly assessment completed or more as needed. Review of the facility policy named Nutritional Management dated 1/1/26 revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. 6. Resident #26's Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #26 was dependent on staff for eating . Resident #26's MDS included diagnoses of Alzheimer's disease, non-Alzheimer's disease, seizure disorder, anxiety and depression. The MDS identified Resident #26 was on a mechanically altered diet. A Progress Note titled Weight Change Note dated 4/7/26 revealed Resident #26 had a weight loss of 5% in the last 30 days. On 03/09/2026, the resident weighed 179.6 lbs (pounds). On 04/02/2026, the resident weighed 169.5 lbs which was a -5.62% loss. The Clinical record lacked documentation the Registered Dietician was notified regarding the significant weight loss and lacked a nutritional assessment.

Based on observations, staff interviews and policy review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. The facility identified a census of 27 residents.Findings include: 1- During the initial tour of the kitchen on 5/4/26 at 10:30 AM observed the oven hood was dirty with build up of debris, dust and grease. A sticker on the hood indicated the last time the hood was cleaned by an outside company was in January 2026.On 5/5/26 at 12:05 PM, observation revealed the Dietary Manager placed one of the oven hood inserts/filters into the sink to soak and to clean. She reported the cold water outside did not help clean the insert. The Dietary Manager acknowledged the hood vent was dirty with a lot of build up. She reported with a lot of Dawn dish soap and scrubbing she might be able to get some of the buildup off. On 5/5/26 at 12:45 PM, the Dietary Manager reported the facility did not have a schedule to clean the hood vent in-between the professional cleaning. She said she did not think the professional cleaning company did a very good job the last time the hood vent was cleaned in January 2026. She reported she thought the facility might purchase new vent inserts/filters and then start a regular cleaning schedule. She said it might not hurt to clean the hood vent monthly.2- On 5/5/26 at 11:30 PM, observation revealed three cans of tomato soup on the steam table. Staff C, [NAME] took a temperature of one can of tomato soup and the temperature was 152 degrees Fahrenheit. Staff C said she heated the tomato soup in the can as she had better luck with the temperatures then putting the soup in a coffee mug on the steam table. On 5/5/26 from 11:30 PM to 12:30 PM, observation revealed Staff C, [NAME] wore gloves during the meal service. Staff C touched multiple services with the gloves that included but not limited to the resident's paper menus, plates, utensils, aluminum foil, serving cart, ketchup bottle, and scissors. Staff C did not use a utensil to serve the buttered bread or when getting the hamburger buns and bread out of the plastic bag. Staff C used her gloved hands that had touched multiple surfaces. In addition, Staff C while wearing contaminated gloves took a hamburger bun out of the plastic bag, reached into the steam table and grabbed a plastic bag that had a hamburger patty in it. Staff C took the hamburger patty out of the plastic bag with her gloved hand and placed the patty on the hamburger bun then served it. On 5/5/26 at 12:30 PM observation revealed one puree pouch of carrots, one puree pouch of green beans and two puree pouches of chicken on the steam table. Staff C, [NAME] reported the puree pouches were reheated on the steam table. Additional observations during meal service included the following:a. Staff D, housekeeper came into the kitchen, walked up next to the steam table during meal service with no hair net in place. b. Three room trays were assembled and taken to the resident's rooms with a piece of cake on each tray not covered. On 5/5/26 at 12:45 PM, the Dietary Manager reported the cook wore gloves during the meal service because she had long finger nails. The Dietary Manager said the expectation was for the staff to use a utensil like tongs when serving the bread/buns and food items should be covered when delivering room trays. On 5/5/26 at 3:20PM, the Dietary Manager reported the steam stable was to be used to hold temperatures and not reheat food. She said she would expect the food to be heated in the microwave to a temperature of 165 degrees Fahrenheit and then held on the steam table at 135 degrees Fahrenheit. The facility policy titled Food Safety Requirements dated 2/1/26 documented the following:a. Reheating food that was cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degree Fahrenheit.b. Cover all food when traveling a distance (down the hallway)c. Dietary staff must wear hair restraints to prevent hair from contacting food. d. Staff should maintain nails that are clean and neat, and wear disposable gloves in good condition that are changed appropriately to reduce the spread of infection. The 2022 Food Code included:46. The observation of food preparation activities and glove use by food employees was necessary. Gloves may serve as a source of cross contamination if misused.3-304.15 Single-use gloves shall be used only for one task such as working with ready to eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruption occurs in the operation. 4-202.18 Filters or other grease extracting equipment should be designed to be readily removable for cleaning and replacement if not designed to be cleaned in place.

Based on clinical record review, staff interviews and policy review, the facility failed to notify the Physician and/or family when a resident had a significant change of condition for 3 of 3 residents reviewed (Resident #26, #17, #32). The facility reported a census of 27 residents.Findings include: 1. Resident #26's Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #26 was dependent on staff for eating . Resident #26's MDS included diagnoses of Alzheimer's disease, non-Alzheimer's disease, seizure disorder, anxiety and depression. The MDS identified Resident #26 was on a mechanically altered diet. A Progress Note titled Weight Change Note dated 4/7/26 revealed Resident #26 had a weight loss of 5% in the last 30 days. On 03/09/2026, the resident weighed 179.6 lbs (pounds). On 04/02/2026, the resident weighed 169.5 lbs which was a -5.62% loss. The Clinical Record lacked documentation Resident #26's family was notified regarding the significant weight loss. On 5/5/26 at 5:00 PM, the Director of Nursing (DON) reported she could not locate any documentation that Resident #26's family was notified of the weight loss. The DON reported it was an expectation for the family to be notified. The facility policy titled Weight Monitoring dated 1/1/26 documented a significant change in weight was defined as: 5% change in weight in 1 month 7.5% changed in 3 months 10% change in weight in 6 months The undated facility policy titled Family Notification and Update Policy and Procedure documented in the event a resident experiences a significant change in level of care or major incident, the facility was to notify the responsible party. The policy documented a list of reasons a family would be notified included significant change in condition and a choking incident. In addition, the policy directed anytime a physician was required to be contacted; the facility policy was to contact the responsible party as well. The facility policy titled Notification of Changes dated 1/1/26 documented the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there was a change requiring notification. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 showed the Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS documented diagnosis of cerebrovascular accident (CVA), anxiety disorder and gastro esophageal reflux disease (GERD). The facility progress notes dated 4/30/26 at 12:14 pm revealed Staff E, MDS Coordinator was informed Resident #17 was choking on a piece of meat, by her tablemate. Staff E took Resident #17 out of the dining room to clear her throat. Resident #17 was talking and coughing. Will assess Resident #17's lung sounds and temperature every shift x 3 days. The facility progress notes dated 4/30/2026 at 12:51 pm revealed Resident #17's temperature was 98.2 and lungs sounds had slight expiratory wheezes. Staff F, Registered Nurse (RN) helped clean food out of teeth and rinse mouth. Resident #17 reported she just chewed her meat wrong. The clinical record lacked documentation Resident #17's physician was notified of the incident. 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 showed the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented diagnosis of Cerebrovascular Accident (CVA), hemiplegia (a form of paralysis affecting one side of the body, either the right or left side, including the arm, leg, and sometimes face) and hemiparesis (a neurological condition characterized by weakness, numbness, or reduced movement capability on one side of the body, often following a stroke, brain injury, or tumor), depression and anxiety disorder. The MDS identified Resident #32 was on a mechanically altered diet. The facility progress notes dated 4/11/2026 at 9:00 am revealed Resident #32 had a choking episode at breakfast while eating scrambled eggs. Resident #32 had a small emesis but reports feeling fine. Lung sounds clear and oxygen saturation at 97%. Resident #32 reported feeling better and went back and finished eating her breakfast. Review of the physician orders dated 7/22/25 reveled Resident #32's diet as regular diet, moistened ground meat texture, thin consistency. The clinical record lacked documentation Resident #32's physician was notified of the incident. On 5/6/26 at 2:00 pm the DON stated the expectation would be if a resident has a choking episode to notify the physician.

Based on facility records, resident interviews, and staff interviews, the facility failed to provide sufficient staff to care for residents in a timely manner. The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) for Resident #24 dated 3/11/26 assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.The Census revealed Resident #24 resided in room [ROOM NUMBER]. On 5/04/2026 at 1:10 PM, Resident #24 reported he had a long call light yesterday afternoon. He said the call light was on for 30 minutes. He said he looked at the clock when he put the light on and looked at the clock again when the light was answered. Resident #24's daughter was present in the room and reported usually the call light was used when Resident #24's wife, who also resides in the room, needed to go to the bathroom. Review of Resident #24's call light reports for room [ROOM NUMBER] from 4/29/26 to 5/6/26 revealed the highest elapsed time was 34 minutes and 50 seconds. The call light report documented Resident #24's call light was on 15 minutes or more on the following dates and times:4/30/26-4:09 AM= 21 minutes and 45 seconds4/30/26- 8:31 PM= 19 minutes and 11 seconds5/1/26- 8:08 AM= 31 minutes and 3 seconds5/1/26- 8:10 PM= 18 minutes and 14 seconds5/2/26 - 6:56 AM= 31 minutes and 18 seconds5/2/26- 1:26 PM= 17 minutes and 34 seconds5/2/25- 8:18 PM= 21 minutes and 38 seconds5/3/26- 9:34 AM= 34 minutes and 50 seconds5/5/26- 7:30 AM= 17 minutes and 56 seconds5/6/26- 7:58 AM= 23 minutes and 9 secondsOn 5/6/26 at 11:23 AM, the Director of Nursing (DON) reported the standard response time for call lights was 15 minutes. She reported the facility did not have a call light policy.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed (Resident #23) for peri care. The facility reported a census of 27 residents.Findings include: Resident #23's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #23 was dependent on staff with toileting hygiene and was occasionally incontinent of urine. Resident #23's MDS included diagnoses of Parkinson's disease and Transient Ischemic Attack (TIA). The Care Plan with target date of 6/15/26 revealed Resident #23 had a urinary tract infection (UTI) and an overactive bladder. The care plan directed staff to clean the peri area and to change the disposable brief after each incontinent episode. The May 2026 Medication Administration Record (MAR) revealed Resident #23 was taking Macrodantin (antibiotic) 100 MG (milligrams) twice a day for a UTI with the last dose scheduled the morning of 5/4/26.The Progress Note on 4/28/26 documented Resident #23 was on enhanced barrier precautions due to positive urine culture for ESBL (extended-spectrum b-lactamases). On 5/5/26 at 9:10 AM, observed Staff A, Certified Nursing Assistant (CNA) in Resident #23's room with a gown and gloves on. Staff A placed a harness for the mechanical stand behind Resident #23's back, attached the harness to the mechanical stand, buckled the chest strap and applied the leg strap. Staff B, CNA assisted Resident #23 to a standing position using the mechanical stand and then pushed Resident #23 into the bathroom in front of the toilet. Staff A assisted with pulling down Resident #23's pants with the same pair of gloves she had worn to hook up the mechanical stand. Staff B then lowered Resident #23 onto the toilet with the mechanical stand. Staff A placed a paper towel on the edge of the sink, took multiple incontinent wipes from the container and laid the wipes on the paper towel while still wearing the same pair of gloves. Staff B then raised Resident #23 off the toilet to a standing position with the mechanical stand. Staff A then proceeded to complete peri care with the incontinence wipes using the same pair of contaminated gloves. On 5/5/26 at 9:30 AM, Staff A, CNA acknowledged she had touched multiple surfaces with her gloves prior to performing peri care. She agreed that she probably should have changed her gloves before completing the peri care. On 5/6/26 at 12:45 PM, the Director of Nursing (DON) said she expected the staff to have their equipment prepared ahead of time and agreed the gloves should have been changed prior to completing the peri care.The facility policy titled Personal Protective Equipment dated 1/3/25 documented the facility promoting appropriate use of personal protective equipment to prevent the transmission of pathogens to resident, visitors and other staff. The policy directed staff to change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn.

Based on interview, record and policy review the facility failed to provide adequate respiratory care for 1 of 3 residents reviewed. Resident #3 required supplemental oxygen. The staff failed to increase monitoring and failed to consult with the resident and family before requesting a change from scheduled oxygen to an as-needed (PRN) order. The resident experienced low oxygen saturations, increased lethargy and was hospitalized . The facility reported a census of 29 residents.Findings include:According to the Minimum Data Set (MDS), dated [DATE], Resident #3 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 13 (intact cognitive functioning) and required partial assistance with toileting hygiene, and transfers. The resident had shortness of breath with exertion and was on continuous oxygen therapy. His diagnoses included: atrial fibrillation, coronary artery disease, renal insufficiency, pneumonia, respiratory failure and sarcoidosis of the lungs.The Care Plan initiated on 4/4/25, showed Resident #3 had altered respiratory status related to respiratory failure. Staff were to observe for signs and symptoms of respiratory distress and report to the doctor on increased respirations, decreased pulse oximetry, increased heart rate, lethargy, cough and skin color change. The oxygen settings were at 2 liters (L), to be increased to 3.5 liters with ambulation.According to National Institute of Standards and Technology, U.S. Department of Commerce ([NAME]), most people have a normal resting pulse oximetry reading between 95% and 100% oxygen saturation (O2). Below 90% indicated oxygen deficiency (hypoxia) and may require immediate medical attention. Retrieved on 9/25/25 at 10:40 AM from: How Do You Measure Blood Oxygen Levels? [NAME] The Medication/Treatment Administration Record (MAR/TAR) for Resident #3 in the month of April showed an order for oxygen at 2L, increase to 3.5L when ambulating. O2 was documented three times a day on the April MAR/TAR.On Saturday, 5/10/25 at 11:24 AM, Staff C, Registered Nurse, completed a communication to the physician to change the oxygen order for Resident #3 from continuous, to PRN. The discontinue/change reason: Resident maintains oxygen (O2) above 89% on room air. O2 is not needed at all times The communication document indicated that the change was approved verbally by Physician #1, the Primary Care Physician (PCP) for Resident #3.On 9/24/25 at 7:30 AM The Director of Nursing (DON) said that on the weekends, the doctor on call depended on who the PCP was for the particular resident. The nurses were to call the emergency department for the PCP, and orders would then be entered with the name of the doctor who verbally approved the order.On 9/24/25 at 10:00 AM The scheduler for Physician #1 checked the weekend of 5/10/25 and found that Physician #2 was on call. Nurses would talk to the House Supervisor at the hospital to get a message to the on-call doctor, or they could contact the doctor directly. The scheduler checked the file for Resident #3 and the weekend of 5/10/25 and did not see any scanned communication sheet or nurses note related to a request to change an order.The electronic record titled: O2 Sats Summary showed the oxygen level for Resident #3 was checked twice on 5/10/25 at 11:21 AM, at 92% on Room Air (RA), and at 2:41 PM, at 90% on RA. The O2 was not checked again until 5/11/25 at 7:14 AM, when he was 91% on RA, and at 2:42 PM, at 90% on RA. His O2 was not checked again until 19 hours later, on 5/12/25 at 10:08 AM, when it was 91% on 2L of oxygen. The chart lacked documentation of the O2 level before the oxygen had been reapplied.On 9/23/25 at 3:30 PM, Staff C, RN, had some difficulty remembering Resident #3 but she did recall that she went into his room one day and the oxygen concentrator had been turned off. She said she checked his oxygen level at that time, and it was above 90% so she continued to check throughout the day and he was doing fine without the supplemental O2. Staff C said that the resident had been doing well with therapy without the oxygen also. Staff C said that she didn't remember requesting the change in order from scheduled to PRN, but when asked if the family agreed, she said she talked to the resident and his wife and they were fine with the change. A Service Note dated 5/9/25, from Occupational Therapy showed that Resident #3 tolerated exercises that day for 3-4 minutes at a time with a significant drop in O2 while on 1L oxygen. The O2 dropped in the low 80s. A Service Note from Physical Therapy dated 5/7/25, showed that the resident ambulated without the supplemental oxygen and O2 decreased to 84%. It took him a little over a minute to recover to 92%. On 5/8/25, the resident ambulated with oxygen on 1L for 200 feet and his O2 was 84% following ambulation and recovered to over 90% in about a minute.A Nursing Progress Note dated 5/12/25 at 11:21 PM, showed that the oxygen level for Resident #3 was in low 70s, that evening. Supplemental oxygen was administered to bring levels back up into the 90s. The resident and the family requested to leave on continuously to prevent from dropping back down below 90s.A communication to the physician was sent on 5/13/25 at 7:06 AM, verbal order, to change the oxygen order from a PRN to continuous oxygen 2 to 5L to keep O2 sats greater than 90%. Nursing Progress Notes included the following: On 5/13/25 at 12:25 PM, lung sounds diminished, on 3 liters oxygen. On 5/13/25 at 12:11 PM, the resident was out of the facility for an appointment. On 5/13/25 at 5:26 PM, the resident was hospitalized .A History of Present Illness note from nephrologist showed that on 5/13/25 at 1:30 PM, the patient came in with complaints of shortness of breath and weakness, on continuous oxygen, and he had a cough. The doctor recommend admission to the hospital for work up and treatment.The Hospital Emergency Department Note, dated 5/13/25 at 5:10 PM, showed that the oxygen saturation for Resident #3 had been in the low 70s at triage. He reported feeling worn out with low energy and low appetite and he had bilateral crackles in his lungs. A chest x-ray showed bilateral pulmonary congestion suggestive of pulmonary edema.On 9/23/25 at 11:21 AM, a Family Member (FM) said that in the days leading up to his hospitalization, Resident #3 wasn't getting enough oxygen, he was shaking and had low energy. She said that he was taken off the supplemental oxygen cold turkey on a Saturday and this decision was not discussed with him or the family. She said she came in to see him on 5/12/25, he was in his room shaking and purple. A staff member came in with his supper and she asked her to get the nurse. When the nurse came back with finger monitor, she found his O2 was in the lower 70s. FM said that when they changed the order they were checking on him less often.On 9/23/25 at 2:00 PM, Staff B, RN said that she came to work the 6 PM shift on 5/12/25 and Resident #3 was struggling to eat, and his lips were blue. She put oxygen on him for the rest of the night. Staff B said she didn't know why the order had been changed on a Saturday without a trial titration.On 9/24/25 at 9:12 AM, Staff E, Licensed Practical Nurse (LPN) said her experience with Resident #3 was that he had trouble keeping his oxygen up so they made sure he always had it on. There were times that she would find him without the mask on, but she directed him to put it on, and he would without resistance. She was not sure why the order would have been changed on a weekend.On 9/24/25 at 10:30 AM, Staff D, RN, said she changed the oxygen order from PRN back to continuous because he wasn't tolerating being on RA very well and his oxygen was running low. She remembered that this was just before he had been hospitalized .On 9/24/25 at 12:03 PM, Staff F, RN, said that Resident #3 was non-compliant and was always taking his oxygen off so she could see why a request for PRN oxygen would have been appropriate. She said that they continued to check his oxygen frequently and he always maintained above 90%. She said that with a titration in oxygen, she would expect increased monitoring.On 9/24/25 at 2:15 PM, Physician #1 said that he was not very familiar with Resident #3 and hadn't actually even seen him while he was at the nursing home. He said that he typically did not like to make any major changes on a resident if he hadn't actually seen them.On 9/25/25 at 7:30 AM, the DON acknowledged that the documentation of the oxygen monitoring had decreased after the order change on 5/10/25. She said that the nurses could have possibly documented the oxygen levels on their communication sheets that they use to write on and keep track of hot charting.According to the facility policy titled: Nursing Policy for Receiving and Noting New Orders, the nurse was to inform resident and/or family of new orders, especially orders received due to change in resident condition.The policy titled: Policy and Procedure of Oxygen Therapy, showed that the nurse should observe for signs of shortness of breath, rapid, shallow breath, cyanosis of lips assess lung sounds, pulse, respiration rates and SAO2 to determine if oxygen was appropriate.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 5 out of 5 sampled residents reviewed (Resident #5, #7, #11, #13 and #28). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of depression, renal insufficiency, and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of Resident #11's April 2025 Medication Administration Record revealed the following orders: Trazodone(antidepressant medication) daily with a start date of 12/2/24. Duloxetine (antidepressant medication) daily with a start date of 12/3/24. Review of the Care Plan with a revision date of 4/7/25 lacked non pharmacological interventions and targeted behaviors for the antidepressant medications. 2. The MDS assessment dated [DATE] for Resident #5 documented diagnoses of depression and anxiety disorder. The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took antianxiety medication and antidepressant medications in the last review period. Review of Resident #5's April Medication Administration Record (MAR) revealed the following orders: a. Lexapro (antidepressant medication) daily with a start date of 2/25/25 b. Lorazepam (antianxiety medication) twice a day with a start date of 2/24/25 Review of Resident #5 ' s Order Summary Report signed and dated 3/3/25 revealed the following orders: a. Lexapro daily with an order date of 2/24/25 b. Lorazepam twice daily with an order date of 2/24/25 Review of the Care Plan with a revised date of 4/8/25 lacked non-pharmacological interventions to use with antidepressant and antianxiety medications and targeted behaviors for usage of antidepressant medication. 3. The MDS assessment dated [DATE] for Resident #7 documented diagnoses of anxiety disorder, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication in the last review period. Review of Resident #7's April MAR revealed the following orders: a. Duloxetine (antidepressant medication) at bedtime with a start date of 8/8/23 b. Duloxetine at bedtime with a start date of 7/17/20 c. Lorazepam daily with a start date of 1/30/25 d. Quetiapine Fumarate (antipsychotic medication) with a start date of 3/18/25 e. Wellbutrin XL (antidepressant medication) with a start date of 2/14/24 Review of Resident #7's Order Summary Report signed and dated 4/3/25 revealed the following orders: a. Duloxetine at bedtime with an order date of 8/8/23 b. Duloxetine at bedtime with an order date of 7/17/20 c. Lorazepam daily with an order date of 1/29/25 d. Quetiapine Fumarate daily with an order date of 3/18/25 e. Wellbutrin XL daily with an order date of 8/7/24 Review of the Care Plan with a revised date of 4/7/25 lacked non-pharmacological interventions and targeted behaviors for the usage of antidepressant medication, antianxiety medication and antipsychotic medication. 4. The MDS assessment dated [DATE] for Resident #13 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication in the last review period. Review of Resident #13's April MAR revealed the following orders: a. Buspirone (antianxiety medication) daily with a start date of 1/21/25 b. Lorazepam as needed with a start date of 3/10/25 Review of Resident #13's Order Summary Report signed and dated 4/3/25 revealed the following orders: a. Buspirone daily with an order date of 1/21/25 b. Lorazepam as needed with an order date of 3/10/25 Review of the Care Plan with a revised date of 4/8/25 lacked non-pharmacological interventions and targeted behaviors for the usage of antidepressant and antianxiety medications. 5. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 14, indicating no cognitive impairment. The MDS revealed resident took antianxiety medication and antidepressant medications in the last review period. Review of Resident #28's April MAR revealed the following orders: a. Duloxetine daily with a start date of 12/27/24 b. Xanax (antianxiety medication) with a start date of 12/11/24 Review of Resident #28's Order Summary Report signed and dated 3/3/25 revealed the following orders: a. Duloxetine daily with an order date of 12/11/24 b. Xanax daily with an order date of 12/11/24 Review of the Care Plan with a revised date of 4/7/25 lacked non-pharmacological interventions for usage of antianxiety medications and antidepressant medications and lacked targeted behaviors for the usage of antidepressant medications. The facility does not have a policy on unnecessary medication usage. Interview on 4/9/25 at 10:15 a.m., with the Director of Nursing revealed the resident should have non-pharmacological interventions and targeted behaviors for the high risk medications they are taking and should be listed on the care plan.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility, or on therapeutic leave, and failed to provide written notice of bed hold for 3 of 3 residents reviewed (Residents #3, #11 and #28). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of diabetes mellitus, renal insufficiency and chronic lung disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of Resident #3's census tab revealed the following information: a. 1/29/25- hospital unpaid leave b. 1/31/25- resident returned to the facility, status active. Review of Progress Notes for Resident #3 revealed the following: a. 1/29/25 at 10:02 PM- resident enroute to hospital via ambulance. Review of the bed hold dated 1/29/24 revealed verbal authorization from Resident #4 but lacked the resident's signature. 2. The MDS assessment dated [DATE] for Resident #11 documented diagnoses of depression, renal insufficiency, and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of Resident #11's census tab revealed the following information: a. 3/27/25- therapeutic leave b. 4/7/25- resident returned to the facility, status active. Review of Resident #11's Progress Notes revealed the following: a. 3/27/25- resident staying overnight with family. Review of the bed hold dated 3/27/25 revealed verbal authorization from Resident #11 but lacked a resident or representative signature. 3. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of stroke, hypertension and depression. The MDS showed the BIMS score of 14, indicating no cognitive impairment. Review of Resident #28's census tab revealed the following information: 10/1/24- hospital unpaid leave 10/4/24- active Review of Progress Notes revealed the following: 10/1/24 at 6:49 p.m., resident left the facility to the local hospital emergency room (ER) for evaluation. 10/1/24 at 10:40 p.m., resident in local ER 10/4/24 at 1:00 p.m., resident returns from the hospital at this time with new orders. Review of the bed hold dated 10/1/24 revealed verbal authorization from Resident #28 but lacked a resident or resident representative's signature. Review of the facility provided policy titled Bed Hold Policy undated revealed this notice will be provided to the resident or resident representative prior to transfer or within 24 hours in case of emergency transfer. Interview on 4/9/25 at 10:17 a.m., with the Director of Nursing revealed the facility does not get a signature on the bed holds but they do them as the resident is leaving the facility or they call the family the next morning.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #7) reviewed for PASRR requirements. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 documented diagnoses of anxiety disorder, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnosis: a. Major depressive disorder b. Post Traumatic Stress Disorder c. Psychotic disorder with delusions d. Anxiety disorder Review of the Order Summary Report signed 4/3/25 by the physician revealed the following diagnosis: a. Psychotic disorder with delusions b. Anxiety disorder c. Major depressive disorder d. PTSD Review of the PASRR dated 1/27/2020 lacked inclusion of psychotic disorder and PTSD. The clinical record lacked an updated PASRR to include psychotic disorder and PTSD. The facility does not have a PASRR policy and follows the Maximus guidelines. Interview on 4/9/25 at 10:23 a.m., with the Director of Nursing revealed the psychotic disorder and PTSD should be on the PASRR.

Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for included in the comprehensive care plans (Resident #5, #7, and #28). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of depression and anxiety disorder.The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #5's April Medication Administration Record (MAR) revealed an order for tramadol as needed for pain with a start date of 1/5/23. Review of Resident #5's Order Summary Report signed and dated 3/3/25 revealed an order for tramadol as needed for pain with an order date of 1/5/23. Review of the Care Plan with a revised date of 4/8/25 lacked non-pharmacological interventions to use prior to the usage of pain medications. 2. The MDS assessment dated [DATE] for Resident #7 documented diagnoses of anxiety disorder, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took opioid medication in the last review period. Review of Resident #7's April MAR revealed an order for hydrocodone-acetaminophen (opioid medication) as needed for moderate to severe pain with a start date of 4/10/24. Review of Resident #7's Order Summary Report signed and dated 4/3/25 revealed an order for hydrocodone-acetaminophen as needed for moderate to severe pain with an order date of 4/10/24. Review of the Care Plan with a revised date of 4/7/25 lacked information regarding usage of opioid medications, side effects to watch for and non-pharmacological interventions to use prior to medications 3. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 14, indicating no cognitive impairment. The MDS revealed resident took opioid medication in the last review period. Review of Resident #28's April MAR revealed an order for hydrocodone-acetaminphen twice a day with a start date of 3/18/25. Review of Resident #28's Order Summary Report signed and dated 3/3/25 revealed an order for hydrocodone-acetaminophen twice daily with an order date of 12/11/24. Review of the Care Plan with a revised date of 4/7/25 lacked non-pharmacological interventions to use prior to the usage of pain medications. Interview on 4/9/25 at 10:15 a.m., with the Director of Nursing revealed she would expect pain medication to be listed on the care plan along with side effects to watch for with usage, non-pharmacological interventions to try prior to medication usage. Review of the facility provided policy titled Care Plan Policy and Procedure dated 4/1/2020 revealed a complete care plan is completed within 21 days of admission per RAI manual. This plan is to capture a comprehensive evaluation of each resident ' s physical and emotional needs.

Based on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) during wound care for 1 out 1 resident reviewed (Resident #3). The facility reported a census of 32 residents. Findings include: Observation on 4/9/25 at 10:26 AM for Resident #3 showed the Infection Preventionist (IP) completed hand hygiene, donned gloves and removed the left lower leg wraps and soiled dressing. The IP discarded the dressing, removed soiled gloves, performed hand hygiene and initiated the dressing change to the left lower leg wound. During the dressing change the IP reported the resident had a history of leg wounds due to peripheral insufficiency. The resident stated, I've had this one for a long time and it's finally getting better, it's almost there. The IP completed the wound care as ordered. The IP failed to don additional Personal Protective Equipment (PPE) in accordance with EBP precautions at any time before or during the dressing change. In an interview on 4/9/25 at 10:54 AM, Resident #3 reported staff failed to wear a protective gown during dressing changes. The resident stated, they used to get dressed up in all that garb when I was in the hospital but not here. The resident reported the next appointment with the wound nurse is tomorrow 4/10/25. In an interview on 4/9/25 at 11:01 AM, the IP reported recently reaching out to regional staff for direction regarding EBP requirements. The IP stated, we had so many people on EBP. The IP explained she received instruction not to use EBP for wound care unless infected with a MDRO. In an interview with the DON on 4/9/25 at 11:28 AM, the DON explained the facility followed Iowa Health Care Association (IHCA) and the latest Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) dated March 20, 2024. The DON reported EBP is only needed for Multidrug-resistant organisms (MDRO), chronic wounds, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. The DON stated, the wound is not considered chronic, it's not over 6 months. The Medical Doctor/Nursing Communication showed staff first notified the physician of Resident #3's left lower leg wound on 1/14/25. The physician ordered the resident to be referred to the wound clinic. The Order Summary Report dated 4/3/25 for Resident #3 identified a diagnosis of Methicillin Resistant Staphylococcus Aureus. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: -Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. The Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 4/9/25, updated 7/12/22, and dated 4/2/24 revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wound and indwelling medical devices are at especially high risk for both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The Centers for Disease Control and Prevention website titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2024 identified question: May nursing homes stop using Enhanced Barrier Precautions if we screen the infected or colonized resident and they test negative for the novel or targeted MDRO. Residents colonized with a novel or targeted MDRO are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Because MDRO colonization is typically prolonged and follow-up testing to determine clearance may yield false negatives, CDC does not recommend routine retesting of residents with a history of colonization or infection with a MDRO or discontinuation of Enhanced Barrier Precautions after a subsequent negative test.

Based on observation, review of the menu, and staff interview, the facility failed to follow the menu as written for 1 meal, and failed to assure menus were reviewed and approved by a dietician. The facility reported a census of 29 residents. Findings include: The noon menu for 4/3/24 included: A 6 ounce lade of creamed chipped beef, A (#8) 4 ounce scoop of mashed potatoes. A 4 ounce serving of green beans, A serving of bread. Staff A Cook served the noon meal 4/3/24. When she was done serving the main dining room the serving scoops she used were: A 4 ounce lade of chipped beef, A #12 scoop about 1/3 cup mashed potatoes, A 1/4 cup, 2 ounce green beans, and served 1/2 slice buttered bread. On 4/3/24 at 12:20 p.m. Staff A could not identify the scoop sizes she was using to serve lunch. She said they were all about 1/2 cup. The Dietary Manager (DM) was not completely sure either and they figured out what serving size she used, which were not the servings on the menu. The DM stated Staff A gave extra of the chipped beef gravy on top of the 1/2 cup, but did not give extra for all. The 2019 facility policy Menu Planning documented the nutritional needs of individuals would be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well balanced diets, unless contraindicated by medical needs. Regular and therapeutic menus would be written by the facility's food and nutrition professional in accordance with the facility's approved diet manual, or purchased from an approved vendor. The registered dietician nutritionist (RDN) or designee would approve all menus. The menus Sunday through Saturday had changes made in writing, none were signed by the dietician. On 4/4/24 at 10:12 a.m. the Administrator stated they were unable to get a dietician for awhile, now they had one from the hospital they were affiliated with. On 4/4/24 at 10:15 a.m. the DM stated the dietician they had started coming less and less, and then not at all, she thought before last March. The company they procured food from sent their menus, so she would email the dietician from the company to make changes. The DM would make changes to the menu if she knew the residents didn't like something. She said they now had the hospital dietician and she came once a month. She did ask for the menus the last time she was there. She did not sign them.

Based on observation and staff interview, the facility failed to assure they stored, prepared, distributed and served food in accordance with professional standards for food service safety. The facility reported a census of 39 residents. Findings include: 1) On 4/1/24 at 9:47 a.m. the stove hood appeared greasy/grimy in the area above where they were cooking. The sprinklers above the oven had greasy feel and fuzz removed. The panel above/in front of the stove hood had fuzz hanging intermittently all the way up. The Dietary Supervisor stated would need to find out when the hood was last cleaned. On 4/4/24 at 10:12 a.m. the Administrator stated they didn't find the oven hood on the cleaning schedule. They did clean it, but did not have a record of when last done. They did clean it on Monday and started a new form. The 2019 facility policy Cleaning Instructions: Hoods and Filters, documented stove hoods and filters would be cleaned according to the cleaning schedule, or at least monthly. 2) During the noon meal service Staff A Cook wore the same gloves throughout. She touched many surfaces including the steam table, utensils, menus, the refrigerator doors, and then touched a beef burger, reached in a bag of buns and retrieved one, picked up a tomato slice, and pulled a sandwich from a plastic bag with her hands wearing the same gloves. The 2019 facility policy, Bare Hand Contact with Food and Use of Plastic Gloves included staff would use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. Gloves like hands got soiled. Anytime a contaminated surface was touched, gloves must be changed and hands washed. The FDA Food Code 2017 included if used, single use gloves should be used for only one task such as working with ready to eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occurred in the operation. 3) When finished serving the main dining room, Staff A temped the foods including the creamed chipped beef at 168 degrees. At 12:23 p.m. Staff C plated food for 5 residents in the North dining room. Staff C removed hot plate holders from the oven and put on trays in the food cart. She plated the food put on the hot plate holders and covered. Staff C closed the cart, and wheeled it to the north dining room. The plates were put on the table for the 3 residents who were there, and removed from the the hot plate. If not there the plated food remained covered and on the hot plate. The last resident arrived in the dining room at 12:43 p.m. The DS temped the mashed potatoes and chipped beef gravy at 120 degrees. The 2019 facility policy, Food Temperatures, documented all food must be cooked to appropriate internal temperatures, held and served at temperatures of at least 135 degrees.

Based on record review and staff interview, the facility failed to assure a discharged resident had a discharge summary that included a recapitulation of the resident's stay for 1 resident reviewed (Resident #30). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #30 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including enterocolitis due to clostridium difficile (c-diff). The Baseline Care Plan Summary dated 12/12/23 documented the resident admitted to the facility related to his c-diff. He was unable to care for himself at home and having as many as 10-12 episodes of diarrhea. He got very weak and unable to clean himself up. He started on a new medication for c-diff. He was very pleasant and said he wanted to get home so he didn't lose his ability to walk and be independent. He had good family support. Physical Therapy would work with the resident to strengthen him. On 1/3/24 at 3:37 p.m. the Progress Notes documented receipt of a signed fax by the physician related to the resident going home on 1/4/24. On 1/4/24 at 10:18 a.m. the Progress Notes documented the resident packed all personal belongings and received discharge paperwork. Home health aware, and the pharmacy had bubble packs ready for the resident to pick up. The resident left the facility at 10:50 a.m. with family. The resident's clinical record lacked a discharge summary including a recapitulation (recap) of the resident's stay. On 4/4/24 at 10:52 a.m. the Director of Nursing (DON) stated they did not do a recap on the resident, and they should have. The undated facility Discharge Summary/Recapitulation Policy documented a discharge summary would be completed for every resident at the time the resident discharged home. A recapitulation of the resident's stay would include diagnoses, treatments, therapies provided as well as a final summary of the resident's status.

Based on record review and staff interview, the facility failed to assure restorative was completed as planned for 1 resident reviewed (Resident #22). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #22 had long and short term memory problems and severely impaired skills for daily decision making. The resident depended on staff for activities of daily living. Diagnoses included Alzheimer's disease, and a seizure disorder. The Care Plan revised 3/15/24 identified the resident had limited physical mobility related to Alzheimer's, anxiety disorder, weakness, immobility, and dependence on staff. The interventions included nursing rehab/restorative: Passive range of motion (ROM) bilateral lower extremities (BLE): ankle flexion (flex)/extension, knee flex/extension, hip flex/extension and hip adduction/abduction x 10 repetitions (reps) 1 time/day 5-7 days/week as the resident tolerated. Nursing rehab/restorative: Passive ROM bilateral upper extremities (BUE): Finger (both hands) flex/extension, wrist (both) flex/extension, elbow (both) flex/extension, shoulder flex/extension & shoulder adduction/abduction x 10 reps 1 time/day 5-7 days/week as the resident tolerated. The POC Response History for Passive ROM bilateral upper extremities (BUE): Finger (both hands) flex/extension, wrist (both) flex/extension, elbow (both) flex/extension, shoulder flex/extension & shoulder adduction/abduction x 10 reps 1 time/day 5-7 days/week as the resident tolerated. The resident did not have upper extremity restorative 5-7 days per week the following weeks: a. 12/10-16/23, 0 times, b. 12/17-23/23, 4 times, c. 12/24-30/23, 4 times, d. 1/7-13/24, 4 times, e. 1/14-20/24, 4 times, f. 1/21-27/24, 3 times, g. 1/28-2/3/24, 3 times, h. 2/4-10/24, 2 times, i. 2/11-17/24, 1 time, j. 2/18-24/24, 3 times, k. 2/25-3/2/24, 4 times, l. 3/3-9/24, 4 times, m. 3/10-16/24, 3 times, n. 3/17-23/24, 4 times, o. 3/24-30/24, 3 times. Days not marked as done were checked not applicable. The POC Response History for Passive range of motion (ROM) bilateral lower extremities (BLE): ankle flexion (flex)/extension, knee flex/extension, hip flex/extension and hip adduction/abduction x 10 repetitions (reps) 1 time/day 5-7 days/week as the resident tolerated. The resident did not have lower extremity restorative 5-7 days per week the following weeks: a. 12/10-16/23, 1 times, b. 12/17-23/23, 4 times, c. 12/24-30/23, 4 times, d. 1/7-13/24, 4 times, e. 1/14-20/24, 4 times, f. 1/21-27/24, 2 times, g. 1/28-2/3/24, 1 times, h. 2/4-10/24, 2 times, i. 2/11-17/24, 5 times, j. 2/18-24/24, 2 times, k. 2/25-3/2/24, 2 times, l. 3/3-9/24, 1 time, m. 3/10-16/24, 3 times, n. 3/17-23/24, 0 times, o. 3/24-30/24, 0 times. Days not marked as done were checked not applicable. On 4/3/24 at 10:40 a.m. the Director of Nursing (DON) stated not applicable could mean refused. But there was no documentation why the resident didn't receive the exercises as often as indicated. She said they would not have had the staff to do them on the weekends. On 4/3/24 at 12:38 p.m. the MDS Coordinator stated she oversaw the restorative program, but she had not done any recent follow ups.

Based on observation, record review and staff interview, the facility failed to provide a resident with a urinary catheter, care and services to prevent infection for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #8 scored 6 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required substantial/maximal assistance with lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, and toileting hygiene. The resident had an indwelling urinary catheter. The resident's diagnoses included Parkinson's disease and neurogenic bladder. The Care Plan initiated 4/4/24 documented the resident had an indwelling catheter related to neurogenic bladder and urinary retention. The interventions included observing/recording/reporting the signs and symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Staff to provide catheter cares. The resident was on antibiotic therapy related to a UTI. The Medication Administration Record (MAR) for April 2024 included the order for Cefdinir (antibiotic) 300 mg 2 times a day until 4/3/24. On 4/2/24 at 11 a.m. the resident sat in the recliner. The catheter bag hung from the garbage can, over the liner, with trash in the bag. On 4/2/24 at 11:45 a.m. Staff B Certified Nursing Assistant (CNA) and Staff C CNA provided pericare for the resident. Staff washed hands and gloved, sprayed washcloths folded to 1/4 with no rinse cleanser, and pulled the resident's pad back. Staff B wiped down the resident's right groin, turned the cloth, wiped down left groin, turned the cloth, wiped down the front of the genital area and tubing in 1 stroke. The 2 turned the resident to his left and Staff B wiped over the anal area and buttocks, turning the cloth with each wipe. Staff B and Staff C placed an incontinent pad before removing their gloves, then pulled up the residents pants, assisted the resident to sit, then stand and sit in his chair. Staff made the resident comfortable before washing their hands. On 4/2/24 at 2:03 p.m. the resident sat in the recliner, and the catheter bag laid on the floor. On 4/3/24 at 10:43 a.m. the resident sat in the recliner, and the catheter bag hung from the trash can. On 4/3/24 at 10:45 a.m. the Director of Nursing (DON) stated she would expect the catheter bag would not be hung on the trash can. The facility Competency Assessment Catheter Care, Urinary included: For male residents use a washcloth with warm water and soap to cleanse around the genital area, changing the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the same technique. Using a clean washcloth with warm water and soap, cleanse and rinse the catheter from the insertion site to approximately 4 inches outward.

Based on record review and staff interview the facility failed to assure residents and/or their representatives were educated on the options for the pneumonia vaccination and given the opportunity to accept or decline for 1 of 5 residents reviewed (Resident #18). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #18 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included chronic obstructive pulmonary (lung) disease (COPD). The clinical record lacked documentation the resident had received a pneumococcal vaccine. The record lacked documentation the facility educated the resident/representative on the pneumonia vaccine. The record lacked a signed consent or refusal. On 4/4/24 at 11:08 a.m. the Director of Nursing (DON) stated she had not offered the resident the pneumonia vaccine. The undated facility Pneumococcal Vaccine Policy documented all residents would be offered the pneumonia vaccine on admission. The risks and benefits would be provided to all residents/representatives.

Based on record review and staff interview, the facility failed to assure residents had access to the most recent COVID-19 Vaccine for 1 of 5 residents reviewed (Resident #6). The facility reported a census of 29 residents. Findings include: The United States (US) Department of Health and Human Services documented the COVID-19 milestones included: On September 11, 2023 the Food and Drug Administration (FDA) approved and authorized the emergency use of the updated Moderna and -BioNTech COVID-19 vaccines formulated to better protect against currently circulating variants. On October 3, 2023 the FDA authorized the updated Novavax COVID-19 Vaccine, Adjuvanted (ingredient used in some vaccines that helped create a stronger immune response) (2023-2024 Formula) for individuals ages 12 and older. On 2/28/24 the Center for Disease Control (CDC) Director endorsed the CDC Advisory Committee on Immunization Practices' (ACIP) recommendation for adults ages [AGE] years and older to receive an additional updated 2023-2024 COVID-19 vaccine dose. The recommendation acknowledged the increased risk of severe disease from COVID-19 in older adults, along with the currently available data on vaccine effectiveness. Previous CDC recommendations ensured that people who were immunocompromised were already eligible for additional doses of the COVID-19 vaccine. Data continued to show the importance of vaccination to protect those most at risk for severe outcomes of COVID-19. An additional dose of the updated COVID-19 vaccine may restore protection that has waned since a fall vaccine dose, providing increased protection to adults ages [AGE] years and older. The clinical records for Resident #6 lacked documentation they, or their responsible party had been educated on the 2023-2024 COVID-19 vaccination, been offered, or received a dose of the vaccine. On 4/4/24 at 11:08 a.m. the Director of Nursing (DON) stated some of her residents received the Covid 23-24 vaccine at the clinic, and she did give some at the facility, but she had to get 10 at a time so she had to have enough residents who wanted it. Now she could get less at a time. She had not asked Resident #6 about it yet. The CDC's Stay Up to Date with COVID-19 Vaccines, updated March 7, 2024, documented: The CDC recommended the 2023-2024 updated COVID-19 vaccines to protect against serious illness from COVID-19. Everyone aged 5 years and older should get 1 dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. People who were moderately or severely immunocompromised may get additional doses of the updated COVID-19 vaccine. People aged [AGE] years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose. People who were up to date had a lower risk of severe illness, hospitalization and death from COVID-19 than people who were unvaccinated, or who had not completed the doses recommended for them by CDC.

Based on observations and staff interviews the facility failed to ensure food was labeled with dates after opening, labeled with product after removing from original package and discarded after product expiration date. The facility identified a census of 26 residents. Findings include: 1. An initial kitchen tour conducted on [DATE] at 12:43 p.m., of the freezer in kitchen revealed the following open items with no label and no open date ready for service: a. bag of frozen onion rings b. bag of curly fries c. chicken breast d. chicken patty e. fish filets f. frozen round meat g. sausage meat h. sausage patty i. strawberries 2. The following items were stored in the kitchens refrigerator open with no label or open date and ready for service: a. shredded cheddar cheese b. mozzarella cheese 3. The following items were stored in the refrigerator ready for service: a. caramel topping with and open date of ,d+[DATE] with and expiration date of [DATE] b. open caramel topping with no opening date c. jelled cranberry with an open date of [DATE] with and expiration date of [DATE] d. unopened summer pasta salad with received date of [DATE] with an expiration date of [DATE] e. potato salad with a received date of [DATE] with no open date f. 3 individual servings of blueberry yogurt with an expiration date of [DATE] g. 1 individual serving of blueberry yogurt with and expiration date of [DATE] h. open cottage cheese with no open date 4. The following items were stored in the kitchen dry storage ready for service: a. open box of graham crackers with and expiration date of [DATE] b. unopened bag of croutons with an expiration of [DATE] c. 2 bags of muffin mix with no label and no open date d. 2 open bags of white chocolate chips with a best by date of ,d+[DATE] e. 1 unopened bag of white chocolate chips with a best by date of ,d+[DATE] f. unopened bag of Reese's peanut butter chips with a best by date of ,d+[DATE] g. 2 unopened jars of hot fudge with best by date of [DATE] h. 3 boxes of au gratin potatoes with a best by date of [DATE] i. sesame oil with an open date of [DATE] and best by date of [DATE] j. unopened [NAME] sauce with a best by date of [DATE] k. open [NAME] cooking wine with a best by date of [DATE] l. open [NAME] cooking wine with a best by date of [DATE] m. open apple cider vinegar with a best by date of [DATE] n. unopened cooking wine with a best by date of [DATE] o. unopened box of white cheddar cheez-its with a best by date of [DATE] 5. The following items were stored in the kitchens freezer in the dry storage area open with no label or open date and ready for service: a. 2 bags of omelets b. bag of garlic bread Review of the facility provided policy titled Dietary: Food Receiving and Storage with a revision date of 2014 revealed the following information: a. Foods shall be received and stored in a manner that complies with safe food handling practices. b. All refrigerated, frozen, and regular food items will be checked periodically for expiration dates. When refilling food items in their respective storage areas, staff should throw out expired food and or cooking products per the manufacturer suggested expiration date. c. Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system. d. All opened foods stored in the refrigerator or freezer will be covered, labeled and dated. Interview on [DATE] at 1:25 p.m., with the Dietary Manager revealed there should not be any expired food in the kitchen and everything should be marked. Interview on [DATE] at 3:25 p.m., with the Administrator revealed there should not be expired food in the kitchen and everything should be labeled.

Based on clinical record review and staff interview, the facility failed to document an accurate code status for 1 of 16 residents reviewed for advanced directives (Resident #6). The facility reported a census of 26 residents. Findings include: The significant change Minimum Data Set (MDS) assessment tool dated [DATE], documented Resident #6 had diagnoses of hypertension, diabetes mellitus, thyroid disorder, seizure disorder, anxiety disorder, depression, psychotic disorder, and tracheostomy status. The MDS documented [DATE] as the resident's admitted . The Care Plan updated on [DATE] had a focus area for the resident to be a full code. The facility CPR (cardiopulmonary resuscitation) and DNR (do not resuscitate) form signed by the resident's son, who was the decision maker, on [DATE] and by the physician on [DATE] revealed a DNR status requested in the event his heart stopped beating. The Electronic Health Record (EHR) was blank under the code status listed in the resident profile area. In an interview on [DATE] at 10:20 AM, Staff A, Licensed Practical Nurse (LPN) reported she looked at the profile area in the EHR for a residents code status but stated there was also a paper copy of their advanced directive and code status in the front of each residents paper chart at the nurses station. In an interview on [DATE] at 12:15 PM, the Director of Nursing (DON) stated it was the expectation that all residents have a code status identified and available for staff review. The code statuses were to be reviewed and updated in the system with any changes in the appropriate places. The MDS coordinator was responsible to review and update the code status with any changes. The MDS coordinator left in [DATE] and the DON stated she was trying to keep up with this task but had missed this one. She further stated any code status changes go through the staff communication book to make staff ware of the change. In an interview on [DATE] at 2:15 PM, the DON stated the facility did not have a policy on advanced directives but it was the facility practice that if a resident does not have a signed DNR, they are to be considered a full code and treated as such.

Based on observation, record review and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 13 residents reviewed, (Resident #25) which resulted in an immediate jeopardy to residents health and safety. The facility reported a census of 27 residents. Findings include: According to the Minimum Data Set assessment, dated 6/13/19 Resident #25 scored 4 on the Brief Interview for Mental Status indicating severe cognitive impairment. The resident's [DIAGNOSES REDACTED]. The current Care Plan with a problem onset date of 6/5/19 identified the resident with an open lesion of the left ear, with a goal for the area to remain free of infection. The interventions included the resident needed wound care as ordered by the physician, administer pain medication prior to initiating treatment, daily observation of skin with routine care, monitor for changes in skin status that may indicate worsening of the open lesion and notify the physician. The care plan identified the resident experienced pain in the left ear due to ulcerated area during treatment changes. The interventions included to evaluate pain using the 1-10 scale or the PAINAD (pain scale) score, administer pain medication as ordered, 1 hour prior to the treatment, and monitor for worsening of symptoms and report to the physician. The Nurse's Notes dated 6/5/19 at 4:50 p.m. documented the resident admitted to the facility. The resident had open ulcers to the left ear related to [MEDICAL CONDITIONS]. The Nurse's Notes dated 6/6/19 at 12:40 p.m. documented a routine dressing change started and noted a large amount of pus and eschar (dead) tissue sloughed off. Consulted with the wound nurse at the hospital and a telephone order received. A Physician's Telephone Order dated 6/6/19 directed to clean the resident's left ear with normal saline, pack with [MEDICATION NAME] AG (sterile dressing with silver), cover with a 4 by 4 dressing every day and as needed. A Physician's Telephone Order dated 6/12/19 directed left ear dressing change 2 times a day. An untitled facility wound form dated 6/24/19 documented the resident had a wound of the left ear and behind the ear. The documentation included the wound not measurable due extreme pain. The wound had large amount green/black drainage with a yellow base. The wound treated with silver cel packed into the wound and covered with a dressing. A Physician's Telephone Order dated 6/24/19 directed to discontinue left ear 2 times a day dressing changes and change every day and as needed due to increased pain. A Patient Transfer Form dated 6/29/19 documented the resident had been very restless and complained of severe head pain. The resident had [MEDICAL CONDITION] and a necrotic wound of the left ear related to [MEDICAL CONDITION]. The resident noted to have apnea every time he fell asleep then bolted up gasping for air and clearing his throat, with a pulse oxygen reading of 70-75% while attempting to rest. Needed assessment for pain management and apnea. The Emergency Department (ED) Notes dated 6/29/19 at 2:02 p.m. documented the resident brought by ambulance for evaluation and treatment of [REDACTED]. The resident had a wound behind the left ear, a combination [MEDICAL CONDITION] and [MEDICAL CONDITION]. An Ear Nose and Throat (ENT) physician consulted and felt conservative management with dressings would be best. A hospital Plan of Care dated 6/30/19 at 5:34 a.m. documented the left ear wound remained covered with dressing, and reinforced the dressing as needed. The Discharge Summary dated 7/1/19 at 9:10 a.m. documented the [DIAGNOSES REDACTED]. The physical exam documented the skin warm to touch, the left ear dressed and had been clean per nursing. The discharge instructions did not include treatment orders. The Nurse's Notes dated 7/1/19 at 11:28 a.m. documented a call out to the wound center related to the resident's right ear dressing not on when returned from the hospital. A Resident Assessment Post-Hospital Stay dated 7/1/19 documented the left ear the same as pre-hospital, no change. The Nurse's Notes dated 7/2/19 at 4 a.m. documented the resident had been restless. The resident did not complain of pain but placed his hand by his ear frequently. physician's orders [REDACTED]. A Treatment Administration Record (TAR) for 7/1-31/19 showed the resident orders included to cleanse the left ear with normal saline, pack with [MEDICATION NAME] AG and cover with 4x4 and tape daily. The TAR showed the treatment for 7/1, 7/2, 7/3, 7/4, and 7/5/19 with initials circled. A PRN Record for 7/2, 7/3, 7/4/19 documented the treatment to the ear held awaiting wound clarification. On 7/5 the TAR documented cleaning the ear. A Patient Transfer Form dated 7/5/19 documented the resident was in the hospital the previous week and since return they had waited for a wound consult, which they scheduled for Monday, 7/8/19. Staff had been cleaning to the best of their ability within the residents pain tolerance. When they cleaned the wound white bugs noted. The clinical record lacked any additional documentation of cleaning the ear from 7/1-5/19. A hospital surgery report with date of service 7/5/19 at 5:07 p.m. documented the resident presented with ulcer on the left ear for debridement and removal of maggots. The surgery performed included irrigation and debridement of the left side of the nose and left ear ulcer and removal of foreign bodies (maggots). The resident received intravenous sedation and a regional air block (local anesthetics to block sensations of pain), debridement and removal of foreign body. The Nurse's Notes dated 7/5/19 at 6:30 p.m. documented the resident returned to the facility from the hospital with new orders for treatment to the left ear. Staff called for a nurse to the resident's room at 9:30 p.m. The resident pulled the dressing from the hospital off with maggots noted in the ear and on the resident's shirt. The resident stated he pulled the bandage off because his ear itched. The resident went to the hospital by ambulance. A Patient Transfer Form Dated 7/5/19 documented the resident had an ear ulceration related to [MEDICAL CONDITION]/cancer and developed maggots when left open to air and draining. The resident seen by the surgeon that day and the left ear debrided. The resident returned to the facility and ate supper. At 9:30 p.m. the resident pulled the dressing off of the ear and maggots were noted coming out of his ear and on the dressing. A hospital surgery report with date of service 7/6/19 at 9:36 a.m. documented the resident with an ulcer of the left ear had maggots within the ulcer and had debridement the previous day and additional maggots were found and the resident was again brought to the operating room for evacuation of additional maggots. The resident had general anesthesia. Preoperative antibiotics were given. They performed manual removal of the maggots. Anterior to the ear, maggots were extruded from the tissues. The area cleansed with soap and water and irrigated with Dakin's solution to kill any additional eggs or maggots. Suction used to remove additional maggots that had crawled into the ear canal and thoroughly irrigated. A Wound Assessment per Wound Nurse dated 7/9/19 documented the resident had a 5.5 by 3 cm wound in the back of the ear and the canal had a 5 by 3 cm wound. A Physician Transfer Order Report printed 7/11/19 documented the resident returned from the hospital with orders for antibiotics and dressing changes. During an observation on 8/12/19 at 10:35 a.m. the resident laid in bed asleep with a bandage over his left ear. At 1:10 p.m. the resident sat in the recliner with his feet up. The dressing remained to the left ear. At 3:30 p.m. the resident laid in bed toward the right, with the dressing intact. During observation on 08/13/19 at 8:06 a.m. the resident laid in bed with a dressing covering the entire left ear area. At 11:38 a.m. the ear area remained covered. At 2:15 p.m. the ear area covered. During observation on 8/14/19 at 8:08 a.m. the resident's ear area remained covered. During an interview on 8/14/19 at 10:23 a.m. the Director of Nursing (DON) stated when the resident returned from the hospital 7/1/19 he did not have a dressing on the left ear. They called to the wound center. She said the ear was draining and that would indicate a need to clean the site. She stated it should have been cleaned and probably dressed. She thought they had an order to leave open after the hospital return 7/1 but had not found it. At 2:04 p.m. the DON stated during the time the ear was left open to air the resident did go outside. During an interview on 8/15/19 at 8:05 a.m. the DON stated she found no order for the ear to be left open to air, only the documentation by the nurse that he returned from the hospital without a dressing. During an interview on 8/15/19 at 8:17 a.m. the Administrator stated they found nothing on the hospital information with an order to leave the ear open to air. He said he was sure there were some flies (at that time) it was seasonal, but nothing out of the ordinary. During an interview on 8/15/19 at 8:29 a.m. Staff B Licensed Practical Nurse (LPN) stated when the resident returned from the hospital on [DATE] he did not have a dressing. She said she called the hospital and they left the dressing off so it could dry up, not documented. The wound nurse had not seen the resident while in the hospital or made recommendations to leave the wound open. She called the wound center for clarification and they held the dressing. The resident was going to be seen by the wound nurse, but she did not know when. She said they normally call again the next business day if they do not hear back. She said she did have concerns about the ear draining. She stated if the wound drained she cleaned it otherwise she left it alone. She said she was sure there were some flies that time of year, but she did not see any around the resident's ear. She worked 7/5/19 and the resident had drainage and yellow exudate visible on the ear and she went to clean it and saw the maggots kind of swimming around in it. During an interview on 8/15/19 at 8:55 a.m. Staff C, LPN stated the resident had no dressing to the ear area when he came back from the hospital, so they held the dressing until he could be seen by the wound nurse, she thought (MONTH) 15th. She stated she worked 7/3/19 and the ear was soupy and she felt a dignity issue so she put an ABD dressing over it. She did nothing else other than cover it. She does not know how long the dressing remained on and did not document any of this. She felt the ear should be covered. She did not note flies in the facility, but the family did take the resident outside. During an interview on 8/15/19 at 9:20 a.m. Staff D, Certified Nursing Assistant (CNA) stated she remembered seeing the resident without the dressing on around that time but did not see it drain. She stated they had some flies in the facility but nothing out of the ordinary. During an interview on 8/15/19 at 9:25 a.m. Staff A, CNA stated she assisted the resident out of the van the day he returned from the hospital without a dressing. She said she told the nurses he needed a dressing to his ear. She said the ear had a bad odor so she didn't get close enough to see if it was draining. She said it didn't smell that way when it had a dressing on it. She was with Staff B when she saw the maggots. She said she thought Staff B was trying to get rid of the smell, it was pretty powerful. She said the family took him outside the day before. She did not see flies around him. During an interview on 8/15/19 at 9:32 a.m. Staff F, CNA stated the area looked terrible and it stunk. She did not see anything coming out of it but it looked liked it had puss, and white milky looking. She said she saw 1-2 flies in his room and he complained about flies in his room. During an interview on 8/15/19 at 10:30 a.m. the Wound Nurse stated she saw the resident in (MONTH) while the resident was at home and recommended a treatment with a dressing. She was supposed to follow up with the resident but they kept canceling appointments. She did not see the resident again until 7/10/19 (during the hospitalization after the maggot infestation) when the doctor asked her to teach the facility staff how to do a dressing change. She did not see the resident during the 6/29-7/1/19 hospital stay. She said there would have to be extenuating circumstances not to treat and cover a draining wound. She said a wound with a dressing could get maggots, but the fact the resident did not have them when he had a dressing on, and developed them when the area was not treated or dressed certainly showed it increased the risk for them. During an interview on 8/15/19 at 11:40 a.m. the DON stated when the resident admitted to the facility he had a cotton ball in his ear and a bandage behind his ear. She called the wound nurse about a treatment, because it drained and she knew he needed a treatment and dressing. She said the family had no complaints about the treatment, telling them whatever needed to be done. She stated it did have a strong odor without the dressing. She said she thought they got an order from the hospital to leave the area open to air, but apparently did not. She concurred the hospital nurse telephone report did not constitute an order. She called to get an order for [REDACTED]. During an interview on 8/19/19 at 9:59 a.m. the resident's Physician stated he checked the ear wounds when the resident was in the hospital (6/29-7/1/19) and they were covered. He said the wounds should have continued to be treated and covered. The wound nurse had recommended the treatments he had prior to the 6/29/19 hospitalization and it was his understanding they would continue those. He said when you have a wound like that you treat it. He was not aware they had not been doing the treatments from the time he returned from the hospital until the resident came in with the maggots. He said the resident had eaten so they did a local anesthetic for the removal. When he came back again they used a general anesthetic so they could do a more thorough cleaning. He said it was possible to get a maggot infestation in a dressed wound, but it would have been much less likely. He had not seen a maggot infestation in a wound being treated and dressed. He said the resident was treated with antibiotics preemptively for the maggots. The facility abated the immediate jeopardy on 8/20/19 by implementing additional policies on the handling of new orders, enhanced their new order checklist, and staff education.

Based on clinical record review and interview, the facility failed to direct nursing services to ensure Resident #7 received adequate supervision against hazards and failed to implement care plan directives to meet the resident's safety needs. Concerns were identified for 1 of 10 residents. The facility reported a census of 27. Findings include: Record review of the Minimum Data Set (MDS), dated [DATE] for Resident # 7 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status score of 12 which signified the resident had moderate cognitive skills for decision making. The resident required 1 assist for ambulation in the room. The MDS documented the resident had 2 falls with no injury since the last MDS created. Record review of the Care Plan with a review date of 10/15/12 revealed the resident had history of falling. Staff were to assist the resident with one staff member for transfers and ambulation during the night hours. Staff were also to ensure a sensor alarm in place at bedtime and night. Record review of the Fall Risk assessment dated [DATE] revealed a score of 12. A total score of 10 or above represented the resident at high risk for falls. The review of the Care Plan dated 7/12/12 directed staff to use a sensor alarm at night/bedtime. A fall documentation sheet dated 8/5/12 identified Resident #7 had gotten out bed on the other side of the bed and was found sitting on the floor (no injury) calling for help. The form identified the sensor alarm was on but did not sound since the resident exited the other side of the bed. Review of the Nurse's Notes, dated 12/24/12 identified at 12:05 AM staff heard the resident calling out for help. The staff found the resident lying on the floor by the bathroom door. At 6:25 AM the resident sent to the emergency room . The resident complained of right thigh pain radiating into the groin. Review of the Fall Documentation Sheet, dated 12/24/12 at 12:05 AM revealed the resident heard calling out for help. The resident found lying on the floor by the bathroom door. Range of Motion within normal limits and no apparent injury. The report documented the alarm not on and the care plan was not followed. Record review of the Radiology Report, dated 12/24/12 of the pelvis revealed an acute fracture of the right superior pubic rami. A commuted fracture with additional fracture of both the proximal and distal. Staff interview with Staff A Registered Nurse (RN) on 1/2/13 at 2:10 PM revealed she found the resident in the room. The resident had transferred himself/herself from the bed to the bathroom and fell at the bathroom door. She said the resident had a sensor alarm in place but the alarm was not turned on or sounding. Staff interview with the Director of Nursing on 1/2/13 at 10:45 AM revealed the resident's sensor alarm did not sound at the time of the fall. She further stated the alarm may have been positioned away from the resident which would have prevented the resident from setting the alarm to sound. Review of the facility policy to check alarms for sound and proper placement documented : 3. Sensor alarm: make sure the alarm is turned on and then move your hand in front of the sensor to set the alarm off. Reset and place in proper position.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision to ensure against hazards to self or elements in the environment and supervise and implement care plan approaches to prevent injury for 1 of 6 residents reviewed (Resident #6). The facility reported a census of 25 residents. Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment, with a reference date of [DATE], which reflected Resident 36, had short term memory problems and moderately impaired skills for daily decision making. Resident #6 exhibited fluctuating periods of inattention, and altered level of consciousness. Resident #6 demonstrated behavioral symptoms which put the resident at significant risk of physical illness or injury. The MDS indicated Resident #6 required full staff performance of 2 plus persons for transfers and toilet use. The resident had [DIAGNOSES REDACTED]. The Significant Change Related to Hospice document, dated [DATE] indicated Resident #6 required extensive to extensive assistance with all activities of daily living except eating. The document reflected staff transferred the resident with an easy stand lift. The transfer required 2 staff persons to transfer the resident with the lift. The document indicated Resident #6 experienced incontinence and required the transfer per the easy stand lift with the assistance of 2 staff persons. Resident #6 triggered for falls due to impaired balance. Resident #6 transferred by easy stand with the assistance of 2 staff persons. The Care Plan, dated [DATE], identified Resident #6 with a problem related to self care deficit. The approaches directed staff to : Transfers with 2 staff person assistance and the easy stand lift. The Care Plan identified the resident had a problem with urinary incontinence related to a loss of muscle tone. The approaches directed staff to: b. Toilet the resident before and after meals, activities, and bedtime per the easy stand and transfer with the assistance of 2 staff persons, The Care Plan identified a problem with the resident a fall potential. The approach directed staff to: c. Transfer with the easy stand and the assistance of 2 staff persons. A Fall Documentation Report, dated [DATE] at 2:20 p.m., documented Resident #6 fell in his/her bathroom. Staff used the EZ Stand to transfer Resident #6 to the bathroom. The report documented Resident #6's legs gave way. The report indicated staff followed the care plan. A corrected report revealed the staff did not follow the care plan. An Outpatient Report, dated [DATE], documented Resident #6 was presented to the emergency room via an ambulance. Resident #6 injured his/her right shoulder. Resident #6's right shoulder appeared swollen and deformed. An x-ray of the shoulder revealed a right proximal humerus neck fracture. The plan indicated to keep the arm in a sling and use only the Hoyer lift. The Doctor Notification of Skin Tear and Bruise Assessment identified the following areas related to Resident #6's fall on [DATE]: a. The resident had a 4.3 by 8 centimeter (cm) bruise to the right cheek. b. 7.1 by 4.9 cm bruise to the right eye area. c. 9.2 by 6 cm abrasion to the right leg below the knee. d. 1 by 0.5 cm bruise to the left upper buttock. e. 0.5 by 0.5 cm bruise to crease of the buttocks. f. 15 by 10 cm bruised swollen area to the right shoulder. g. 1.5 by 2 cm bump to the forehead. h. 1 by 0.5 cm bruise to the right side of the forehead. i. 15 by 17 cm bruise to the right antecubital and forearm. j. 2.8 by 4.5 cm bruise to the right wrist. k. 1.3 by 2.2 cm bruise to the right hand. l. 1.5 by 0.7 cm bruise to the second knuckle of the left hand. m. 8.5 by 10.5 cm bruise to the left forearm. n. 3.7 by 5.3 cm bruise to the left forearm. o. 8 by 5.4 cm bruise to the left elbow. p. 2.8 by 2.9 cm bruise of the dorsal left foot. q. 0.5 by 0.5 cm bruise to the left medial great toe. r. 1 by 2 cm bruise to the left medial heel s. 2 by 2.5 cm bruise to the 5th knuckle of the left hand. t. 2.8 by 3.1 cm bruise to the 3rd/4th knuckle of the left hand. A Hospice note, dated [DATE], indicated Resident #6 apparently fell when lifted with the easy stand in the bathroom yesterday. The incident happened around 2:30 p.m. The staff reported during the transfer the resident ' s legs became weak, and then he/she hung by the arms on the stand with both elbows straight up in the air with the left leg bent and completely off the foot rest. The facility investigation documented Resident #6 transferred in the EZ Stand by staff. Resident #6's legs gave way. Staff lowered Resident #6 to the floor with the assistance of 2 staff persons. The Hospice Nurse, Director of Nursing (DON) and Administrator investigated how the incident occurred on [DATE]. The Hospice Nurse determined that an event could have occurred to cause Resident #6 to remove his/her feet from the EZ Stand and thereby causing an unbalance which in turn caused him/her to hit head against the metal part on the arm of the stand causing the black eye and jaw. Resident #6 was found with his/her arms hanging in the lift. Resident #6 found to have sustained a fracture of the right shoulder at the emergency room . Resident #6 returned to the facility with a sling to the right arm. The DON observed Resident #6 eating breakfast with his/her left hand on [DATE]. Because of no surgical intervention and no complication noted at the time, the Nurse Practitioner determined no major injury had occurred. Resident #6 expired on [DATE]. The Nurse's Notes indicated the following: a. On [DATE] at 2:40 p.m. during transfer to the bathroom with a Certified Nursing Assistant (CNA) and the EZ Stand, Resident #6 ' s legs gave way and staff lowered him/her to the floor. Staff used a sling lift to place the resident in bed. Staff noted an abrasion to Resident #6's right knee, the right eye beginning to bruise, and the neurological assessment within normal limits. At 4:15 p.m. Resident #6 complained of right shoulder pain, and noted a large swelling over the clavicle. Staff notified the physician and transferred Resident #6 to the hospital. At 8:30 p.m. the resident returned to the facility with new physician orders. b. On [DATE] at 4:10 a.m. Resident #6 rested well. The resident voiced no complaints of pain. At 9:20 a.m. staff assisted Resident #6 to the wheelchair with the Hoyer lift and the assistance of 3 staff persons. Resident #6 received pain medication 40 minutes prior to the transfer. Resident #6 moaned, but tolerated the movement. At 6:30 p.m. staff assisted Resident #6 to the wheelchair with the Hoyer lift and the assistance of 3 staff persons. The staff administered pain medication to control the pain. . c. On [DATE] at 4:45 a.m. Resident #6 rested well except when changed related to incontinence. The resident moaned and struck out at staff, did not tolerate activity well. At 7:15 a.m. Resident #6 moaned with personal cares and dressing, and also moaned loudly when staff had not touched the resident. Resident #6 transferred per the sling lift with 2 staff person assistance. Staff provided scheduled pain medication for pain management. At 12:45 p.m. staff sent a facsimile (fax) to the emergency room and questioned the use of a catheter for Resident #6's urinary incontinence, due to severe pain with right shoulder fracture. Resident #6 experienced increased pain with personal/perineal care due to turning of the resident. At 8:00 p.m. staff inserted a urinary catheter. d. On [DATE] at 3:30 a.m. Resident #6 rested well. Staff noted an occasional, harsh, non productive cough. Resident #6 moaned upon any movement. At 9:30 a.m. Resident #6 had increased chest congestion and gurgling, and staff placed a call to hospice. At 11:20 a.m. hospice visited with new orders for Atropine and Roxanol. The Certificate of Death dated [DATE] identified the immediate cause of Resident #6's death as frailties of advanced age. During an interview on [DATE] at 3:26 p.m. Staff F, Certified Nursing Assistant (CNA) stated she worked the day of Resident #6's incident with the lift. Staff F was taking Resident #6 to the bathroom with the stand lift. Staff F got Resident #6 to the bathroom and the resident started going down. Staff F tried to hold Resident #6 up as long as she/he could. Staff F stated this to be the first time she/he worked with Resident #6. Staff F stated Staff B (Registered Nurse) had told her Resident #6 could be transferred with 1 person. Staff F stated she/he told Staff B she/he was nervous about transferring Resident #6 and his/her roommate by herself and Staff B assured her she could do it. Staff F stated had received the nurse aide certification about a month prior. A statement dated [DATE] documented at approximately 2:30 p.m. Staff E CNA, walked down the hall to see who still needed to get up. Resident #6's door was closed so she knocked and walked in. She opened the bathroom door and Resident #6 hung by the lift straps almost on the floor with another CNA in the room with him/her. Staff E used the walkie device and notified Staff D CNA and Staff C RN, ASAP. Staff D arrived first. Staff C came in and they finished lowering Resident #6 to the floor. Vital signs were taken and oxygen put on the resident to bring the oxygen up to 91%. The staff placed a sling under Resident #6 and got him/her up off the floor with the sling lift and assistance of Staff D, Staff C, Staff H CNA, and Staff F. The staff transferred the resident to bed, undressed him/her and put a gown on. Staff C did an assessment of Resident #6. During an interview on [DATE] at 6:45 p.m. Staff E stated the day of the incident she/he checked rooms to see if anyone needed assistance; She walked in to find Resident #6 hanging in the lift and Staff F standing there. A statement dated [DATE] at 2:30 p.m. documented Staff D heard on the walkie talkie they needed her and Staff C in Resident #6's bathroom ASAP. Staff D ran down and when she entered the bathroom Resident #6 was hanging by his/her arms on the stand lift with both elbows straight up in the air and his/her left leg bent and completely off the bottom of the lift. Staff C, Staff E, Staff F and Staff D tried a couple of times to get Resident #6 back up on the toilet but he/she expressed discomfort and his/her face was red and his/her right eye had a big blood blister under it. After trying to get him back on the toilet they decided to lower him/her to the floor. When he/she lowered to the floor, Staff D sat behind him/her to support his/her back. Staff C took vital signs and put his/her oxygen on and let him/her catch his/her breath. They put a sling sheet under him/her and lifted him/her up and to the bed. During an interview on [DATE] at 11:08 a.m. Staff D stated she did not know Resident #6 was a 2 person assistance with the lift. Staff D stated it may have helped to have a second person there at the time of the incident. Staff D stated staff used the lift so you could weigh the residents on (at the time of the incident). During an interview on [DATE] at 9:20 a.m. Staff C stated she worked the evening of Resident's incident with the lift. Shortly after report she heard Staff E call for help ASAP. She saw Resident #6 on the lift in the bathroom, suspended. The staff tried to get Resident #1's legs back on the platform. It didn't take long to decide they just had to lower him/her to the floor. Staff D sat behind Resident #6 when they lowered the resident down. Staff C checked Resident #6's vital signs and his/her oxygen registered a little low so she/he put the oxygen on the resident. Staff C stated Resident #6 did moan but that was not unusual for the resident. Staff C performed an assessment of the resident and the range of motion was normal for the resident. The resident did squeeze Staff C's hand with the affected side. Staff C checked him/her routinely and later noted an abnormality of the right shoulder. Staff C made the appropriate notifications and transferred the resident to the hospital. Staff C stated to her knowledge, prior to the fracture, Resident #6 transferred with the assistance of 1 or 2 staff persons. Staff C stated unaware the resident had changed to a 2 staff person transfer. During an interview on [DATE] at 1:45 p.m. Staff A, Director of Nursing stated the day Resident #6 fell , the staff member did not follow the care plan. The staff member transferred Resident #6 with the sit to stand lift without another person assisting. Staff A stated Resident #6's assistance with the sit to stand lift changed to 2 persons a week before the incident. Staff A admitted the 2 p.m. to 10 p.m.staff were not aware of the change in the care plan. Staff A stated the day shift knew this Staff A stated Resident #6 changed to a 2 person staff assistance due to the bruising. Staff A stated Resident #6's feet slipped off the platform and he/she hung by arms. Staff A stated the staff did not use the leg strap on the lift at the time of the incident, and staff didn't routinely use the leg strap at that time. At 3:45 p.m. Staff A stated they had care plans behind the mirrors in the resident's bathrooms. Staff A did not know which of the sit to stand lifts was used at the time of the incident. On [DATE] at 6:33 p.m. Staff A clarified Resident #6's care plan changed to a 2 person assistance with the stand lift because he/she would bump his/her arms going through doorways. Staff A stated the staff never had any trouble using the lift with Resident #6. Staff A stated Staff F did not call for help when the incident occurred. Staff A stated she/he did not interview Staff F about the incident. Staff A stated any 1 of the 3 sit to stand lifts could be used for the residents. During an observation on [DATE] at 3:45 p.m. Staff A retrieved Resident #6's care plan from behind the mirror in the bathroom where he/she resided. The undated care plan directed staff to transfer with the stand lift and 2 staff assistance. The facility failed to update the care plan in the room after the fracture occurred on [DATE] and Resident #6 changed to a Hoyer lift only. During an interview on [DATE] at 11:00 a.m. Staff B stated she thought Resident #6 transferred with assistance of 1staff person with the stand lift unless he/she had behaviors, and then would be assisted by 2. Staff B stated did not know Resident #6 changed to 2 assist with transfers. Staff B stated usually if they changed the care plan, then they put it on the report sheet. Staff B stated it obviously fell through. Staff B stated they just recently updated the care plans in the resident's rooms because they were a little behind. An undated typed sheet at the Nurse's station titled "Transfers" listed residents and their transfer techniques. At the bottom of the sheet in larger writing it read; Effective Immediately- *Leg strap is to be used with all residents when using the stand lift! Strap may be released when resident is sitting on the toilet. During an observation on [DATE] at 5:57 p.m. noted 3 Sit to Stand lifts in the facility, 2 Med Care Stand and Weigh lifts, and 1 EZ Stand lift. All 3 of the sit to stand lifts had a leg strap attached. According to the Med Care Products Operation Manual (RevXXX,[DATE]), the Care Stand Operations on page 10 included: a. Open the legs of the stand with the leg spreader bar or foot pedal and position stand in front of the resident. b. Have the resident place their feet on the foot support plate, with their shins against the shin support pad. For added stability, fasten strap around calves. Review of the facility policy, Lifting Without Harm to Staff dated [DATE], indicated all Care Plans should be followed in relationship to mobility to ensure safe lifting/transferring for staff and residents.