Every finding on record at Hermitage Nursing & Rehab

This citation is uncorrected. For prior example, please see 1F1B06-H1, exit date 03/05/26. Please refer to event ID 1F1B06-H2, exit date 05/11/26, for details.Complaint #2984406

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse when one staff member (Certified Nurse Assistant (CNA) A) yelled at and physically forced one resident (Resident #1), with a diagnosis of dementia, back into his/her room twice while the resident was resisting and trying to exit his/her room. The resident received multiple bruises on their hands and forearms and exited their room visibly upset after the altercation and stating he/she wanted the staff member arrested. The CNA was later arrested and charged with assault. The facility census was 65. The Administrator was notified on 02/26/26, at 12:30 P.M., of an Immediate Jeopardy (IJ) which began on 02/20/26. The IJ was removed on 02/27/26, as confirmed by surveyor on-site verification. Review of the facility's policy titled, Abuse Policy, undated, showed the following:-It is the policy of the facility that each resident will be free from abuse;-Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion;-Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility;-No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection;-An owner, licensee, Administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat, or neglect a resident. Review of Resident #1's face sheet showed the following:-admission date of 04/01/24;-Diagnoses included vascular dementia (progressive decline in thinking, memory, and behavior, caused by impaired blood flow to the brain) with agitation. Review of the resident's care plan, dated 07/17/25, showed the following:-The resident will not sustain serious injuries due to memory/recall deficit;-Ensure resident's areas are free of hazards;-Redirect resident when entering unsafe areas.-Resided on the special care unit (SCU) for safety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/12/25, showed the following:-Usually understood and usually understands communication;-Severely cognitively impaired;-Exhibited inattention, behavior present, fluctuates (comes and goes, changes in severity);-Exhibited disorganized thinking, behavior present, fluctuates;-No physical, verbal, or other behavioral symptoms directed toward others;-No rejection of care;-No wandering. Review of the resident's progress note dated 02/20/26, at 12:53 P.M., showed the Director of Nursing (DON) documented resident had been up and active in the SCU per usual routine. He/she was observed ambulating around the unit throughout the shift. Resident was seen in the dining room consuming meals without difficulty. Resident noted to spend most of his/her days in his/her room watching television. He/she did come out occasionally and would talk with other residents. Resident denied pain or any current concerns. No behavioral issues noted at this time. Will continue current plan of care. Review of the resident's progress note dated 02/23/26, at 12:59 P.M., showed the DON documented a skin assessment. Resident noted to have scattered bruising on his/her bilateral upper extremities (hands/arms) in various stages of healing. When the nurse asked the resident about the cause of the bruising, the resident said he/she woke up that way. Resident denied pain or drainage associated with the bruised areas. No tenderness reported. Resident demonstrated full range of motion to fingers without difficulty. No functional impairment observed. Physician notified of bruising. During an interview on 02/25/26, at 10:56 A.M., the Administrator said the following:-On Monday, 02/23/26, at approximately 9:00 A.M. to 9:30 A.M., the resident's responsible party (RP) came to the Administrator's office and said the resident had bruises on his/her hands and arms and an unnamed staff member in the SCU told him/her CNA A abused the resident;-The Administrator interviewed CNA C who said he/she worked the day shift at the facility on the morning of 02/20/26. He/she arrived at work on 02/20/26 at approximately 5:55 A.M. and entered the SCU, walked down the hallway, and saw CNA A in the resident's room holding the resident's arms;-CNA C asked why CNA A was in the resident's room and CNA A informed CNA C he/she was putting the resident back to bed;-The Administrator said the resident was typically very pleasant and cared for him/herself. If not for the resident wandering on occasion, he/she would not need to be in the SCU;-The Administrator said the facility had video surveillance cameras (without audio) in the common areas, including the hallway of the SCU. On 02/23/26, the Administrator viewed (02/20/26) video footage from the hallway of the SCU. The video showed CNA A grab the resident by the arms and push the resident back into his/her room on two separate occasions;-The Sherriff's department arrived and arrested CNA A on the evening of 02/23/26 and he/she was charged with assault of the resident. Observation of the facility's surveillance video (with no sound), dated of 02/20/26 showed the following:-At display time 6:45 A.M., CNA A grabbed the resident's right forearm while the resident stood in the doorway of his/her room. The resident pulled his/her arm away from CNA A;-Between display time 6:45 A.M. and 6:50 A.M., the resident stood (fully dressed) in the open doorway to his/her room with his/her back to the door frame and CNA A stood facing the resident, just outside the resident's door frame. CNA A's arms were crossed over his/her chest and the staff member stood in a wide stance with feet apart. The resident appeared to be motioning/pointing toward the day area and the staff member pointed toward the resident's room. They each pointed several times;-At display time 6:50 A.M., the resident raised his/her own hands and arms up in front of CNA A. CNA A appeared to knock the resident's arms down using his/her hands. CNA A held the resident's forearms and pushed the resident back into his/her room. CNA A exited the resident's room, closed the door, and walked toward the day area. The resident opened his/her door and again and stood in the doorway, CNA A walked quickly toward the resident and grabbed the resident's forearms with his/her hands. CNA A again appeared to forcefully push the resident into his/her room while holding the resident's forearms;-At display time 6:51 A.M., CNA C (the day shift aide) entered the SCU and walked down the SCU resident hall. CNA C stopped at the doorway to the resident's room and turned and appeared to look inside the room. CNA A exited the resident room and walked toward the day area. The resident exited his/her room.(Note: The facility staff stated the time on the time stamp on the video was off.) During an interview and observation of the resident on 02/26/26, at 8:50 A.M., Licensed Practical Nurse (LPN) B reported the bruising on the resident's hands and forearms looked like somebody had grabbed him/her and he/she measured the following:-Right inner arm had a 2 centimeter (cm) by 2 cm purple colored circular bruise;-Right middle forearm had a 5 cm by 2 cm purple colored linear shaped bruise;-Right inner wrist had a 1 cm by 1 cm purple colored circular bruise;-Right inner wrist had a 4 cm by 2.5 cm light purple colored oblong bruise;-Right base of thumb had a 0.5 cm by 0.5 cm circle black colored scab;-Right hand on the base of the index finger had a 1 cm by 0.75 cm purple colored bruise;-Top of the right wrist had a 1.5 cm by 0.75 cm purple colored bruise;-Left upper wrist area had a 0.5 cm by 0.5 cm circular purple colored bruise;-Left outer hand base of thumb had a 0.75 cm by 0.75 cm purple colored circular bruise;-Left forearm had a 1.5 cm by 1 cm circular purple colored bruise;-Left forearm had a 2 cm by 1.25 circular purple colored bruise;-Left upper wrist had a 1.5 cm by 1 cm oblong purple colored bruise;-Left inner wrist had a 4 cm by 2.5 cm oblong purple colored bruise;-Left outer wrist had a 1.5 cm by 2 cm circular purple bruise;-Left top of the hand had a 0.75 cm by 0.75 cm linear bruise;-Left top of hand had a 6.5 cm by 4 cm rectangular purple colored bruise;-Left hand at the base of the index and middle finger had a 4 cm by 2 cm purple colored bruise. During an interview on 02/25/26, at 12:56 P.M., CNA C said the following:-He/she arrived to work on Friday, 02/20/26, at a little before 6:00 A.M., clocked in and entered the SCU;-Upon entering the unit he/she heard CNA A repetitively yell, You have to get back in bed;-The resident yelled back, I don't want to go back to bed;-CNA C walked down the hall, stopped at the resident's doorway and looked into the resident's room;-CNA A and the resident was standing near the resident's bed and CNA A had his/her hands on the resident's forearms;-The two were struggling, the resident was trying to get loose from CNA A's grasp, but CNA A continued to hold onto the resident's arms;-CNA C told CNA A to get out of the resident's room and leave the resident alone;-CNA A argued saying he/she was not doing anything wrong;-CNA C told CNA A he/she did not need to bother the resident because the resident was able to do his/her own care;-CNA A continued to try to force the resident back toward the bed by holding the resident's arms and pushing the resident;-CNA C then told CNA A to come out of the room and leave the SCU;-CNA A came out of the resident's room and left the unit shortly after;-The resident was mad and wanted to call the police;-CNA C said he/she had a hard time calming the resident down;-CNA C told the RP he/she needed to talk to the facility administrator about the incident, but he/she kept asking and eventually CNA C informed the RP that CNA A was holding the resident's arms trying to force the resident back into bed;-The resident did not have bruises on his/her arms on 02/19/26, the day before the incident, but did have the bruises after the incident on 02/20/26;-The resident did not usually bump into things, and he/she did not have any recent falls or injuries that he/she was aware of;-The resident was not a difficult resident, he/she generally just sat in his/her room. The resident generally came out around 7:30 A.M. each morning for Cheerios and a breakfast tray. During an interview on 02/25/26, at 1:47 P.M., CNA K said the following:-On 02/20/26, he/she arrived in the SCU around 6:00 A.M., and CNA C was already in the SCU;-CNA K walked down the SCU resident hallway and the resident came out of his/her room and said, That person did this to me and he/she needs to be arrested;-The resident pointed to one of his/her forearms to an open area approximately one-half inch and oval shaped. The area was bleeding;-The resident was loud, very upset, and angry and said again, He/she need to be arrested and if you don't arrest him/her then you need to be arrested too;-The resident then followed CNA K down toward the day area where CNA A and CNA C were standing;-The resident pointed at CNA A and said, He/she was the one that did it to me, he/she needed to be arrested;-CNA C then said CNA A had a hold of the resident's arms and CNA A was trying to make the resident go back to bed;-He/she felt the incident with the resident and CNA A was abusive;-The resident was generally pretty accurate with his/her short-term memory and h/she was also independent with hygiene;-When the resident got up in the morning, he/she generally would come out and sit in the dining room. The resident was independent with walking, toileting, hygiene, and dressing;-It took approximately two hours for the resident to calm back down on 02/20/26 after the incident. CNA K said he/she tried to reassure the resident. During an interview on 02/25/26, at 2:33 P.M., Certified Medication Technician (CMT) P said the following:-He/she passed medication on 02/20/26 and he/she noticed the bruising on the resident's hands and forearms, but was never told that it was from an employee;-The resident was not an aggressive resident and was mostly independent. The resident was not clumsy and did not fall. During an interview on 02/25/26, at 3:45 P.M., LPN B said the resident was low key, was physically independent with walking, and did not fall. There was no reason staff should make the resident stay in his/her room. During an interview on 02/26/26, at 10:00 A.M., the resident's physician said the following:-A staff member trying to keep residents from falling or hurting themselves, would be the only acceptable reason to grab a resident's arms;-A resident should not have multiple bruises to his/her arms/hands, unless the resident was on a lot of blood thinners;-The resident had a diagnosis of dementia but had exhibited no recent behaviors. During an interview on 02/25/26, at 11:00 A.M., the DON said the following:-The resident generally got him/herself up out of bed around the same time each day, dressed him/herself, and walked to the dining/day area in the unit;-The DON could not think of any reason why CNA A would try to prevent the resident from exiting his/her room;-After the Administrator informed the DON of the allegation on 02/23/26, the DON assessed the resident for injuries;-The DON observed multiple circular and oval shaped reddish-purple bruises to the resident's forearms and to the back of his/her hands. The bruises were reddish-purple in color. During an interview on 03/05/26, at 5:45 P.M., the Administrator said abuse should be reported immediately. The resident should be assessed, and notifications should be initiated after abuse allegation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. Complaint 2785595 and 2785807

Based on observation, interview, and record review, the facility failed to monitor, obtain and document treatment orders, and care plan wounds for three residents. Resident #4 had a head laceration and right wrist splint, Resident #8 had open leg ulcers, and Resident #5 a skin tear and multiple scabbed areas to left arm. The facility census was 65. Review of an undated facility policy titled 'Wound Care and Treatment' showed the following:-It is purpose of the facility to prevent and treat all wounds;-Prevention strategies include ongoing skin assessments with weekly documentation of status;-Dietician consultation to obtain suggestions on dietary modifications and protein supplementation and to assess the need for a house vitamin supplement if a wound is present;-Obtain a consultation with the quality assurance nurse when resident has no improvement in existing wounds following a two-to-three-week plan of care;-Reevaluate dressing and skin integrity every shift;-Reevaluate the wounds response to the prescribed treatment on a regular basis;-Make recommendations for treatment changes and inform the physician of changes in wound status when needed;-Date, time, and initial all dressings at time of application;-Thoroughly document all wound information such as type, location, stage (if applicable), length, width, depth, drainage, notation of tunneling or undermining, description of tissue, state of peri wound area, and treatment of wound. Facility was unable to provide a policy regarding orthotics upon request. 1. Review of Resident #4's face sheet (a general information sheet) showed the following:-admitted to the facility on [DATE];-Diagnoses included vascular dementia (progressive decline in thinking, memory, and behaviors caused by impaired blood flow to the brain), diabetes mellitus (chronic disease that causes high blood sugar), and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/2026, showed the following:-Had severe cognitive impairment; -Had delusions and hallucinations;-Had a skin tear;-Dependent on staff for toileting, showering, and dressing;-Utilized a walker for mobility. Review of the resident's care plan, revised 01/29/26, showed the following:-Potential for injury or harm due to visual issues;-At risk for skin issues due to impaired sensory perception, cognitive deficit, impaired communication, and medication regimen;-At risk for falls related to cognitive deficit, delusions, anxiety, and frequent walking.(The care plan was not updated to include recent fall with laceration and right wrist sprain) Review of a nursing progress note dated 02/12/2026 at 4:37 P.M., showed staff were called to the special care unit (SCU) dining area after the resident experienced an unwitnessed fall. The resident was found face down in front of the wall in the dining area. Assessment revealed a laceration to the forehead extending into the eyebrow. Bleeding was controlled. The resident was noted to have slurred speech. Nurse practitioner was notified, and the resident was sent to the emergency room for further evaluation. Emergency medical services were called, and first responders were in the facility with the resident. Review of a hospital Discharge summary, dated [DATE], showed the resident was seen for a right wrist sprain, forehead laceration, closed head injury, and a cervical sprain. Resident should follow up with primary physician in one week and is to wear a splint until cleared by his/her physician. The resident is to return to the hospital immediately if he/she develops increased pain, weakness, tingling, confusion, or other troubling symptoms. Follow-up and re-examination by his/her doctor is essential to complete medical care because it is often impossible recognize and treat all elements of injury. Review of a nursing progress note, dated 02/12/2026 at 10:27 P.M., showed, at 9:05 P.M., the resident returned via an ambulance. Report was received from the hospital registered nurse (RN). A computed tomography (CT- medical imaging procedure that uses x-rays and computers to create detailed images of bones, blood vessels, and soft tissues) scan and cervical spine assessment showed no injury. The right wrist was sprained and a removeable splint was on. The left forehead laceration was closed with Dermabond (liquid tissue adhesive that acts as a liquid bandage to lacerations and surgical incision). The laceration was without redness and with well approximated edges. The right hand splint was in place. Skin warm and pink. Review of a physician progress note dated 02/13/2026, at 1:54 P.M., showed the patient recently had a fall. No acute complaints were otherwise reported by the nursing staff. No acute complaints or obvious injuries noted. Reevaluate patient for physical and occupational therapy services for fall prevention and continue fall precautions and safety measures. Review of a nursing progress note dated 02/16/2026, at 6:16 P.M., showed the resident up per usual in the SCU. Laceration to forehead slightly draining. Resident denies pain. (No interventions implemented for draining laceration.) Review of a wound assessment dated [DATE] showed resident had a laceration on the middle of the forehead that measured 3 centimeters (cm) by 1 cm with no drainage and skin red in color. (Assessment completed six days after laceration occurred.) Observation on 02/23/26, at 9:07 A.M., showed the resident walking in the hallway with a splint to his/her left arm and a laceration to the forehead. Observation on 02/26/26, at 9:10 A.M., showed the resident walking in the hallway with a splint to his/her left arm and a laceration to the forehead. Review of a skin assessment, dated 02/26/26, showed the resident had a laceration to the forehead. The wound was closed with Dermabond. There were no further discharge orders from the hospital. During an interview on 02/27/26, at 1:50 P.M., Licensed Practical Nurse (LPN) A said Resident #4 had a fall and sustained a laceration. The laceration is closed, and they are just watching it. Observation on 02/27/26, at 4:09 P.M., showed the resident wearing the splint on the left arm walking in the SCU. During an interview on 02/27/29 at 4:10 P.M., Certified Nurse Assistant (CNA) E said a couple weeks ago the resident was leaning in his/her wheelchair and fell out. He/she had a super glued forehead and a splint. CNA E remembers the splint on the right arm upon return from the hospital. He/she is unsure as it is currently on the right arm. During an interview on 02/27/29, at 11:15 A.M., CNA F said the resident had a laceration to the forehead. The resident had a fall resulting in a fractured left hand. He/she thinks the resident always had it on the left hand and never saw it on the right. During an interview on 02/27/26, at 11:25 A.M., LPN G said the resident had a laceration to the forehead and it should be monitored and included in the treatment administration record. The splint to the left arm is due to a fracture, but he/she was unsure how the resident obtained the fracture. The laceration and the splint should be included in the care plan. Review of a physician progress note dated 02/27/26, at 7:45 P.M. showed a follow up evaluation after recent fall with head laceration and right wrist sprain. Patient sent to hospital for evaluation and returned same day. Right wrist sprain requiring splinting, patient non-compliant with splint use. Continue fall precautions and enhanced safety measures. Encourage splint compliance with frequent redirection and education. Monitor for signs of wrist reinjury or complications. Encourage right wrist splint compliance with frequent redirection. Follow-up as needed for acute changes or splint non-compliance. (follow up visit completed fifteen days after hospital visit) Review of the resident's February 2026 physician's order sheet (POS) showed the following:-An order dated 02/27/26, to monitor head laceration every shift until healed;-An order dated 02/27/26, to monitor skin under wrist split daily until wrist is healed, discontinued on 03/03/26. Review of a nursing progress note dated 02/28/26, at 10:14 A.M. showed the resident's laceration to forehead is healing well. During an interview on 03/03/26, at 3:10 P.M., Nurse Assistant (NA) M said the resident should have the splint on the left arm. The aide that gets him/her up in the morning is responsible for putting it on. The resident does take the brace off at times. During an observation on 03/03/26, at 3:15 P.M., showed the resident resting in bed with the splint on the counter near sink. Review of a wound assessment dated [DATE], showed the resident had a laceration that measured 3 cm by 0.25 cm with no drainage and skin pink in color.(No progress notes showing the resident refused to wear splint to right wrist or additional notes regarding monitoring of forehead laceration.) During an interview on 03/05/26, at 11:45 A.M., Nurse Practitioner (NP) O said the following:-Resident #4 should have an order to check his splint, including circulation and skin condition;-Nurse should check the laceration site every shift for infection or bleeding;-The resident should be monitored for any latent injuries following a fall. During an interview on 03/05/26, at 5:45 P.M., the Administrator said a resident with a brace or laceration should have an order for monitoring. The nurses should be monitoring the resident every shift and documenting it in a progress note. 2. Review of Resident #8's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses included intracerebral hemorrhage (ruptured blood vessel which caused bleeding into the brain), high blood pressure, open wound of the left lower leg, non-pressure chronic ulcer, open wound to right leg. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Had severe cognitive impairment; -At risk for pressure injuries;-Dependent on staff for all activities of daily living (ADLs -essential, routine self-care tasks such as bathing, dressing, touting, and transfers) except eating;-Had one unhealed stage one pressure injury (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) and three stage two pressure injuries (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister). Review of resident's care plan, revised 12/23/25, showed the following:-At risk for skin issues related to edema (swelling caused by excess fluid trapped in body tissues), -Incontinence, impaired functioning and mobility;-Staff should report any signs of skin breakdown to the charge nurse and physician;-Required staff assistance with ADLs related to impaired mobility. Review of the resident's current POS showed an order, dated 12/18/25, to cleanse the right calf with wound cleanser, apply skin prep (skin barrier) to peri wound. Apply calcium alginate to wound bed, cover with border gauze. Change daily and as needed. Review of the resident's January MAR showed the order dated 12/18/25, to cleanse the right calf with wound cleanser, apply skin prep (skin barrier) to peri wound. Apply calcium alginate to wound bed, cover with border gauze. Change daily and as needed except on 01/04/26 due to leaving it open to air. Review of the resident's January progress notes showed no documentation related to right calf wound. Facility unable to provide any wound assessments for January 2026. Review of a skin assessment dated [DATE], showed the skin intact and no treatment in place. No skin assessment noted for 01/12/26 or 01/19/26. Review of a skin assessment, dated 01/26/26, showed skin intact and no treatment in place. Review of the resident's February POS showed an order dated 12/18/25, to cleanse the right calf with wound cleanser, apply skin prep to peri wound. Apply calcium alginate to wound bed, cover with border gauze. Change daily and as needed was documented as completed as ordered except on the following:-On 02/11/26, no documentation as completed;-On 02/14/26, documented as not completed. Review of a skin assessment, dated 02/02/26, showed skin intact with no treatment in place. Review of a nursing progress notes dated 02/06/26, showed treatment to bilateral lower extremities completed as ordered with two nurses. Review of a skin assessment dated [DATE], showed skin intact with no treatment in place. Review of a wound management report dated 02/18/26, showed the resident had an unspecified ulcer on the right ankle lower calf/top of ankle identified on 02/18/26. Wound measured 3 cm by 3 cm with moderate serosanguineous (thin, watery, pink or light red) drainage. Wound bed indicated as covered in slough (pale, yellow, white, or gray, moist, and stingy tissue that covers the wound bed of chronic or stalled wounds, acts as a barrier to healing). Review of a skin assessment dated [DATE], showed skin intact with no treatment in place. Review of a skin assessment dated [DATE], showed skin intact with no treatment in place. No additional progress notes related to wounds in February. During an observation and interview of wound care with Resident #8 on 02/26/26 at 2:00 P.M., showed LPN B entered the resident room and reported the resident had a wound to the right calf. No dressing was in place upon arrival to the resident's room. The resident was sitting in the recliner with a blanket under his/her legs. The blanket had yellow colored, dried drainage under the right leg where the wound was located. The resident was noted to have two wounds on the right outer calf. Both circular shaped wounds appeared moist with a yellow-colored wound bed. LPN B said the resident had one treatment listed for wounds. LPN B cleansed both wounds with wound cleanser, applied skin prep, and then ripped the calcium alginate in half with his/her hands and applied it to both wound beds. LPN B then applied a dressing, covering both wounds. LPN B said the resident had more wounds, but they had healed and this was the only treatment ordered. During an interview on 02/27/26, at 11:25 A.M., LPN G said Resident #8 had wounds on the right calf area. He/she had not seen the resident in a while but remembers three small open areas on the right calf. Skin assessments should include all wounds or bruises. The Director of Nursing (DON) is responsible for completing the wound assessments weekly. A wound assessment should include size, drainage, depth, description of the wound, and if any odor is present. Review of a wound management report dated 03/04/26, showed the resident had an unspecified ulcer on the right ankle lower calf/top of ankle, identified on 02/18/26. The wound measured 2 cm by 3 cm with light serous (clear, amber thin, and watery) drainage. The wound bed indicated as covered in epithelial (pink or pearly white) tissue. Observation on 03/05/26 at 10:57 A.M, showed the following:-Resident #8 sat in his/her room in a wheelchair;-LPN B unwrapped a dressing from around the resident's right lower leg;-The resident had a total of 5 open areas, resembling shallow open blisters to his/her right lower leg with pink and yellow tissue present to the wound beds of each area;-Three open areas to the posterior (back side) lower leg, one approximately the size of a quarter and two pea sized areas;-Two open areas to the lateral (outside) lower leg, one approximately the size of a nickel and one approximately the size of a dime;-The nurse cleansed the areas with wound cleanser, patted dry, applied skin prep to the intact skin around the open areas, applied a Maxorb Extra dressing (highly absorbent dressing with antimicrobial silver) and attempted to cover all 5 open areas with one bordered gauze dressing (with an adhesive border);-The nurse placed the bordered gauze dressing, but did not sufficiently cover the nickel sized open area to the lateral lower right leg and the nurse attached the adhesive border to the open area. During an interview on 3/05/26 at 3:00 P.M., Registered Nurse (RN) V said the following:-The treatment order should list all the open areas on his/her legs instead of one area;-The bandage should cover the open areas and the adhesive border should not touch the open areas. During an interview on 03/05/26 at 10:45 A.M., NP O said nurses should be assessing any type of wound and documenting that observation. Resident # 8 should have all open areas monitored and have individualized orders for each. An adhesive bandage should not be put directly on the wound bed as it would impede the healing of the wound. During an interview on 03/05/26, at 5:45 P.M., the Administrator said staffing issues have affected nurses completing observations and follow up for wounds. The Assistant Director of Nursing (ADON) should complete the weekly wound assessments, however the current ADON resigned on 02/17/26. The nurse should document monitoring of skin areas in the progress notes. Skin treatment orders should address all open areas and not just one. 3. Review of Resident #5's face sheet showed:-admitted to the facility on [DATE];-Primary diagnosis of atrial-fibrillation (an irregular heart rhythm causing the heart to beat faster). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Short-term and long-term memory problem;-Severely impaired cognitively skills for daily decision making;-Exhibited inattention and disorganized thinking, behaviors were continuously present;-Experienced hallucinations (sensory perceptions that seem real but are not) and delusions (false beliefs);-Functional limitation to range of motion to both lower extremities;-Dependent on staff for assistance with eating, oral hygiene, , personal hygiene, toilet hygiene, showers, upper and lower body dressing, turning and transfers;-Always incontinent of bowel and bladder;-Diagnoses of psychotic disorder, stroke, dementia, and anxiety;-No skin tears present. Review of the resident's care plan last reviewed/revised on 1/29/26, showed:-Resident at risk for skin impairment and/or breakdown;-Interventions will remain in place to reduce the resident's risk of skin impairment/breakdown to the extent possible;-A licensed nurse should look at the resident's skin at least weekly;-Avoid shearing during positioning, transferring, and turning;-Resident has skin tears, use a mechanical lift for transfers, if resident becomes combative stop care and come back later;-Report any signs of skin breakdown (sore, tender, red, or broken areas) to the charge nurse and the resident's physician. Review of the resident's most recent weekly skin assessment, dated 02/22/26, showed a nurse documented skin intact with no skin issues. Review of the resident's progress notes from 02/22/26 thru 02/26/26 showed no nurse notes. Observation of the resident on 02/26/26 at 8:50 A.M., showed the following:-The resident sat in a geriatric chair (reclining wheeled chair) in his/her room;-The resident scratched at his/her left forearm using his/her right fingers;-The resident's fingernails were long and extended approximately 0.5 cm beyond the end of his/her fingers;-The resident had four scabbed areas to his/her left forearm with redness to the surrounding skin, the largest scabbed area was approximately 3.0 centimeters (cm) long by 2.0 cm wide and the three smaller areas were approximately 1.0 cm long by 1.0 cm wide in size;-The areas were not covered and did not appear to have any ointment present. During an interview on 02/26/26 at 8:56 A.M., Certified Nurse Assistant (CNA) W said the resident's scabbed areas were most likely from skin tears cause by a previous fall or from combative behavior during cares. During an interview on 02/26/26 at 9:07 A.M., CNA R said the following:-The scabbed areas to the resident's left arm started as skin tears;-The areas were looking worse due to the presence of surrounding redness;-He/she thought the areas were present on Friday, 2/20/26. During an interview on 02/26/26 at 3:20 P.M., CNA X said the following:-The larger scabbed area to the resident's left forearm started out as a skin tear;-The CNA first saw the skin tear approximately one week ago and at that time, the resident had steri-strips (adhesive strips used for skin closure) to the open area;-The next time the CNA saw the area, the resident had a band aid covering the area;-Yesterday, 02/25/26, the resident had a bordered gauze (a wound dressing with an adhesive border) covering the open areas;-Today, 02/26/26, the scabbed areas were uncovered. During an interview on 02/27/26 at 11:00 A.M., CNA T said the following:-No one could explain how the resident sustained the left forearm skin tear;-He she came in to work approximately two weeks ago and the resident had an approximately 2-inch skin tear with steri-strips covering the wound to his/her left forearm;-Someone tried to cover the resident's open areas with a bandage, but the resident appeared to have a reaction to the adhesive;-The other open areas were caused by the adhesive and/or the resident scratching. Review of the resident's physician orders showed an order, dated 02/27/26, for staff to cleanse the resident's left forearm scratches with wound cleanser, pat dry, apply A&D ointment (a skin protectant/moisture) daily. Review of the resident's progress notes from 02/28/26 thru 03/03/26 showed no nurse notes. During an interview on 03/03/26 at 1:50 P.M., the DON said the following:-If staff discovered a skin tear or open area on a resident, the nurse should document in the progress notes and notify the physician for treatment orders or for orders to monitor the areas until resolved;-The nurse should notify the DON and the resident's family about the skin tear;-He/she suspected the areas to the resident's left forearm started out as a skin tear;-He/she was not aware of the areas until 2/26/26;-On 2/26/26, he/she notified the physician and obtained a treatment order to apply A&D ointment to the areas. During an interview on 3/03/26 at 3:25 P.M., LPN G said the following:-If a resident's sustained a skin tear, the nurse should notify the resident's physician and the resident's family;-If the open area required a treatment, the nurse should obtain a treatment order from the physician;-The nurse should document in the resident's progress note daily until the areas were resolved. Review of the resident's progress note, dated 03/04/26, showed the DON documented the following:-Wound care note: Resident's left forearm continues to show improvement. Scabs remain present on the left forearm. Surrounding skin is intact but noted to be fragile and dry. Skin flaking observed to surrounding tissue. No drainage noted. Continue current skin treatment as ordered. During an interview on 3/05/26 at 3:00 P.M., RN V said the following:-The resident's had fragile skin and the resident picked at his/her skin;-If the resident sustained a skin tear, nurses should monitor the skin tear for signs and symptoms of infection, such as redness or drainage and obtain a physician's order for treatment, if needed. Complaint 2784515

Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment, including a review of the clinical rationale and approved indication for use of psychotropic medications (prescription drugs that manage mental health conditions by affecting brain activity, mood, thoughts, and behavior), for one resident (Resident #3) with a diagnosis of dementia, prior to utilizing anti-psychotic medications (a class of medications primarily used to manage psychosis) to treat the resident's behaviors. The facility failed to consistently monitor, identify, and implement nonpharmacological interventions to address the resident's behaviors and failed to care plan use of antipsychotic medication. The facility census was 65. Review of the facility's policy titled, Abuse Policy, undated, showed the following:-It is the policy of the facility that each resident will be free from abuse;-The resident will be free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the resident's medical symptoms. Review of the facility policy titled Care Plan Comprehensive, undated, showed the following:-An individualized comprehensive care plan that includes measurable goals and time frame will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being;-The interdisciplinary team with input from the resident, family, and legal representative will develop a comprehensive care plan for each resident;-Care plan will be revised as changes occur in the resident's condition;-The care plan will be based on a thorough assessment;-The comprehensive care plan should be developed within seven days of the comprehensive assessment;-A well-developed care plan will be oriented preventing avoidable declines in functioning; managing risk factors or indicating the limit of interventions; applying current standards of practice in care planning process; and evaluating treatment of measurable goals, timetables, and outcomes of care;-Use an interdisciplinary approach to care plan development to improve the resident's functional abilities;-Assess and plan for care to meet the resident medical, nursing, mental, and psychosocial needs. 1. Review of Resident #3's face sheet (a general information sheet) showed the following:-admission date of 02/06/26;-Diagnoses included dementia (loss of mental functions that are severe enough to affect your daily life and activities), anxiety, and cerebral infarction (a blockage in an artery that restricts blood flow to the brain, leading to tissue death). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/12/26, showed the following:-Severe cognitive impairment; -Did not have a psychiatric diagnosis;-Did not have delusions or hallucinations;-Had physical behavioral symptoms directed towards others one to three days a week;-Had other behavioral symptoms not directed at others one to three days a week;-Behavioral symptoms put resident at risk for physical illness or injury;-Required moderate staff assistance for toileting, bed mobility, dressing, and transfers;-Dependent on staff for showering and hygiene;-Utilized a wheelchair for mobility;-Resident received antipsychotic medication;-One injection had been administered in last seven days;-Did not utilize any restraints. Review showed the facility did not provide a care plan for the resident. Review of the resident's hospital Discharge summary, dated [DATE], showed the resident did not receive antipsychotic, antianxiety, or antidepressant medications upon discharge. Review of the resident's physician admission progress note, dated 02/06/26, showed the resident denied acute complaints today. The resident was alert and oriented with a pleasant demeanor. No acute delirium today. Resident alert and oriented but unable to state location. Resident was awake and conversant and followed commands appropriately with clear speech. Staff should monitor neurological status and report any changes in mental status or weakness. (The physician did not document regarding need for, orders for, or use of anti-psychotic medications.) Review of the resident's nursing progress note dated 02/06/26, at 9:17 P.M., showed the following: -Resident attempted to ambulate without assistance;-Resident was alert, oriented to self, and did not take redirection;-Resident brought to nurses' desk to be monitored closely;-Resident continued to attempt to ambulate without assistance;-Staff called the on-call Nurse Practitioner (NP) and received an order for melatonin (a hormone in the body that plays a role in sleep) 5 milligrams (mg) at bedtime. Staff attempted to give it to the resident, and he/she spit it at the nurse on two separate attempts;-Staff contacted the NP and received an order to give Haldol (antipsychotic medication) 2.5 mg IM (intermuscular – into the muscle) injection. Resident returned to his/her room and the Haldol IM injection was given;-Staff brought resident back to nurses' station to be observed until the medication took effect to provide for safety. Review of the resident's February 2026 Physician's Order Sheet (POS) showed an order, dated 02/06/26, for haloperidol lactate (Haldol) solution, 5 mg/milliliter (ml), give 2.5 mg IM injection one time for a diagnosis of dementia. Review of the resident's February 2026 Medication Administration Record (MAR) showed on 02/06/26, staff documented haloperidol lactate solution 5 mg/ml, 2.5 mg IM was given but documentation did not show a time or an indication for administration. Review of the resident's nursing progress note dated 02/07/26, at 3:13 P.M., showed the following: -The resident slid out of the wheelchair with no injuries were noted;-Staff moved the bed next to the wall and fall mats placed on the floor;-Staff notified all parties and the physician for as needed medication for anxiety and restlessness;-Resident will not stay in his/her wheelchair and tries to walk down hallways. Review of the resident's nursing progress note dated 02/07/26, at 3:13 P.M., showed a new order for risperidone (antipsychotic medication) 0.5 mg daily, as needed (prn) received. Staff updated the pharmacy, family, and the administrator were updated. Review of the resident's February 2026 POS showed an order, dated 02/07/26, for risperidone (antipsychotic medication) 0.5 mg tablet, give one tablet daily as needed for a diagnosis of dementia without behavioral, psychotic, mood disturbance, and anxiety. Review of the resident's February 2026 MAR showed staff documented on 02/07/26, at 4:22 P.M., risperidone 0.5 mg one tablet given prn to the resident for crawling on the floor. Review of the resident's February 2026 MAR showed the following:-On 02/08/26, at 11:40 A.M., staff documented risperidone 0.5 mg one tablet given prn for anxiety;-On 02/09/26, at 3:58 P.M., staff documented risperidone 0.5 mg one tablet was given prn for anxiety. Review of resident's nursing progress notes, dated 02/08/26 and 02/09/26, showed staff did not document regarding the behaviors at the time of administration or nonpharmacological interventions tried. Review of the resident's nursing progress note dated 02/10/26, at 6:35 P.M., showed the resident was alert and oriented to person and place with confusion and occasional delusions. The resident's speech was clear, and he/she was usually able to make needs known. As needed risperidone given this morning following episode of yelling and agitation when staff attempted to redirect resident after continual attempts to walk unassisted. Staff noted medication effective and resident calm rest of shift. Review of the resident's February 2026 MAR showed on 02/10/26, at 11:08 A.M., staff documented risperidone 0.5 mg one tablet was given prn for anxiety and yelling out. Review of the resident's February 2026 MAR showed the following: -On 02/13/26, at 5:13 P.M., staff documented risperidone 0.5 mg one tablet was given for being restless and agitated;-On 02/14/26, at 8:10 P.M., staff documented risperidone 0.5 mg one tablet prn was given for roaming;-On 02/15/26, at 4:36 P.M., staff documented risperidone 0.5 mg one tablet prn was given for yelling. Review of the resident's nursing progress notes, dated 02/13/26 to 02/15/26, showed staff did not document regarding the behaviors at the time of administration or nonpharmacological interventions tried. Review of the resident's nursing progress note dated 02/16/26, at 3:25 P.M., showed the following: -Resident noted to have increased confusion, attempting to stand without assistance, observed walking down the hallway without supervision, throwing items, and exhibiting increased anxiety;-Resident had a prn risperidone available and the as needed dose was administered as ordered;-Staff notified physician on the resident's change in behavior and increased symptoms. New orders received to change risperidone 0.5 mg to daily administration and to initiate Zoloft (antidepressant) 25 mg daily. Review of the resident's February 2026 POS showed the following:-An order, dated 02/16/26, for risperidone 0.5 mg tablet, give one tablet daily for a diagnosis of dementia without behavioral, psychotic, mood disturbance, and anxiety; -An order, dated 02/16/26, for Zoloft (antidepressant) 25 mg tablet, give one tablet once daily for a diagnosis of dementia without behavioral, psychotic, mood disturbance, and anxiety. Review of the resident's February [DATE] showed on 02/16/26, at 2:16 P.M., staff documented risperidone 0.5 mg one tablet prn was given for throwing things and yelling. Review of the resident's nursing progress note dated 02/17/26, at 1:25 A.M., showed staff had kept the resident at the desk due to attempting to stand and/or walk by him/herself. The resident was alert to self only. Resident was cursing and uncooperative with directions and staff assistance. He/She attempted to bite and hit staff. Scheduled risperidone started. Review of the resident's February 2026 POS showed an order, dated 02/17/26, for lorazepam (antianxiety) 0.5 mg tablet, give one tablet four times daily for anxiety disorder. Review of the resident's medical record showed staff did not document regarding receipt of a new order for lorazepam on 02/17/26. Review of resident's nursing progress dated 02/18/26, at 4:09 A.M., showed the following: -Staff kept resident at the desk due to attempting to stand and/or walk by him/herself;-Resident alert to self only;-Resident cursing and uncooperative with directions and staff assistance;-Resident attempted to bite and hit staff;-Scheduled risperidone and lorazepam 0.5 mg four times daily started;-Resident had three falls on this shift regardless of keeping resident at nurses' station; -Resident currently resting in bed with call light in reach. Review of the resident's February 2026 POS showed the order for lorazepam, dated 02/17/26, was discontinued on 02/19/26. Review of the resident's medical record showed staff did not document regarding the lorazepam order being discontinued. Review of the resident's nursing progress note dated 02/20/26, no time noted, showed the following: -Resident demonstrated an increase in confusion this shift;-Resident observed walking to the exit doors and attempting to leave the unit;-Resident informed he/she was safe and redirected from the exit;-Resident continued to display confusion and required ongoing verbal assurance;-No physical behaviors noted. Review of the resident's February 2026 POS showed a new order, dated 02/20/26, for lorazepam 0.5 mg tablet, give one tablet every four hours, as needed, for anxiety disorder. Review of a nursing note dated 02/20/26, no time noted, showed the following:-Resident alert and oriented to self and time;-Resident did not get out of bed until noon;-Staff sat resident in wheelchair at nurses' station;-Resident spit out medications on the floor when administered;-Resident went to the fire alarm and attempted to break it by punching it;-Staff redirected the resident from the area. Resident continued to grab other residents' arms;-Resident was aggressive and continued one-to-one supervision. Review of the resident's February 2026 MAR showed on 02/22/26, at 2:20 P.M., lorazepam 0.5 mg one tablet was given because the resident was yelling for family, then at staff, when they attempted to redirect. Review of the resident's nursing progress note dated 02/22/26, at 4:20 P.M., showed the following: -Resident was aggressive with actions;-Resident threw a butter knife and a fork in the dining room;-Resident always looked for family members;-Resident wanted his/her purse and wanted to leave;-Resident had issues with following directions. Review of the resident's February 2026 POS showed the following:-A new order, dated 02/22/26, for risperidone 4 mg disintegrating tablet, 4 mg to be given every morning for a diagnosis of dementia, mild, with psychotic disturbance;-A new order, dated 02/22/26, for risperidone 4 mg disintegrating tablet, may give 4 mg once daily, as needed, for a diagnosis of dementia, mild, with psychotic disturbance;-A new order, dated 02/22/26, for haloperidol lactate solution 5 mg/mL, give 0.5 ml (2.5 mg); IM injection as needed for dementia, mild, with psychotic disturbance; -A new order, dated 02/22/26, for haloperidol decanoate 100 mg/mL solution, give 25 mg via IM injection every four hours as needed for dementia, mild, with psychotic disturbance. Review of the resident's medical record, dated 02/22/26, showed staff did not document regarding the new medication orders. Review of the resident's February 2026 MAR showed on 02/22/26, at 8:36 P.M., staff documented haloperidol lactate 2.5 mg given IM due to resident being aggressive, continuous standing, cussing, and knocking on wall. Staff noted medication as effective as the resident appeared relaxed and asleep. Review of the resident's nursing note dated 02/23/26, at 12:41 A.M., showed the following:-Resident refused medication, spitting them at staff;-Resident was redirected;-Resident attempted to grab anyone that walked by;-Resident being very aggressive;-Resident placed on one-on-one with staff and Haloperidol prn given to resident for safety;-Staff will continue the current plan of care. Review of the resident's February 2026 POS showed a new order, dated 02/23/26, for Seroquel (an antipsychotic) 25 mg tablet, give one tablet at bedtime for a diagnosis of anxiety disorder. Review of the resident's nursing progress note dated 02/26/26, at 9:00 A.M., showed the following:-The medication regimen reviewed with the physician due to increased fall risk and history of stroke;-Verbal orders received for to discontinue IM Haldol and lorazepam;-Verbal orders received to decrease risperidone from 4 mg to 1 mg twice daily for agitation related to dementia;-Verbal orders to start Haldol 0.5 mg every six hours as needed;-Verbal orders to continue Seroquel 25 mg at bedtime. Review of the resident's February 2026 POS showed the following:-The orders for IM Haldol and lorazepam were discontinued;-A new order, dated 02/26/26, for haloperidol 0.5 mg tablet, give one tablet every six hours as needed for a diagnosis of dementia without behavioral, psychotic, mood disturbance, and anxiety; -A new order, dated 02/26/26, for risperidone 1 mg tablet, give one tablet twice daily for a diagnosis of dementia without behavioral, psychotic, mood disturbance, and anxiety. Review of the resident's February 2026 MAR showed on 02/27/26, at 3:26 A.M., staff documented haloperidol 0.5 mg one tablet prn given with no behaviors indicated. Review of the resident's nurse's note 02/27/26, at 3:26 A.M., showed staff noted the resident spit the medication out. Review of the resident's nursing progress note dated 02/27/26, at 6:57 A.M., showed the following:-The resident continued to argue, hit, spit, and grab at staff and other residents aggressively;-Since crawling in the hallway at 2:00 A.M., the resident had been on one-to-one supervision with staff;-On one-to-one supervision due to attempting to get up and walk;-Attempted to give as needed medication but the resident spit it at the nurse;-Redirection was unsuccessful. Review of the resident's physician note, dated 02/27/26, showed staff should monitor the resident for changes in mental status or behavioral disturbances. Recent medication adjustments were made for agitation and behavioral disturbances. Review of the resident's February MAR showed on 02/28/26, at 2:24 P.M., staff documented haloperidol 0.5 mg one tablet prn was given due to resident yelling out. Review of the resident's nursing progress notes, dated 02/28/26, showed staff did not document behaviors at time of administration. Review of the resident's record for February 2026 showed the facility did not provide documentation of resident behavior monitoring, nonpharmacological interventions, or assessment for antipsychotic medication. During an interview on 03/05/26, at 3:00 P.M., Registered Nurse (RN) V said the following:-The resident tried to stand up from his/her wheelchair a lot, but RN V did not have many issues redirecting the resident;-Standing up was not a justification for administering an antipsychotic medication;-The only justification would be if the resident was causing harm to him/herself or another resident;-RN V had never seen the resident demonstrate behaviors that justified a nurse administering IM Haldol;-RN V would offer the resident's snacks, ask the resident to sit back down;-RN V said if a staff member took time with the resident to find out what he/she wanted and to re-direct his/her behaviors he/she did not have many issues;-The resident did slap at staff and call the staff names;-RN V said nurses should not request an antipsychotic medication for a resident from the provider, unless they had tried all other non-pharmacological approaches;-Some of the nurses were quick to call the physician and ask for a medication for a resident without trying other approaches, the nurse should assess the resident for incontinence, pain, or hunger. Some of the residents have difficulty communicating their needs;-Some of the nurses did take the time/effort with the resident;-A urinary tract or other infection can also lead to increased behaviors, especially in the elderly. During an interview on 02/27/26, at 2:08 P.M., the Director of Nursing (DON) said the increase of the resident's risperidone from 0.5 mg to 4 mg was a huge increase and concerns him/her. Antipsychotic medications should be initiated one and a time and increased in smaller dosages. During an interview on 03/05/26, at 11:45 A.M., NP O said the following:-It was not appropriate to give a resident haloperidol to prevent them from getting out of a wheelchair;-Antipsychotic medications can cause behaviors;-He/she was not comfortable ordering haloperidol very often due to side effects such as extrapyramidal symptoms (EPS -involuntary movement disorders caused primarily by antipsychotic medications);-He/she would be more comfortable ordering Seroquel or Zyprexa (antipsychotic medication). During an interview on 03/05/26, at 2:17 P.M., the resident's physician said the following:-An as needed antipsychotic order should be given for a resident who is a danger to others or self;-Antipsychotics should not be given for a resident standing up;-A diagnosis of vascular dementia is justification for administration of antipsychotics;-Short term antipsychotic medication is for serious harm, agitation, or psychosis when nonpharmacological measures fail;-A dose of 0.25 mg to 0.5 mg of haloperidol is appropriate for a first-time dose;-Risperidone 4 mg is too high of a dose for a resident;-He/she had never given 0.5 mg Haloperidol to a resident;-Possible issues with antipsychotic medications are increased falls, EPS, and cognitive impairment;-IM injection of haloperidol is for worst case scenario;-He/she did not think 2.5 mg haloperidol injection was appropriate when given to the resident on 02/06/26. He/she was not comfortable with this dosage;-He/she usually starts with Seroquel for resident behaviors. During an interview on 03/05/26, at 5:45 P.M., the Administrator said staff should have tried nonpharmacological interventions first for a confused resident trying to stand. Dementia without behaviors is not an appropriate diagnosis for antipsychotic medication. An as needed antipsychotic medication would be used for a dementia diagnosis or behaviors. Antipsychotics should not be administered for behaviors that do not affect the resident or other residents. Antipsychotic medications should be ordered based on past behaviors, interventions tried, and documented behaviors. Complaint 2784515

Based on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately to facility management and within two hours of staff being aware of the allegation, when staff did not report two allegations of abuse involving two residents (Resident #1 and #2) to administration and the Department of Health and Senior Services (DHSS) in a timely fashion. The facility census was 65.Review of the facility's policy titled, Abuse Policy, undated, showed the following-It is the policy of the facility that each resident will be free from abuse;-Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion;-Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the nursing home Administrator;-The nursing home Administrator or designee will report abuse to the state agency per state and federal requirements;-All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources, and misappropriation of resident property by facility employees, contract employees, volunteers, contract services, consultants, physicians, visitors, family members, or other individuals will be reported immediately, but no later than the following timeframes;-If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made;-If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24 hours after the allegation was made;-The facility will ensure that all reports are made within two hours (abuse or serious bodily injury) or 24 hours (non-abuse);-The 2-hour timeframe must be met even during the night shift or during the weekend. 1.Review of Resident #1's face sheet showed the following:-admission date of 04/01/24;-Diagnoses included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen) with agitation. Review of the resident's care plan, dated 07/17/25, showed the resident resided on the special care unit (SCU) for safety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/12/25, showed the following:-Usually understood and usually understands communication;-Severely cognitively impaired;-Exhibited inattention, behavior present, fluctuates (comes and goes, changes in severity);-Exhibited disorganized thinking, behavior present, fluctuates;-No physical, verbal, or other behavioral symptoms directed toward others;-No rejection of care;-No wandering. Review of the resident's progress note dated 02/23/26, at 12:59 P.M., showed the Director of Nursing (DON) noted resident had scattered bruising on his/her bilateral (both sides) upper extremities (hands/arms) in various stages of healing. When the nurse asked the resident about the cause of the bruising, the resident said he/she woke up that way. Resident denied pain or drainage associated with the bruised areas. No tenderness reported. Resident demonstrated full range of motion to fingers without difficulty. No functional impairment observed. Staff notified physician of bruising. During an interview on 02/25/26, at 10:56 A.M., the Administrator said the following:-On Monday, 02/23/26, at approximately 9:00 A.M. to 9:30 A.M., the resident's responsible party (RP) came to the Administrator's office and said the resident had bruises on his hands and arms and an unnamed staff member in the SCU told him/her Certified Nurse Assistant (CNA) A abused the resident;-The Administrator interviewed CNA C who said he/she worked the day shift at the facility on the morning of 02/20/26. He/she arrived at work on 02/20/26, at approximately 5:55 A.M. and entered the SCU, walked down the hallway, and saw CNA A in the resident's room holding the resident's arms;-CNA C asked why CNA A was in the resident's room and CNA A informed CNA C he/she was putting the resident back to bed;-CNA C, said on 02/20/26 between 6:00 A.M. and 6:30 A.M., he/she informed Licensed Practical Nurse (LPN) L about CNA A holding onto the resident's arms;-On 02/23/26, the Administrator viewed 02/23/26 video footage from the hallway of the SCU. The video showed CNA A grab the resident by the arms and push the resident back into his/her room on two separate occasions. Review of Department of Health and Senior Services records showed the facility self-reported the allegation of abuse on 02/23/26, at 11:38 A.M. (Three days after the allegation of abuse was made.) During an interview on 02/25/26, at 12:56 P.M., CNA C said the following:-If he/she suspected resident abuse, he/she would notify the nurse immediately, and if they did not respond, he/she would go to the Administrator immediately;-He/she thought the facility had 12 hours to report an allegation of abuse to DHSS;-He/she arrived to work on Friday, 2/20/26, at a little before 6:00 A.M., clocked in and entered the SCU;-Upon entering the unit CNA C said he/she heard CNA A repetitively yell, You have to get back in bed;-The resident yelled back, I don't want to go back to bed.-CNA C walked down the hall, stopped at the resident's doorway and looked into the resident's room;-CNA A and the resident were standing near the resident's bed and CNA A had his/her hands on the resident's forearms;-The two were struggling. The resident was trying to get loose from CNA A's grasp, but CNA A held on to the resident's arms;-CNA C told CNA A to get out of the resident's room and leave the resident alone;-CNA A argued saying he/she was not doing anything wrong;-CNA C told CNA A he/she did not need to bother the resident because the resident was able to do his/her own care;-CNA A continued to try to force the resident back toward the bed by holding the resident's arms and pushing the resident;-CNA C then told CNA A to come out of the room and leave the SCU;-CNA A then came out of the resident's room and left the unit shortly after;-The resident was mad and wanted to call the police;-He/she had a hard time calming the resident down;-Approximately 15 minutes later, CNA C said he/she used the phone to call out to the nurses' station and told the nurse on duty, Licensed Practical Nurse (LPN) L, to come to the SCU and look at the resident's arms. CNA C told LPN L that CNA A was trying to hold the resident's arms down and the arms looked bruised;-LPN L came to the SCU and looked at the resident's arms;-He/she assumed LPN L would make out an incident report;-Later that same day on 02/20/26, at approximately 2:00 P.M., CNA C said he/she stood at the nurses' station at the end of his/her shift and told some of the aides and the DON thatCNA A had bruised the resident's arms while trying to force the resident back into bed;-He/she found out on Monday, 02/23/26, that LPN L did not report the incident to anyone. During an interview on 02/25/26, at 8:04 P.M., LPN L said the following:-He/she would report allegations of abuse immediately to the Administrator;-The facility had two hours to reports any allegation of abuse to DHSS;-He/she worked overnight on Thursday night 02/19/26 into Friday morning 02/20/26;-LPN L said he did not go to the SCU to make rounds because he/she did not have time;-No one informed LPN L of any incident involving the resident and CNA A. During an interview on 02/26/26, at 11:31 A.M., CNA I said the following:-CNA C told CNA I about the resident abuse on 02/20/26, but CNA I did not report the abuse, because CNA C said he/she had reported to the Administrator;-He/she would consider grabbing a resident's arms and causing bruises to be abuse;-All allegations of abuse should be immediately reported to the charge nurse or Administrator;-The facility should notify DHSS of allegations of abuse within two hours. During an interview on 02/25/26, at 7:42 P.M., Registered Nurse (RN) Q said the following:-No one reported an incident regarding the resident and CNA A to him/her;-If staff reported an allegation of abuse, he/she would immediately notify his/her DON. During an interview on 03/03/26, at 1:55 P.M., the DON said:-He/she would consider grabbing a resident's arms and causing bruising to be physical abuse;-Staff should have immediately reported the abuse to the DON or Administrator. 2. Review of Resident #2's face sheet showed the following:-Admisison date of 8/12/21;-Diagnoses included dementia, depression, anxiety disorder, delusional disorder, and paranoid personality disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Experienced inattention and disorganized thoughts, behavior present, fluctuates (comes and goes, changes in severity);-Dependent on staff for toileting hygiene, personal hygiene, showering, lower body dressing, and transfers. Review of the resident's care plan, revised 01/16/26, showed the following:-On occasion the resident has signs and symptoms of mood distress, weepy, crying, and doesn't think anyone likes him/her;-Resident has cognitive deficit, anxiety, and depression;-Resident will verbalize feelings of acceptance from others and involve self in activities of his/her choice;-Take resident to quiet, calm area; -Acknowledge to the resident that the current situation must be difficult; -Encourage resident to verbalize feelings, concerns, fears, etc.;-Clarify misconceptions; -Explore with resident past effective and ineffective coping mechanisms. Review of the resident's progress note dated 02/17/26, at 1:15 P.M., showed the DON documented the resident experienced episodes of increased confusion and hallucinations during the shift. Resident repeatedly asked for someone by name, stating that person was present at the facility. Resident also reported that a gentleman was present. Staff redirected the resident and informed the resident that the men present were staff members. Resident became mildly defensive with redirection but was able to be redirected. RN U (hospice nurse) was present and witnessed the hallucination. Staff will continue current plan of care. During an interview on 02/27/26, at 12:15 P.M., RN U said the following:-RN U visited the resident every week;-The resident was confused but during the previous two weeks, the resident would say, Don't let that man in here. He's raped me;-RN U said, I just kind of blew it off;-He/she did tell the family about the resident's comments, to see if the resident had a history of abuse in the past;-He/she believed he/she told LPN B or the DON about the resident's comments;-The nurse said the resident was hallucinating and would say, the man was coming to get us. We need to leave. The resident then said there he was and would point to no one;-RN U was unsure if he/she documented the resident's comments or not;-The nurse was unsure exactly when the resident made the rape allegation, but thought it occurred around the last part of January 2026;-On a couple of occasions, the resident was tearful and said this man comes in and rapes me;-He/she thought he/she told CNA H of the resident's comments about being raped on 02/17/26;-The nurse said he/she did not know he/she had to report the resident's allegation of rape since the resident had a diagnosis of dementia. During an interview on 02/27/26, at 1:15 P.M., CNA H said the following:-He/she recalled a time when the resident was at the nurses' station and stated he/she had been raped;-The resident was unable to provide any information about the person that had raped him/her when asked;-The charge nurse and him/her heard the resident say he/she had been raped;-The resident made the same comment about rape a couple days later while he/she and another aide were getting the resident out of bed;-He/she told LPN B or possibly another nurse about the allegation;-The nurse stated the resident had been confused;-He/she would report an allegation to the charge nurse, DON, or the Administrator immediately;-Abuse should be reported to the state in two hours. Review of the DHSS records showed the facility did not self-report the allegation of rape made by the resident. During an interview on 02/27/26, at 1:39 P.M., LPN B said the following:-If a resident reported they were raped, the nurse would speak with the resident and then immediately contact the DON and Administrator to notify;-LPN B would consider a resident claiming rape, to be an allegation of abuse and assault. Review of the resident's progress notes dated 2/27/26, at 2:21 P.M., showed an allegation of sexual assault reported to DHSS. During an interview on 02/27/26, at 2:04 P.M., the DON said the resident had never mentioned rape and no staff/visitor had informed the him/her of an allegation or rape. During an interview on 02/27/26, at 2:12 P.M., CNA I said the following:-He/she would report abuse right away to charge nurse, even if the resident was confused;-The resident would yell rape when he/she had a brief change;-He/she reported the resident allegation of rape to an unknown charge nurse over two months ago. During an interview on 02/27/26, at 2:20 P.M., CNA J said the following:-He/she would report any abuse to the charge nurse right away;-Abuse should be reported to the state within two hours;-He/she would report if a confused resident told him/ they had been raped. During an interview on 02/27/26, at 2:30 P.M., CNA F said the following:-He/she had heard the resident reported he/she had been raped;-He/she thinks this occurred sometime at the end of last year;-The resident had reported rape multiple times;-The rape allegation should have been reported to the Administrator or DON immediately;-The state should be notified of abuse within two hours. During an interview on 03/03/2,6 at 3:25 P.M., LPN G if a resident made an allegation of rape, he/she would notify the DON, Administrator, family, the physician, and DHSS within two hours. During an interview on 03/05/26, at approximately 3:00 P.M., RN V said the following:-If a resident alleged rape, he/she would immediately report the allegation to the Administrator and let the Administrator report to DHSS the allegation;-Staff should treat all allegations or rape as legitimate;-All allegations of rape should be called to DHSS within 2 hours. During an interview on 03/03/26, at 1:55 P.M., the DON said the following:-The hospice nurse should have immediately notified the charge nurse and the DON of the resident's allegation of rape;-Any staff with knowledge of the resident's comments should have also notified the DON;-The DON considered the comment to be an allegation of abuse. 3. During an interview on 02/26/26, at 9:07 A.M., CNA R said the following:-Staff should report all alleged abuse to the charge nurse immediately;-The facility should report all allegations of abuse to DHSS within two hours. During an interview on 03/03/26, at 3:25 P.M., LPN G said the following:-Any staff aware of an allegation of resident abuse should immediately report to their supervisor;-The facility DON or Administrator should report all allegations of abuse to DHSS within two hours. During an interview on 03/05/26, at 5:45 P.M., the Administrator said the following:-Allegations of abuse should be reported immediately to the Administrator;-He/she would notify the state within two hours. Complaint 2785595

Based on interview and record review, the facility failed to ensure after an allegation of abuse, an immediate investigation was completed with steps implemented to protect all residents during the investigation, when staff failed to complete timely investigations of two allegations of abuse involving two residents (Resident #1 and #2). The facility census was 65.Review of the facility's policy titled, Abuse Policy, undated, showed the following-It is the policy of the facility that each resident will be free from abuse;-Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion;-All employees who have been alleged to commit abuse will be suspended immediately pending investigation. Accused visitors will be removed from the building and not allowed to visit until the investigation is completed. Accused residents will be isolated and monitored;-Report the results of all investigations to the Administrator or his/her designated representative and to other officials in accordance with State law, including immediate or 24-hour reporting to the State Survey Agency (SSA – Department of Health and Senior Services (DHSS)) and law enforcement. Send follow-up report to the SSA within five working days of the incident.-If the alleged violation is verified appropriate corrective action must be taken. 1.Review of Resident #1's face sheet showed the following:-admission date of 04/01/24;-Diagnoses included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen) with agitation. Review of the resident's care plan, dated 07/17/25, showed resident resided on the special care unit (SCU) for safety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/12/25, showed the following:-Usually understood and usually understands communication;-Severely cognitively impaired;-Exhibited inattention, behavior present, fluctuates (comes and goes, changes in severity);-Exhibited disorganized thinking, behavior present, fluctuates;-No physical, verbal, or other behavioral symptoms directed toward others;-No rejection of care;-No wandering. Review of the resident's progress note dated 02/23/26, at 12:59 P.M., showed the Director of Nursing (DON) noted resident had scattered bruising on his/her bilateral (both sides) upper extremities (hands/arms) in various stages of healing. When the nurse asked the resident about the cause of the bruising, the resident said he/she woke up that way. Resident denied pain or drainage associated with the bruised areas. No tenderness reported. Resident demonstrated full range of motion to fingers without difficulty. No functional impairment observed. Staff notified physician of bruising. During an interview on 02/25/26, at 10:56 A.M., the Administrator said the following:-On Monday, 02/23/26, at approximately 9:00 A.M. to 9:30 A.M., the resident's responsible party (RP) came to the Administrator's office and said the resident had bruises on his/her hands and arms. An unnamed staff member in the SCU told him/her Certified Nurse Assistant (CNA) A abused the resident;-The Administrator informed the RP he/she was not aware of this allegation of abuse, but would investigate the allegation;-The Administrator interviewed CNA C who said he/she worked the day shift at the facility on the morning of 02/20/26. He/she arrived at work on 02/20/26, at approximately 5:55 A.M., entered the SCU, walked down the hallway, and saw CNA A in the resident's room holding the resident's arms;-CNA C asked why CNA A was in the resident's room and CNA A informed CNA C he/she was putting the resident back to bed;-CNA C said on 02/20/26, between 6:00 A.M. and 6:30 A.M., he/she informed Licensed Practical Nurse (LPN) L about CNA A holding onto the resident's arms;-After reviewing timeclock information, the Administrator said CNA A worked overnight at the facility on Thursday night, 02/19/26. CNA A clocked out on Friday, 02/20/26 at 6:54 A.M. CNA A also worked overnight at the facility on Friday night, 02/20/26, from 5:57 P.M. until Saturday morning, 02/21/26, at 7:01 A.M.; -CNA A worked after the alleged abuse, because the Administrator was not aware of the allegation until 02/23/26;-Both nights, CNA A worked in the dementia unit (SCU) alone;-On 02/23/26, the Administrator viewed 02/20/26 video footage from the hallway of the SCU. The video showed CNA A grab the resident by the arms and push the resident back into his/her room on two separate occasions. During an interview on 02/25/26, at 12:56 P.M., CNA C said the following:-He/she arrived to work on Friday, 02/20/26, at a little before 6:00 A.M., clocked in and entered the SCU;-Upon entering the unit CNA C said he/she heard CNA A repetitively yell, You have to get back in bed;-The resident yelled back, I don't want to go back to bed;-CNA C walked down the hall, stopped at the resident's doorway and looked into the resident's room;-CNA A and the resident were standing near the resident's bed and CNA A had his/her hands on the resident's forearms;-The two were struggling. The resident was trying to get loose from CNA A's grasp, but CNA A held onto the resident's arms;-CNA C told CNA A to get out of the resident's room and leave the resident alone;-CNA A argued saying he/she was not doing anything wrong;-CNA C told CNA A he/she did not need to bother the resident because the resident was able to do his/her own care;-CNA A continued to try to force the resident back toward the bed by holding the resident's arms and pushing the resident;-CNA C then told CNA A to come out of the room and leave the SCU;-Resident #1 was mad and wanted to call the police;-He/she had a hard time calming the resident down;-Approximately 15 minutes later, CNA C said he/she used the phone to call out to the nurses' station and told the nurse on duty, Licensed Practical Nurse (LPN) L, to come to the SCU and look at the resident's arms. CNA C told LPN L that CNA A was trying to hold the resident's arms down and the arms looked bruised;-LPN L came to the SCU and looked at the resident's arms. He/she assumed LPN L would make out an incident report. During an interview on 02/25/26, at 8:04 P.M., LPN L said the following:-If a staff member reported an allegation of resident abuse, he/she would ensure the residents immediate safety. If the abuse involved a staff member, LPN L would walk the alleged staff member out of the building;-He/she worked overnight on Thursday night 02/19/26 into Friday morning 02/20/26;-LPN L said he did not go to the SCU to make rounds because he/she did not have time;-No one informed LPN L of any incident involving the resident and CNA A. During an interview on 02/26/26 at 11:31 A.M., CNA I said the following:-CNA C told CNA I about the resident abuse on 02/20/26, but CNA I did not report the abuse, because CNA C said he/she had reported to the Administrator;-He/she would consider grabbing a resident's arms and causing bruises to be abuse;-If he/she observed CNA A grabbing the resident's arms, he/she would have taken CNA A to the nurse and reported the incident immediately;-If the nurse did not respond appropriately, he/she would have notified the Administrator. During an interview on 02/25/26, at 7:42 P.M., Registered Nurse (RN) Q said the following:-If staff reported an allegation of abuse, he/she would remove the alleged perpetrator from resident care areas and immediately notify his/her DON;-CNA A worked another shift after he/she allegedly abused a resident, but RN Q was unaware of the alleged abuse until 02/23/26. During an interview on 03/03/26, at 1:55 P.M., the DON said:-He/she would consider grabbing a resident's arms and causing bruising to be physical abuse;-Staff alleged to have abused residents should be suspended immediately pending the outcome of the abuse investigation;-The Administrator was responsible for abuse investigations. 2. Review of Resident #2's face sheet showed the following:-Admisison date of 8/12/21;-Diagnoses included dementia, depression, anxiety disorder, delusional disorder, and paranoid personality disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Experienced inattention and disorganized thoughts, behavior present, fluctuates (comes and goes, changes in severity);-Dependent on staff for toileting hygiene, personal hygiene, showering, lower body dressing, and transfers. Review of the resident's care plan, revised 01/16/26, showed the following:-On occasion the resident has signs and symptoms of mood distress, weepy, crying, and doesn't think anyone likes him/her;-Resident has cognitive deficit, anxiety, and depression;-Resident will verbalize feelings of acceptance from others and involve self in activities of his/her choice;-Take resident to quiet, calm area; -Acknowledge to the resident that the current situation must be difficult; -Encourage resident to verbalize feelings, concerns, fears, etc.;-Clarify misconceptions; -Explore with resident past effective and ineffective coping mechanisms. Review of the resident's progress note dated 02/17/26, at 1:15 P.M., showed the DON documented the resident experienced episodes of increased confusion and hallucinations during the shift. Resident repeatedly asked for someone by name, stating that person was present at the facility. Resident also reported that a gentleman was present. Staff redirected the resident and informed the resident that the men present were staff members. Resident became mildly defensive with redirection but was able to be redirected. RN U (hospice nurse) were present and witnessed the hallucination. Staff will continue current plan of care. During an interview on 02/27/26, at 12:15 P.M., RN U (hospice nurse), said the following:-RN U visited the resident every week;-The resident was confused but during the previous two weeks, the resident would say, Don't let that man in here. He's raped me.-RN U said, I just kind of blew it off.-RN U said he/she believed he/she told Licensed Practical Nurse (LPN) B or the DON about the resident's comments;-The nurse was unsure exactly when the resident made the rape allegation, but thought it occurred around the last part of January 2026;-After the nurse reviewed his/her notes, said he/she did not document the allegation of rape;-The nurse said he/she did not know he/she had to report the resident's allegation of rape since the resident had a diagnosis of dementia. During an interview on 03/03/26, at 1:55 P.M., the DON said the following:-The hospice nurse should have immediately notified the charge nurse and the DON of the resident's allegation of rape;-Any staff with knowledge of the resident's comments should have also notified the DON;-The DON considered the comment to be an allegation of abuse. 3. During an interview on 02/26/26, at 9:07 A.M., CNA R said staff should ensure the resident's immediate safety by removing the alleged perpetrator and then report all alleged abuse to the charge nurse immediately. During an interview on 02/26/26, at 9:41 A.M., CNA X said staff should ensure the resident's immediate safety by removing the alleged perpetrator and report all alleged abuse to the charge nurse immediately. During an interview on 03/03/26, at 3:25 P.M., LPN G said if a staff allegedly abused a resident, the facility should suspend the staff member pending the outcome of the investigation. During an interview on 03/05/26, at 5:45 P.M., the Administrator said the following:-Allegations of abuse should be reported immediately to the Administrator;-The nurse should assess the resident(s) involved and notify the resident's family and physician;-He/she would notify the state within two hours and investigate after the allegation;-The investigation should be completed in 5 days. Complaint 278559

Based on observation, interview and record review, the facility failed to complete skin assessments, document accurate wound assessments, obtain and update orders timely, provide treatment as ordered, and care plan for one resident (Resident # 2) with a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 65. Review of an undated facility policy titled 'Wound Care and Treatment' showed the following:-It is purpose of the facility to prevent and treat all wounds;-Prevention strategies include ongoing skin assessments with weekly documentation of status;-Dietician consultation to obtain suggestions on dietary modifications and protein supplementation and to assess the need for a house vitamin supplement if a wound is present;-Obtain a consultation with the quality assurance nurse when resident has no improvement in existing wounds following a two-to-three-week plan of care;-Reevaluate dressing and skin integrity every shift;-Reevaluate the wounds response to the prescribed treatment on a regular basis;-Make recommendations for treatment changes and inform the physician of changes in wound status when needed;-Date, time, and initial all dressings at time of application;-Thoroughly document all wound information such as type, location, stage (if applicable), length, width, depth, drainage, notation of tunneling or undermining, description of tissue, state of peri wound area, and treatment of wound.Review of Resident #2's face sheet (document that gives resident's information at a quick glance) showed the following:-admission date of 08/12/21;-Diagnoses included diabetes mellitus (chronic disease that causes high blood sugar), depression, and edema (fluid accumulation in the body's tissues).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/31/25, showed the following:-Severe cognitive impairment;-Had delusions and hallucinations;-Resident had four unhealed stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough (pale, yellow, white, or gray, moist, and stingy tissue that covers the wound bed of chronic or stalled wounds, acts as a barrier to healing). May also present as an intact or open/ruptured blister) pressure injuries;-Resident is dependent on staff for all activities of daily living (ADLs -essential, routine self-care tasks such as bathing, dressing, touting, and transfers) except eating.Review of the resident's care plan, revised 01/16/26, showed the following:-Resident at risk for skin issues related to impaired function and mobility;-Right heel blister is 100% eschar (thick, dry, black or brown layer of dead tissue that forms over severe pressure ulcers). Area measures 3.5 centimeters (cm) by 7 cm with no drainage. Resident complains of pain to area. Continue treatment, dated 12/04/25;-Skin assessment and inspection every shift with close attention to heel, dated 08/14/24;-Right heel eschar is smaller. Stage 2 pressure area measures 3.5 cm by 4 cm. No depth, drainage or signs or symptoms of infection. Continuing skin prep treatment. Resident complains of pain with treatment, dated 12/26/25;-Observe me for changes in my skin condition during daily care and on bath days. Report any redness or open areas to my nurse, dated 08/14/24.Review of the resident's current 2026 physician's order sheet (POS) showed the following:-An order dated 11/07/25, to apply boot to right heel and float heels at all times;-An order dated 11/07/25, to apply skin prep to right heel blister daily, discontinued on 11/13/25;-An order dated 11/13/25, to skin prep to right heel blister twice daily.Review of a nursing progress note dated 11/07/25 at 4:22 P.M., showed hospice nurse here and noted the resident had a large blister on his/her right heel. Fluid filled, but not eschar. The foot was floating and the boot applied. This information was also added to plan of care.Review of a wound observation report dated 11/07/25 at 11:37 A.M., showed the resident had an unstageable (a full thickness wound where the true depth and stage cannot be determined due to slough or eschar) pressure ulcer measuring 4 cm by 8 cm on the right heel with no drainage.Review of a wound observation report dated 11/13/25 at 10:12 A.M., showed the resident had an unstageable pressure ulcer measuring 4 cm by 8 cm on the right heel with no drainage.Review of a nursing note dated 11/13/25 at 10:17 A.M., showed right heel had an unstageable pressure ulcer which presented as a blister at this time. A 4 cm by 8 cm fluid filled blister appeared dark under the fluid. The resident had a soft boot on for protection, is to have skin prep applied twice daily, and foot is to be elevated for edema.Review of a wound observation report dated 11/20/26 at 11:20 A.M., showed the resident had a stage 2 pressure ulcer measuring 5 cm by 7.5 cm on the right heel, with no drainage. Wound edges noted as a blister.Review of a nursing note dated 11/20/25 at 1:43 P.M., showed the right heel blister remains intact. Measurements are 5 cm by 7.5 cm with darkened skin cover or fluid. Treatment continues. Surrounding skin is pink. Review of a wound observation report dated 11/27/25 at 10:20 A.M., showed the resident had a stage 2 pressure ulcer was measured to be 3.8 cm by 7 cm on the right heel with no drainage. The wound bed was noted to be 100% necrotic (dead, nonviable tissue that prevents healing) tissue.Review of a nursing note dated 11/27/25 at 10:24 A.M., showed right heel measurements are 3.8 cm by 7 cm. Eschar covering the blister remains intact. Fluid filled area palpated to be smaller than the entire area. Surrounding skin is pink/normal.Review of a physician progress note dated 11/30/25 at 10:43 A.M., showed the wound on the right heel is being treated and a protective boot is in place. Staff was to continue current wound care regimen and monitor for improvement or deterioration.Review of the resident's December 2025 Medication Administration Record (MAR) showed heel protectors and skin prep to the right heel were documented as completed as ordered.Review of a wound observation report dated 12/04/25 at 9:00 A.M., showed resident had a stage 2 pressure ulcer measuring 3.5 cm by 7 cm on the right heel with no drainage. Wound bed noted to be 100% eschar tissue.Review of nursing progress note dated 12/04/25 at 2:46 P.M., showed right heel blister is 100% eschar measuring 3.5 cm by 7 cm. No drainage noted. Resident complains of pain with area.Review of a wound observation report dated 12/11/25 at 4:40 P.M., showed the resident had a stage 2 pressure ulcer measuring 3.5 cm by 6.8 cm on the right heel with no drainage. Wound bed noted to be 100% eschar tissue.Review of nursing progress note dated 12/11/25 at 4:44 P.M., showed the stage 2 pressure ulcer to the right heel measured 3.5 cm by 6.8 cm with no depth noted. The area was covered with eschar but was starting to loosen. No drainage, odor, or signs or symptoms of infection noted.Review of a wound observation report dated 12/18/25 at 10:33 A.M., showed the resident had a stage 2 pressure ulcer measuring 3.4 cm by 5 cm on the right heel with no drainage. The wound bed was noted to be 100% eschar tissue.Review of nursing progress note dated 12/18/25 at 10:41 A.M., showed eschar covering the right heel measured 3.4 cm by 5 cm today. No drainage or infection noted. Review of a wound observation report dated 12/23/25 at 9:11 A.M., showed resident had a stage 2 pressure ulcer measuring 3.5 cm by 4 cm on the right heel with no drainage. Wound bed noted to be 100% eschar tissue.Review of nursing progress note dated 12/23/25 at 9:21 A.M., showed the right heel eschar is smaller. Stage 2 pressure area measures 3.5 cm by 4 cm. No depth, drainage, or infection. Continuing skin prep treatment. The resident complained of pain with treatment.Review of a skin assessment dated [DATE], showed no skin issues.Review of the resident's January 2026 MAR showed heel protectors and skin prep to the right heel documented as completed as ordered.Review of a skin assessment dated [DATE], showed no skin issues.Review of a skin assessment dated [DATE], showed no skin issues.Review of a skin assessment dated [DATE], showed no skin issues.Review of a physician progress note dated 01/20/26 at 11:00 A.M., showed the resident had no acute skin concerns noted by staff.No further progress notes for January 2026 related to heel wound.No wound assessments completed for January 2026 to the right heel wound.Review of the resident's February 2026 MAR showed heel protectors and skin prep to the right heel documented as completed as ordered.Review of a skin assessment dated [DATE], showed no skin issues.Review of a skin assessment dated [DATE], showed no skin issues.Review of a skin assessment dated [DATE], showed no skin issues.Review of a skin assessment dated [DATE], showed no skin issues.During an interview and observation of wound care for Resident #2 on 02/25/26 at 1:40 P.M., showed the resident resting in bed with heel protectors and socks on prior to wound care. Licensed Practical Nurse (LPN) B removed the resident's sock and there was a notable odor coming from resident's foot. LPN B said he/she thought the wound treatment should be re-evaluated due to the smell. He/she had noticed an odor since Monday. A black colored round scabbed area was noted to the right heel with no drainage noted. LPN B applied skin prep to the wound bed and then reapplied the sock and heel protector. The resident complained of discomfort upon touching his/her heel.Review of a nursing progress note dated 02/26/26 at 11:17 A.M., showed the resident has an unstageable right heel wound with necrotic tissue, measuring approximately 4 cm x 3.5 cm. Wound borders are no longer attached. The surrounding tissue is pink and warm. No drainage or odor noted. Resident denies pain unless the area is palpated. The hospice nurse and physician were notified and given an update. Continue the current treatment per hospice and physician.Review of a physician progress note dated 02/27/26 at 2:21 P.M., showed the resident had a functional decline and staff should monitor for pressure ulcer development with increased bed rest.Review of a nursing progress note dated 02/27/26 at 3:31 P.M., showed the resident had an unstageable ulcer to the right heel.No additional wound assessments or progress notes related to right heel wound were noted.During an interview on 02/27/26, at 11:25 A.M. and at 3:05 P.M., LPN G said the resident has eschar on his/her right heel that had been there for a while. The resident's order for skin prep to the right heel had not been changed. The wound did not have an odor one week ago when he/she saw it. Skin assessments should include any wounds or bruises. The DON is responsible for completing wound assessments weekly. A wound assessment should include size, drainage, depth, description of the wound, and if any odor is present. An odor from a wound would indicate an infection. During an interview on 02/27/26 at 12:15 P.M., the hospice registered nurse (RN) U said the following:-The resident noted to have a firm black eschar wound to the right heel that measured 3 cm by 3 cm;-The wound measured 8 cm by 4 cm on 11/07/25 and was a fluid filled blister with black soft eschar;-The wound care treatment order is for skin prep to the area and had not changed since initial order on 11/07/25;-He/she does not provide wound assessments to the facility, and he/she does not have access to the facility wound assessments;-He/she did not view the resident's wound during visit today.During an interview on 02/27/26 at 2:08 P.M., the Director of Nursing (DON) said the former Assistant Director of Nursing (ADON) was responsible for wound assessments. He/she did not know why there are no wound assessments since December 2025. He/she had been trying to get started on wound assessments for the last couple weeks.Review of a skin assesssent dated 03/01/26, showed no skin issues.Review of a nursing progress note dated 03/03/26 at 7:32 P.M., showed the right heel was assessed to have no change. Wound measurements were 3 cm by 3 cm with no drainage noted. The foot was elevated to keep the heel off the bed. Hospice nurse was present during treatment.During an interview on 03/05/26 at 22:45 A.M., NP O said nurses should be assessing any type of wound and documenting the observation. He/she had not seen the resident's wound recently. The hospice nurse should be documenting so other providers are able to view his/her notes. The providers would not know how the wound is progressing or, if it is getting worse, if documentation is not shared. During an interview on 03/05/26 at 5:45 P.M., the Administrator said staffing issues have affected nurses completing observations and follow up for wounds. The ADON should complete the weekly wound assessments. The current ADON resigned on 02/17/26. The nurse should document monitoring of skin areas in progress notes and stage all wounds correctly. The facility nurse and hospice nurse should both complete wound assessments if a resident is on hospice.Complaint 2784515

Based on interview and record review, the facility failed to provide laboratory services per standards of practice when the facility staff did not obtain an ordered urinalysis (UA) timely, did not follow-up to obtain timely results of a UA/culture and sensitivity result (a urine sample grown in a lab to identify bacteria or other pathogen and then tested against various bacteria to determine how effective different antibiotics are at killing the bacteria), and did not document follow-up or delays related to the UA for one resident (Resident #3) with an untreated urinary tract infection (UTI). The facility census was 65. Review of the nursing facility laboratory agreement, dated 11/02/20, showed the following:-Common tests will be reported the same day and most other tests will be reported within a 24-hour period;-For those tests that cannot be reasonably reported in those time frames listed, the lab will report results as soon as possible and in a time consistent with leading standards;-The lab provides routine lab days Monday through Friday, excluding holidays.Review of Resident #3's face sheet (a general information sheet) showed the following:-admission date of 02/06/26;-Diagnoses included dementia (loss of mental functions that are severe enough to affect your daily life and activities), anxiety, and cerebral infarction (a blockage in an artery that restricts blood flow to the brain, leading to tissue death).Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/09/26, showed the following:-Resident had severe cognitive impairment; -Resident required moderate staff assistance for toileting, bed mobility, dressing, and transfers;-Resident dependent on staff for showering and hygiene;-Resident incontinent of bladder.Review showed the facility did not provide a care plan for the resident. Review of the resident's physician order, dated 02/14/26, showed an order for UA and urine culture for diagnosis of UTI.Review of the resident's progress notes, dated 02/14/26 to 02/17/26, showed staff did not document regarding obtaining the UA order, lab contact, if UA was obtained, if there was difficulty obtaining the UA, or results from a UA. Review of the resident's progress note, dated 02/18/26, showed a UA was obtained at 7:41 P.M. (four days after initial UA order).Review of the resident's progress notes, dated 02/19/26 to 02/26/26, showed staff did not document regarding the UA status, UA follow-up, or UA findings. Review of the resident's UA and culture final report dated 02/27/26, at 12:37 P.M., showed the following: -Specimen collected from facility on 02/18/26;-Greater than 100,000/milliliter (ml) Klebsiella Aerogenes (a gram-negative bacteria commonly found in the human gut and in the environment that can cause serious infections) and >100,000/ml Hafnia Alvei (a gram-negative bacteria commonly found in the human gut and in the environment that can cause serious infections);-Susceptibility results showed several antibiotics the bacteria were sensitive to, but the report showed both bacteria were resistant (indicating the bacteria will not be killed by the antibiotic) to nitrofurantoin (an antibiotic).Review of the resident's progress note, dated 02/27/26, showed the UA with culture and sensitivity results came in. The physician was in the facility and ordered nitrofurantoin (an antibiotic) 100 (milligrams) mg twice daily for seven days (13 days after initial urinalysis order). Staff did not document regarding a discussion of the infection being resistant to the antibiotic ordered. During an interview on 03/03/26, at 3:25 P.M., Licensed Practical Nurse (LPN) G said medical records used to check for lab results, but they do not have a medical records person now. Nurses should be looking for results by logging into the lab website and checking. He/she did not check the lab website for results regularly. The nurses do not have good communication at the facility.During an interview on 03/05/26, at 11:45 A.M., Nurse Practitioner (NP) O said an UA result with a culture should be complete in three to four days. The lab comes to the facility on Tuesdays and Thursdays. Nine days would be too long for results from a culture. During an interview on 03/03/26, at 2:08 P.M., the Director of Nursing (DON) said resident's initial UA came back and did not appear to be bad, but when the culture and sensitivity returned it was bad. He/she should be calling the laboratory to check on the status but is on the floor working. A culture and sensitivity result should be returned within 24 to 48 hours. He/she never received the results, and no staff had checked on the results. The results came back and said the sample was contaminated. A delay in receiving UA results could cause resident behaviors and a delay in treatment.During an interview on 03/05/26, at 5:45 P.M., the Administrator said he/she was unsure of the time element to receive lab results. A delay in results could have an adverse outcome and cause the resident to not be treated properly. He/she was not aware of any delays for the lab.

Based on observation, record review and interview, the facility failed to implement a complaint infection prevention and control program when the facility failed to review and update their infection prevention and control program policies and procedures manual annually as required. The facility also failed to ensure all staff were trained regarding the use of Enhanced Barrier Precautions (EBP - refers to an infection control method using gowns and gloves for high-contact care of residents with or at risk for MDROs) and failed to follow EBP guidelines as indicate for three residents (Resident #5, #69, #40). Staff failed to follow standard infection control practices when providing cigarettes to two residents (Resident #49 and #68) who smoke when staff touched the filters with the bare hands without performing hand hygiene or donning gloves. Staff failed to complete proper hand hygiene during medication pass involving threes residents (Resident #53, #63, and #43). The facility census was 63. 1. Review of the facility Infection Prevention and Control Policy (IPCP) manual showed the following:-Initial date of the manual was April 2014;-The page entitled Infection Prevention and Control Plan Review was last signed and dated by the Medical Director and the Administrator on 02/06/24;-A document entitled Infection Prevention and Control Program showed Facility Name and Date were not specified;-Review and evaluate the infection prevention/control plan no less than annually and revise as necessary.-Program Evaluation showed no signed/dated approval by the Quality Assurance Committee, Administrator, and Medical Director. During an interview on 12/10/25, at 11:10 A.M., the Administrator said all facility policies were now kept electronically, and he/she did not think the facility did an annual review of the infection prevention and control policies and procedures. The Registered Nurse/Quality Assurance Consultant said he/she was aware of the regulation that required the annual review but had not been involved in that process for the facility. During an interview on 12/11/25, at 2:10 P.M., the MDS Coordinator/Infection Preventionist (IP) said he/she was not aware of the requirement for an annual review of the IPCP. During an interview on 12/11/25, at 2:50 P.M., the Administrator said he/she was not able to locate signed documentation by the Medical Director and the Administrator of an annual review of infection control policies and procedures. 2. Review of the Centers for Disease Control's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 07/12/22, showed the following:-Multidrug-Resistant Organisms (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs;-EBP are infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities;-EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO;-Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care;-EBP use of PPE refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing;-Examples of high-contact resident care activities requiring gown and glove use for EBP includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central line, urinary catheter, feeding tube, and tracheostomy/ventilator, and wound care on any skin opening requiring a dressing;-Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility policy titled Enhanced Barrier Precautions to Infection Control Guidance, showed the following:-To prevent broader transmission of MDRO and to help protect patients with chronic wounds and indwelling devices;-EBP should be implemented for the period of the of their stay or until wounds have resolved or indwelling medical devices have been removed;-Resident known to be infected or colonized with MDRO, with an indwelling medical device regardless of the MDRO status, and/or with a wound, regardless of their MDRO status should have EBP in place;-Use EBP when providing high-contact resident care activities including performing wound care, using an indwelling medical device, and providing hygiene;-Staff should conduct proper hand hygiene before starting care;-Gloves and donning and doffing of gown are required when conducting high-contact resident care activities;-Residents that are placed on EBP should have personal PPE in proximity outside the door and a trash can in residents' room for disposal prior to leaving the room. 3. Review of Resident #5's face sheet (a brief information sheet about the resident), showed the following:-admission date of 08/12/21;-Diagnoses included pressure ulcer of sacral region (area just above the tailbone). Review of the resident's admission Minimum Data Set (MDS- a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/09/25, showed the following:-At risk for developing pressure ulcers/injuries;-Had 1+ unhealed pressure ulcers/injuries;-One stage 1 (intact skin that is red or discolored) pressure ulcer/injury;-Two stage 2 (a shallow, open wound appearing as a pink or red sore, blister, or abrasion) pressure ulcers;-Received hospice care. Review of the resident's December 2025 facility physician order sheet (POS), showed an order, dated 12/10/25, for EBP related to wounds/pressure areas. Observation on 12/10/25, at 9:33 A.M., showed Licensed Practical Nurse (LPN) B and Certified Nurse Aide (CNA) H provide wound care to the resident. Both staff washed their hands upon entering the resident room and applied gloves. CNA H assisted the resident with rolling on his/her left side and removing his/her adult brief. LPN B cleansed the resident's buttock, removed his/her gloves, washed his/her hands, and applied new gloves. The resident was noted to have two scabbed areas to the upper buttock area with surrounding redness. LPN B applied barrier cream to the buttock wounds. CNA H assisted the resident with reapplying the resident's adult brief. LPN B removed his/her gloves, washed his/her hands, and applied new gloves. CNA H removed the resident's right heel boot and sock. LPN B cleaned the large right heel wound, which was a dried black area, with wound cleanser and two skin pads. The wound was air dried. CNA H reapplied the resident's sock and right heel boot. CNA H removed his/her gloves and washed his/her hands in the resident's room before exiting. LPN B removed his/her gloves in the room but did not wash his/her hands in the room or use hand sanitizer prior to exiting the resident's room. LPN B and CNA H did not wear a medical gown during the wound care process as required for EBP. During an interview on 12/12/25, at 9:28 A.M., CNA C said does the typical hand washing before and after providing care to the resident but does nothing different than with any other resident. The resident has a sore, but he/she did not know if the resident is or should be on EBP. During an interview on 12/12/25, at 9:50 A.M., Certified Med Tech (CMT) D said the resident had a sore and should be on EBP. During an interview on 12/12/25, at 11:04 A.M., LPN E said he/she did not think the resident had a wound and the resident was not on EBP that he/she is aware of. During an interview on 12/12/25, at 11:16 A.M., LPN B said the resident was on EBP. He/she should have worn a gown when he/she changed his/her wound dressings. During an interview on 12/12/25, at 12:50 P.M., the Director of Nursing (DON) said the resident had two pressure sores. He/she would expect staff to use EBP when providing care to the resident. During an interview on 12/12/25, at 1:03 P.M., the Administrator said staff were expected to use EBP for the resident. 4. Review of Resident #69 's face sheet showed the following:-admission date of 12/09/25;-Diagnoses included discitis (rare but serious inflammation or infection of the intervertebral disc space—the soft cushions between your spinal bones) thoracic regions (middle part of the chest, situated between the neck and abdomen), infection of intervertebral disc thoracic region, osteomyelitis (infection of bone), and infective myositis (inflammation of the muscles, often leading to weakness, fatigue, and pain). Review of the resident's care plan, dated 12/11/25, showed the following:-EBP Precautions;-Staff should assist with transfers, positioning and other cares. Review of the physician order sheet, current as of 12/12/25, showed the following:-An order, dated 12/09/25, for ceftriaxone reconstitute solution (powerful antibiotic used to treat a wide variety of serious bacterial infections), 2 grams intravenous (IV – administered in the veins) once per day;-An order, dated 12/11/25, to flush peripherally inserted central catheter line (PICC - is a long, thin tube inserted into a vein in the arm and threaded to a large central vein near the heart ) with 0.9% sodium chloride solution (sterile solution of sodium chloride (salt) and water for injection) before and after administration of antibiotic;-An order, dated 12/10/25, resident on EBP related to PICC line of the right upper arm. During an observation on 12/11/25, at 9:04 A.M., RN A applied gloved and prepared resident's IV antibiotic in the medication room. RN then entered resident room with IV supplies and placed IV bag on the IV pole. The nurse inspected the resident PICC line dressing and the insertion site. He/she the wiped the end of the PICC line IV with an alcohol wipe. He/she flushed the PICC line and then attached the IV tubing and started the antibiotic IV drip. He/she left the room and removed his/her gloves. There was no sign or butterfly on the outside of the resident's room door noting EBP required. The nurse did not apply a gown when working with the resident. 5. Review of Resident #40's face sheet showed the following:-admission date of 06/18/24;-Diagnoses included nontraumatic intracerebral hemorrhage (severe type of stroke with high death rates), methicillin susceptible staphylococcus aureus infection (MSSA – common bacterial infection causing various infections, skin issues to bloodstream infections), non-pressure chronic ulcer of skin (persistent skin sore lasting over 4 weeks that fails to heal normally), open wound right lower leg, blister of left foot, furuncle (pus filled skin abscess resulting from bacterial infection) of buttock open wound left lower leg, pressure ulcer (skin and soft tissue damage from prolonged pressure) of unspecified site. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident had pressure ulcer or injury over bony prominence;-Resident at risk for developing pressure ulcers;-Use of wheelchair for mobility. Review of the resident's care plan, last updated 12/04/25, showed the following:-Resident was at risk for skin issues related to bilateral lower extremity edema, (edema) incontinence (lack of voluntary control over urination), impaired functions and mobility, and other disease processes;-Resident had EBP precautions;-Staff should use EBP precautions;-Wound culture reports showed pseudomonas aeruginosa and staphylococcus aureus. Review of the resident's physician order sheet, current as of 12/12/25, showed the following:-An order, dated 11/27/25, apply skin prep to right outer calf daily until healed;-An order, dated 12/04/25, clean left heel area with wound cleaner, apply skin prep (applying a special liquid or wipe to the skin around a wound or medical device to create a protective, breathable film, preventing irritation) to peri-wound (skin and tissue immediately surrounding a wound). Cover with island dressing. Change daily and as needed;-An order, dated 12/05/25, cleanse upper buttock with wound cleaner, apply skin prep to peri-wound. Apply calcium alginate (wound dressing to absorb fluid and create a moist healing environment) to wound bed, cover with island dressing. Change daily and as needed.(There was no order for EBP.) During observation on 12/10/25, at 1:25 P.M., LPN B entered resident room with wound care supplies and placed on bedside table. CNA I entered resident room to assist. The staff washed their hands at the sink and applied gloves. Staff did not apply gowns. Staff assisted resident to roll to right side and completed wound care to upper right buttock. Staff removed gloves and wash hands at sink. The CNA left the room. The nurse applied gloves and removed the resident's foam boot from the left foot, completed wound care, and re-applied foam boot. The nurse removed gloves and washed hands at sink. The nurse applied gloves and pulled back covers and observed resident right side of right leg showed healed wound and returned covers and did not complete any wound care. The nurse washed hands at sink and left room. There was no EBP sign on door and no PPE readily available. The staff did not wear a gown while completing wound care. 6. During an interview on 12/12/25, at 9:28 A.M., CNA C said the following:-EBP means having barrier cream in the room;-The charge nurse or DON would let him/her know if a resident is on EBP;-He/She has not received any training on EBP, so he/she does not know for sure what that is;-He/She is not aware of any residents being on EBP. During an interview on 12/12/25, at 9:50 A.M., CMT D said the following:-EBP means staff should wear proper PPE such as gowns and gloves;-Residents on EBP should have a basket in their room with gowns available and a butterfly sticker on the wall outside his/her room;-Residents with infections, catheters, and intravenous lines should be on EBP;-On occasion, he/she receives an in-service on EBP. The training is different each month. During an interview on 12/12/25, at 11:04 A.M., LPN E said the following:-He/She has received training and education on EBP;-EBP consists of hand washing and wearing gowns and gloves. During an interview on 12/12/25, at 11:16 A.M., LPN B said the following:-The process of EBP involved handwashing, hand hygiene, and the use of gloves, and gowns;-EBP should be used with residents who have wounds, catheters, and infections;-Residents on EBP should have a butterfly sticker on the wall outside their door to alert staff. During an interview on 12/12/25, at 12:50 P.M., the DON said staff are expected to wear gowns and gloves with residents on EBP. During an interview on 12/12/25, at 1:03 P.M., the Administrator said staff are expected to use hand hygiene, gowns, and gloves for EBP. 7. Observation on 12/09/25, at 10:30 A.M., showed the following:-RN A entered the locked medication room and exited with three unpackaged resident cigarettes and one unpackaged resident cigar in his/her bare hands. The RN did not complete handwashing, hand sanitizing, or use of glove;-Housekeeper F pushed his/her work cart to the nurses' station, put his/her coat on, and received the individual, unpackaged cigarettes and cigar with his/her bare hands from RN A. The housekeeper did not complete hand washing, hand sanitizing, or use of gloves;-Housekeeper F held the cigarettes and cigar in one hand while also pushing one resident outside in his/her wheelchair using both hands;-At the outside designated smoking area, Housekeeper F handed each resident their cigarette/cigar with his/her bare hands, and lit them for each resident;-Housekeeper F smoked his/her own cigarette at the same time the residents were smoking. Observation on 12/10/25, at 1:12 P.M., showed the following:-LPN B entered the locked medication room and obtained three cigarettes by grabbing the filters from three separate cigarette packages with his/her bare hands. The LPN did not complete hand washing or hand sanitizing, and did not use gloves;-LPN B carried the cigarettes to the nurse's station with his/her bare hands and handed the cigarettes to Floor Technician G, who had just arrived at the nurses' station and had just put his/her coat on. The floor tech did not complete hand washing or hand sanitizing, and did not use gloves;-Floor Technician G took the cigarettes into his/her bare hands, touching each cigarette filter;-Floor Technician G kept the cigarettes in his/her right hand while attempting to push one resident outside in his/her wheelchair with both hands;-He/She was observed having difficulties holding the cigarettes while pushing the resident in his/her wheelchair;-Floor Technician G placed all three cigarettes in his/her coat pocket. 8. Review of Resident #49's face sheet showed an admission date of 06/11/25. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, dated 06/11/25, showed the resident smokes with potential for injury/adverse effects and required staff supervision during all scheduled smoke breaks. During an interview on 12/12/25, at 10:43 A.M., the resident said the following:-He/She would prefer that staff not touch his/her cigarettes with their bare hands;-He/She would like staff to give his/her cigarettes to him/her directly from the cigarette package, without touching them;-The resident felt like he/she could get an illness from staff due to them touching the filter of his/her cigarettes with their bare hands, especially with two staff touching the cigarettes with their bare hands every time he/she smokes. 9. Review of Resident #68's face sheet showed an admission date of 12/05/25. During an interview on 12/12/25, at 10:33 A.M., the resident said the following:-He/She did not like the staff touching his/her cigarettes with their bare hands;-He/She thought he/she could get sick from staff touching his/her cigarettes, especially since at least two staff members touch the cigarettes with their bare hands during each smoke break;-He/She does not want to get sick if staff do not wash their hands before touching his/her cigarettes with their bare hands;-The resident did not think it was appropriate for staff to put his/her cigarettes in their coat pocket after they remove them from the cigarette package;-He/She would like to have his/her cigarettes provided to him/her directly from the cigarette package, without staff touching them. 10. During an interview on 12/09/25, at 10:00 A.M., RN A said the following:-The charge nurse or another nursing staff member who has a key to the locked medication room will take an individual cigarette out of each resident's cigarette package while they are in the medication room and hand the individual cigarettes directly to another staff member in one of the following departments (restorative therapy, housekeeping, activities, dietary, or nursing), and that staff member hands the individual cigarettes to each resident once they reach the designated smoking area outside.-The facility currently has four smokers;-Residents are allowed to smoke up to seven times per day;-Residents are only allowed one cigarette per smoking event. During an interview on 12/12/25, at 9:28 A.M., CNA C said the following:-The nursing staff takes the individual cigarettes out of the locked medication room with their bare hands and hands them to the staff responsible for taking the residents out to smoke;-He/She assumed it was not appropriate for staff to touch the resident's individual, unpackaged cigarettes with their bare hands;-Staff should wear gloves when touching resident cigarettes;-It was not appropriate for staff to put resident cigarettes in their coat pocket while escorting residents outside to smoke;-There was a potential for residents to become ill from staff touching their cigarette filter with their bare hands and without the use of gloves. During an interview on 12/12/25, at 9:50 P.M., CMT D said the following:-The nurses or medication technicians pull one cigarette out of each resident's cigarette package with their bare hands while in the locked medication room and they hand the cigarettes to the staff that will be taking the residents out to smoke;-The cigarettes change hands a couple of times before the residents receive them;-The cigarettes packs never leave the medication room, only the individual, unpackaged cigarettes;-It is not appropriate for staff to touch the filters of the resident's cigarettes with their bare hands that have not been washed;-Usually, the housekeeping staff take the residents out to smoke;-It is not appropriate for staff to put the resident's cigarettes in their coat pocket while taking them out to smoke;-If staff is not using proper handwashing there is a potential for residents to become ill from staff touching the filter on their cigarettes with their bare hands and without gloves. During an interview on 12/12/25, at 11:00 A.M., Housekeeper F said the following:-He/She asked the charge nurse to get the resident's cigarettes out of the locked medication room for him/her;-He/She was a smoker, so he/she knew which unpackaged cigarette went to which resident without having the packaging. If he/she had any questions the charge nurse will show him/her which cigarette belongs to each resident;-It was not appropriate for staff to touch the resident's cigarettes with their bare hands that have not been washed or sanitized or without gloves;-It was not appropriate for two staff to touch the resident's cigarettes with their bare hands, especially the filter that the resident will be putting in their mouth;-It was not okay for staff to put the resident's cigarettes in their coat pocket while taking the residents out to smoke;-There is a potential for residents to become ill from staff touching the filter of their cigarette without using gloves. During an interview on 12/12/25, at 11:04 A.M., LPN E said the following:-The nurses have the key to the locked medication room, so they get the resident cigarettes out and hand them to the staff member that is scheduled to take the resident's out to smoke;-Individual cigarettes that have been removed from the packaging are handed to the staff that supervises the smokers;-It was not appropriate for staff to touch the resident's cigarettes, especially the filter of the cigarettes with their unwashed, non-sanitized, and non-gloved bare hands, but that is what has been happening;-It was probably not appropriate for staff to put a resident's unpackaged cigarette in their coat pocket;-Residents could become ill from staff touching the filter of their cigarette with their bare, ungloved hands, but that is what has been happening, even though staff try not to touch the cigarette filters. During an interview on 12/12/25, at 11:16 A.M., LPN B said the following:-Each resident gets one cigarette per smoke break;-Staff use their bare hands to obtain the cigarettes from the resident's cigarette package in the locked medication room;-The cigarette package does not go outside of the locked medication room;-Since only four residents smoke, he/she just remembers which cigarette each resident gets once the cigarettes are removed from the packages;-It was not appropriate for staff to touch the resident's cigarettes with their bare hands that have not been washed or sanitized or without wearing gloves, but that is what has been happening.-It was not appropriate for two staff to touch the resident's cigarettes with their bare hands, particularly the filter that the residents will be putting in their mouth;-It was not appropriate for staff to put the resident's cigarettes in their coat pocket while taking them out to smoke;-There was a potential for the resident to become ill from staff touching the filter of their cigarette with their bare hands and without using gloves. During an interview on 12/12/25, at 12:50 P.M., the Director of Nursing (DON) said the following:-The nurses and medication technicians have a key to the locked medication room where the cigarettes are kept. They obtain the cigarettes and pass them on to the staff scheduled to take the residents outside to smoke;-The cigarettes are handed to the residents outside the building;-The residents know what their cigarette looks like, and staff know which cigarette to give each resident since there are only three or four residents that smoke;-All staff are supposed to be wearing gloves to handle the resident's cigarettes;-It was not appropriate for staff to put individual, unwrapped cigarettes in their coat pocket while residents are being escorted outside the facility to smoke;-Unfortunately, yes there is a potential for the residents to become ill from staff touching the filters of the cigarettes with their bare hands and without the use of gloves. During an interview on 12/12/25, at 1:03 P.M., the Administrator said the following:-The nursing staff obtain the resident's cigarettes from the locked medication room and give them to staff that are responsible for taking the residents outside to smoke;-The facility has three smokers and they all smoke different kinds. The cigarettes are kept in a bin with the resident's name on it. Staff just know which cigarette to give each resident after they are removed from the cigarette package and the residents know which cigarette is theirs; -In his/her mind, staff should be wearing gloves to handle the individual, unpackaged cigarettes since the cigarettes are going into the resident's mouths;-Staff should not hold the cigarette at the filter for sure since that is the part the resident puts in his/her mouth;-It is not appropriate for staff to touch the cigarettes with their bare hands or put the cigarettes in their coat pocket;-There is always a potential for the resident to become ill from staff touching the filter of a resident's cigarette with their bare hands because we don't know if the staff washed their hands or not;-He/She prefers that staff wear gloves or have clean hands while touching the resident cigarettes. 11. Observation on 12/11/25, at 8:30 A.M., showed the following:-RN A applied gloves and picked up the glucometer (device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip) from the top of the medication cart. The RN entered Resident #53's room. The nurse wiped the resident's right middle finger with an alcohol wipe, poked the finger with a lancet (small, sharp, pointed surgical blade used for making precise, small incisions or punctures), and obtained a blood sample onto the test strip attached to the glucometer. He/she left the room and disposed of supplies at the medication cart. He/she placed the glucometer on a towel on the top of the medication cart. He/she did not wipe down the glucometer; -He/she removed his/her gloves and without completing hand hygiene he/she documented in the computer and applied new gloves. and went to the medication techs medication cart to obtain oxycodone (strong prescription narcotic used to treat moderate to severe pain) for the Resident #53. He/she pulled up 0.25 ml of oxycodone into the syringe. The syringe slipped and fell on the floor. The RN picked up the syringe from the floor and went to the cart and disposed of the medication and the syringe into sharps container with LPN A observing. The RN used the same gloved hands and looked through the medication cart and located a new syringe. He/she opened the syringe from the plastic wrap and pulled up 0.25 ml oxycodone. He/she then entered the resident room and administered oxycodone;-He/she left room and put syringe and oxycodone back to locked box. He/she removed gloves and documented medications. The nurse did not complete hand hygiene and moved the medication cart down the hall to the nurse station. Observation on 12/11/25, at 8:50 A.M., showed the following: -RN A applied gloves without completing hand hygiene between residents and obtained Trulicity injection (brand-name prescription medication used primarily to treat Type 2 diabetes (chronic condition that affects the way the body processes blood sugar (glucose)) for Resident #63. He/she then went down the hall and entered the resident's room and administered the injection to resident's abdomen. He/she then returned to the cart, disposed of syringe, and remove gloves. He/she used hand sanitizer on hands. Observation on 12/11/25, at 8:56 A.M., showed the following:-RN A applied gloves and picked up the glucometer from the top of the medication cart. He/she did not wipe down or sanitize the glucometer between residents. The nurse then wiped Resident #43's left middle finger with an alcohol wipe and poked the finger with lancet and obtained blood sample onto the test strip attached to the glucometer. The nurse then prepared Lantus Insulin Pen (prefilled injection device containing long-acting insulin glargine, a man-made insulin that helps control high blood sugar) and prepared Novolog Insulin Pen (prefilled injection device containing insulin aspart, a rapid-acting human-made insulin used to manage blood sugar levels). He/she then administered insulin in abdomen. The nurse disposed of the insulin needles and put away the insulin pens and removed his/her gloves. The nurse did not complete hand hygiene and moved on to the next resident. During an interview on 12/12/25, at 10:40 A.M., LPN B said staff should complete hand hygiene between each resident and each dirty to clean process. The glucometer should be cleaned with the sanitizing wipes on the carts. He/she said he/she should have worn a gown during wound care. During an interview on 12/12/25, at 11:45 A.M., MDS Coordinator/Infection Preventionist said the staff should complete hand hygiene between every resident and between dirty to clean tasks. The staff should clean the glucometer between each resident. During an interview on 12/12/25, at 12:30 P.M., DON said staff should complete hand hygiene between each resident interaction and the glucometer should be cleaned between each resident contact. During an interview on 12/12/25, at 12:50 P.M., the Administrator said the nursing staff should clean the glucometer between each resident and should be completing hand hygiene between each resident interaction, as well as between dirty and clean process, picking up an item on the floor then picking another clean item.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) level one was retained in the resident's medical record and accessible for one resident (Resident #38) of four residents reviewed for PASARR. The facility census was 63.Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) level one was retained in the resident's medical record and accessible for one resident (Resident #38) of four residents reviewed for PASARR. The facility census was 63. Review showed the facility did not provide a written policy pertaining to PASARRs. 1. Review of Resident #38's face sheet (gives brief profile information) showed the following:-admission date of 06/11/12;-Diagnoses included paranoid schizophrenia (mental disorder characterized by intense delusions and hallucinations), bipolar disorder (mental health condition causing shifts in mood), borderline intellectual functioning (cognitive profile between normal intelligence and intellectual disability), major depressive disorder, and insomnia.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 10/29/25, showed the following:-Mild cognitive impairment;-Diagnoses included bipolar disorder and schizophrenia;-Medications included routine antipsychotic, antidepressant, and antianxiety.Review of the resident's care plan, last reviewed/revised 10/29/25, showed the following information:-Potential for elopement and poor safety awareness;-Talk with psychologist every two weeks if willing to participate;-At risk for behaviors related to diagnosis of schizophrenia;-Administer medications as ordered and monitor effectiveness and adverse effects, offer interventions if behaviors occur;-Displays signs and symptoms of mood distress;-Encourage and allow resident to talk and verbalize feelings, be a good listener, non-judgmental, offer reassurance, even if it's incoherent or delusional;-Has delusions/hallucinations and believes they are real; -Reorient when needed if reorientation does not cause distress;-Observe for non-verbal signs of distress;-Experienced trauma in life since a very young age and may need assistance to address the physical, behavioral and or social impacts of the trauma;-Has developed fear, terror, dread or helplessness following exposure to a traumatic event of sexual assault/rape, mental abuse, and violence; -Actively listen to details and recollections surrounding the traumatic event; -Maintain safety and integrity during post-traumatic episodes using appropriate therapeutic interventions;-Impaired decision making and tends to isolate related to diagnosis of paranoid schizophrenia, bipolar, and depression;-Report worsening signs of isolation. Review of the resident's physician order sheet (POS), current as of 12/12/25, showed active orders for Abilify (an antipsychotic medication), bupropion hydrochloride (an antidepressant), divalproex (an anticonvulsant used to treat bipolar disorder), Invega Sustenna (an antipsychotic medication); sertraline (an antidepressant medication), and trazodone (an antidepressant medication) tablet.Review of the resident's medical record showed no copy/documentation of a completed Level 1 PASARR screening. During an interview on 12/12/25, at 12:06 P.M., the Assistant Director of Nursing (ADON) said the facility should obtain a copy of the completed Level 1 PASARR from the discharging hospital before a resident is admitted to the facility. If the resident is admitting from home, the facility should request a Level 1 or DA-124 as soon as possible through the resident's primary care physician (PCP). During an interview on 12/12/25, at 12:10 P.M., the Business Office Manager (BOM) said a Level One PASARR screening should be completed by the hospital prior to their facility admitting the resident. If triggered, a Level Two screening should also be completed. The facility should obtain and maintain copies of any screenings. If the resident is admitting from home, the facility should contact the resident's PCP to initiate a DA-124/Level One screening as soon as possible. The BOM said he/she had contacted the state agency (COMRU) and was told the original screening was no longer available; the screening was done prior to 2013. The facility is requesting a replacement screening currently. During an interview on 12/12/25, at 12:30 P.M., the Director of Nursing (DON) said the Level One PASARR screening is to be completed by the hospital prior to discharging a resident to a skilled nursing facility; the Level Two is also to be completed if it was triggered/indicated. The facility should make sure they have the completed assessments prior to accepting the resident. If the resident is admitting from home, the facility should initiate the screening through the resident's PCP based on the diagnoses. During an interview on 12/12/25, at 12:35 P.M., the Administrator said the facility should have a copy of the Level One and/or Level Two PASARR screening(s) completed by the hospital for each resident. The facility did not have specific policies for the completion of the PASARRs, but they would follow guidelines and refer to the regulations.

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to provide wound care per physician orders for one resident (Resident #40's). The facility had a census of 63.Review of the facility provided policy, Wound Care and Treatment, undated, showed the following:-It is the purpose of this facility to prevent and treat all wounds;-There must be a specific order for the treatment. 1. Review of Resident #40's face sheet (brief information sheet about the resident) showed the following:-admission date of 06/18/24;-Diagnoses included nontraumatic intracerebral hemorrhage (severe type of stroke with high death rates), methicillin susceptible staphylococcus aureus infection (MSSA - common bacterial infection causing various infections, including skin issues to bloodstream infections), non-pressure chronic ulcer of skin (persistent skin sore lasting over four weeks that fails to heal normally), open wound right lower leg, blister of left foot, furuncle (pus filled skin abscess resulting from bacterial infection) of buttock open wound left lower leg, and pressure ulcer (skin and soft tissue damage from prolonged pressure) of unspecified site. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 11/21/25, showed the following:-Severe cognitive deficit;-Resident had pressure ulcer or injury over bony prominence;-Resident at risk for developing pressure ulcers. Review of the resident's care plan, last updated 12/04/25, showed the following:-Resident was at risk for skin issues related to bilateral lower extremity edema (swelling), incontinence (lack of voluntary control over urination), impaired functions, and mobility, and other disease processes;-Interventions will remain in place to reduce resident risk of skin impairment and breakdown to the extent possible with disease process;-Staff should follow treatment for all areas in place;-Staff should continue current plan of care. Review of the resident's Physician Order Sheet (POS), current as of 12/12/25, showed the following:-An order, dated 11/27/25, to apply skin prep (special liquid or wipe to the skin around a wound or medical device to create a protective, breathable film, preventing irritation) to right outer calf daily until healed;-An order, dated 12/04/25, to clean left heel area with wound cleaner, apply skin prep to peri-wound (skin and tissue immediately surrounding a wound), cover with island dressing, and change daily and as needed;-An order, dated 12/05/25, to cleanse upper buttock with wound cleaner, apply skin prep to peri-wound, apply calcium alginate (wound dressing to absorb fluid and create a moist healing environment) to wound bed, cover with island dressing, and change daily and as needed. Observation on 12/10/25, at 1:25 P.M., showed the following-Licensed Practical Nurse (LPN) B entered the resident's room with wound care supplies and placed them on the bedside table;-The LPN removed dressing from resident's upper right buttock and wiped the open area with wound cleanser on gauze. The nurse applied applied a small piece of calcium alginate to the wound, applied non-stick gauze and border tape over the wound, and initialed and dated tape. The LPN said he/she did not find any island dressing to apply (resident's orders stated to apply island dressing over calcium alginate);-The LPN removed the soft boot from residents left foot. No dressing covered the resident's heel. The LPN applied skin prep to the area approximately 2 centimeter (cm) in diameter, red area The nurse re-applied the soft boot over the left foot. (The LPN did not cover the heel with the ordered island dressing and did not clean the wound with wound cleanser as ordered.);-The LPN pulled back covers to observe the outer aspect of the resident's right leg. The area had a dried scab approximately 1/2 cm in diameter with no drainage and no redness. The LPN did not wipe with skin prep as he/she said the wound was healed;-The nurse returned the covers over the resident legs and did not complete any wound care. During an interview on 12/12/25, at 9:50 A.M., Certified Medication Tech (CMT) D said that staff should follow physician's orders when providing medications or completing treatments. During an interview on 12/12/25, at 10:40 A.M., LPN B said that staff should follow wound care orders. If the order states to use wound cleanser, skin prep, and cover with dressing the orders should be followed. If the order states to use skin prep until healed, staff should follow the order. Staff should notify the doctor that wound is healed and discontinue the order. During an interview on 12/11/25, at 8:28 A.M., Registered Nurse (RN) A said staff should follow physician orders for wound care. If a wound was healed, the staff should notify the doctor and get approval to discontinue the order. During an interview on 12/12/25, at 11:45 A.M., the MDS Coordinator/Infection Preventionist said staff should follow physician orders when completing wound care or other treatments. The nursing staff should contact the doctor if the order needed discontinued. During an interview on 12/12/25, at 12:20 P.M., RN L said nursing staff should be following physician orders when completing wound care or treatments. During an interview on 12/12/25, at 12:30 P.M., the Director of Nursing (DON) said nursing staff should follow physician orders for wound care. The nurse should contact the doctor if the order needed to be adjusted or discontinued. During an interview on 12/12/25, at 12:50 P.M., Administrator said staff should follow physician's orders for wound care. If order states wound cleanser, skin prep and dressing, this should be followed. If the order is no longer relevant, if wound was healed, staff should get a new order to discontinue the wound care.

Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to change oxygen tubing per professional standards, failed to document the change of oxygen tubing, failed to ensure appropriate storage of oxygen tubing that was not in use, failed to document pulse ox readings, failed to follow oxygen orders, and failed to ensure that the facility oxygen orders and the Hospice oxygen orders matched for one resident (Resident #5). The facility census was 63. Review of the facility's policy Oxygen Administration, undated, showed the following:-For nasal cannula, connect tubing to humidifier outlet and adjust liter flow as ordered;-At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier, and assess resident's respiration to determine further need for oxygen therapy;-Place cannula tubing in plastic bag attached to concentrator when tubing is not in use. 1. Review of Resident #5's face sheet (a brief information sheet about the resident), showed the following:-admission date of 08/12/21;-Diagnoses included atherosclerotic heart disease (a heart disease caused by plaque buildup in the arterial walls), chronic obstructive pulmonary disease (COPD - a lung disease that makes breathing difficult), hypoxemia (a lower than normal oxygen level in your blood), and heart failure. Review of the resident's admission Minimum Data Set (MDS- a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/09/25, showed the following:-Moderate cognitive impairment;-Dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, putting on and taking off footwear, rolling left and right, sit to lying, sit to stand, chair/chair-to-bed transfer, toilet transfer, and tub/shower transfer;-Partial to moderate assist for oral and personal hygiene;-Oxygen therapy;-Hospice care. Review of the resident's care plan, last revised 12/09/25, showed the following:-Resident receiving hospice services;-At risk for respiratory distress/infections related to seasonal allergies and COPD;-Interventions will remain in place to reduce risk of having signs of respiratory distress;-Administer oxygen as ordered;-Observe oxygen precautions;-Explain the importance of keeping oxygen at the prescribed setting;-Stress more oxygen may not be better;-Monitor and report signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds) and report to charge nurse and physician;-Monitor oxygen saturation via pulse oximetry (pulse ox-device that measures blood oxygen) as ordered;-On 10/04/25, over the weekend, the resident had an episode of oxygen saturation being around 60%. Oxygen applied continuous, but resident would not leave it on continuous. Continue to encourage resident to use oxygen when necessary. Review of the resident's December 2025 Physician Order Sheet (POS), showed the following:-An order, dated, 05/19/22, for oxygen 2 liters per nasal cannula as needed for shortness of breath, or oxygen saturation below 92% room air;-An order, dated 05/19/22, to check oxygen saturation as needed and notify physician if less than 90%;-An order, dated 09/02/24, to change oxygen tubing and humidifier bottle weekly and as needed, place in plastic bag when not in use. Review of the resident's Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report, dated 10/17/25, showed the following:-On 09/29/25, the resident's oxygen saturation level was greater than 98% on room air;-A physician order, dated 10/05/25, for oxygen at 2 to 4 liters per nasal cannula as needed for comfort. Review of the resident's progress notes showed the following:-On 10/05/25, at 12:37 P.M., staff noted oxygen saturation initially 45%, rechecked and still low at 60%. No cyanosis (blue color) or respiratory distress. Oxygen placed per nasal cannula at first then switched to non-rebreather mask at 4 liters per minute. Staff notified hospice nurse notified. (Staff did not document physician notification of the low oxygen saturation);-On 10/05/25, at 2:50 P.M., staff noted hospice nurse present and assessed the resident. Hospice nurse recommended the resident wear oxygen continuously to maintain oxygen saturation greater than 90%.Review of the resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report, date 10/31/25, showed a physician order, dated 10/05/25, for oxygen at 2 to 4 liters as needed for shortness of breath.Review of the resident's progress notes showed the following:-On 10/06/25, at 6:06 A.M., staff noted oxygen saturation 92% on room air;-ON 10/06/25, at 6:55 P.M., staff noted oxygen saturation 74% on room air. Oxygen placed on resident and oxygen saturation increased to 90%. (Staff did not document the liters of oxygen the resident received or physician notification of the low oxygen saturation);-On 10/07/25, at 10:34 A.M., staff noted the resident's oxygen saturation was 78% on room air. Oxygen placed on the resident at 4 liters per minute to maintain oxygen saturation at 90%. (Staff did not document physician notification regarding the low oxygen saturation.) Review of the resident's Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report, dated 10/17/25, showed the following:-On 10/07/25, oxygen saturation was 76% on 2 liters of oxygen;-On 10/10/25, oxygen saturation was 99% on room air;-On 10/15/25, oxygen saturation was 100% on room air. Review of the resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 10/31/25, on 10/17/25, oxygen saturation was 98% on room air. Review of the resident's progress notes showed the following:-On 10/24/25, at 5:31 P.M., staff noted oxygen saturation 95% on room air;-On 10/26/25, at 2:03 P.M., staff noted oxygen saturation 94% on 2 liters of oxygen;-On 10/26/25, at 6:33 P.M., staff noted oxygen saturation 95% on 2 liters of oxygen per nasal cannula. Review of the resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 10/31/25, showed on 10/28/25, oxygen saturation was 94% on 2 liters of oxygen. Review of the resident's October 2025 Treatment Administration Record (TAR) showed the following:-Staff did not document related to the oxygen tubing and humidifier bottle being changed weekly and placed in a plastic bag when not in use;-Staff did not document related to the resident's oxygen saturation being checked as needed or the physician being notified regarding an oxygen saturation of less than 90%;-Staff did not document related to oxygen 2 liters per nasal cannula being applied as needed for shortness of breath or oxygen saturation below 92% on room air. Review of the resident's progress notes showed the following:-On 11/02/25, at 2:27 P.M., staff noted oxygen saturation 96%. (Staff did not document regarding room air or liters of oxygen.);-On 11/06/25, at 3:32 P.M., staff noted resident continued to exhibit signs of decline and increased confusion. Oxygen saturation reading 70%, but likely inaccurate due to poor perfusion and nail beds cyanotic. Resident placed on oxygen but refused to wear it. (Staff did not document how many liters of oxygen were provided to the resident);-On 11/11/25, at 6:37 P.M., staff noted resident had 3 liters per minute of oxygen on at all times today. Review of the resident Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 11/28/25, showed the following:-On 11/18/25, oxygen saturation was 97% on 2 liters of oxygen;-On 11/21/25, oxygen saturation was 96% on 2 liters of oxygen;-On 11/25/25, oxygen saturation was 100% on 2 liters of oxygen. Review of the resident's progress notes showed on 11/25/25, at 9:42 A.M., staff noted oxygen saturation 95% on 1.5 liters of oxygen. Resident had to be reminded to keep the oxygen on. Facility order was for 2 liters of oxygen and the Hospice order was for 2 to 4 liters of oxygen. Review of the resident's November 2025 TAR showed the following:-Staff did not document related to oxygen tubing and humidifier bottle being changed weekly and placed in a plastic bag when not in use;-Staff did not document related to the resident's oxygen saturation being checked as needed or the physician being notified regarding an oxygen saturation of less than 90%;-Staff did not document related to oxygen 2 liters per nasal cannula being applied as needed for shortness of breath or oxygen saturation below 92% on room air. Review of the resident's progress note dated 12/04/15, at 5:49 P.M., showed resident always wore oxygen and kept it in place. (Staff did not document related to the liters of oxygen the resident was receiving.) Review of the resident's December 2025 TAR showed the following:-Staff did not document related to the oxygen tubing and humidifier bottle being changed weekly and placed in a plastic bag when not in use;-Staff did not document related to the resident's oxygen saturation being checked as needed or the physician notified regarding an oxygen saturation of less than 90%;-Staff did not document related to the oxygen 2 liters per nasal cannula being applied as needed for shortness of breath or oxygen saturation below 92% on room air. Oservation on 12/08/25, at 12:59 P.M., showed the resident sat in his/her wheelchair in his/her room. Resident had oxygen on at 2 liters per nasal cannula. There was no date or staff initials on the oxygen tubing. Observation on 12/10/25, at 8:40 A.M., showed the resident sat in his/her wheelchair in his/her room. The resident received oxygen at 3 liters per nasal cannula per the use of a portable oxygen tank. There was no date or staff initials observed on the oxygen tubing attached to the portable oxygen tank. The regular oxygen concentrator was in the room with oxygen tubing attached and the tubing was lying on the floor under the resident's bed. There was no bag present to store the unused oxygen tubing in and no date or staff initials observed on the oxygen tubing attached to the regular concentrator in the room. Observation on 12/11/25, at 2:10 P.M., showed, the resident rested in bed with his/her eyes closed. Resident had on oxygen on 2 liters per minutes per nasal cannula. There was no date or staff initials on the oxygen tubing. During an interview on 12/12/25, at 9:28 A.M., Certified Nurse Aide (CNA) C said the following:-He/she did not know how many liters of oxygen the resident was on, but he/she thought the resident was on continuous oxygen all the time;-Typically, the nurses tell him/her if a resident is on oxygen and how many liters of oxygen they should be on;-Nurses adjust the oxygen titration or liters of oxygen for the resident;-There should be a physician's order for oxygen;-He/She was not sure who writes orders for residents on hospice. He/she does not look at hospice orders;-Typically, the facility orders in the resident's record should match the orders in their hospice record;-He/She was unsure who was responsible for transcribing or reconciling hospice orders in the resident's record;-He/She only obtains a pulse ox reading on a resident if the nurses tell him/her to do so;-He/She would document a pulse ox reading at the nurses' station and the nurses would enter the reading into the resident's record;-Nurses document the resident's liters of oxygen;-Med techs change the oxygen tubing, but he/she was not sure how often;-He/She assumed the med technician would document the tubing change in the resident's chart, but he/she was not sure how often they would chart the tubing change;-He/She thought there should be an order to change the oxygen tubing;-It was not appropriate for oxygen tubing to be laying on the floor;-If he/she saw oxygen tubing on the floor, he/she would throw it away and get new tubing for the resident;-The oxygen tubing should be put in a bag when it is not being used;-Typically, the oxygen tubing should be dated and initialed by staff when it is changed.During an interview on 12/12/25, at 9:50 A.M., Certified Medication Tech (CMT) D said the following: -The resident was on 3 liters of continuous oxygen;-He/She knew when a resident had oxygen and how many liters of oxygen they were on because they will have orders in the computer;-There should be a physician's order for oxygen;-He/She was responsible for setting up the resident's oxygen tanks for the number of liters ordered by the physician;-The facility oxygen orders and hospice oxygen orders should match in the resident's electronic medical record (eMAR);-The Director of Nursing (DON) and MDS Coordinator were responsible for transcribing or reconciling hospice orders in the resident's record;-CNA's, CMT's, and nursing staff should be checking the pulse ox status for residents on oxygen and documenting the readings in the resident's chart;-The CNA's should chart pulse ox readings in the computer and report to a nurse if a resident's pulse ox reading was less than 90%;-Staff should be documenting resident oxygen observations in the resident's record;-Oxygen tubing is changed by the CMT's every Monday and they should be documenting that in the resident's eMAR;-There should be an order in the resident's eMAR for staff to change oxygen tubing;-The bubbler on the oxygen concentrator should be labeled with the date it was changed, but not the oxygen tubing;-If he/she saw a resident's oxygen tubing on the floor, he/she would replace it with new tubing;-If the oxygen tubing and mask is not being used, it should be wrapped up and put in a zip lock bag. During an interview on 12/12/25, at 11:04 A.M., Licensed Practical Nurse (LPN) E said the following: -The resident was on continuous oxygen, but he/she was not positive how many liters of oxygen the resident is receiving;-Residents should have a physician's order for oxygen and the number of liters they require in their chart; -Nurses and CMT's adjust the liters of oxygen for residents;-The admitting nurse should ensure that the facility and hospice oxygen orders for each resident match;-Staff should be checking the pulse ox reading of residents who are on oxygen, but the orders vary on how often;-The nurses are mostly the ones that check a resident's pulse ox status, and they should document the reading in the nurses eMAR;-Staff should be documenting resident oxygen observations in the eMAR;-CMT's change oxygen tubing weekly and they should have an order to change the tubing;-The date the tubing is changed should be on the bag or maybe the oxygen concentrator, but not usually on the tubing;-If he/she saw oxygen tubing on the floor, he/she would change the tubing;-If oxygen tubing was not in use, it should be stored in a bag.During an interview on 12/12/25, at 11:16 A.M., LPN B said the following: -The resident was on continuous oxygen, and he/she thought the resident was on 2 liters, but he/she would have to look at the resident's order to be sure;-Residents should have an order in their chart for oxygen, including the number of liters they should be on;-Nurses and CMT's are responsible for adjusting oxygen titration or liters of oxygen for the residents;-The facility oxygen order should match the hospice oxygen order for each resident. The hospice physician would write the oxygen order, and the nurses would transcribe or reconcile the order on the residents eMAR or TAR;-Staff should be checking the pulse ox reading on residents who have oxygen, but the frequency would depend on the resident specific order;-A resident's pulse ox reading should be recorded on the resident's MAR or TAR;-Resident oxygen observations by staff should be documented by the nurses in the residents eMAR;-Oxygen tubing should be changed weekly by CMT's and documented in the resident's eMAR or TAR;-There should be a physician's order on the TAR to change oxygen tubing;-Staff should label the oxygen tubing with the date it was changed and the staff's initials;-If he/she found oxygen tubing on the floor, he/she would change it;-Unused oxygen tubing should be stored in a bag. During an interview on 12/12/25, at 12:50 P.M., the DON said the following: -He/she believed the resident wore 3 liters of oxygen all the time, but he/she would have to double check that in his/her record;-There should be oxygen orders in the resident's record that the nurses and med techs can see;-Nurses chart on oxygen, but they never chart how much oxygen a resident is on;-Nurses monitor to make sure a resident's pulse ox reading is above 90%, but they monitor pulse ox status based on the circumstance. They also monitor for shortness of breath;-Nurses would document oxygen and pulse ox information on the eMAR or in a progress note;-There should be an order for the oxygen tubing, and it should be changed weekly by the CMT's and charted in the eMAR;-When the tubing is changed it should be labeled with the date it is changed and the staff's initials;-CNA's cannot see oxygen orders, so they would communicate with the nurses to know that information;-Nurses adjust the oxygen titration or liters of oxygen that a resident receives, and they communicate any concerns with the physician;-The physician writes the oxygen order and nurses enter the orders into the computer system;-Every hospice has their own physician, and they consult with the facility doctor. The nursing staff are responsible for transcribing or reconciling the residents' hospice orders in the facility record as soon as they receive them, so the orders match;-The facility physician orders say to maintain the resident's pulse ox reading above 90% and to check for shortness of breath;-Hospice does not have any routine orders to check a resident's pulse ox reading;-Residents who have a medication change or an order change will get vital signs taken and recorded in their record;-There should be a physician's order in the resident's electronic health record for oxygen tubing changes;-Staff should label the oxygen tubing with the date and their initials when it is changed;-CMT's should document oxygen tubing change in the CMT TAR. During an interview on 12/12/25, at 1:03 P.M., the Administrator said the following: -He/she had observed the resident wearing oxygen. The resident was supposed to have oxygen on all the time, but sometimes the resident refuses or takes it off;-The physician or nurse practitioner writes the oxygen order, and the nursing staff put the orders into the resident's electronic health record;-If a resident was on Hospice, the facility physician coordinated care with the hospice physician, and the facility nurse ensures that that the facility and hospice orders match in the resident's record;-The nurses are responsible for monitoring the resident's oxygen administration;-The nursing staff are responsible for setting the titration or liters of oxygen the resident is on based on physician orders;-Residents on oxygen should have a physician order for pulse ox checks and staff should document the pulse ox readings in the resident's electronic health record under the vitals section or MAR/TAR section;-CMT's change the oxygen tubing weekly and they should document the tubing change on the residents MAR/TAR;-Staff should label the oxygen tubing with the date and their initials when the tubing is changed;-If staff find oxygen tubing on the floor, they should wipe it off or sanitize it and place it in a bag.

Based on observation, interview and record review, the facility failed to keep food safe from potential contamination or bacterial growth when staff stacked wet dishware inside one another, trapping moisture, which could potentially contaminate food served from those items. The facility census was 60. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated April 2011, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 1. Observations on 01/28/24, beginning at 9:57 A.M., of the kitchen showed 48 juice cups with water droplets trapped inside, upside down, stacked on top of one another on trays. Observations on 01/30/24, beginning at 12:20 P.M., of the kitchen showed the following: -There were 41 juice cups with water droplets trapped inside, upside down on top of each other, stacked on trays; -Three clear, square measuring bowls with water droplets trapped inside, upside down, stacked trapping the moisture. Observation on 01/31/24, beginning at 12:30 P.M., showed the following items stacked, and/or placed upside down on one another, not allowing for air flow and keeping and trapping moisture: -102 clear juice cups; -Two small round clear measuring bowls; -Five plastic bowls; -Nine plastic plates; -Three large metal baking bins from the steam table -One metal cup with lid During an interview on 02/01/24, at 11:58 A.M., Dietary Aide P said he/she knows not to put dishes away wet, but thinks the kitchen staff still needs to be educated about this. During an interview on 02/01/24, at 12:18 A.M., Dietary Aide Q said he/she has not been trained on how to stack the dishes once clean. During an interview on 02/01/24, at 11:58 A.M., the Dietary Manager said the following: -He/she knows that dishes cannot be stacked or placed upside down if they still have moisture in them; -He/she is aware of the fact that bacteria can possibly grow if the dishes are not air dried. During an interview on 02/01/24, at 2:08 P.M., the Administrator said all items should be left out until done being air dried.

Based on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity when staff left two residents (Residents #42 and #27) exposed during transfer and/or incontinent care, stood over two residents (Residents #15 and #8) while assisting the residents to eat, and cursed at one resident (Resident #43). The facility census was 60. Review of a facility policy entitled Resident Rights, undated, showed the following: -It is the purpose of this facility to meet the Federal and State mandate in respect to resident rights. The resident has a right to a dignified existence. A facility must protect the rights of each resident; -Rights include privacy and respect. Review of a facility policy entitled Perineal Care, undated, showed to provide privacy for the resident. Review of the facility policy, Feeding the Resident (Dependent Eating), undated, showed the following: -Purpose to assist the resident with feeding and provide adequate nutrition; -Do not discuss unpleasant subjects while resident is eating; -Never make the resident feel that the meal must be hurried, but that the experience is pleasant; -Sit so you (staff) are at the same level as the resident when possible. 1. Review of Resident #42's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 12/02/23, showed the following information: -admitted [DATE]; -Diagnoses included dementia, anxiety, and high blood pressure; -Severely impaired cognition; -Incontinent of bowel and bladder. Review of Resident #27's annual MDS, dated [DATE], showed the following information: -admitted [DATE]; -Diagnoses included dementia, Parkinson's disease (disorder of the central nervous system that affects movement), anxiety, depression, high blood pressure, and gastroesophageal reflux disease (GERD - stomach acid backs up into the esophagus); -Moderately impaired cognition; -Incontinent of bowel and bladder. Observation on 01/29/24, at 1:14 P.M., showed Nurse Aide (NA) A and Certified Nurse Aide (CNA) B entered the room of Residents #42 and #27 and closed the residents' door. The NA and CNA used a Hoyer (mechanical) lift to transfer Resident #42 from a Broda chair (specialty reclining wheelchair) to his/her bed. The privacy curtain between the roommates remained open. Resident #27 sat in his/her wheelchair facing Resident #42. NA A and CNA B lowered Resident #42's pants and rolled him/her to his/her right side facing the wall. Without closing the privacy curtain, CNA B removed the resident's wet brief and cleaned the buttocks and coccyx (tailbone) area of feces smear. NA A applied barrier cream to the buttocks and coccyx before covering the resident. Observation on 01/30/24, at 1:26 P.M., showed the room door remained closed, but the privacy curtain between the roommates remained open. NA A and CNA B used a sit-to-stand mechanical lift to raise Resident #27 from his/her wheelchair. With the resident suspended in the lift and facing the door and roommate, NA A lowered the resident's pants and removed his/her wet brief. The resident was left exposed from waist to knees for two to three minutes while the NA retrieved supplies. NA A then used wipes to clean the resident's perineal area and buttocks. NA A and CNA B then turned the lift around and lowered the resident onto his/her bed before covering him/her. During an interview on 02/01/24, at 8:30 A.M., CNA D said staff should always close the room door and pull the privacy curtain closed when provided personal cares for a resident to provide privacy. He/she said it was not okay to not close curtain if resident has roommate during cares. During an interview on 02/01/24, at 8:55 A.M., CNA I said that staff should shut the room door and pull curtain for privacy when completed personal hygiene cares for a resident. He/she said it was not okay to keep curtain open if resident has roommate. During an interview on 02/01/24, at 10:35 A.M., Certified Medication Tech (CMT) J said that staff should always ensure that the room door and privacy curtain was closed for privacy during resident personal cares. He/she said it would not be okay to leave the curtain open, especially if there was a roommate in room. During an interview on 02/01/24, at 10:55 A.M., CMT K said staff should close the door and pull the privacy curtain when providing care for a resident. The privacy curtain should not remain open when there is a roommate. During an interview on 02/01/24, at 11:05 A.M., Registered Nurse (RN) H staff should close the room door and pull the privacy curtain when assisting the resident with personal cares. Staff should not leave the curtain open if the resident has a roommate. 41787 2. Review of Resident #15's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and personal history of traumatic brain injury (TBI - Brain dysfunction caused by an outside force, usually a violent blow to the head). Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive deficit; -Required supervision or touching assistance with eating; -Resident received a mechanically altered diet. Review of the resident's care plan, last updated 09/18/23, showed the following: -The resident was unable to perform activities of daily living (ADLs - fundamental skills required to independently care for oneself); -The resident was not able to feed him/herself; -Staff should place a clothing protector on the resident and over the resident's lap to protect the clothing. Observation on 01/28/24, at 5:50 P.M., showed CNA L stood over the resident and gave him/her bites of pureed food. The resident sat in a Broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and patient falls) with a clothing protector on. 3. Review of Resident #8's face sheet showed the following information: -admitted [DATE]; -Diagnoses included Parkinson's disease with dyskinesia (abnormality or impairment of voluntary movement), psychotic disorder (group of serious illnesses that affect the mind) with hallucinations, chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive deficit; -Resident received a mechanically altered diet; -Resident received a therapeutic diet. Review of the resident's care plan, last updated 11/28/23, showed the following: -The resident would continue to assist with care task completion to the extent possible, related to the disease process; -The resident was able to feed self with set up assist at meals; -The resident preferred someone to feed him/her most of the time; -Staff should allow plenty of time to eat the meal; -Staff should not allow the resident to feel rushed; -Staff should encourage meals in the dining room unless contraindicated. Observation on 01/29/24, at 12:20 P.M., showed Licensed Practical Nurse (LPN) M stood over the resident and gave him/her bites of pureed food. The resident sat in a Broda chair with a clothing protector on. Observation on 01/30/24, at 12:32 P.M., showed CNA I was stood over the resident and gave him/her bites of pureed food. The resident sat in a Broda chair with a clothing protector on. 4. During an interview on 02/01/24, at 8:30 A.M., CNA D said that staff should assist the resident with items at meals, including opening items. The CNA said that staff should be seated next to the resident and said that it was okay to stand over the resident during meals. During an interview on 02/01/24, at 8:45 A.M., CNA I said that generally staff should sit next to a resident to assist with meals. The CNA said if the resident was in a Broda chair he/she could not reach the resident, so he/she had to stand up to help. The CNA said that staff should try to remain at the resident's level when talking to or assisting a resident. During an interview on 02/01/24, at 10:35 A.M., CMT J said that he/she was usually seated when providing feeding assistance to residents at mealtime. He/she said that he/she was so short that sometimes he/she would have to stand to feed residents in Broda chairs. During an interview on 02/01/24, at 11:05 A.M., Registered Nurse (RN) H said that he/she was unsure if it mattered if staff were standing above a resident when feeding. He/she said that he/she liked to sit with the resident to keep eye contact. During an interview on 02/01/24, at 12:25 P.M., the Assistant Director of Nursing (ADON) said staff are not supposed to stand over resident when assisting with feeding. The ADON said that staff should sit and chat to make the resident have a more homelike environment. During an interview on 02/01/24, at 2:05 P.M., the Administrator said staff should not be standing over the residents when assisting with meals and should only be feeding or assisting one resident at time. 5. Review of Resident #43's face sheet showed the following information: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis on one side of the body) affecting left non-dominant side following cerebral infarction, congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), and generalized anxiety disorder. Review of the resident's care plan, last updated 11/28/23, showed the following: -Resident had an ADL self-deficit; -Staff will assist the resident with ADLs as needed; -Resident at risk for behavioral episodes; -Staff should report any behavior changes and/or verbal behaviors to the charge nurse for assistance. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitively intact; -Resident has almost constant pain; -Resident has physical and verbal behavioral symptoms directed to others daily. Review of the facility Grievance/Complaint Report, dated 12/21/23, showed the following: -Resident and resident representative initiated the complaint; -Housekeeper E came into Resident #43's room and he/she was taking a piss. The housekeeper told the resident to cover it up. The resident told him/her to pull the curtain which the staff did and called the resident little fucking asshole. The resident told the staff to look in the mirror. The staff was always hateful when coming into the resident's room. Then the staff threatened the resident saying, I'll go get the Administrator on your ass; -The Administrator took a statement from Housekeeper E via telephone with Social Service Director (SSD) and the Housekeeping Supervisor present as witnesses; -Education to staff and discipline write-up completed; -Housekeeper E was given a write-up and educated on abuse of residents, including verbal, physical, and emotional abuse. Staff notified the resident of the results in one-to-one conversation and notified resident's representative phone. During an interview on 01/30/23, at 11:15 A.M., the resident said that only one staff member had talked to him/her without respect by yelling and cursing at him/her. He/she said that the Administrator took care of it and there were no other problems. During an interview on 02/01/24, at 11:20 A.M., Housekeeper E said that he/she received abuse and neglect training at least once per year, and this included resident right to be treated with respect and dignity. The staff said that he/she knocked on the resident's door one day in December and after entering the room he/she started coughing. The housekeeper had recently recovered from being ill, but had a continued lingering cough. The resident said, Don't bring that shit in to me. The staff said he/she told the resident that he/she was not ill and only had a cough. The resident then said, pull that curtain closed bitch. The staff then said he/she called the resident an asshole. Housekeeper E said that he/she should not have cursed at the resident. During an interview on 02/01/24, at 8:30 A.M., CNA D said that he/she received training on hire that included the resident rights to be treated with dignity and respect. He/she said it was not okay for staff to curse or yell at residents. During an interview on 02/01/24, at 8:55 A.M., CNA I said he/she received abuse and neglect training, which included resident rights to be treated with dignity and respect. He/she said it was not okay to talk mean or yell at residents, and it was not okay to curse at residents. He/she would notify the charge nurse and DON of any concerns. During an interview on 02/01/24, at 10:35 A.M., CMT J said residents have the right to be treated with dignity and respect, and staff should not curse or yell at residents. During an interview on 02/01/24, at 10:45 A.M., Housekeeper G said that staff should not cuss at a resident and staff should notify the supervisor if witness any incident. During an interview on 02/01/24, at 11:05 A.M., RN H said that he/she had received resident right training and in-services, that included the right to be treated with respect. Staff should not cuss or speak inappropriately to residents. During an interview on 02/01/24, at 11:10 A.M., Housekeeper F said he/she received training on hire that included treating resident with respect and dignity. He/she said that if he/she heard anyone yell or curse at a resident, he/she would go to the supervisor. During an interview on 02/01/24, at 12:25 P.M., the ADON said that the facility reviews abuse and neglect in-service every February and more often any time there is an incident. The training includes resident rights to be treated with dignity and respect. He/she said that staff should report any allegation of staff not treating residents with respect to the supervisors. During an interview on 02/01/24, at 2:05 P.M., the Administrator said that on 12/21/23 there was an incident with a housekeeper cussing at a resident. This occurred during the holiday weekend. She said that she was notified on Monday 12/25/23 by finding a note on her desk that evening when she came into the facility. She had to wait until the following day to talk to the supervisors to see if anyone had done anything about the incident. At that time a full investigation was started, and the resident's representative was notified. During the interview with Housekeeper E, he/she said that Resident #43 was rude and yelling at him/her. Housekeeper E said that the resident called him/her a grumpy old bitch and he/she called the resident an asshole. The employee was given a first and final warning, and educated on resident rights, as well as education on de-escalating situation with a resident in the nursing home.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff administered medication to one resident (Resident #2) after touching the medication with bare hands and placing the medication directly on top of the medication cart, and when staff failed to complete routine hand hygiene during and after wound care for three residents (Resident #8, Resident #37, and Resident #11). The facility census was 60. Review of the Centers for Disease Control and Prevention's (CDC) Hand Hygiene Guidance, dated 01/30/20, showed the following in reference to healthcare settings: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient; before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or the patient ' s immediate environment; after contact with blood, body fluids, or contaminated surfaces; and immediately after glove removal; -Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. Review of the facility policy entitled Wound Care and Treatment, undated, showed the following: -Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -The treatment cart should be left in the hall and locked. Move the cart to the resident's room and park it outside the room. Remove the supplies needed and re-lock the cart; -Medications should be for one designated resident only except large volume liquids (i.e., saline). These may be poured into a cup to take to the bedside; -Set up the supplies on a clean surface. Cover the surface with a clean, impervious barrier before putting the supplies down; -Hand washing must be done as outlined in the guidelines; -Cut the tape with clean scissors; -Put gloves on; -Remove the soiled dressing and place in the trash bag. Place the soiled scissors on one corner of setup, not touching any other supplies; -Remove the gloves and discard in the bag; -Clean scissors with 60 seconds of contact with alcohol and place on a clean corner of setup; -Wash hands and put on clean gloves; -Clean the wound according to the order; -Place soiled gauze in the trash bag; -Remove gloves, place in trash bag, and put on clean pair of gloves; -Apply clean dressing as ordered; -Wash hands. 41787 1. Review of Resident #'2's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinsonism (umbrella term that refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors), bipolar disorder (mental health condition that causes extreme mood swings), and dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). Review of the resident's Physician Order Sheet (POS), current as of 02/01/24, showed the following: -An order, dated 10/23/23, for carbidopa/levodopa (used to treat Parkinson symptoms) 25-100 milligram (mg), administer one tablet three times per day; -An order, dated 10/23/23, for gabapentin (used to treat nerve pain) 100 mg, administer one capsule three times per day; -An order, dated 10/24/23, for ropinirole (used treat the symptoms of Parkinson's disease and restless legs syndrome) one mg, administer one tablet three times per day; -An order, dated 02/01/24, for acetaminophen (used to relieve mild or chronic pain and to reduce fever) 325 mg, administer two tabs three times per day; -An order, dated 02/01/24, for lorazepam (used to treat anxiety) 0.5 mg, administer one tablet three times per day. Observation on 01/31/24, at 10:45 A.M., showed Certified Medication Tech (CMT) J and Registered Nurse (RN) N preparing medications at the medication cart near the nurses' station: -CMT J removed the medication cards for the resident from the medication cart; -CMT reviewed the orders and began popping medications out of the card and into the cup; -The CMT popped the gabapentin 100 mg pill into his/her hand and then put the pill into the medication cup; -The CMT completed putting the medications into the cup, including lorazepam, ropinirole, carbidopa/levodopa, and acetaminophen; -The CMT handed the cup to RN N; -RN N attempted to deliver the medications to the resident near the nurses' desk; -The resident refused the medications and said that he/she would only take the medication for Parkinson's; -The RN returned the medication cup to the CMT and the CMT poured the pills out into his/her bare hand without completing hand hygiene; -The CMT then removed the carbidopa/levodopa pill with his/her fingers from his/her hand and put into a new medication cup. -He/she then put the remaining tablets into the medication cup and put into the medication cart drawer to be disposed of later; -The resident took the medication. During an interview on 02/01/24, at 10:35 A.M., CMT J said the following: -Staff should not touch pills when preparing medications, the medication should be popped into a medication cup; -If a resident refused a medication, the staff should put away the medications to be disposed of properly and notify the charge nurse;. -He/she said that he/she should probably have put on a glove to touch the pills when the resident only wanted one of the prepared pills; -He/she said that he/she sanitizes the medication cart before every shift, so if a pill fell on the cart, he/she would pick it up and put into the medication cup. During an interview on 02/01/24, at 10:55 A.M., CMT K said that staff should complete hand hygiene between every resident when administering medications. He/she said that medications should be popped into medication cup and staff should not touch the pills with their bare hands. During an interview on 02/01/24, at 11:05 A.M., RN H said that staff should not pop medications into hands. Staff should put on a glove if need to touch any pills. Hand hygiene should be completed between each resident. During an interview on 02/01/24, at 12:25 P.M., Assistant Director of Nursing (ADON) said that staff should complete hand hygiene between each resident when administering medications. Staff should not touch any pills with their bare hands. Staff should not pour medications into their bare hand and pick out the one pill the resident wanted. During an interview on 02/01/24, at 2:05 P.M., Administrator said that staff should complete hand hygiene in between resident with medication pass. Staff should not touch the pills with their hands. 2. Review of Resident #8's face sheet showed the following: -Most recent re-admission on 04/04/21; -Diagnoses included open wound on right foot and open wound on left lower leg. Review of the resident's POS, current as of 02/01/24, showed the following: -An order, dated 01/25/24, for staff to clean the left ankle with wound cleanser, apply skin prep (barrier wipe to create an invisible layer on your skin to protect it from adhesive), apply gentamicin (used to treat skin infections), and optifoam (adhesive foam dressing that is waterproof and has a high fluid-handling capacity). Staff to wrap with kerlix (bandage roll) and secure with tape. Staff to change daily and as needed. Observation on 01/30/24, at 1:10 P.M., showed the following: -RN C prepared supplies for wound care; -The RN entered the resident's room with the wound cleanser bottle and resident's antibiotic gentamicin tube, dry gauze and two skin prep pads; -The resident was seated in the Broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and patient falls) in room; -The nurse placed the supplies on the top of the resident's dresser with no clean barrier; -The nurse removed protective the boot and put it on the resident's bed. The nurse then took off the sock on the left foot to show a dressing dated 01/29/24; -The nurse applied gloves without performing no hand hygiene; -The nurse wiped the scissors with an alcohol wipe and removed the dressing using the scissors. The nurse then removed the optifoam cover from wound; -Without changing gloves or completing hand hygiene, the nurse picked up the wound cleanser bottle and sprayed onto dry gauze pads. The nurse then wiped the wound and entire foot with the wound cleanser gauze; -The nurse removed his/her gloves and disposed of the gloves. The nurse donned new gloves without completing hand hygiene; -The nurse opened the gentamicin ointment tube and squeezed it onto the optifoam dressing. The nurse then applied the dressing to the open wound; -He/she opened the skin prep wipe and wiped entire left ankle, heel, foot, and toes with same skin prep; -He/she used a second skin prep wipe and wiped entire foot with wipe a second time; -The nurse removed his/her left glove to return to nurse cart at room door and obtain an ABD (highly absorbent gauze) pad; -He/she entered room and removed his/her right glove; -Without completing hand hygiene, the nurse opened the ABD pad package, applied it to leg and covered with kerlix. The nurse applied tape and dated the dressing; -The nurse re-applied the resident's sock; -Without completing hand hygiene the nurse removed the resident's right sock and inspected resident's foot, reapplied sock; -The nurse removed the supplies and washed hands at sink; -The nurse left the resident's room and put the wound cleanser on the top of the cart and the ointment into the cart without cleaning the containers. 3. Review of Resident #37's face sheet showed the following: -admitted [DATE]; -Diagnoses included superficial (shallow) injury of left lower leg and laceration (cut or skin wound) of right lower leg. Review of the care plan, last reviewed on 11/28/23, showed the following: -Resident had a wound on the left lower leg; -The goal was for the wound was to heal without signs and symptoms of infection; -Staff should complete treatments as ordered; -Wound care clinic to be involved as ordered. Review of the resident's physician orders, current as of 02/01/24, showed the following: -An order, dated 01/03/24, for skin prep on right lower extremity once per day. -An order, dated 01/29/24, for wound care on left lower extremity. Staff to cleanse with Pure & Clean (brand name of a wound cleanser), blot dry, apply collagen wound dressing (protein dressing used to encourage wound healing), cover with ABD, wrap with kerlix, secure with tape, and change every other day and as needed for soiling; Observation on 01/31/24, at 8:55 A.M., showed the following: -RN H applied hand sanitizer, applied gloves, put wound cleanser on dry gauze, and entered the resident's room with supplies; -The nurse put the supplies on the residents bedside table on a clean paper towel. -The nurse cut the gauze wrap off the resident's left lower leg. The dressing was dated 01/29/24; -The nurse removed soiled dressing and placed it in trash bag; -The nurse applied wound cleanser gauze to remove the stuck on optifoam on the wound bed; -The nurse removed his/her gloves and without completing hand hygiene and applied new gloves; -The nurse cut the collagen to the wound size and placed it on the wound bed. He/she then applied an ABD pad, wrapped with Kerlix, secured the wrap with tape, and dated the dressing 01/31/24; -Without removing his/her gloves or completing hand hygiene, the nurse moved to right leg and applied skin prep to two areas of dried unopened wounds; -The nurse disposed of supplies into trash bag and removed gloves; -The nurse washed his/her hands at the sink and left the room. 4. Review of Resident #11's face sheet showed the following: -Re-admission to the facility on [DATE]; -Diagnoses included superficial injury of right thigh. Review of the resident's POS, current as of 02/01/24, showed the following: -An order, dated 01/11/24, for nystatin ointment (antibiotic used to treat fungal infections) 100,000 unit/gram. Mix with A&D (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) and Zinc cream (used to treat and prevent diaper rash and other minor skin irritation). Staff to apply to left and right inner thigh wounds with incontinence (lack of voluntary control over urination and defecation) cares. -An order, dated 01/28/24, to cleanse posterior (back) left thigh with wound cleanser, apply optifoam to open area, and cover with border gauze; -An order, dated 01/28/24, to cleanse right posterior thigh with wound cleanser, apply optifoam to open area and cover with border gauze; Review of the resident's care plan, dated 01/28/24, showed the following: -Resident currently had a pressure ulcer/wound; -The goal was for the wound to heal without signs and symptoms of infection; -Staff should complete treatments as ordered; -Wound clinic to be involved in treatment as ordered. Observation on 01/31/24, at 9:30 A.M., showed the following: -RN H applied hand sanitizer and prepared wound care supplies at the nurse cart. The nurse sprayed wound cleanser on dry gauze; -RN H and CNA D entered the resident's room; -The nurse brought the wound cleanser dry gauze to the resident room; -The nystatin powder and zinc oxide tube were on the resident's shelf in the room; -The nurse put on gloves and mixed the nystatin powder with zinc oxide in a mediation cup to make a paste; -The staff assisted the resident to roll to his/her right side; -The nurse placed the wound care supplies on the resident's bed; -The nurse wiped the back side of the upper left thigh with the gauze with wound cleanser, the wound area was bleeding; -The nurse wiped the right upper thigh area with wound cleanser on a gauze pad. The area was open with no drainage; -The nurse wiped fecal matter off the resident's buttock with the gauze and put the gauze on the bed pad. The nurse continued wiping the wounds with wound cleanser on a gauze pad. The nurse did not complete a glove change or hand hygiene; -The nurse applied the zinc nystatin paste with a wooden applicator with the same gloved hands; -The nurse touched the resident's left hip area with his/her right gloved hand while applying paste to the wounds with left gloved hand; -The nurse wiped his/her soiled gloved left hand on the bed pad; -The nurse rolled the soiled pad under the resident and removed his/her gloves; -The nurse applied new gloves with no hand hygiene; -The nurse put clean bed pad under resident; -Staff then assisted the resident to roll to his/her left side; -The CNA pulled the soiled bed pad out from under the resident and pulled through the clean pad; -Staff then assisted the resident to roll to his/her right side; -The CNA went to the bathroom, removed his/her glove from the right hand and obtained a trash bag then put on a new glove on the right hand without completing hand hygiene; -The aide picked up the soiled laundry and put into the trash bag; -The nurse pulled the lift sheet through and assisted the resident to roll to his/her back; -The nurse and the aide pulled the resident up in the bed, to the head of bed with the same gloved hands; -The staff covered resident, ensured had call light and bed control in reach; -The nurse put a pillow under residents left buttock area for pressure relief; -The nurse removed his/her gloves and washed hands at sink; -The CNA cleaned up the room and removed gloves and washed hands at the sink. 5. During an interview on 02/01/24, at 8:30 A.M., CNA D said staff should complete hand hygiene before care and after resident cares. Depending on what the staff was doing, staff would only change gloves if soiled during cares. During an interview on 02/01/24, 8:45 A.M., CNA I said staff should complete hand hygiene before entering any resident room, in between glove changes, when visibly soiled, and after completed with resident cares. During an interview on 02/01/24, at 10:35 A.M., CMT J said that staff should be completing hand hygiene between every dirty and clean process, when assisting with resident meals, after every glove change, and before starting the shift. During an interview on 01/31/24, at 10:00 A.M., RN H said the following: -He/she washed hands before and after wound care; -He/she liked to change gloves between clean and dirty; -It was really not convenient to use hand sanitizer between glove changes, but it probably would be best practice. During an interview on 02/01/24, at 11:05 A.M., RN H said that staff should complete hand hygiene before and after every resident care, including wound care, and between glove changes, and if visibly soiled. During an interview on 02/01/24, at 12:25 P.M., Assistant Director of Nursing (ADON) said staff should complete hand hygiene before, during, and after wound care. Staff should always wash hands or use hand sanitizer between glove changes, and gloves should be change between any dirty to clean process. Staff should use hand sanitizer between each resident. During an interview on 02/01/24, at 2:05 P.M., the Administrator said staff should use hand sanitizer or wash hands before starting a resident care and after finished. Depending on the type of care, the staff should use hand sanitizer in between glove changes, and they should change gloves between the dirty to clean process. Staff should complete hand hygiene before wound care, and between dirty and clean process of glove changes.

Based on record review, observation, and interview, the facility failed to ensure one resident's (Resident #36) code status (if the resident wished to received cardiopulmonary resuscitation (CPR - a lifesaving technique that is used when someone's breathing or heartbeat has stopped) was consistent and accurate throughout the resident's medical record. The facility census was 60. Review showed the facility did not provide a policy regarding code status. 1. Review of Resident #36's face sheet showed the following information: -admitted [DATE]; -Diagnoses included dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), cerebral infarction (stroke), unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by eschar (dry, dark scab) of left heel, and left knee osteoarthritis (degeneration of joint cartilage and the underlying bone); -Do not resuscitate (DNR - person has decided not to have CPR attempted on them if their heart or breathing stops); -On hospice services (program designed to make the process of dying as comfortable as possible for patients and their families). Review of the resident's physician order sheet, current as of [DATE], showed the following: -An order, dated [DATE], for full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of the resident's care plan, last reviewed [DATE], showed the following: -Resident on hospice services; -Resident chooses to be full code and plan long term care; -Staff should start CPR and call 911, in case of no pulse or no respirations. Review of the resident's nursing progress note, dated [DATE] showed the following: -Staff documented there was a care plan meeting on [DATE], at 11:25 A.M. The resident's family members were in attendance, along with facility staff and hospice provider. The family chose hospice on [DATE]. Observation of the resident's room door showed a name tag, along with a red dot on the tag. (The red tag indicated the resident wished to be a DNR.) During an interview on [DATE], at 8:30 A.M., Certified Nurse Aide (CNA) D said resident code status can be located on the resident's name tag at room door. A red dot indicated DNR code status and a green dot indicated full code status. The aide said that he/she believed it was also in electronic medical chart and the information should match. During an interview on [DATE], at 8:45 A.M., CNA I said that resident's code status was located on the resident room door name tags by a red or green sticker. The information was also located in the electronic medical record by their name and the information should match. During an interview on [DATE], at 10:35 A.M., Certified Medication Tech (CMT) J said that resident code status was located on the medication administration record and the face sheet. He/she said the information should match. During an interview on [DATE], at 11:05 A.M., Registered Nurse (RN) H said the following: -Resident code status was located on the resident door and in computer; -Code status was also in a code book at the nurses' station with a purple sheet if resident was a DNR; -Review of the book with the nurse showed that Resident #36 did not have a purple sheet in the book; -The nurse said that the resident had recently changed to hospice status; -The nurse said that the code status should match throughout chart. During an interview on [DATE], at 12:25 P.M., the Assistant Director of Nursing (ADON) said that code status was located on resident doors with a red or green dot. The red dot was for DNR and green dot was for full code. The information would also be on the resident's face sheet and on the physician order sheet. This information is printed when sending a resident out of the facility. The care plan will also indicate if the resident wishes for full code or DNR. The information should match throughout the records. During an interview on [DATE], at 2:05 P.M., the Administrator said resident code status was on resident doors by red or green dot, and on the staff computer kiosk with the resident names. There was also a book up front with all the face sheet with code sheet on the front of it. Code status would be noted on the physician orders. The Social Service Designee (SSD) checks all code status at least once week to make sure they are accurate. The information should match throughout chart.

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff attempted to provide one resident (Resident #27) with a double dose of medication during a random medication pass observation. The facility had a census of 60. Review of the facility policy titled Medication Administration, undated, showed the following: -Staff should read the label three times before administering medication: -First when comparing the label top the medication sheet; -Second when setting up the medication; -Third when preparing to administer the medication to the resident. 1. Review of Resident #27's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) with dyskinesia (abnormality or impairment of voluntary movement), dementia without behavioral disturbance, and drug induced akathisia (state of agitation, distress, and restlessness that is an occasional side-effect of antipsychotic and antidepressant drugs). Review of the resident's physician order sheet, current as of 02/01/24, showed the following: -An order, dated 07/10/20, to rush or alter mediations unless otherwise indicated; -An order, dated 11/22/23, for carbidopa/levodopa (used to treat Parkinson's) 25-100 milligram (mg), two tablets orally three times per day; Review of the resident's care plan, dated 11/17/23, showed the following: -Resident at risk for behaviors related to diagnosis of Parkinson's, dementia, depression, and anxiety; -Staff should administer medications as directed; -Staff should monitor for signs and symptoms of adverse effects. Observation on 01/31/24, at 11:20 A.M., of the medication pass showed the following: -Certified Medication Technician (CMT) J and Registered Nurse (RN) N were at the medication cart near the nursing station preparing medication administration; -The CMT had multiple empty medication cups that were labeled with resident names; -The CMT removed a medication card from the cart for Resident #27 and found the medication card to be empty; -The CMT and RN went to the medication room to the stat safe; -The CMT held the empty medication card with the pharmacy label; -The RN entered his/her access information into the stat safe; -The RN then entered the resident and the medication needed - carbidopa/levodopa (brand name Sinemet CR) 25-100 mg (milligram, dosage of medication); -The CMT and RN reviewed the medication card and noted it to say carbidopa/levodopa 25-100 mg, administer carbidopa/levodopa two tablets (50-100 mg) three times per day; -The stat safe drawer opened, the RN removed the appropriate medication box; -The RN removed four tablets of carbidopa/levodopa 25-100 mg and put into the medication cup; -The RN and CMT returned to the medication cart; -The CMT took a small plastic bag out of medication cart and stated that the resident's medications were to be crushed; -As the CMT began to pour the four tablets into the plastic bag, the state surveyor requested the CMT stop and review the orders again in the computer; -The CMT reviewed the orders again and said that his/her calculation was off and he/she should have only provide two tablets. During an interview on 02/01/24, at 10:35 A.M., CMT J said the following: -Staff should review the physician orders and the medication card when providing medications to residents; -Staff should double and triple check the orders and the medication administration record; -Medication errors should be reported the nurse and the Director of Nursing (DON); -Providing a double dose of carbidopa/levodopa would not be good for the resident. If a resident received too much medication, he/she would require increased monitoring and observation and staff would notify the physician. During an interview on 02/01/24, at 10:55 A.M., CMT K said the following: -Staff should review medication cards and medication orders multiple time when administering medications; -Medication should not be given as a double dose during medication administration; -A medication error should be reported immediately when staff become aware and staff would have to explain what occurred; -He/she do not know what the outcome would be if a resident received an overdose of any medication. During an interview on 02/01/24, at 11:05 A.M., Registered Nurse (RN) H said the following: -Staff should triple check the directions and dose on the medication cards and the electronic medication administration record before completing medication administration; -A a resident should not receive four tablets of a medication if the order was for two tablets. That would be a medication error; -Staff would report to the DON and the physician for any medication error. The resident would likely require increased monitoring. During an interview on 02/01/24, at 12:25 P.M., the Assistant Director of Nursing (ADON) said that staff should not provide residents with a double dosage of medication. Staff should be checking the orders to verify medication provided each time. Medication errors should be reported, doctors should be notified, and residents should be monitored or follow doctor new orders. During an interview on 02/01/24, at 2:05 P.M., the Administrator said that staff should follow physician orders for medication administration and should not give four tablets if the order was for two tablets. If a medication error occurs the staff should notify the DON or ADON and fill out the medication error form. Staff should contact the physician, chart the error, and provide extra monitoring of resident.

Based on observation, interview, and record review, the facility failed to ensure all residents who entered the facility received appropriate treatment to increase or maintain range of motion when two residents (Resident #1 and Resident #5) had a decline in activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) and mobility and one resident (Resident #2) failed to maintain/improve in ADLs, when the facility did not document and care plan specific restorative therapy plans, did not notify the physician for possible therapy orders, and did not provide regular restorative therapy to the residents. The facility census was 71. Review of the facility's policy titled The Restorative Nursing (RNA) Program, undated, showed the following: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -It is the purpose of this facility see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -The RNA program is a means of providing restorative treatment to those residents identified as having a change in function that has stabilized and is no longer in need of skilled intervention or residents who exhibit a potential for decline; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility; -Clear lines of authority, expectations, and responsibilities are necessary for implementation of the RNA program; -Referrals to the RNA program may be made by nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), and physicians, as well as through the Minimum Data Set (MDS - a federally mandated assessment tool to be completed by facility staff) process, certified nursing assistant (CNA), and family/resident input; -Upon assessment by nursing, PT, OT, ST, the referral to RNA is made; -The nurse or therapist initiating the referral transfers the assessment information to the Restorative Nursing Treatment Plan; -Distribute the form to the licensed supervising nurse and RNA with a copy to be kept by referring therapist; -The Care Plan Coordinator will make the entry into the Care Plan with input from the RNA. The Care Plan must include the problem, need and/or concern of the resident, measurable and time limited goal(s) to be reached, and the approach to be taken; -RNA initiates treatment and documentation per facility protocol; -Criteria for resident entry to, movement within, and discharge from the RNA program must be clearly established; -Residents are discharged from the restorative program when certain criteria/guidelines are demonstrated; -A mechanism for monitoring and on-going evaluation of the RNA programs must be established; -Repeated assessment through MDS, nursing assessments, therapist screens, etc., will assist in determining if and when certain criteria are met. Nursing will be responsible for final determination. 1. Review of Resident #1's face sheet (general information sheet) showed an admitted [DATE] and diagnoses that included kidney disease, anxiety, and depression. Record review of the resident's Physician's Order Sheet (POS), current as of 06/24/23, showed a physician's order, dated 06/01/22, for PT and OT to evaluate and treat the resident as needed. The order had no end date. Record review of the resident's OT discharge summary, dated 12/08/22, showed the following: -Supervision or touching assistance for toileting and transfers; -Independent with bed mobility; -No restorative program indicated at this time. Record review of the resident's PT discharge summary, dated 02/07/23, showed the following: -Independent with transfer from chair to bed; -Resident ambulated on level surface for 75 feet using two-wheeled walker with supervision or touching assistance; -Restorative Program Established/Trained=Restorative Ambulation Program. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility and transfers (a decline from 12/08/22); -Total dependence on staff for toileting assistance (a decline from 12/08/22); -No walking occurred in room or corridor during prior seven days (a decline from 02/07/23). -No indication regarding functional rehab potential. Review of the resident's nurse's note, dated 02/23/23, showed the following: -Resident feels weaker; -CNA indicated resident was able to transfer his/herself while working with therapy; -Resident needs assistance with transfers; -Family concerned resident will continue to get weaker without therapy. Review of the therapy referral log showed the following: -On 03/01/23, staff referred the resident to therapy due to decline in mobility; -On 03/02/23, the facility Interdisciplinary Team (IDT) denied the therapy request stating the resident could participate in restorative therapy. Review of the resident's POS showed no new order regarding restorative therapy. Review of the resident's care plan, dated 03/08/23, showed staff care planned PT/OT/ST as ordered. Staff did not care plan regarding restorative therapy. Review of the resident's nurse's note, dated 3/10/23, showed resident on restorative therapy for ambulation. The resident not feeling well this week and refusing therapy. Review of the resident's records showed staff did not documention completion of therapy between 03/10/23 and 03/26/23. Review of the resident's restorative therapy log, dated 03/26/23 to 03/31/23, showed staff did not document regarding restorative therapy. Review of the therapy referral log showed the following: -On 04/13/23, staff referred the resident to therapy due to a decline in mobility; -On 04/14/23, the facility IDT denied the therapy request stating the resident could participate in restorative therapy. Review of resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed the following; -Staff did not document regarding restorative therapy from 04/01/23 to 04/13/23; -On 04/14/23, resident walked 15 minutes; -Staff did not document regarding restorative therapy from 04/15/23 to 04/16/23; -On 04/17/23, resident received 15 minutes of active range of motion assistance; -Staff did not document regarding restorative therapy from 04/18/23 to 04/20/23; -On 04/21/23, resident received 15 minutes of passive range of motion assistance; Staff did not document regarding restorative therapy from 04/22/23-04/30/23. During an interview on 05/23/23, at 2:30 P.M., the Director of Rehab (DOR) said the following: -The resident's family voiced concern regarding resident's decline; -The resident participated in therapy until February 2023; -While in therapy, the resident could walk 180 feet; -After completion of therapy, staff noticed a decline as the resident's legs started to contract; -On 03/01/23, therapy fill out a therapy evaluation request; -On 03/02/23, the IDT denied the request as they felt restorative therapy could address the issue; -On 04/13/23, a second request was submitted by therapy for the resident to receive an evaluation; -On 04/14/23, the request was denied again, as restorative therapy could address the issue and the resident had previously been refusing restorative therapy; -The resident's family continued to voice concerns to management, and the resident was approved for PT on 4/21/23. During an interview on 05/24/23, at 10:30 A.M., the resident said he/she declined after completing therapy. During an interview on 05/24/23, at 11:20 A.M., Certified Nursing Assistant (CNA) A said he/she noticed the resident had a decline after completing therapy. He/she started to have trouble standing. During an interview on 05/24/23, at 11:34 A.M., CNA B said the resident started to decline when he/she finished therapy. The resident is no longer able to stand. CNA B notified therapy about his/her concerns. During an interview on 05/24/23, at 12:00 P.M., Restorative Nursing Assistant (RNA) D said the resident received restorative therapy, but has returned to physical therapy. During an interview on 05/24/23, at 3:28 P.M., the Director of Nursing (DON) said the following: -After completion of therapy, therapy wrote the resident a restorative program; -The resident often denied restorative services and said he/she only wanted to walk with therapy staff; -The DON did not observed a decline in the resident's physical abilities, as the resident normally stays in bed; -The DON is unsure if anyone contacted the physician in regard to the request for a therapy evaluation. Review of the resident's record showed staff did not document a restorative program for the resident. During an interview on 05/24/23, at 4:30 P.M., the Administrator said therapy intercepted restorative and advised staff that the resident only liked to walk with therapy. Staff contacted the physician and therapy was approved. 2. Review of Resident #5's face sheet showed the following: -admitted [DATE]; -Diagnoses included lymphedema (swelling in an arm or leg that may be accompanied by pain or discomfort), dementia, major depression disorder, and muscle weakness; -High fall risk. Review of the resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed the resident received 15 minutes of transfer therapy on 02/22/23. Review of the resident's nurse's note, dated 02/09/23, showed resident on restorative nursing for transfer training. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior 7 days; -No indication regarding functional rehab potential. Review of the resident's nurse's notes, dated 03/10/23, showed the following: -Resident on restorative therapy for transferring; -Resident doing well, will continue to monitor. Review of the resident's record showed no specific restorative plan noted. Review of resident's restorative therapy log, dated 03/01/23 to 03/31/23, showed the following: -Staff did not document an restorative therapy activities from 03/01/23 to 03/07/23; -On 03/08/23, 03/09/23, and 03/09/23, resident received 15 minutes per date of transfer assistance. Review of the resident's care plan, dated 03/10/23, showed the following: -Implement an exercise program that targets strength, gait, and balance; -Extensive assistance with transfers/mobility. Notify charge nurse of changes in level of assistance needed. (Staff did not care plan specifically regarding the restorative plan.) Review of resident's restorative therapy log. dated 03/01/23 to 03/31/23, showed the following: -Staff did not document an restorative therapy activities from 03/11/23 to 03/12/23; -On 03/13/23, resident received 15 minutes of transfer assistance; --Staff did not document an restorative therapy activities from 03/14/23 to 03/16/23; -On 03/17/23, resident received 15 minutes of transfer assistance; -On 03/18/23, resident received 15 minutes of transfer assistance; --Staff did not document an restorative therapy activities from 03/19/23 to 03/31/23. Record review of the therapy referral log showed on 03/30/23, special care unit staff referred the resident for an evaluation due to a decline when performing transfers. Record review of resident's physician progress note, dated 04/05/23, showed the resident to have a slow physical decline. Record review of the therapy referral log on 04/06/23, the facility Interdisciplinary Team (IDT) denied the therapy request stating the resident could participate in restorative therapy. Record review of resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed no restorative therapy data recorded. Record review of restorative therapy log, dated 05/01/23 to 05/24/23, showed no restorative therapy data recorded. Review of the resident's current POS, dated 05/24/23, did not reflect any orders for PT/OT. Review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with transfers twice a week (no start date indicated). Review of the resident's care plan showed staff did not care plan related to restorative therapy. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -Staff approached therapy and advised they were having difficulty transferring the resident; -The resident received therapy from 09/20/22 to 11/23/22; -Therapy staff observed the resident and noted a decline; -On 03/30/23, therapy filled out a therapy evaluation request; -On 05/23/23, the IDT denied the request as they felt restorative therapy could address the issue; -The DOR is unsure if the resident received restorative therapy. During an interview on 05/24/23, at 10:14 A.M., the resident said he/she does not receive much therapy, maybe once a week. The resident said more therapy would help. During an interview on 05/24/23, at 11:34 A.M., CNA B said the resident used a sit to stand to assist with transfers. CNA B does not know if the resident receives restorative therapy. During an interview on 05/24/23, at 3:28 P.M., the DON said the following: -The resident was referred to therapy because the DOR reported the resident had declined; -The resident had been sick, but once better he/she did not require therapy; -The DON is unsure if staff contacted the physician in regard to the request for a therapy evaluation. During an interview on 05/24/23, at 4:30 P.M., the Administrator said the resident was denied a therapy evaluation because he/she was receiving restorative services. The Administrator is unsure if staff contacted the physician in regard to the request for a therapy evaluation. 3. Review of Resident #2's face sheet showed an admitted [DATE] and diagnoses which included heart failure, restless leg syndrome, heart disease, Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), Type 2 diabetes with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Supervision with movement between locations; -Extensive assistance from staff with bed mobility, toileting, transfers, and walking within room; -No indication regarding functional rehab potential. Review of the resident's care plan, updated 03/10/23, showed restorative plan as as ordered. (Staff did not care plan specifics.) Review of the resident's physician progress note, dated 3/21/23, showed the following: -Resident reported having trouble standing to transfer to chair; -Resident would like to have someone to work with him/her to increase strength. Review of the therapy referral log showed the following: -On 04/10/23, therapy referred the resident for an evaluation as they noticed a decline from when resident was previously in treatment; -On 04/14/23, the facility IDT denied the therapy request stating the resident had no capacity to retain the therapy. Review of the resident's current POS, dated 05/24/23, showed an order, dated 04/15/22, for PT and OT to evaluate and treat for lumbar (lower back) pain. The order did not have an end date. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assistance from staff with bed mobility, toileting, transfers, and walking within room; -No indication regarding functional rehab potential. Record review of the resident's care plan, dated 5/17/23, showed the following: -Assist resident in designing a progressive activity/exercise program to maximal potential; -Staff to encourage resident to exercise to maximal potential. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -Therapy observed a decline in the resident's mobility; -The resident asked for therapy in order to increase strength and decrease dependence on mechanical lifts; -On 04/10/23, therapy filled out a therapy evaluation request; -On 04/14/23, the IDT denied the request as they felt the resident was incapable of retaining what was learned in therapy; -The IDT team advised they would have the physician speak to the resident. During an interview on 05/24/23, at 10:34 A.M., the resident's Nurse Practitioner (NP) said he/she did not receive a request for a therapy order for the resident. If staff or therapy believes a resident would benefit from treatment, he/she will write an order for a therapy evaluation. The NP or the physician should have been notified if the the resident requested therapy. During an interview on 05/24/23, at 11:34 A.M., CNA B said the resident uses the sit to stand to assist with transfers. CNA B said the resident requested therapy, but they discontinued. During an interview on 05/24/23, at 1:22 P.M., the resident said approximately three months ago, he/she walked with assistance. He/she has declined and cannot walk even with assistance. He/she requested therapy. Staff have not worked with him/her. During an interview on 05/24/23, at 3:28 P.M., the DON said the following: -The DON does not recall the basis for the resident's therapy evaluation request; -The resident has moments when he/she believes they can walk; -The resident uses a sit to stand lift to transfer; -The physician talked to the resident about therapy, but does not recall what happened; -The resident does not receive restorative services; -The DON is unsure if anyone contacted the physician in regard to the request for a therapy evaluation. During an interview on 05/24/23, at 4:30 P.M., the Administrator said the resident is receiving restorative therapy, but was not included on their facility list. The resident started restorative therapy on 05/01/23. Record review showed the residents medical record and care plan did not reflect a restorative therapy plan in place. 4. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -A physician's order is needed to screen a resident for therapy; -Staff will alert therapy to residents that are declining and feel can benefit from therapy; -Therapy will make a referral and a meeting is held approximately once a week with the Administrator and DON to discuss the referral; -The Administrator and DON will determine if a resident is appropriate for a therapy evaluation; -The DOR does not contact the physician directly about obtaining a therapy evaluation as there is a process he/she is to follow, which is to have the Administrator and DON review all therapy requests. 5. During an interview on 05/24/23, at 10:34 A.M., the NP said the following: -The NP or physician should be notified regarding all therapy referrals; -Nursing will notify the NP if a resident needs an order for therapy. If the NP has concerns/questions, they will talk with therapy; -The NP can assess residents and give an order for a therapy evaluation; -Therapy can reach out the NP or the facility physicians and request an order for a therapy evaluation; -Verbal orders are given for restorative therapy and nursing enters the order. 6. During an interview on 05/24/23, at 11:11 A.M., the physician said the following: -He/she should be contacted if therapy is recommending a resident receive a therapy evaluation; -Residents do not always have an order for restorative therapy. Residents sometimes receive an order when progressing off of therapy. 7. During an interview on 05/24/23, at 11:20 A.M., CNA A said the following: -He/she discusses concerns regarding a resident's physical decline with a nurse and therapy; -The transport driver is also the restorative therapy aide; -CNA A does not know when restorative therapy is complete since the aide is often out on transport; -CNA A believes therapy and restorative is documented in the care plan, which are located at the nurse's station; -Nurses update care plans. 8. During an interview on 05/24/23, at 11:34 A.M., CNA B said the following: -He/she talks to therapy about any concerns regarding resident's physical decline; -He/she does not know if residents receive restorative therapy; -The restorative aide also is in charge of transportation; -Therapy and restorative should be documented in the care plans, which are located at the nurse's station; -Medical records updates the care plan to document the resident's needs. 9. During an interview on 05/24/23, at 11:45 A.M., CMT C said the following: -The restorative aide quit; -Residents are not receiving restorative therapy; -Care plans document therapy and restorative; -Medical Records updates the care plans based on a resident's needs. 10. During an interview on 05/24/23, at 12:00 P.M., Restorative Nursing Assistant (RNA) D said the following: -RNA D was the restorative aide and the transport driver for approximately six months; -The facility hired a new RNA, however he/she quit two weeks ago; -The previous RNA was unable to complete his/her RNA duties as he/she was often pulled to work the floor as a CNA; -RNA D has been on leave for the last few weeks, but returned last week; -RNA D has resumed transport duties, but not restorative therapy; -Residents have not received restorative therapy in the month of May 2023; -RNA D documents restorative therapy in the electronic chart; -Any concerns regarding a resident's physical decline is reported to the DON or Administrator during their morning meeting; -Care plans are located in the resident's electronic chart; -Therapy and restorative should be documented in the care plan; -The MDS coordinator updates the care plans. 11. During an interview on 05/24/23, at 1:00 P.M., CNA F said the following: -CNA F does not know if the facility currently has a restorative aide; -When the facility had a restorative aide, they did not provide therapy to the SCU; -CNA F believes the restorative aide was often pulled to the floor to work. 12. During an interview on 05/24/23, at 1:50 P.M., Registered Nurse (RN) E said the following: -If a resident's physical ability is declining, he/she will discuss concerns with the DON and will proceed based on the DON's recommendation; -Orders are obtained from the physician for restorative or other therapies/evaluations; -The facility does not currently have a restorative aide; -Residents are not receiving restorative therapy; -Care plans are located in the resident's electronic chart; -Therapy and restorative is documented in the care plan. It should be accurate and not vague; -The MDS coordinator normally updates the care plan based on nursing recommendations, however there is not an MDS coordinator at this time. 13. During an interview on 05/24/23, at 2:30 P.M., the Assistant Director of Nursing (ADON) said the following: -The ADON described restorative therapy as hit or miss as it has not been completed for a couple of weeks; -The facility does not currently have a restorative aide; -The ADON believes the CNA assigned to the SCU works with those residents; -The CNA's on the floor are not educated to perform restorative duties with residents; -The ADON is filling in for the MDS coordinator; -The ADON or the DON updates care plans; -Care plans are located in the resident's electronic chart; -Therapy and restorative is documented in the care plan. 14. During an interview on 05/24/23, at 3:28 P.M., the DON said the following: -Restorative therapy is provided twice a week; -During February and March 2023, residents received restorative therapy consistently; -Since March 2023, residents have not received restorative therapy consistency as the RNA had to perform CNA duties and transport; -At this time, residents are not receiving restorative therapy; -All residents when admitted , have an order to be screened for therapy; -Staff can discuss concerns regarding a resident's decline in physical abilities with therapy staff; -Therapy attends the weekly Residents at Risk (RAR) meetings; -Therapy will advise a resident needs a therapy evaluation, and staff will discuss what is going on with the resident and resident is capable of retaining information; -The physician or NP is notified of all therapy evaluation requests; -The physician has the final decision if a resident will be screened for therapy; -Physician contact regarding requests for therapy evaluations is not always documented; -Any nurse can contact the physician and request a therapy evaluation; -The DON does not know if therapy staff can contact the physician directly; -Aides can request a resident receive restorative therapy; -When a resident discharges from therapy, therapy staff will write out a restorative request; -No physician order is needed for a resident to be placed on restorative therapy; -Residents have an open order for therapy; -A new order will be entered when a resident is re-evaluated; -Therapy and restorative should be documented in the care plan. 15. During an interview on 05/24/23, at 4:30 P.M., the Administrator said the following: -Therapy will not screen residents to see if their appropriate for a therapy evaluation; -Screenings do not require a physician's order and currently nurses are performing screenings; -Therapy wants an order for a therapy evaluation and follow up treatment; -Residents with an open therapy order can be evaluated by therapy any time; -Therapy uses a lot of the resident's skilled minutes and they are not progressing or meeting their goals; -The IDT/RAR meeting, which therapy staff attend, is held to make group decisions on what is best for the resident; -A physician's order is not required to place a resident on restorative therapy; -Any staff can recommend a resident for restorative therapy; -Residents completing therapy normally follow up with restorative therapy; -Therapy is supposed to develop the restorative therapy guidelines, but the DON has been writing the restorative recommendations; -Residents have not received restorative therapy since 05/12/23; -The Administrator believes the activity aide is performing restorative duties in the SCU; -The previous RNA had floor days and restorative days; -Transporting residents does not interfere with RNA D performing his/her restorative duties; -Restorative therapy is documented in the resident's electronic chart; -Staff can discuss concerns with therapy, but the preference is for staff to talk to the nurse so the information to be charted, and then addressed with the physician; -Therapy can contact the physician directly, but it is preferred that they request for a therapy evaluation go through the RAR to ensure the referral is appropriate; -The physician has not been notified every time a request has been made for a resident to receive a therapy evaluation; -Care plans are updated by the MDS coordinator; -Therapy and restorative are documented in the care plan. MO00218099

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standard and the resident's choice when the facility failed to obtain complete orders for restorative therapy, failed update care plans regarding specific restorative therapy plans, and failed to consistently provide restorative therapy for six residents (Residents #3, #4, #6, #7, #8, and #10). The facility census was 71. Review of the facility's policy titled The Restorative Nursing (RNA) Program, undated, showed the following: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -It is the purpose of this facility see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -The RNA program is a means of providing restorative treatment to those residents identified as having a change in function that has stabilized and is no longer in need of skilled intervention or residents who exhibit a potential for decline; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident tin the facility; -Clear lines of authority, expectations, and responsibilities are necessary for implementation of the RNA program; -Referrals to the RNA program may be made by nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), and physicians, as well as through the Minimum Data Set (MDS - a federally mandated assessment tool to be completed by facility staff) process, certified nursing assistant (CNA), and family/resident input; -Upon assessment by nursing, PT, OT, ST, the referral to RNA is made; -The nurse or therapist initiating the referral transfers the assessment information to the Restorative Nursing Treatment Plan; -Distribute the form to the licensed supervising nurse and RNA with a copy to be kept by referring therapist; -The Care Plan Coordinator will make the entry into the Care Plan with input from the RNA. The Care Plan must include the problem, need and/or concern of the resident, measurable and time limited goal(s) to be reached, and the approach to be taken; -RNA initiates treatment and documentation per facility protocol; -Criteria for resident entry to, movement within, and discharge from the RNA program must be clearly established; -Residents are discharged from the restorative program when certain criteria/guidelines are demonstrated; -A mechanism for monitoring and on-going evaluation of the RNA programs must be established; -Repeated assessment through MDS, nursing assessments, therapist screens, etc., will assist in determining if and when certain criteria are met. Nursing will be responsible for final determination. 1. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, anxiety, and depression. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Independent with bed mobility, toileting, transfers, and walking; -No indication regarding functional rehab potential. Review of the facility's restorative therapy participants, not dated, showed the resident received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's nurses' notes, dated 02/24/23, showed the resident on restorative therapy for ambulation. Review of the resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed on 02/14/23, 02/21/23, and 02/22/23, staff documented the resident walked 15 minutes. Review of restorative therapy log, dated 03/01/23 to 03/10/23, showed on 03/03/23, 03/08/23, 03/09/23, and 03/10/23, staff documented the resident walked 15 minutes. Review of the resident's care plan, dated 03/10/23, showed the following: -PT/OT/ST as ordered; -Implement exercise program that targets strength, gait, and balance. (Staff did not care plan regarding a specific restorative plan.) Review of restorative therapy log, dated 03/11/23 to 03/21/23, showed staff did not document regarding restorative therapy data recorded from 03/11/23 to 03/31/23. Review of the therapy referral log showed the following: -On 03/22/23, therapy staff requested an evaluation due to decline in mobility; -On 03/23/23, the facility Interdisciplinary Team (IDT) denied the therapy request as the resident's fall risk status had not changed and the resident participates in restorative therapy. Review of the resident's annual MDS, dated [DATE], showed the following: -Supervision with bed mobility, toileting, transfers, and walking; -No indication regarding functional rehab potential. Review of the resident's Physicians' Orders Sheet (POS), current as off 05/23/24, showed a physician's order, dated 03/31/22, for PT and OT to evaluate and treat as needed. The order did not have an end date. There were no orders related to restorative program. Record review of restorative therapy log dated 04/01/23 to 04/30/23 showed no restorative therapy data recorded. Record review of restorative therapy log dated 05/01/23 to 05/24/23, showed no restorative therapy data recorded. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -The resident received therapy from 03/31/22 to 05/4/22; -Therapy staff observed the resident declining; -On 03/22/23, therapy fill out a therapy evaluation request; -On 05/23/23, the IDT denied the request as the resident has always been a fall risk and nothing has changed. During an interview on 05/24/23, at 10:30 A.M., the resident said he/she does not receive any type of therapy. During an interview on 05/24/23, at 11:11 A.M., the physician said the following: -He/she has not received a request for a therapy evaluation for the resident; -The resident should not be denied a therapy evaluation, because he/she has always been a fall risk. During an interview on 05/24/23, at 11:20 A.M., CNA A said the resident walks bent over with his/her walker. CNA is fearful the resident could fall. During an interview on 05/24/23, at 11:34 A.M., CNA B said he/she is unsure if the resident receives therapy or restorative therapy. CNA B said the resident leans when walking and is a fall risk. During an interview on 05/24/23, at 11:45 A.M., CMT C said the resident scares him/her when walking. He/she is a fall risk. The resident does not receive any therapy. During an interview on 05/24/23, at 3:28 P.M., the Director of Nursing (DON) said the following: -The resident has Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors); -No falls documented in the last 6 months; -Therapy recommended the resident have an evaluation; -The resident only needs to be reminded by staff to stand up straight when using his/her walker; -Therapy is not necessary as the resident just needs to be prompted; -The resident receives restorative therapy. During an interview on 05/24/23, at 4:30 P.M., the Administrator said that therapy observed the resident using his walker inappropriately. The resident constantly needs re-education/reminders on proper walker usage. The resident would not benefit from treatment and currently receives restorative therapy. 2. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, unsteadiness on feet, repeated falls, difficulty in walking, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, transfers, walking in room, and in corridor; -No indication regarding functional rehab potential. Review of the resident's therapy referral log showed the following: -On 04/05/23, the special care unit (SCU) staff referred the resident for an evaluation due to a decline when performing transfers; -On 04/06/23, the facility Interdisciplinary Team (IDT) denied the therapy request stating the resident could participate in restorative therapy. Record review of the resident's annual MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior 7 days; -No indication regarding functional rehab potential. Record review of the resident's care plan, dated 04/28/23, showed the following: -Consider PT consult for conditioning and wheelchair assessment; -Resident is able to transfer self and ambulate short distances. Resident unsteady, but able to stabilize. Notify charge nurse of changes in level of assistance needed; -Therapy as per physician orders with quarterly and PRN (as needed) screenings by therapist; -Restorative plan as ordered. (Staff did not care plan specifics regarding the restorative program.) Review of the facility's restorative therapy participants, not dated, did not show resident receiving restorative therapy. Review of the resident's POS, current as of 05/24/23, did not reflect any orders for PT/OT. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -Staff from the SCU referred the resident to therapy due to a decline in the ability to stand for transfers; -On 04/05/23, therapy filled out a therapy evaluation request; -On 04/06/23, the IDT denied the request as they felt restorative therapy could address the issue; -The DOR is unsure if the resident received restorative therapy. During an interview on 05/24/23, at 10:34 A.M., the NP said he/she did not receive a request for a therapy order for the resident. If staff or therapy believes a resident would benefit from treatment, he/she will write an order for a therapy evaluation. The NP or the physician should have been notified if the the resident requested therapy. During an interview on 05/24/23, at 12:00 P.M., RNA D said the resident no longer receives restorative therapy. During an interview on 05/24/23, at 3:28 P.M., the DON said the following: -The resident was referred to therapy because the DOR said the resident was not transferring; -Nursing staff did not report any concerns regarding transfers to the DON; -The DON did not observe a decline and observed the resident transfer themselves; -The resident did not receive restorative therapy because the DOR would not write out a restorative program for the resident; -The DON believes he/she contacted the physician about the request for a therapy evaluation, and the physician said to do what the DON deemed appropriate. During an interview on 05/24/23, at 4:30 P.M., the Administrator said the resident wanted to walk again, but hadn't walked in a year. Restorative was working with the resident with strength and standing. The Administrator is unsure if staff contacted the physician in regard to the request for a therapy evaluation. 3. Review of Resident #6's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle weakness. Review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's nurse's notes, dated 02/09/23, showed resident on restorative nursing for ambulation. Review of resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed resident received therapy 15 minutes of ambulation therapy on 02/21/23 and 02/22/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -Extensive assistance from staff with walking in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of the resident's restorative therapy log, dated 03/01/23 to 03/08/23, showed resident received 15 minutes of ambulation therapy on 03/03/23. Review of the resident's care plan, dated 03/08/23, showed the following: -Resident at risk for falls; -Therapy as per physician orders with quarterly and as needed screenings by therapist. (Staff did not care plan regarding the restorative program.) Review of the resident's restorative therapy log, dated 03/09/23 to 03/31/23, showed resident received 15 minutes of ambulation therapy on 03/09/23 and 03/10/23. Review of the resident's nurse's notes, dated 03/10/23, showed resident on restorative therapy for ambulation. Resident doing well, will continue to monitor. Review of the resident's restorative therapy log, dated 03/01/23 to 03/31/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 03/13/23; -On 03/14/23; -On 03/17/23; -On 03/22/23; -On 03/23/23; -On 03/24/23. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 04/11/23; -On 04/13/23; -On 04/14/23; -On 04/18/23; -On 04/19/23; -On 04/21/23. Review of the resident's nurse's note, dated 04/28/23, showed the resident on restorative therapy for ambulation. Review of the resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed no restorative therapy data recorded. Review of the resident's POS, current as of 05/34/23, showed it did not reflect any orders for therapy. During an interview on 5/24/23, at 1:00 P.M., CNA F said he/she has not observed a restorative aide work with the resident on ambulation. 4. Review of Resident #7's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, unsteadiness on feet, Alzheimer's disease, and major depressive disorder. Review of the resident's POS, current as of 05/24/23, showed a physician's order, dated 07/21/22, for PT and OT to evaluate and treat the resident as needed. The order did not have an end date. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, transfers, walking in room and in corridor; -No indication regarding functional rehab potential. Review of the facility's restorative therapy participants, not dated, showed resident to receive restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed staff did not document regarding restorative therapy. Review of the resident's nurse's note, dated 02/09/23, showed resident on restorative nursing for transfer training. Review of resident's nurse's note, dated 02/24/23, showed resident on restorative nursing for transfer training. Review of the resident's restorative therapy log, dated 03/01/23 to 03/10/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 03/03/23; -On 03/08/23; -On 03/09/23; -On 03/10/23. Review of the resident's nurse's note, dated 3/10/23, showed the resident rolled out of bed and onto the floor. No injuries noted. Review of the resident's nurse's notes, dated 03/10/23, showed the resident on restorative therapy for ambulation. Resident doing well, will continue to monitor. Review of the resident's restorative therapy log, dated 03/11/23 to 03/31/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 03/13/23; -On 03/14/23; -On 03/21/23; -On 03/22/23; -On 03/23/23; -On 03/24/23. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 04/11/23; -On 04/12/23; -On 04/13/23; -On 04/14/23. Record review of the resident's annual MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 04/18/23; -On 04/19/23; -On 04/21/23. Record review of the resident's care plan, dated 04/28/23, showed the following: -Resident at risk for falls; -Therapy as per physician orders with quarterly and as needed screenings by therapist. (Staff did not care plan regarding restorative therapy.) Record review of resident's nurse's note, dated 04/28/23, showed resident on restorative nursing for transfer training. Record review of the resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed staff did not document regarding restorative therapy. During an interview on 5/24/23, at 1:00 P.M., CNA F said the following: -He/she transfers resident, but no one specifically works with the resident on transfers; -The resident has requested therapy to assist him/her with transfers; -CNA F spoke to therapy about the resident's request; -CNA F believes the resident would benefit from therapy. 5. Review of Resident #8's face sheet showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), repeated falls, restless leg syndrome, major depressive disorder, and anxiety. Record review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's POS, current as of 05/24/23, did not reflect any orders for therapy. Review of the resident's nurse's notes, dated 02/09/23, showed the resident on restorative nursing for range of motion. Review of restorative therapy log, dated 02/01/23 to 02/28/23, showed the following: -On 02/09/23, resident received 15 minutes of active range of motion therapy; -On 02/14/23, resident received 15 minutes of passive range of motion therapy; -On 02/21/23. received received 15 minutes of passive range of motion therapy. Review of restorative therapy log, dated 03/01/23 to 03/03/23, showed on 03/05/23, resident received 15 minutes of active range of motion therapy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of restorative therapy log, dated 03/06/23 to 03/10/23, showed the following: -On 03/09/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/10/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's nurse's notes, dated 03/10/23, showed the following: -Resident on restorative therapy for range of motion; -Resident doing well, will continue to monitor. Review of restorative therapy log, dated 03/06/23 to 03/13/23, showed on 03/13/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Record review of the resident's care plan, dated 03/14/23, showed the following: -Resident at risk for pressure ulcer; -Consider PT consult for conditioning and wheelchair assessment; -Resident at risk for falls; -Implement exercise program that targets strength, gait, and balance. (Staff did not care plan regarding restorative plan.) Review of restorative therapy log, dated 03/14/23 to 03/10/23, showed the following: -On 03/17/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/22/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/23/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/24/23, the resident received 15 minutes of passive range of motion therapy and resident received 15 minutes of active range of motion therapy. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received the following therapy: -On 04/11/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/12/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/13/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/14/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Record review of the resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed staff did not document regarding restorative therapy. During an interview on 5/24/23, at 1:28 P.M., the resident said staff do not come in and work with him/her. The resident was not aware staff were supposed to be working with him/her. During an interview on 05/24/23, at 1:30 P.M., Resident #9 said the following: -He/she and Resident #8 have been roommates for approximately a year; -Resident #9 does not leave the room often and has not observed staff come in and work with Resident #8. 6. Review of Resident #10's face sheet showed the following: -admitted [DATE]; -Diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), anxiety disorder, major depressive disorder, Type 2 diabetes, heart failure, weakness, abnormalities of gait and mobility, and muscle wasting and atrophy (wasting or thinning of muscle mass). Review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's POS, current as of 05/24/23, did not reflect any orders for therapy. Review of the resident's nurse's notes, dated 02/09/23, showed resident on restorative nursing for range of motion for contractures. Review of the residents' restorative therapy log, dated 02/01/23 to 02/28/23, showed the resident received therapy on the following dates: -On 02/09/23, resident received 15 minutes of passive range of motion therapy; -On 02/14/23, resident received 15 minutes of passive range of motion therapy; -On 02/21/23, resident received 15 minutes of active range of motion therapy. Review of the resident's nurse's notes, dated 02/24/23, showed resident on restorative nursing for range of motion. Review of the residents' restorative therapy log, dated 03/01/23 to 03/09/23, showed the resident received therapy on the following dates: -On 03/03/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/09/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's nurse's note, dated 03/10/23, showed the following: -Resident on restorative therapy for range of motion; -Resident doing well, will continue to monitor. Review of the residents' restorative therapy log, dated 03/10/23 to 03/12/23, showed on 03/10/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of the residents' restorative therapy log, dated 03/13/23 to 03/19/23, showed the resident received therapy on the following dates: -On 03/13/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/14/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/17/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; Review of the resident's care plan, dated 03/20/23, showed the following: -Assist resident in designing a progressive activity/exercise program to my maximal potential -Resident is a fall risk due to generalized weakness and paralysis from a stroke; -Observe, document, and report any functional decline and provide increased assistance as needed; -Therapy as per physician order with quarterly and PRN screenings by therapist. (Staff did not care plan regarding the resident's restorative plan.) Review of the resident's restorative therapy log, dated 03/20/23 to 03/09/23, showed the resident received therapy on the following dates: -On 03/21/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/22/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/23/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/24/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed the resident received therapy on the following dates: -On 04/11/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/12/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/13/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy -On 04/14/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/17/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/18/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/21/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's nurse's notes, dated 04/28/23, showed resident on restorative nursing for range of motion. Record review of resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed staff did not document regarding restorative therapy. 7. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -A physician's order is needed to screen a resident for therapy; -Staff will alert therapy to residents that are declining and feel can benefit from therapy; -Therapy will make a referral and a meeting is held approximately once a week with the Administrator and DON to discuss the referral; -The Administrator and DON will determine if a resident is appropriate for a therapy evaluation; -The DOR does not contact the physician directly about obtaining a therapy evaluation as there is a process he/she is to follow, which is to have the Administrator and DON review all therapy requests. 8. During an interview on 05/24/23, at 10:34 A.M., the NP said the following: -The NP or physician should be notified regarding all therapy referrals; -Nursing will notify the NP if a resident needs an order for therapy. If the NP has concerns/questions, they will talk with therapy; -The NP can assess residents and give an order for a therapy evaluation; -Therapy can reach out the NP or the facility physicians and request an order for a therapy evaluation; -Verbal orders are given for restorative therapy and nursing enters the order. 9. During an interview on 05/24/23, at 11:11 A.M., the physician said the following: -He/she should be contacted if therapy is recommending a resident receive a therapy evaluation; -Residents do not always have an order for restorative therapy. Residents sometimes receive an order when progressing off of therapy. 10. During an interview on 05/24/23, at 11:20 A.M., CNA A said the following: -He/she discusses concerns regarding a resident's physical decline with a nurse and therapy; -The transport driver is also the restorative therapy aide; -CNA A does not know when restorative therapy is complete since the aide is often out on transport; -CNA A believes therapy and restorative is documented in the care plan, which are located at the nurse's station; -Nurses update care plans. 11. During an interview on 05/24/23, at 11:34 A.M., CNA B said the following: -He/she talks to therapy about any concerns regarding resident's physical decline; -He/she does not know if residents receive restorative therapy; -The restorative aide also is in charge of transportation; -Therapy and restorative should be documented in the care plans, which are located at the nurse's station; -Medical records updates the care plan to document the resident's needs. 12. During an interview on 05/24/23, at 11:45 A.M., CMT C said the following: -The restorative aide quit; -Residents are not receiving restorative therapy; -Care plans document therapy and restorative; -Medical Records updates the care plans based on a resident's needs. 13. During an interview on 05/24/23, at 12:00 P.M., Restorative Nursing Assistant (RNA) D said the following: -RNA D was the restorative aide and the transport driver for approximately six months; -The facility hired a new RNA, however he/she quit two weeks ago; -The previous RNA was unable to complete his/her RNA duties as he/she was often pulled to work the floor as a CNA; -RNA D has been on leave for the last few weeks, but returned last week; -RNA D has resumed transport duties, but not restorative therapy; -Residents have not received restorative therapy in the month of May 2023; -RNA D documents restorative therapy in the electronic chart; -Any concerns regarding a resident's physical decline is reported to the DON or Administrator during their morning meeting; -Care plans are located in the resident's electronic chart; -Therapy and restorative should be documented in the care plan; -The MDS coordinator updates the care plans. 14. During an interview on 05/24/23, at 1:00 P.M., CNA F said the following: -CNA F does not know if the facility currently has a restorative aide; -When the facility had a restorative aide, they did not provide therapy to the SCU; -CNA F believes the restorative aide was often pulled to the floor to work. 15. During an interview on 05/24/23, at 1:50 P.M., Registered Nurse (RN) E said the following: -If a resident's physical ability is declining, he/she will discuss concerns with the DON and will

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN), other than the Director of Nursing, for at least eight consecutive hours per day seven days per week with the facility average daily occupancy over 60 residents. The facility census was 70. Record review showed the facility did not provide a policy regarding RN coverage. 1. Record review of the facility Daily Nurse Staffing Form (posted staffing sheets), dated December 2021 and January 2022, showed no RN was scheduled from 6:00 A.M.-2:00 P.M., 2:00 P.M.-10:00 P.M., and 10:00 P.M.-6:00 A.M. shifts on the following days: -On 12/6/21, with a census of 72. -On 12/10/21, with a census of 73; -On 12/11/21, with a census of 72; -On 1/10/22, with a census of 70. During interview on 1/13/22, at 11:05 A.M., the Director of Nursing (DON) said the following: -The facility currently only had one full-time RN, two part-time RN's, and two as needed (PRN) RN's; -There had been no Assistant Director of Nursing (ADON) since 12/20/21 and no Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) staff since 12/23/21; -She thought that she was able to count herself as the RN in the building. During an interview on 1/12/22, at 9:50 A.M., the Administrator said the facility had multiple days over the past three months where there was no RN coverage, and the DON covered those days. The DON covered multiple weekends as well, and was under the assumption that if the weekends were not her usual scheduled days, those days would be covered as an RN, and not as DON.

Based on observation, record review, and interview the facility failed to develop and implement a system for prevention of falls related to transfers, a system ensuring proper assessment of the possible need for additional care related to falls and a system to ensuring proper investigating of falls. The facility failed to provide adequate trained staff to assist one resident (Resident #5) who required extensive assistance of two staff during transfers. One staff member assisted the resident with a transfer; the resident fell during the transfer and sustained a fractured hip. The staff member present during the fall moved the resident, without help prior to a clinical assessment of the resident. The nursing staff member who assessed the resident was unable to determine the resident had a hip fracture when the resident complained of hip pain and did not continue to monitor the resident for the rest of his/her shift. Administrative staff failed to investigate the fall. The deficient practice affected one of 13 residents selected for review. The facility census was 80 residents. 1. During an interview on 3/3/16 at 7:05 P.M., the Director of Nursing (DON) said the facility had a book that contained policies regarding what staff should do related to falls. She said staff do not follow or use the book. The DON did not provide a policy regarding fall investigations. Record review of the Resident #5's current physician's orders [REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment completed by facility staff, dated 8/12/15, showed the following information: -Cognitively intact; -Balance was not steady and the resident required assistance from staff when moving from seated to standing position, walking, moving on and off the toilet and transferring from bed to chair or wheelchair; -Required extensive assistance of two staff with transfers, bed mobility, dressing toileting and hygiene; -No falls; -Paralysis of one side of the body; -Stroke; -Heart failure; -Blood clot. Record review of the resident's electronic medical record showed the resident discharged to the hospital on [DATE], had surgery related to a hip fracture and readmitted to the facility on [DATE]. Record review of the hospital discharge showed the resident admitted to the hospital on 10-31-15 for left hip pain after a fall at the nursing home. Radiology results showed a left hip fracture. Left hip fracture repaired with surgery and resident discharged back to facility with orders for physical therapy. Record review of the resident's care plan, which staff identified as the plan of care prior to the fall (10/30/15) and developed originally on 2/19/15 showed the following information: -The resident was at risk for falls due to impaired balance, impaired safety awareness, and impaired mobility; -The resident required extensive assistance from staff for transfers and mobility. During interviews on 3/2/16 at 2:10 P.M., and on 3/3/16 at 1:43 P.M., the resident said there should always be two staff to assist him/her when moving from wheelchair to bed or from bed to wheelchair. The staff should use a gait belt when assisting with transfers. In October of 2015, the resident said he/she had a fall when only one Certified Nursing Assistant (CNA) assisted him/her without using a gait-belt. The CNA assisted him/her from his/her wheelchair to the bed. The CNA lifted the resident from the wheelchair by placing his/her hands under the resident's arms. As the resident stood the CNA tried to turn the resident around and the resident's right leg slipped under the bed; he/she fell to the floor on the left side. The resident said, it really hurt bad and he/she knew he/she was in trouble . The CNA used a gait belt to assist the resident up off the floor to the bed and then the resident asked for assistance back into the wheelchair. The CNA was sorry. The resident did not know whether the CNA reported the fall or the resident's pain to the nurse because no one came to assess the resident. The resident said he/she was in pain and about five minutes after the CNA left the room, he/she propelled him/her self to the therapy department where he/she had hoped somebody could look at his/her left leg. The therapy staff members were busy so the resident went back to his/her room and told two different CNAs that he/she was really hurting. Licensed Practical Nurse (LPN) H finally came down to assess the resident; the resident told LPN H he/she wanted an X-ray done of his/her left side. LPN H assessed the resident and said without bruising there was no need for an x-ray. The resident remained in pain the rest of the day. It was not until the night nurse; Registered Nurse (RN) C came on duty that anyone else assessed the resident. RN C assessed the resident and had another nurse assess the resident and they both agreed the resident's feet pointed in the wrong direction. RN C sent the resident to the hospital. The hospital discovered he/she had a fractured left hip and had to have surgery to repair it. During an interview on 3/2/16 at 5:37 P.M., CNA L said he/she had assisted the resident during the transfer when the resident fell , in October. On that day, after breakfast the resident put his/her call light on and CNA L was the only staff on the hall because the other CNA was on lunch break. CNA L said he/she responded to the call light and found the resident sliding out of his/her wheelchair. CNA L said he/she assisted the resident by placing a gait belt around his/her chest and as CNA L walked behind the wheel chair the resident slipped out of the wheelchair with his/her legs out in front of him/her. CNA L said he/she was able to get around to the front of the wheelchair and lowered the resident to the floor. The resident sat on the CNA's foot and ankle. CNA L said he/she assisted the resident up off the floor and back into his/her wheelchair. CNA L said he/she should have called for help when the resident was on the floor but he/she did not because the resident was on the CNA's foot/ankle. It would have taken awhile to get help since he/she was the only CNA on the hall at that time. The resident complained of pain and CNA L said he/she reported to the charge nurse, LPN H. The LPN had CNA L and another CNA transfer the resident to the bed so he/she could assess the resident's pain. The resident did not have swelling or bruising at that time. CNA L was not sure what happened after LPN H assessed the resident. CNA L said he/she heard the resident went to the hospital later that evening and had surgery for [REDACTED]. CNA L said if a resident has any change in position, from wheelchair to the floor he/she should have called for a nurse immediately. The CNA said he/she should not have moved the resident until the nurse assessed the resident. Record review of the resident's nurses' notes on 10/30/15 showed the following information: -At 3:34 P.M., LPN H documented he/she went to resident's room because the resident complained of left hip pain; the resident stated he/she fell at 2:30 P.M. The resident and CNA L informed the nurse that the resident's right leg slipped out from underneath him/her during a transfer. CNA L held the resident up off the floor and assisted the resident back to the wheelchair. The resident complained to the CNA of left hip pain all shift. The nurse assessed the resident and found no bruising, no shortening of left leg and the LPN performed passive range of motion with some discomfort. The resident complained of some pain when palpated along resident's right buttocks. -At 4:34 P.M., LPN H documented the pain medication he/she administered was effective. Staff did not document any further monitoring of the resident's pain. During an interview on 3/3/16 at 11:00 A.M., LPN H said prior to the fall the resident need assistance of one staff person to transfer with a gait belt. The resident is alert and oriented. The LPN said, as far as he/she knew, the resident was not at risk for falls and did not require extensive assistance with transfers. The resident could only bear weight on his/her right leg due to paralysis of the left leg. The staff should always use a gait belt when transferring any resident. Staff should follow the care plan. LPN H said if a resident is an extensive assistance with transfers there should be two staff and a gait belt or a mechanical lift used when transferring a resident. On the day the resident fell in October at approximately 2:00-2:30 P.M., CNA L told the LPN that while transferring the resident, the resident's leg gave out and the CNA sat the resident down on the floor on the CNA's foot. The CNA was able to get the resident back in his/her wheelchair. LPN said he/she assessed the resident within five minutes of CNA L reporting the fall. The resident complained of left hip pain, which he/she has always complained of hip and knee pain. The LPN said he/she assessed the resident and there was no rotation or shortening of the resident's left leg. LPN said he/she did passive range of motion on that leg and the resident did not really complain. The resident complained of pain in buttocks and the LPN gave her pain medication. The resident rested until supper with no other complaints of pain. There were no signs of a broken hip. LPN H said he/she contacted the physician and family regarding the fall but did not document in the chart. Record review of the resident's nurses' notes dated 9/1/15 through 10/30/15 showed the resident complained of hip pain one time and that was on 10/30/15 after the fall. Record review of the resident's October 2015 medication administration record (MAR) showed the following information: -From 10/1/15 through 10/29/15 the resident complained of pain five times, general pain, joint pain two times, knee pain, and pre-therapy pain. Staff did not document anything regarding hip pain until 10/30/15. -On 10/30/15, the resident rated hip pain at as eight out of 10 using the pain scale. At 2:30 P.M., LPN H gave the resident one tablet of Norco 5-325 milligram of pain medication to the resident and documented the results were effective. During an interview on 3/3/16 at 5:25 P.M., the ADON said she was on call and was in the facility the day Resident #5 fell . LPN H did not report anything regarding the fall. The night shift nurse RN C notified the ADON regarding the fall and fractured hip. The resident required one to two people assistance with a gait belt for transfers. The ADON said when a resident has a fall the nursing assistants should not move the resident they should immediately report to their charge nurse, charge nurse should assess the resident, notify the physician for direction and notify the family. Record review of the resident's nurses' notes on10/30/15 and 10/31/15 showed the following information: -At 9:40 P.M., RN C documented the resident reported severe pain in left hip, the resident reported the pain has been ongoing since fall earlier in the day; the resident reported nine out of 10 pain rating; very noticeable hip draw and outward rotation of left hip, resident was grimacing and gasping with manipulation of lower left extremity; -RN C notified the physician and sent the resident to the hospital for evaluation; -At 10:30 P.M., the resident left for the hospital; -At 1:55 A.M., RN C called the hospital and hospital staff reported the resident had a left hip fracture; the hospital scheduled surgery for [REDACTED]. During an interview on 3/3/16 at 3:35 P.M., RN C said the resident required extensive assistance of two staff with a gait belt prior to the fall and is now two staff assistance with a mechanical lift for transfers. The resident has left sided weakness due to the stroke. The resident can bear some weight but should always have two staff assisting him/her with transfers. RN C said his/her 12-hour shift began a 7:00 P.M. He/she received report that evening and when the aides transferred the resident earlier that day they had to lower the resident to the floor and the resident did not have any injury or concerns. RN C said he/she did not see the resident until approximately 9:30 P.M. He/she assessed the resident and said it was text book obvious a fractured hip. The resident's left hip showed to be withdrawn and there was outer rotation shortening. The resident was grimacing and gasping anytime RN C touched the area, the resident was in obvious pain. He/she wished he/she had gone down to assess the resident sooner. The resident told RN C he/she had done the splits during a transfer. RN C said he/she knew one of the aides involved was CNA L and was under the impression there were two aides. Resident #5 should always have two aides assisting with transfers. RN C said anytime a resident has a fall, the nurse should do an incident report and contact the physician and family. If a resident has a fall the aides should never move the resident, they should immediately call for the nurse to assess the resident. During an interview on 3/3/16 at 1:43 P.M., a family member said the facility staff called him/her on 10/30/15, at 10:30 P.M., to tell him/her that the resident was going to the hospital. The family member had been at the facility until 2:00 P.M. that day and the resident fell after that. The resident was in pain all day with a fractured hip until RN C came on shift and was able to help the resident. During observations on 3/1/16 and 3/2/16, the resident sat in a wheelchair in the dining room or his/her room. The resident propelled self to and from the dining room. The resident was able to feed his/her self and ate in the dining room. The resident required two staff people assistance with a mechanical sit-to-stand lift for transfers. The resident was alert and oriented. Record review of the resident's MDS dated [DATE], showed the following information: -Cognitively intact; -Fall with Fracture; -Resident was participating in physical therapy. Record review of the resident's current plan of care, dated 2/19/15 and updated 2/17/16, showed the following information: -The resident was at risk for falls due to impaired balance, impaired safety awareness, history of fall with hip fracture and impaired mobility; -Required extensive assistance from staff for transfers and mobility. During an interview on 3/2/16 at 1:58 P.M., CNA J said the resident required extensive assist of two staff for all transfers and most activities of daily living (ADLs). Staff should use a gait belt when transferring a resident from wheelchair to bed and bed to wheelchair or toileting the resident. If a resident falls during a transfer staff should report immediately to the charge nurse. Staff should never move a resident after a fall until the nurse has assessed the resident. During an interview on 3/3/16 at 3:15 P.M., CNA K said the resident has always required extensive assist of two staff for all transfers. Extensive assistance for transfers should involve two staff and a gait belt or a mechanical lift. The CNA said the resident would always tell them his/her legs did not work well and he/she needed two people to help with transfers. The CNA said he/she would never transfer Resident #5 without help. During an interview on 3/3/16 at 4:38 P.M., restorative nursing aide (RNA) D said prior to the resident's fall back in October 2015 the resident required extensive assistance of two staff with a gait belt. There should always be two staff assisting this resident with transfers. The resident had been working with restorative prior to the fall. During an interview on 3/2/16 at 5:55 P.M., and on 3/3/16 at 1:25 P.M., and 5:15 P.M., the DON said the assistant director of nursing (ADON) was on call that weekend and staff should have notified her of any incident to include falls. The DON said staff witnessed the fall and the resident did not hit the floor. There was no investigation or in-service trainings done regarding this fall. During an interview on 3/3/16 at 7:05 P.M., the administrator and the DON said staff should always use a gait belt when transferring a resident. When staff members lower a resident to the floor this is a fall and staff should not move the resident until the nurse has assessed the resident. Staff should notify the physician and family. The DON said she has looked into falls but did not do an investigation on Resident #5's fall.

Based on record review and interview the facility failed to ensure staff performed and documented an assessment following one resident's (Resident #13) fall which resulted in a fractured hip. The resident had a history of [REDACTED]. Staff failed to document findings reported to the resident's physician and failed to inform the resident's physician of a change in condition when the resident developed pain, swelling, and redness following the fall. Staff failed to implement interventions aimed to prevent further accidents other than an alarm which sounded when the resident removed. Staff knew the resident removed the alarm, but continued to use the alarm as an intervention for the prevention of accidents without adding additional interventions. Staff failed to provide adequate supervision to the resident related to his/her fall risk. The facility failed to utilize an air mattress correctly and according to manufacturer's instructions for one resident (Resident #1). Staff failed to use two side rails for the air mattress and the resident slid out off of the air mattress due to the facility's noncompliance with the air mattress instructions for use. The facility failed to ensure staff followed their policy for neurological assessments following falls for two residents (Residents #1 and #3). The facility failed to update one resident's (Resident #3) plan of care when the resident had multiple falls in the facility in a sample selection of 13 residents in a facility with a census of 51. 1. Record review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 10/19/10, showed the following information: -One fall without injury since admission or previous assessment; -Two falls with a non-major injury since admission or previous assessment. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Able to recall the current day, month, and year; -No behaviors noted; -Required supervision and set-up help from staff for bed mobility, transfers, walking in his/her room, and eating; -Used a walker; -Falls prior to admission; -No falls since previous assessment. Record review of the resident's fall care plan showed the resident fell on the following dates: -On 06/20/10 the resident fell and received a skin tear; -On 07/26/10 the resident fell and received a bruise; -On 09/07/10 the resident fell and received a laceration; -On 10/16/10 the resident fell and did not receive an injury. Record review of a telephone order, dated 09/07/10 at 4:30 A.M., showed an order for [REDACTED]. Record review of the resident's care plan showed a handwritten update, dated 09/08/10, for the resident to use an alarm in the bed. Record review of a telephone order, dated 09/08/10, showed the following: -May use a pressure alarm or tab monitor (personal alarm which attaches to a resident's clothing and alarms if the resident moves away from the alarm which alerts staff of an attempted self transfer or fall) to alert staff of any self transfer attempts for the safety of the resident. Record review of the resident's care plan, dated 01/12/11 (last reviewed date), showed the resident had a risk for falls due to his/her decreased functional ability, gait disturbance, and shortness of breath. The care plan directed staff to provide the following care: -Complete an assessment after a sustained fall prior to moving the resident; -Notify the physician and responsible party after a fall; -Observe and document any functional decline and provide assistance as needed; -Quarterly and as needed fall risk assessment; -Sturdy, non-skid shoes; -Used walker for mobility; -The resident's care plan showed no evidence staff placed interventions designed to decrease the resident's risk of falling other than to use the alarm after the resident fell on [DATE]. The care plan showed no interventions in response to the resident's falls on 06/20/10, 07/26/10, and 10/16/10. Record review of the resident's most recent monthly summary dated 01/17/11 at 3:19 A.M., showed the following information: -No short or long term memory problems; -Moderately impaired cognitive skills for daily decision making; -Made poor decisions and required cueing and supervision from staff; -Transferred independently; -Ambulated without assistance; -Use a cane/walker; -Used a wheelchair at times; -History of falls; -Bed mobility monitor to alert staff of self transfer attempts, due to frequent falls; -Does not turn call light on to summon assistance from staff; -Turns off bed mobility monitor. The information staff documented in the resident's monthly summary conflicted with resident's care needs identified in the resident's most recent care plan. Record review of the Acute Change of Condition Nurses' Notes showed the following: -On 02/15/11 at 8:31 A.M., licensed practical nurse (LPN) C documented the resident continued to receive antibiotics for a urinary tract infection (UTI) with no adverse reactions. Staff encouraged fluids and continued to monitor the resident. Staff found the resident on the floor in the morning with no apparent injuries. The resident had no problems with range of motion. LPN C notified the resident's family, the physician, and the director of nursing. Staff to continue to monitor and to attempt to prevent further incidents. The documentation did not show a full assessment including the time of the fall, location of the fall, the circumstances of the fall, and/or a head to toe assessment of the resident. The nurse's note did not address the resident's specific individual risks for additional falls or any resident-directed interventions to prevent future falls. During telephone interview on 03/07/11 at 3:35 P.M., the resident's family member said the following:-Staff notified him/her on the morning of the fall; -Prior to the fall the resident ambulated with a walker; -Prior to the fall the resident's cognition was fine; -Staff did not obtain X-Rays until the resident's family insisted; -This was the second time the resident fell that his/her family had to insist for X-Rays; -Staff did not send the resident to the hospital and instead obtained portable X-Rays. During an interview on 03/04/11 at 10:50 A.M., LPN C said after a resident falls staff should document the time of the fall, where staff found the resident, who staff notified of the fall, and what assessments were completed. He/she said the following about the resident and his/her fall on 02/16/11: -The resident wore nylon socks when he/she ambulated in the facility and would not wear shoes over the nylons; -The resident ambulated without assistance; -The resident had mild confusion; -The resident had a bed alarm which he/she removed; -On 02/15/11 he/she heard another resident say Resident #13 was on the floor; -The night shift nurse and him/herself went to the resident's room; -The resident fell around 6:30 A.M. ("give or take five minutes"); -The bed alarm did not sound; -He/she found the resident on the floor; -He/she and the night shift nurse transferred the resident to bed, but could not remember if they used the Hoyer lift; -The resident had "a little pain" and complained of pain in his/her center of hip/buttock; -He/she gave the resident a pain medication around "mid morning"; -He/she "checked" on the resident a "couple of times" and the resident had no rotation or pulling up (indicating an injury to the hip joint); -The resident's family came to the facility and wanted the resident to have an X-Ray; -He/she called the physician and called for the X-Ray service to come to the facility to obtain the X-Rays; -The X-Ray results came back at night; -The resident had a history of [REDACTED]. -The resident returned to the facility after surgery with orders for comfort care only. Record review of the nurses' notes showed the following: -On 02/17/11, LPN C wrote a late entry for 02/15/11. LPN C failed to document a time for the late entry. LPN C documented the following: -He/she heard a resident yell "help". The night shift nurse and him/herself responded to the room and found the resident on the floor on his/her right side and back with his/her walker leaned against the resident. LPN C and the night shift nurse assisted the resident back to bed and performed an assessment. LPN C palpated the resident's head, shoulders, ribs, pelvis, hips, and bilateral arms and legs. The resident denied pain except for minimal pain in the middle of his/her left buttock. The resident's legs were flat without shortening or rotation. The resident refused to get out of bed for breakfast and refused to eat the food brought to his/her room. LPN C notified the director of nursing and sent a fax to the physician. The resident refused to allow the nurse to complete a full body assessment without clothes on. LPN C documented he/she saw the resident's hips, back, abdomen, and lower legs and did not see visible wounds. During an interview on 03/04/11 at 12:08 P.M., LPN C said she wrote the initial note regarding the resident's fall in the resident's medical record. He/she was asked to complete a more detailed note regarding the resident's fall. He/she could not recall who asked him/her to write the more detailed note. Record review of the nurses' notes showed the following: -On 02/15/11 at 4:30 P.M., LPN C noted the resident complained of left leg pain from his/her knee to hip and the ankle. LPN C spoke with the resident's family and physician. He/she received an order to obtain X-Rays of the resident's left hip, knee, and ankle. Record review of a telephone order, dated 02/15/11 at 4:30 P.M., showed an order for [REDACTED]. Record review of the nurses' notes showed the following: -On 02/15/11 at 7:00 P.M., the X-Ray service took the X-Rays. Staff noted the resident also had a skin tear with a blue bruise to his/her left outer hip with swelling. The resident's family were aware of the ordered X-Rays and wished to be notified of the X-Ray results. The nurses' note showed no evidence staff notified the resident's physician about the change to the resident's condition including the skin tear, bruising, or swelling. Record review of an X-Ray report, dated 02/15/11, showed the following conclusion: -Very suspicious for a left femoral neck fracture; -Recommend CT or MRI (medical tests to determine injuries) correlation; -The interpreting physician electronically signed the report on 02/16/11 at 12:38 A.M. Record review of the nurses' notes showed the following: -On 02/16/11 at 6:50 A.M., staff notified the resident's family and physician of the X-Ray results of a possible left hip fracture. -On 02/16/11 at 6:55 A.M., staff noted the resident rested in bed during the shift and recorded the resident's vital signs. -On 02/16/11 at 8:25 A.M., the resident denied pain and took sips of juice and water. The resident refused his/her breakfast tray. The resident's son sat at the resident's bedside. -On 02/16/11 at 9:30 A.M., the resident's physician visited the resident and his/her family; -On 02/16/11 at 9:45 A.M., staff received an order to send the resident to the hospital. Record review of the physician's progress note, dated 02/16/11, showed the physician saw the resident and noted the resident's complaints of hip pain. The physician's plan included for staff to send the resident to the emergency room . Record review of a telephone order, dated 02/16/11 at 9:45 A.M., showed an order for [REDACTED]. Record review of the hospital's X-Ray report, dated 02/16/11 at 11:55 A.M., showed the resident had a compressed fracture of the subcapital portion of the left femoral neck (medical terminology referring generally to the hip). Record review of the hospital's history and physical, dated 02/16/11, showed the resident fell in the facility and developed left hip pain. The resident apparently fell bending to obtain his/her slippers. The resident complained of "rather severe pain" involving the left hip. The admitting physician ordered a consultation from an internal medicine physician. Record review of the hospital's consultation report, dated 02/16/11, showed the physician's plan included surgery to repair the fractured hip. Record review of the hospital's operative report, dated 02/16/11, showed the pre and post-operative [DIAGNOSES REDACTED]. The physician performed a reduction and internal fixation (surgical procedure where an incision is made along the hip and the hip joint bones are repaired using surgical hardware devices). Record review of the nurses' notes showed the following: -On 02/17/11 (late entry) timed 10:25 A.M., staff documented an ambulance arrived at the facility. Staff assisted the resident to change clothing, provided pericare, and applied a new incontinence brief due to incontinence. Staff assisted the resident to a cart and gave the transfer papers to the ambulance staff. Record review of the hospital's discharge summary, dated 02/21/11, showed the resident admitted to the hospital with [REDACTED]. The resident required surgery to repair the fracture despite his/her high risk factors. Hospital staff discharged the resident back to the facility with orders for comfort care only. During an interview on 03/03/11 at 12:35 P.M., LPN H said the residents' care plans includes interventions for fall prevention and the care plans reflect the residents' current needs. During an interview on 03/03/11 at 1:40 P.M., the director of nursing (DON) said after a resident fell she expected staff the assess the resident for range of motion and transfer the resident using a Hoyer lift (mechanical lift). Staff should obtain a set of vital signs and begin neuro assessments. Staff should notify the resident's physician, family, the DON, and the administrator of the fall. Staff should document the information in the nurses' notes or the acute change of condition nurses' notes. Staff place the resident's medical record in the "hot rack". She expected staff to look at the situation and circumstance of the fall and add interventions. Staff should document the interventions on the residents' care plans. During an interview on 03/03/11 at 1:40 P.M., the administrator said staff monitor the residents in the "hot rack" for 72 hours following a fall. The administrator said staff should document (including vital signs) in the resident's medical record every shift following a fall. She expected staff to complete neuro assessments following a fall if the fall was unwitnessed or the resident hit their head. She expected staff to notify the resident's physician and expected staff to report the findings to the physician. During an interview on 03/04/11 at 11:40 A.M., occupational therapy assistant I said he/she worked with the resident to increase strength, transfers, and pain management. The resident had "good" cognition and ambulated in the facility using a walker. The resident had a "couple" of falls. He/she screened the resident after the falls and worked on safety with the resident. During an interview on 03/04/11 at 11:45 A.M., the physical therapist said he worked with the resident for twice for general mobility, safety, and transfers. The therapy department screens residents after falls and would work with the residents if services were needed. During an interview on 03/04/11 at 12:20 P.M., the DON said the resident used a walker and had no other interventions in place regarding fall prevention. During an interview on 03/04/11 at 12:20 P.M., the administrator said facility staff could implement immediate interventions following a fall. The facility had a fall committee which reviewed every fall and recommended interventions. Staff should document the interventions on the resident's care plan. Staff could implement interventions for ambulatory residents such as: therapy screening, walker training, personal body alarms, pressure alarms, sensor alarms, or low beds. She expected staff to perform and document the following: -A head to toe assessment; -The time and location of the fall; -All of the details of the fall; -Who staff notified (i.e. the resident's physician and family); -What orders they received from the physician; -Any comments from the family. Refer to the following complaint numbers: -MO 503; -MO 512; -MO 563; -MO 572. 2. Record review of Resident #1 quarterly MDS, dated [DATE], showed the following information: -Scored 13 out of a possible 15 points during a brief interview for mental status; -Extensive assistance required with two staff for bed mobility and transfers; -Only able to stabilize with human assistance during locomotion, toileting and personal hygiene; -History of falls since last assessment with injury. Record review of the physician's orders showed an order, dated 01/18/11, for an air mattress. Record review of the nurses' notes, dated 01/18/11, showed staff received an order for [REDACTED]. Record review of the care plan, last reviewed on 02/02/11, showed the resident had a risk for falls. The care plan directed staff to provide the following care: -If fall sustained, complete an assessment prior to moving resident to include vital signs. Notify the physician and responsible party; -Observe, document, and report any functional decline and provide assistance as needed; -Monitor for changes in cognitive status and report any concerns to physician; -Side rail in bed to assist with turning/repositioning and for safety to remind resident to call for assist. Record review of a handwritten care plan update, dated 01/18/11, showed staff added an air mattress to the resident's bed in response to the resident's skin breakdown. The care plan showed no evidence staff addressed the safety needs of the air mattress related to the use of side rails. Record review of the owner's operation and maintenance manual for the Turn-Q Plus automatic turning mattress low air loss therapy system, undated, showed the following information regarding low air loss therapy: -The Turn-Q Plus must be installed on medical bed frames or medical-grade homecare beds with full length side rails. After placing the patient on the mattress, verify the side rails provide adequate protection for the patient. The side rails must be in the raised position whenever the patient is on the bed. Record review of the nurses' notes showed the following: -On 02/13/11 at 3:30 A.M., Staff entered the resident's room and found the resident on the floor on his/her right side with a top sheet and a blanket under him/her. Two staff members transferred the resident using a Hoyer lift (mechanical lift). The resident denied discomfort. The resident stated he/she bumped his/her head. The resident hit his/her right upper forehead and sustained a six centimeter (cm) by three cm hematoma (blood filled bruise). Staff applied an ice pack for 20 minutes. Staff asked resident to recall the events; he/she stated, "I just rolled out of bed, slid right off". Staff initiated neurological checks (an assessment to evaluate the resident's level of mental function) per protocol. Staff notified the resident's physician's office, the administrator, and the director of nursing (DON). Record review of the facility policy titled, "Emergency Procedure-Head Injury", undated, showed staff should obtain neurological vital signs for suspected head injury every hour for the first four hours, then every four hours for the next 20 hours. Record review of a facility form titled neurologic assessment, dated 02/13/11 showed staff documented neurological checks starting at 3:30 A.M., 3:45 A.M., 4:15 A.M., 4:45 A.M., 5:45 A.M., 6:45 A.M., 7:45 A.M. and 8:45 A.M. The Neurologic Assessment form showed no further neurologic assessment after 8:45 A.M. Staff failed to monitor Neurologic checks per facility policy. Record review of the nurses' notes showed the following: -On 02/13/11 at 9:45 A.M. the resident stated he/she did not remember the fall over night. He/she stated he/she wanted another side rail. He/she had only one half side rail in the bed. Staff received an order to have two side rails on the bed per the resident's request. Staff informed the DON of the resident's request for a second side rail. Record review of acute changes of condition nurses' notes for an incident/accident showed the following: -On 02/13/11 at 2:19 P.M., the resident had a greenish/purple bruise to his/her right forehead. The resident appeared somewhat confused and complained of pain in his/her tailbone and behind his/her right knee; -On 02/13/11 at 6:13 P.M. ; the resident fell overnight and received a purple/ greenish bruise to his/her forehead. The resident had more anxiety today and requested staff to stay with him/her. He/she requested staff to call family members. Staff called the resident's family and the resident spoke with them. The resident did not complain of any new pain areas. He/she stated his/her lower back and behind his/her knee have hurt off and on, but nothing unusual. The resident has two side rails on his/her bed after incident, per his/her request. The resident got up for supper and wheeled him/herself around the hallways as usual this evening. Record review of the side rail rationale screen, dated 02/15/11, showed the following: -The DON completed the screen for side rail usage; -The resident expressed a desire for raised side rails; -The resident used the side rails for positioning or support; -The resident required extensive assistance from staff for transfers; -The resident fell in the past 30 days; -The screen showed no evidence staff used the side rails to comply with the manufacturer's instructions for use related to the air mattress. Record review of the current (March 2011) physician orders showed an order, dated 02/17/11, for two half side rails. Record review of the hand written care plan update, dated 02/17/11, showed staff added two side rails. During an interview on 03/03/11 at 11:50 A.M., certified nursing assistant (CNA) E said the resident required assistance with all care. During an interview on 03/03/11 at 11:50 A.M., CNA F said the resident used an air mattress. At first the resident used only one side rail with the air mattress, then staff added the second side rail. During an interview on 03/03/11 at 12:35 P.M., licensed practical nurse (LPN) H said after a resident fell staff should complete an assessment prior to moving the resident. Staff initiate neurological checks if the resident fell unwittnessed by staff or if the fall was suspicious for a head injury. He/she explained the time frame for neurological checks as: every 15 minutes (twice), then every 30 minutes (twice), then every hour (four times). During an interview on 03/03/11 at 12:52 P.M., LPN C said the resident used only one side rail when he/she first received the air mattress. Staff requested a second side rail for the resident after he/she fell out of bed. During an interview on 03/03/11 at 1:40 P.M., the DON said the resident required two staff members for transfers. The resident had an air mattress related to a pressure ulcer. Staff obtained the air mattress in January 2011 for the resident. 3. Record review of Resident #3's quarterly MDS, dated [DATE], showed the following information: -The resident scored a total score of six out of a possible 15 points during a brief interview for mental status (a structured cognitive test); -[DIAGNOSES REDACTED]. -Extensive assistance required with two staff for bed mobility and transfers; -Only able to stabilize with human assistance during locomotion, toileting and personal hygiene; -History of falls since last assessment with injury. Record review of the care plan, dated last reviewed on 02/02/11, showed the resident had a risk for falls. The care plan directed staff to provide the following care: -If fall sustained, complete an assessment prior to moving resident to include vital signs. Notify physician and responsible party; -Observe/document/report any functional decline and provide assistance as needed; -Monitor for changes in cognitive status, report any concerns to physician. Record review of the hand written fall care plan, dated 08/14/09, last updated on 01/11/11, showed the following: -On 01/07/11, the resident fell out of bed and did not have any injuries. Staff noted no new interventions. -On 01/11/11, the resident fell while attempting to transfer him/herself and received a bruise to his/her hand. Staff noted no new interventions; -On 02/06/11, the resident fell while attempting to transfer him/herself and did not have any injuries. Staff noted no new interventions; Record review of a departmental note (form used interchangeably with nurses' note), dated 01/07/11 at 9:11 P.M., showed the resident attempted to transfer him/herself to bed without assistance from staff. The resident sat on the side of the bed and slid off of the bed. The resident received a "quarter sized bump" on his/her right forehead. Staff documented the resident's neurological check was within normal limits. Record review of a facility form titled neurologic assessment, dated 01/07/11, showed staff documented neurological checks starting at 6:12 P.M., 6:30 P.M., 7:00 P.M., 7:30 P.M., 8:00 P.M., 9:00 P.M., 10:00 P.M. and 11:00 P.M. The Neurologic Assessment form showed no further neurologic assessment after 11:00 P.M.. The facility failed to monitor Neurologic checks per facility policy. Record review of a departmental notes, dated 02/10/11, showed the resident fell on [DATE] while he/she attempted to get out of bed without supervision. Staff instructed the resident to use call light, but the resident requires constant verbal cues for safety with functional transfers. Record review of the nurses' notes, dated 02/06/11, showed the resident fell attempting to get out of bed without supervision. The resident slipped on a loose bowel movement. The bed alarm failed to alert staff the resident was out of bed. Staff initiated a new care plan intervention to fix the bed alarm and educate the resident use of call light. The nurse's notes showed no further evidence of interventions placed after the fall to prevent further incidents. Observation on 03/02/11 at 1:52 P.M. showed resident rested in bed. Staff left the bed in the normal position. The resident shared a room with one roommate. A mat lay on either side of the roommate's bed, however, Resident #3 had no mats next to his/her bed. During an interview on 03/03/11 at 12:52 P.M., licensed practical nurse (LPN) C said the resident used a bed or body alarm or "maybe both". Staff can place immediate interventions after a resident fell . The care plan should reflect the resident's current plan of care and interventions for fall prevention should be listed on the care plans. During an interview on 03/03/11 at 1:40 P.M., the director of nursing (DON) said the resident required one person to assist with transfers. The DON said the resident's only intervention for fall prevention was a bed alarm. She said after a resident fell staff should look at the circumstances of the fall and place interventions as needed. During an interview on 03/03/11 at 1:40 P.M., the administrator said staff should modify the approach to fall prevention and move forward with new interventions as needed.