Every finding on record at Hillcrest Health Care Center

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to provide dignity to residents during personal care for 2 of 13 residents (Residents #1, #7). The facility reported a census of 50 residents. Findings Include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS documented the resident required partial/moderate assistance with toilet hygiene. The document indicated the resident was continent of bowel and bladder. The MDS revealed diagnoses of lymphedema, morbid obesity and other disorders of electrolyte and fluid imbalance. The Care Plan revised 4/3/26 identified the resident had self care deficits directing staff the resident required 2-4 staff for toilet transfers, and used disposable briefs.On 5/4/26 at 3:00 PM Resident #1 stated she felt like she had not been provided with dignity and respect during personal care during the overnight shift. The resident stated an unnamed male staff member was completing her perineal care and she requested the staff complete the task in a different manner to ensure she was thoroughly cleaned. Resident #1 stated following her request, the staff member removed his gloves, walked to the door stating you are telling me how to do my job?. The resident stated the comment upset her and she tried explaining why she wanted the task completed a certain way with the staff moving closer to the door, staring at her and replying to the resident not to yell at him and proceeded to walk off. The resident stated no other staff had done this to her before.2. Resident #7's MDS dated [DATE] revealed a BIMS of 15/15 indicating normal cognition. The MDS documented that the resident required substantial/maximal assistance with toilet hygiene, partial/moderate assistance with lower body dressing and substantial/maximal assistance for transfers. The document included the resident had an indwelling catheter, always incontinent of bowel, had impairments of movement of bilateral upper and lower extremities, and utilized a wheelchair. The MDS revealed the resident had diagnoses of hemiparesis following a stroke affecting her left non-dominant side, neuromuscular dysfunction of the bladder, aphasia, anxiety and depression. The Care Plan revised 4/24/26 identified the resident had bowel incontinence related to confusion, impaired mobility and inability to communicate with staff directives to provide use of brief and incontinence care with each episode. The document identified self care performance deficits with staff interventions that required total dependence on staff for toilet use and used a dependent non weight bearing mechanical lift (Hoyer) for transfers. The clinical record's Physician Orders revealed the indwelling catheter was discontinued on 4/22/26.A facility posted document dated 1/5/26 above Resident's 7 bed revealed the resident could use the weight bearing standing lift (EZ Stand) for transfers with the assistance of 2 staff. The facility failed to update the Care Plan to reflect the change in resident's transfer status and discontinuation of the catheter.Continuous observation on 4/29/26 at 3:45 PM of Staff B Certified Nurse Assistant/Certified Medication Aide (CMA)/Housekeeping Supervisor and Staff I, CNA, provided transfers and personal care to Resident #7. The staff positioned the EZ Stand in front of the resident and her wheelchair. The resident notified Staff B she had a secret, told the staff and then began to cry. The resident indicated she had been incontinent and was upset. Staff B and Staff I completed the waist harness and leg straps prior to initiating the lift. Staff B and Staff I worked together and moved the resident in the lift into the bathroom. When the resident was positioned at the toilet, Staff B provided a verbal cue that she was going to lower the resident's pants to which the resident stated no. The staff stopped and questioned whether the resident wanted to stop the transfer with toileting and be completed later. The resident responded that she was joking and the staff could continue. Staff B removed the resident's pants and brief, and lowered the resident onto the toilet. As soon as the resident was seated on the toilet, she indicated she was finished as she had been incontinent prior to the initiation of the lift. Staff B raised the resident in the lift into a standing position to complete perineal care during which the resident did state ow followed by it's ok. Staff B completed dressing with a tabbed brief and pulling up the resident's pants and Staff I moved the resident with the lift to the wheelchair for positioning. The staff worked together to position the resident in the wheelchair. On 4/29/26 at 1:00 PM Resident #7 with the Director of Nursing (DON) and Social Services Director present indicated she required staff assistance for self care and transfers. The resident stated she required 2 staff for transfers but mostly had only 1 staff. Resident #7 stated she was mostly incontinent of bowel and bladder, and had recently had her catheter discontinued. The resident stated on 4/22/26 Staff J, CNA, was assisting her alone with personal care. The resident stated the staff connected her to the lift, moved her into a standing position, and lowered her pants/brief. Resident #7 stated Staff J patted my butt. The resident reiterated she did not have her pants on. The resident stated the staff continued to provide perineal care as she had been incontinent and that she felt her care was rough. The resident stated she did not tell the staff that it was uncomfortable, caused discomfort or she did not like being patted on her bottom. The resident did acknowledge that Staff J was not the only staff member she felt was rough at times during her perineal care. The resident was observed during the interview to become teary eyed and require a moment for recomposing. On 4/29/26 at 1:30 PM the Social Services Director stated on 4/24/26 at approximately 4:30 PM she was notified that Resident #7 wanted to speak with her. The staff stated Resident #7 stated Staff J patted her on the butt while providing care and wiped her too hard. The staff stated the resident originally did not state whether her pants were up or down when she was patted. The Social Services Director indicated the resident appeared upset during her conversation and was not known to make false statements.On 4/29/26 at 1:40 PM the DON stated she had been made aware of the resident's complaint about the care she had received by Staff J. The DON stated the resident had not made any previous complaints or voice concerns about other staff that she was aware of. On 4/29/26 at 4:00 PM Staff F, Licensed Practical Nurse (LPN), stated she had been told by Resident #7 that Staff J tapped her on the bottom. The staff stated the resident did not indicate whether her pants were up or down. On 4/30/26 at 8:33 AM Staff K, LPN, stated Resident #7 called her into her room during her shift and told her Staff J had put the resident in the stand assist and had patted her on the bottom. Staff K stated Resident #7 made the statement of couldn't do anything about it and had cried. The staff stated she made sure the resident knew that if something was uncomfortable she needed to talk to staff. On 5/6/26 1:55 PM The DON stated 2 staff were to present with the use of the EZ lift. The DON stated it was her expectation that residents be treated with dignity and respect during all cares. The DON stated residents have the right to express how they would like their cares to be completed and staff need to respect their wishes. On 5/6/26 at 3:30 PM the Administrator acknowledged residents were to be treated with dignity and respect during care.The facility's undated Resident Rights Dignity and Privacy Policy disclosed all residents were to be treated with dignity, respect, and privacy. The document revealed staff shall provide respect to residents when providing care as constant affirmation of their individuality and dignity as human beings.

Based on record review, staff interviews and facility policy review the facility failed to complete skin assessments to include measurements and wound status for 2 of 3 residents (Resident #1 and #2) reviewed with pressure ulcers. The facility also failed to sign out wound treatment orders and being completed for 1 of 3 residents (Resident #1) reviewed with pressure ulcers. The facility reported a census of 50 residents.Findings include:According to Resident #1's quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/23/2026, she had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 suggested mild cognitive impairment. The MDS documented she had two unstageable pressure ulcers/injuries present on admission. The following diagnoses were documented for Resident #1: lymphedema, respiratory failure, morbid obesity, persistent mood (affective) disorder, sleep apnea, venous insufficiency, and cellulitis of left lower limb.The Care Plan Focus Area with an initiated date of 3/2/2026 documented Resident #1 had impaired skin integrity. The Care Plan directed staff to assess, record, and monitor wound healing. Staff are to: measure length; width; and depth where possible; assess and document status of wound perimeter; wound bed and healing process.Review of Resident #1's Assessment tab for skin assessments from 4/8/2026 to 4/30/2026 revealed skin checks were completed on 4/14/2026, 4/21/2026, 4/28/2026, and 4/30/2026. Assessment completed on 4/14/2026 failed to include measurements when her coccyx, left lateral thigh, and left shin were assessed. Assessment completed on 4/21/2026 and 4/28/2026 failed to include measurements when her coccyx was assessed. The assessments documented the area was previously deteriorating, wound characteristics plateaued.On 4/29/2026 the facility provided skin and wound assessments for Resident #1 from 4/8/2026 to 4/29/2026 related to non-fluid filled blister like areas to her coccyx. Assessments completed on 4/16/2026, 4/21/2026, and 4/28/2026 failed to include measurements.On 4/29/2026 the facility provided skin and wound assessments for Resident #1 from 4/8/2026 to 4/29/2026 related to a stage 1 pressure ulcer/injury to her left shin: non-blanchable erythema of intact skin. Assessments completed on 4/16/2026 and 4/21/2026 failed to include measurements. Assessment completed on 4/28/2026 documented the following measures to the pressure ulcer/injury to her left shin: 2-centimeter (cm) x 2cm.On 4/29/2026 the facility provided skin and wound assessments for Resident #1 from 4/8/2026 to 4/29/2026 related to a stage 1 pressure ulcer/injury to her left lateral thigh. Assessment completed on 4/16/2026 failed to injury measurements.Review of Resident #1's April 2026 Treatment Administration Record (TAR) revealed the following orders were not signed out as being completed:Keep drigo wicking cloths to folds: leg, feet, under abdomen and groin folds. Utilize pillow cases if resident refuses wicking clothes, change daily and as needed. Order not signed out as being completed on 4/24/2026, 4/26/2026, 4/27/2026, and 4/29/2026.Apply Aquaphor to bilateral lower legs every shift for skin treatment. Order not signed out as being completed on 4/17/2026, 4/22/2026, 4/24/2026, 4/26/2026, 4/27/2026, and 4/29/2026.Left medial thigh wound care: cleanse with vashe wound cleanser-apply vashe moistened gauze compress to wounds and allow to soak 3-5 minutes, cleanse wound and peri-wound skin. Cover wound bed with maxorb alginate dressing, secured with a bordered foam dressing, two times a day for wound care. Order not signed out as being completed on 4/15/2026, 4/17/2026, 4/22/2026, 4/24/2026, 4/26/2026, 4/27/2026, and 4/29/2026.Zinc oxide external paste: apply to coccyx/buttocks topically every shift for skin irritation. Order not signed out as being completed on 4/24/2026, 4/26/2026, 4/27/2026, and 4/29/2026.Cleanse area to right knee with wound wash, apply mepilex to wound; change every 3 days. Order not signed out as being completed on 4/15/2026, 4/24/2026, and 4/27/2026.According to Resident #2's 5-day MDS assessment tool with a reference date of 4/20/2026, Resident #2 had a BIMS score of 9. A BIMS score of 9 suggested mild cognitive impairment. The MDS documented he had one stage 3 pressure ulcer/pressure injury present on admission. The following diagnoses were documented for Resident #2: urinary tract infection (UTI), cancer, neurogenic bladder, diabetes mellitus, malnutrition, sepsis, bactermia, and mild cognitive impairment.The Care Plan Focus Area with an initiated dated of 3/13/2026 documented Resident #2 had pressure ulcers present upon admission. The care plan directed staff to monitor areas weekly.Review of Resident #2's Assessment tab of skin check assessments from 4/8/2026 to 4/21/2026 revealed a skin check was completed on 4/16/2026. The skin check failed to include measurements and characteristics.On 4/30/2026 the facility provided skin and wound assessments for Resident #2 from 4/8/2026 to 4/21/2026, related to a pressure ulcer/injury: stage 4 full-thickness skin and tissue loss to his sacrum. This pressure ulcer/injury was present on admission. An assessment was completed on 4/18/2026 with no measurements documented. The reason for measurements not documented was due to the wound spreading to his back with necrotic tissue at the center.On 4/29/2026 at 3:47 PM Staff F Licensed Practical Nurse (LPN) stated if an order is not signed out on a resident's TAR the order did not get completed or it was completed but did not sign it out as completed.On 4/30/2026 at 12:25 PM Staff E Nurse Consultant requested to look through Resident #1 and Resident #2's skin assessments with the surveyor. She acknowledged the skin assessments for Resident #1 and Resident #2 failed to include measurements. She added they hired a wound nurse that started on 4/29/2026 and will come to the facility every Wednesday to complete all wound/skin assessments.On 5/1/2026 at 8:59 AM Staff G Registered Nurse (RN) stated skin assessments are to be completed weekly by the nurses with measurements completed if needed. When asked what completed if needed meant, she stated if the area is new or if the area is open measurements will be obtained. Staff G stated if an order on the TAR is not signed out it means the treatment was not completed.On 5/6/2026 at 12:40 PM the Wound Nurse stated she started at the facility last week and today was her first day completing skin assessments in the building. She will come on Wednesdays to complete skin assessments. She stated skin assessments should be completed every 7 days and should include measurements and wound characteristics to include any changes in the wound.On 5/6/2026 at 1:33 PM the Director of Nursing (DON) stated skin checks are to be completed weekly on the resident's bath day. They hired a Wound Nurse that will come in every Wednesday to complete skin assessments, obtain measurements, notify providers if treatments need to be adjusted and complete documentation. The DON stated wound measurements should be obtained and documented weekly along with the wound appearance. When asked what it meant when an order is not signed out on the TAR, she assumed or would say the order was not completed. If there is no documentation, it was not done. She added if something is done, document it.The facility provided a document titled Medication Administration with a reviewed date of 5/2022. It is the policy of this facility that medications shall be administered as prescribed by the attending physician. The seven rights of medication administration are as follows to ensure safety and accuracy of administration:6. Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns.The facility provided a document titled Skin/Wound Management with a revision date of 5/2007. It is the policy of this facility to have a routine skin/wound assessment completed by a nurse. A skin alteration is identified as an Arterial Ulcer, Diabetic Neuropathic Ulcer, Pressure Ulcer, Venous Insufficiency Ulcer, Surgical Wound, and Lacerations.PROCEDURES:1. A skin review will be completed on all residents routinely and documented in the Electronic Health Record (EHR) by a nurse.2. Any identified wounds will be assessed routinely.

Based on clinical record, observations, resident interviews, staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents (Resident #12, #13) reviewed, requiring the use of oxygen. The facility failed to provide oxygen as documented in the physician orders. The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 indicating moderate cognitive impairment. The MDS recorded diagnoses of hypertension, diabetes mellitus, Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease (COPD). The MDS revealed the resident utilized oxygen while a resident and during the last 14 days of the assessment period. The Care Plan revised on 5/1//26 identified Resident #12 has an altered cardiovascular status related to hypertension with interventions of giving oxygen as ordered by the physician initiated on 1/22/26. The document included use of oxygen therapy related to ineffective gas exchange due to the history of COPD initiated 5/1/26 with interventions of oxygen per physician orders, oxygen via nasal prongs at 2-4 liters per minutes (lpm) continuously initiated 5/1/26. The document revealed the need for assistance to and from the activity area and wear oxygen at all times with interventions including wearing oxygen at all times, having a portable unit and use of portable concentrator initiated 1/15/26. The clinical record's Physician Orders revealed oxygen 2-4 lpm via nasal cannula or mask every shift for COPD ordered 1/11/26. Review of the Medication Administrator Record (MAR)/Treatment Administration Record (TAR) for 4/26 found lack of documentation on 4/16/26 day. Observed on 4/28/26 at 12:00 PM Resident #12 seated in the dining room with oxygen via nasal cannula and use of a concentrator set at 3 lpm. Observed on 5/4/26/at 12:46 PM Resident #12 seated at the dining room table with head down towards table. Observed the nasal cannula in place, the concentrator plugged in but not turned on. The resident presented with a congested cough.Continuous observation with interviews on 5/4/26 at 12:49 PM provided Staff A, Certified Nurse Assistant (CNA) and Staff B, CNA/Certified Medication Aide (CMA)/Housekeeping Supervisor approached Resident #12 with Staff A pushing button to turn the concentrator off only to turn the concentrator on. Observed Staff A and Staff B look at each other with Staff A stating the concentrator was not on. Observed Staff B proceed to remove the nasal cannula from Resident #12 and prompted the resident to walk to her room. Observed Staff B and Resident #12 using a 4 wheeled walker to walk to the resident's room. Requested Staff C, Registered Nurse (RN), to obtain an oxygen saturation from the resident. With Resident #12 seated on the edge of her bed, Staff C obtained an oxygen saturation from the resident of 76%. Staff C stated CNAs can move concentrators within the facility. Staff C stated Resident #12 had an order for continuous oxygen at 2-4 lpm. When asked if an oxygen saturation of 76% could be the result of not having her oxygen on, Staff C confirmed with Staff A that the resident did not have her oxygen on prior to the assessment and Staff A confirmed the resident did not have oxygen on. With the confirmation of Resident #12 not having her concentrator turned on, Staff C stated the low saturation could be the result of that. Resident #12 stated she was short of breath prior to the oxygen being turned on in the room. Staff C stated she would be coming back to check on the resident and in the future she would be double checking to ensure the resident's concentrator was turned on. Observed on 5/4/26 at 12:58 PM Staff C return to Resident #12's room and reported the resident's oxygen saturation was 94% with 3 lpm. Observed on 5/4/26 at 1:56 PM Resident #12 walk into the dining room with the nasal cannula in place and the remaining oxygen tubing dragging on the floor behind her. Observed Staff E, Agency CNA, intervene, remove the oxygen tubing, carry it back to the resident's room, connect it to the resident's concentrator and move the concentrator to the dining room for the resident to attend an activity.On 5/4/26 at 2:00 PM Staff E confirmed she had picked the resident's oxygen tubing up off the floor to prevent the resident from tripping on it, connected it to the concentrator and moved the concentrator to the activity for resident's use. The staff stated CNAs were allowed to move concentrators within the facility.On 5/4/26 at 2:05 PM Staff B confirmed Resident #12's oxygen concentrator was not on following the noon meal. The staff stated when finding oxygen not on when it is supposed to be she would immediately turn the oxygen on. The staff stated she did not know who had brought the concentrator out for the noon meal. When asked what she would do if found, she stated she would turn it on and ask whoever brought the resident out why they had not turned the oxygen on. The staff confirmed that CNAs could move oxygen tanks within the facility. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed a BIMS score of 11/15 indicating moderate cognitive impairment. The MDS recorded diagnoses of hypertension, depression, and COPD. The MDS revealed the resident utilized oxygen while a resident and during the last 14 days of the assessment period. The Care Plan revised on 5/4/26 revealed an alteration in respiratory related to COPD with interventions of giving oxygen therapy as ordered by the physician, checking oxygen tank frequently when in use to ensure it was not empty initiated 9/17/22. The document included use of oxygen therapy related to hypoxia secondary to COPD with an intervention of oxygen settings as ordered revised on 1/11/23. An additional area on the document revealed the need for oxygen when coming out to activities if the level was too low with interventions of ensuring the resident has oxygen when needed and assistance to turn on the portable oxygen tank on the wheelchair.The clinical record's Physician Orders disclosed an order to apply oxygen at 2 lpm via nasal cannula to keep oxygen levels above 90%, check oxygen saturations every shift for hypoxia ordered 3/19/26. The 4/26 MAR-TAR revealed no documentation on 4/27/26 day. The 5/26 MAR -TAR revealed the resident had oxygen saturation of 73%. The Physician's Orders revealed staff were to check the oxygen tank to ensure it was not empty every shift with an order date of 12/30/25. The 4/26 MAR-TAR lacked documentation on 4/14/26 day and 4/28/26 night. Observed on 4/28/26 at 12:00 PM Resident #13 seated at the dining room table with oxygen via a nasal cannula using a portable oxygen tank (E-tank) set at 2 lpm. Observed on 5/4/26 at 12:40 PM Resident #13 without nasal cannula, the E-tank set at 2 lpm and the tank reading empty. Continuous observation on 5/4/26 beginning at 1:11 PM revealed Staff H, Nurse Consultant, stop and look at Resident #13's oxygen tank. The staff applied the nasal cannula, obtained a tank key from the nurses station and turned the lock on the tank. The staff left the resident, and returned carrying a new E-tank. Following return and request of resident's oxygen saturation, Staff H stated the resident's initial oxygen saturation was 81% then moved to 85%. The staff proceeded to change the oxygen tanks and turn the tank on. On 5/4/26 at 1:19 PM Resident #13 stated she used oxygen most of the time. The resident stated she was short of breath prior to the staff applying the oxygen.On 5/4/26 at 1:22 PM Staff H stated she had observed Resident #13 did not have her oxygen on when she normally had it. The staff stated she went and obtained a key to make sure the oxygen was on and it was, but the tank read empty therefore she obtained a new tank. The staff stated with resident's saturations in 80 percentiles the resident required the oxygen to be applied.On 5/5/26 at 3:00 PM the DON stated she expected a concentrator to be turned on when it was plugged in and the nasal cannula in place. The Administrator present during the conversation concurred. On 5/6/26 at 1:52 PM The DON stated CNAs can walk residents with oxygen. The DON stated if a tubing end was on the floor it should be disposed of and new tubing obtained. The DON stated the expectation was oxygen to be used as per physician orders with tanks and concentrators to be turned on. The facility's undated Oxygen Administration Policy revealed oxygen therapy was administered as ordered by the physician. The document included that the unit should be turned on to the desired flow rate, assess for proper functioning, apply to the resident and reassess the oxygen flowmeter for correct liter flow.

Based on clinical record review, facility record review, resident and resident family interviews, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 2 out of 3 residents (Resident #3 and #50) reviewed from abuse. The facility reported a census of 57 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of muscle weakness, stroke and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of facility provided Incident Report dated 3/8/26 at 3:21 p.m., revealed Staff I, Registered Nurse (RN) was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated, just letting you know Resident #2 was in this resident room attempting to get in bed with her. This writer hung up and immediately rushed down the hall with a caregiver. Staff I met Resident #3 in her bed, resting in bed, and call light within reach. Resident #3 stated, I was in bed, my door was halfway closed when this man came in and just kept coming towards me. He touched my leg and I told him to stop immediately. He moved my bedside table away from me and I thought he wanted to take my dentures on the table, but he had this weird look you know, placed his hand under my blanket and tried to touch me. I pushed my call light and screamed twice. My neighbor heard me and pushed his call light as well, and he took off then the aide came in and I told them. Interview on 3/17/2026 at 11:08 a.m., with Resident #3 revealed she had been laying in bed and her door opened and a guy in a wheelchair came into her room and touched her feet. He then moved her tray over that was next to the bed and all of a sudden his wheelchair was going up the side of her bed and his hand was going up her leg. She stated she screamed twice and pushed the call light. After she screamed he scooted out of her room. Resident #3 further revealed it is not a secret that she is trying to get out of here because he is still in the. There are times she cannot sleep when she sees him and she feels he is just a creep. She has told everyone that she will kill him if he touches her again. Resident #3 stated that it isn't that she feels unsafe in the facility but it bothers her that he also violated another person and it is sad to think about it wasn't just me. She continues that her heart starts to race when she is in the dining room when he is there and sees him. She doesn't understand why the facility allows him to sit at the table where they assist people with eating as they are not able to defend themselves from him. The facility was really short that night and they would have been able to handle it better with more people. 2. The MDS assessment dated [DATE] for Resident #50 documented diagnoses of need for assistance with personal care, hypertension and unspecified symptoms and signs with cognitive functions and awareness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of facility provided Incident Report dated 3/8/26 at 3:22 p.m., revealed Staff I, RN was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated just letting you know, Resident #2 was in Resident #3's room attempting to get in bed with her. Staff I immediately rushed down the hallway to make sure the resident was safe. Staff I and caregiver check rooms to make sure Resident #2 is out of the hallway and is safe. At about 3:22 p.m., Staff I and caregivers found Resident #2 in bed with Resident #50 with her pant and brief halfway down and Resident #2's left hand was in this resident's pants on her buttocks. Resident #2's wheelchair was parked in front of Resident #50's bed and door was locked. Resident #50 was lying in bed on her right side facing the window half asleep and Resident #2 was on bed and not moving. Review of Resident #50's Progress Notes revealed Staff I, RN was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated just letting you know, Resident #2 was in Resident #3's room attempting to get in bed with her. Staff I immediately rushed down the hallway to make sure the resident was safe. Staff I and caregiver check rooms to make sure Resident #2 is out of the hallway and is safe. At about 3:22 p.m., Staff I and caregivers found Resident #2 in bed with Resident #50 with her pant and brief halfway down and Resident #2's left hand was in this resident's pants on her buttocks. Resident #2's wheelchair was parked in front of Resident #50's bed and door was locked. Resident #50 was lying in bed on her right side facing the window half asleep and Resident #2 was on bed and not moving. Resident #50 was unable to state or describe what happened. Both residents were separated immediately. Notified Director of Nursing (DON) immediately via phone call. 3. The MDS dated [DATE] for Resident #2 documented a BIMS of 11 indicating moderate cognitive impairment. On 3/17/26 at 9:33 AM Resident #3's Daughter stated her mother was still living at the facility. Resident #3's Daughter stated her mother was in bed and Resident #2 entered her room and put his hands under the blanket. Resident #3's Daughter stated her mother called her first and the facility called 6 hours later. Resident #3's Daughter stated it was Staff I, Registered Nurse (RN) who called her. Resident #3's Daughter stated did not know which nursing staff her mother had talked to. Resident #3's Daughter stated her understanding was the police were called. Resident #3's Daughter stated the police were not called until 7:00 PM and after they left she was called by the facility. Resident #3's Daughter stated there was a second assault the same day and the nurse had to pull Resident #2 off the resident. Resident #3's Daughter stated from what she understood the second incident was worse than the incident with her mother. Resident #3's Daughter stated the trauma advocate told her about the second assault. Resident #3's Daughter stated the incident occurred on 3/8/26. Resident #3's Daughter stated another CNA told her mother the DON told the nurse not to do anything about it. Resident #3's Daughter stated the nurse said she needed to because she was worried about her license. Resident #3's Daughter stated her mother said she was able to scare the resident before he fondled her. Resident #3's Daughter stated he did not put his hands up her shirt or down her pants. Resident #3's Daughter stated her mother acted like she was not scared but inside she felt she was. Resident #3's Daughter stated her mother seemed to have some increased sadness since the incident. Resident #3's Daughter stated there was no penetration. Resident #3's Daughter stated her mother felt assaulted but not abused or sexually abused. On 3/26/26 at 8:08 AM Resident #3's Daughter stated her mother had called her at 2:15 pm on 3/8/26 and told her about the incident and the facility called her at 8:17 PM on 3/8/26 to tell her. Resident #3's Daughter stated previously her mother would talk to another resident frequently and now after the incident her mother was much more self isolating. Resident #3's Daughter stated her mother left the faciity on 3/24/26. The incident had increased her want to leave as soon as possible. On 3/24/26 at 1:17 PM Staff I, Registered Nurse (RN) acknowledged she worked 3/8/26 when the incident with Resident #2, #3 and #50. Staff I stated she called Resident #2's family. Staff I stated she called Resident #3 and #50's family. Staff I stated she called the police also. Staff I explained that she called the Director of Nursing (DON) immediately and did not remember what the DON said. Staff I stated the DON said that since Resident #2 had not penetrated the resident's vagina then she just needed to call the police later. Staff I explained that the DON stated the police would probably only take the report over the phone. Staff I explained that when she called the police they said they were going to come up. Staff I stated she called all the resident's families after that. Staff I stated Staff J, LPN was the other nurse working with her on 3/8/26. Review of Resident #2's EHR dated 3/8/26 at 3:21 PM entered by Staff I documented Staff I was at the nursing station when a Certified Nurse Assistant (CNA) came to the nurse station and stated Resident #2 was in another resident's room trying to get into bed with Resident #3. Staff I immediately went down the hall Resident #2 was seen in Resident #50's room in her bed with the door locked at 3:22 PM, Resident #50's pants were halfway down her buttocks with Resident #2's left hand on Resident #50's buttocks. Resident #2's wheelchair was backed in front of the bed. Resident #50 was unable to state what had happened. Resident #2 was immediately moved out of Resident #50's bed to his wheelchair and out of the room. Staff I assessed both Resident #3 and #50. DON was notified at 3:22 PM. Resident #2 was taken to the nursing station for 1:1 monitoring. Resident #50 stated bathroom and was helped to the bathroom. Staff I documented Staff J explained Resident #2 was last seen about 2:20 PM when she administered his medications. Sheriff was notified at 7:09 PM, Resident #2's Power of Attorney (POA) notified at 8:30 PM. Resident #2's POA stated if Resident #2 took Carbidopa-levodopa, then the resident would get sexual. On 3/24/26 at 2:58 PM Staff N, Licensed Practical Nurse (LPN) stated she was working the day of 3/8/26 and received a report from Staff I. Staff N explained that she worked at 6:00 PM that evening. Staff N stated the incident with Resident #2, #3 and #50 had happened several hours before she came in. Staff N stated Staff I was the nurse that completed an assessment on Staff #50 and on Resident #2. Staff N stated Staff I was told not to document the incident because they did not know what he was exactly doing. Staff N stated she was not going to take the assignment at the facility unless Staff I reported the incident because it needed to be reported. Staff N stated the Administrator and the DON did not come to the building. Staff N explained Staff I called the family members after that and the police. Staff N stated the police were at the facility for an hour or two. Staff N stated there was also another resident involved Resident #3. Staff N stated Resident #2 did not get as far with Resident #3 as with Resident #50. Staff N explained Resident #3 was very upset. Staff N stated Resident #50 was probably unaware of what was happening because of her lower cognitive function. Staff N stated Resident #3 was very upset that Resident #2 was allowed to stay at the facility. Staff N explained Resident #3 was in therapy room one day and they brought Resident #2 in and she asked to leave. Staff N stated Resident #3 was planning on going to another facility because Resident #2 remained at the facility. On 3/25/26 at 11:28 AM Staff J, Licensed Practical Nurse (LPN) stated it was about 2:00 PM on 3/8/26. Staff J explained she had taken 2 or 3 residents outside and Staff I came out and asked when she had last seen Resident #2 and she said last time she medicated him. Staff J stated she was outside around 3:00 PM or 3:15 PM and gave him his medication at 2:30 PM and saw him about 15 minutes later. Staff J stated he appeared to be sleeping when she last saw him. Staff J stated she had not seen Resident #2 for about 30 minutes. Staff J stated she came inside at that time and gave Staff I a brief statement about what was going on. Staff J stated she went back outside with the residents. Staff J stated Staff I was on the phone with the DON. Staff J stated all the residents were brought in and she was still talking to the DON about the incident. Staff J stated Staff I said she was told by the DON not to make a note of it because they could not be sure what actually happened with the residents. Staff J stated Resident #3 used to participate in activities, sit in the dining room with other residents and talk before the incident with Resident #2. Staff J explained Resident #3 very rarely comes out to participate in activities now. Staff J stated Resident #3 asked to be taken back to her room during the meal the other day when Resident #2 came out and that was not normal for her. Staff J stated where Resident #3 normally sits her back would be towards Resident #2. Staff J stated Resident #3 usually would stay out and chat with the other residents but left because she was uncomfortable. Staff J stated there were no attempts to call the police, the family, or the physician because it was not physically witnessed. Staff J stated Staff I said it was witnessed she had witnessed it at the time. Staff J stated the DON told her it did not need to be reported. Staff J stated Staff N said if Staff I did not report the incident to the police, the POA's and the physicians she was going to have to. Staff J said that was when Staff I reported the incident. Review of a policy provided by the facility reviewed on 1/22 titled, Abuse: Prevention of and Prohibition Against documented it was the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on Electronic Health Records (EHR) review, observations, resident interview, and staff interview the facility failed to provide the residents with a comfortable / clean homelike environment when bed linens were not applied to beds in a timely manner and rooms were not clean for 3 for 20 residents reviewed (Resident #17, #30 and #55). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #30 documented a Brief Interview of Mental Status (BIMS) of 14 indicating no cognitive impairment. An observation on 3/18/26 at 10:20 AM revealed the linen on Resident #30's bed rolled up at the foot of the bed and the bed was not made. On 3/18/26 at 10:20 AM Resident #30 explained she would like her bed to be made in the morning. Resident #30 said it would be nice if it was made by the time breakfast was over but for sure before the lunch meal. An observation on 3/18/26 at 10:42 AM revealed the linen on Resident #30's bed remained rolled up at the foot of the bed and the bed remained unmade. 2. The MDS dated [DATE] for Resident #55 documented a BIMS of 9 indicating moderate cognitive impairment. The MDS documented Resident #33 had diagnoses of unspecified intellectual disabilities, muscle weakness and need for assistance with personal care. An observation on 3/18/26 at 11:37 AM revealed Resident #55's lying in bed with a small lap blanket on and all bedding at the bottom of his bed wrapped up. On 3/18/26 at 11:38 AM Resident #55 stated a lady placed all the bedding at the bottom of the bed that morning and had not been back to make the bed. An observation on 3/18/26 at 11:41 AM revealed down hall G bedding not on the bed at all in Resident #40 and #58 On 3/18/2026 3:06 PM Staff F, Certified Nurse Assistant (CNA) stated she usually made the resident's bed when she got the resident up in the morning. On 3/18/26 at 3:17 PM Staff G, CNA stated it was the first time he had worked at the facility. Staff G explained the morning was very busy and he was working on the hardest hall. Staff G acknowledged he worked on hall G that morning. Staff G explained he was all over the place that morning and had to do so many bed strips. Staff G explained he was pulled away from the hall at 10:00 PM. Staff G stated he tried to get beds made before 10:00 AM but did not have the time. On 3/18/26 at 3:34 PM Staff D, Licensed Practical Nurse (LPN) stated each day of the week they strip certain beds on certain halls and wash them. Staff D explained she had noticed frequently that resident beds are not made until after 11:00 AM. Staff D said she usually told the staff to make the bed or she will make the bed herself. On 3/18/26 4:21 PM Staff H, CNA stated he came in at 10:00 AM on 3/18/26. Staff H stated when he came in that morning the beds had been stripped, linen was not changed and beds were not made on hall G. Staff H explained he had to help with resident care and was unable to make the beds until after care for all the residents was completed. On 3/25/26 at 2:18 PM the Director of Nursing (DON) stated the resident's beds are stripped and house keeping will come behind, clean the mattress and remake the bed on certain days of the week. The DON acknowledged 3/18/26 was not the day that hall G was supposed to have the beds stripped, the mattress cleaned and bed remade by housekeeping. The DON acknowledged she would expect the beds would have been made by 10:30 AM. On 3/26/26 at 12:00 PM the Administrator stated she expected the linen would have been placed on the bed and the beds made for the residents on hall G by 10:40 AM. Review of a facility provided policy revised on 05/07 titled, Homelike Environment documented it was the policy of this facility to provide a homelike environment, and to encourage and provide opportunities for each resident to occupy an area reflecting his/her interests, family, and/or is made personalized by bringing photos or items from home. 3. Observation on 03/18/2026 at 11:29 a.m., of Resident # 17's room. The room was noted to have the bed pulled away from the wall and the floor was noted to have streaks of dried fluid. The baseboard heat was noted to have brown debris scattered along the area next to the bed. The baseboard heat was also noted to have a white object in the baseboard. The wall above the baseboard heat noted to have several areas of brown debris on the wall. Resident #17 confirmed the areas had been there for a while and unsure what the debris is. Review of the facility provided policy titled Homelike Environment with a revised date of 5/2007 revealed it is the policy of this facility to provide a homelike environment Interview on 03/25/26 at 2:59 p.m., with the Administrator revealed the rooms should be clean.

Based on clinical record review, Medication Administration Records and Treatment Administration records (MAR-TAR) review, resident and resident family interviews, staff interviews and facility policy review the facility failed to provide physician ordered medications and failed to notify the physician of missed medications for 3 of 3 residents reviewed (Resident #7, #20 and #35) and the facility failed follow physician ordered interventions to notify the physician for a resident with weight fluctuations for 1 of 3 residents (Resident #10). The facility reported a census of 57 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of insomnia, depression and Multiple Sclerosis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of the facility provided document titled Order Summary Report signed by the physician 6/4/25 revealed the following orders: Fibercon tablet with an order date of 8/20/23 Melatonin tablet with an order date of 3/29/25 Fluvoxamine tablet with an order date of 2/20/25 Omeprazole tablet with an order date of 5/20/21 Review of Resident #7's Progress Notes revealed the following: On 2/6/26 at 11:36 a.m., omeprazole tablet- medication not available. On 2/25/26 at 10:55 a.m., fluvoxamine tablet- medication not found. On 3/15/26 at 6:58 p.m., melatonin tablet- medication not available. On 3/16/26 at 7:20 p.m., FiberCon tablet- medication not available. Review of Resident #7's Electronic Health Records (EHR) failed to indicate physician notification for omitted administrations. 2. The MDS assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 12, indicating moderate cognitive impairment. Review of the facility provided document titled Order Summary Report signed by the physician 10/6/25 revealed the following orders: Pantoprazole tablet with an order date of 10/6/25 Lactulose solution with an order date of 1/13/25 Famotidine tablet with an order date of 1/28/25 Duloxetine capsule with an order date of 9/10/25 Review of Resident #20's Progress Notes revealed the following: On 1/3/26 at 7:20 a.m., Pantoprazole tablet- drug unavailable. On 2/6/26 at 8:06 a.m., Lactulose solution- drug not available. Reordered. On 2/6/26 at 8:06 a.m., Famotidine tablet- drug not available. Reordered. On 2/11/26 at 11:41 a.m., Duloxetine capsule- medication unavailable. On 3/10/26 at 11:17 a.m., Lactulose solution- on order. Review of Resident #20's EHR failed to indicate physician notification for omitted administrations. 3. The MDS assessment dated [DATE] for Resident #35 documented diagnoses of acute pain due to trauma, muscle spasm, femur fracture. The MDS showed the BIMS score of 11, indicating moderate cognitive impairment. Review of the facility provided document titled Order Summary Report signed by the physician dated 1/9/26 revealed the following orders: Lidocaine patches for pain with an order date of 1/9/26 Sitagliptin Phosphate with an order date of 1/9/26 Review of Resident #35's Progress Notes revealed the following: On 1/19/26 at 7:26 a.m., Sitagliptin Phosphate- awaiting medication arrival. On 2/12/26 at 11:16 a.m., Lidocaine patch- medication not available. On 3/3/26 at 10:08 a.m., Lidocaine patch- patch not available. On 3/4/26 at 6:57 a.m., Lidocaine patch- medication not available. On 3/16/26 at 7:46 a.m., Lidocaine patch- medication not available. On 3/18/26 at 9:11 a.m., Lidocaine patch- not available. On 3/19/26 at 11:06 a.m., Lidocaine patch- no patches available. On 3/23/26 at 7:18 a.m., Lidocaine patch- on order. Review of Resident #35's EHR failed to indicate physician notification for omitted administrations. Review of facility provided policy titled Physician Orders with a revised date of 5/2007 revealed it is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. The charge nurse or the director of nursing services shall place the order for all prescribed medications. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to assure that refills are on hand. Interview on 3/24/2026 at 2:12 p.m., with the Director of Nursing revealed if a medication is missed the facility should be notifying the physician the medication had been missed. 4. The MDS dated [DATE] documented Resident #10 had a BIMS of 9 indicating moderate cognitive impairment. On 3/17/26 at 10:57 AM Resident #10's Daughter stated Resident #10 had a weight loss of 27%. Resident #10's Daughter stated Resident #10's weight had fluctuated a little bit in the past but as of right now he is 136 lbs in the hospital. Resident #10's Daughter stated a few weeks ago before the hospital visit the facility had a sheet printed out that said Resident #10 weighed 207 lbs on 2/25/26. Resident #10's Daughter stated Resident #10 did not look 200 lbs at the facility at that time. Review of Resident #10's documented weights: -Resident #10's weight at the facility: Weight at the facility on 8/15/25 was 191 lbs. Weight at the facility on 10/7/25 was 202 lbs. Weight at the facility on 1/23/26 was 176 lbs. Weight at the facility 2/1/26 was 174.2 lbs. went to hospital on 2/10/26 Weight at the facility 2/25/26 was 207.4 lbs. -Resident #10's weight at the hospitals: Review of Hospital discharge documented on admission [DATE] Resident #10 weighed 201 lbs. Review of Hospital discharge documented weight on 1/10/26 of 181. Review of Hospital discharge documented a weight of 141 on 2/16/26. An oral nutritional supplement ordered TID at the hospital for poor intake documented on discharge summary from 2/25/26. Review of hospital discharge documented a weight of 136.6 lbs from 3/16/26. -Resident #10's Dialysis Clinic weight: Weight at dialysis 1/31/26 weight of 178.5 lbs. Review of Resident #10 MAR-TAR documented a physician's order with a start date of 8/14/26 to notify the provider if Resident #10 had signs or symptoms of fluid overload every shift for weight gain. On 3/25/26 at 2:18 PM the Director of Nursing (DON) stated 134 lbs. was reported as a dry weight from the dialysis clinic. The DON explained she did not feel that 207 appropriately identified the weight of Resident #10 when obtained at the facility on 2/25/26. The DON stated the staff may not have taken the wheelchair weight off. The DON stated she would expect the physician would have been notified of the weight difference between the weights at the facility. The DON stated Resident #10 should have been reweighed when he returned from the hospital on 2/25/26. On 3/26/26 at 10:26 AM Staff D, Licensed Practical Nurse (LPN)/Admissions stated she had not noticed the difference in weight from the facility to the hospital on 2/25/26 for Resident #10. Staff D acknowledged when the weight of 207 was obtained at the facility another weight should have been obtained and the physician should have been notified. Staff D said she did not see the discharge order for an oral nutritional supplement for Resident #10. Staff D acknowledged she should have notified Resident #10's physician of the oral nutritional supplement and did not. On 3/26/26 at 8:22 AM the DON stated she had spoke to the dialysis clinical manager and Resident #10 weighed 169 lbs. on 2/3/26. The DON stated the dialysis clinic manager stated Resident #10 weighed 138 lbs. on 3/3/26. The DON stated if the hospital had ordered supplements then the supplements would have been reported to Resident #10's primary physician and would have requested for Resident #10 to have them at the facility. The DON stated with the weight loss she would have expected the staff to re-weigh Resident #10 and for the physician to have been notified of the difference since returning from the hospital. On 3/26/26 at 9:07 AM Staff O, Nurse Practitioner (NP) stated she had Resident #10 on her case load. Staff O stated the facility had explained in the past that they were having problems with their scales. Staff O explained with any drastic weight loss the facility was obligated to notify her. Staff O explained that a consideration would have to be taken for the amount of food and medications Resident #10 had refused. Staff O explained if she was notified of Resident #10's weight change she would have started him on the supplement. Staff O explained Resident #10 was already deteriorating and did not feel it would have made a difference in his outcome. Review of a policy provided by the facility reviewed 7/23 titled, Documentation and Charting documented it was the policy of the facility to provide A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Guidance to the physician in prescribing appropriate medications and treatments. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. Nursing service personnel with a record of the physical and mental status of the resident. Assistant in the development of a Plan of Care for each resident. The elements of quality medical nursing care. Review of a policy provided by the facility reviewed 7/24 titled, Change of Condition Reporting documented a licensed nurse will inform the physician and family/responsible party of change of condition and document notification. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response.

Based on observation, electronic health record (EHR) review, resident interview and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 16 resident reviewed (Resident #30, #32 and #33). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS indicated Resident #30 had diagnoses of Dysphagia, hemiplegia and hemiparesis following cerebral infarction, and stiffness of right shoulder. The MDS also indicated Resident #30 required partial/moderate assistance with oral hygiene, substantial/maximal assistance with toileting hygiene, partial/moderate assistance with upper body dressing, substantial/maximal assistance with lower body dressing and substantial/maximal assistance with personal hygiene. On 3/18/26 at 10:21 AM Resident #30 stated last night on overnights before 12:00 AM she looked for her call light and it was not in bed with her. Stated she could not get any help and urinated on herself two times. Resident #30 explained last week she sat in the bathroom on the toilet for 45 minutes waiting for help and she timed the response on her phone. 2. The MDS dated [DATE] for Resident #32 documented a BIMS of 13 indicating no cognitive impairment. The MDS documented Resident #32 required partial/moderate assistance with eating, oral hygiene, upper body dressing and personal hygiene. The MDS also documented Resident #32 was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.On 3/18/26 at 11:31 AM Resident #32 stated she has to wait longer than 30 minutes at times when she turns the call light on and she needs to use the restroom. Resident #32 stated the facility is severely understaffed. 3. The MDS dated [DATE] for Resident #33 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented Resident #33 required setup or clean-up assistance for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene. The MDS also documented Resident #33 partial/moderate assistance with lower body dressing and putting on/taking off footwear. On 3/18/26 at 8:02 AM Resident #33 stated the staff tell her they are short on the floor frequently. Resident #33 explained the facility was short 3/17/26 last week there was only one person working this side and her hall. Resident #33 stated it could take up to an hour to answer her call light. Resident #33 stated last night it was much longer than 15 minutes for staff to respond to her call light. Review of a document provided by the facility titled, January Grievance Log documented call light times were reported on 1/7/26, 1/13/26 and 1/21/26.Review of a document provided by the facility titled, February Resident Council 2026 documented the residents reported call light response had been slower lately.On 3/25/26 at 10:08 AM Staff P, Licensed Practical Nurse (LPN) stated she worked the evening of 3/8/26 and that night there was only one Certified Nurse Assistant (CNA) and two nurses. Staff P stated Staff N, LPN also called the Director of Nursing (DON) about the situation. Staff P stated no CNA came into help until 12:00 AM or 12:30 AM. Staff P stated she worked with Staff M that night. Staff P stated she was sure there were call lights that were not responded to within 15 minutes simply because they just did not have enough staff.On 3/18/26 at 3:06 PM Staff F, Certified Nurse Assistant (CNA) stated she had heard residents complain about call lights taking a long time to respond to daily. Staff F stated Hall 4/G is a busy hall and has a lot of complaints from that hall. Staff F stated she has been at the facility when it has taken call lights longer than 15 minutes to answer. Staff F stated she has seen times for call light responses that took up to 45 minutes. Acknowledged there were call lights that lasted longer than 15 minutes that morning. Staff F stated the facility was short this morning. On 3/19/26 at 8:24 AM Staff K, CNA stated she typically worked overnight shifts from 6:00 PM - 6:00 AM. Staff K stated they always work short. Staff K stated she was the only CNA in the building until 2:00 AM last night on 3/18/26. Staff K stated there were 2 nurses last night, but sometimes they are short as well and there is only one nurse. Staff K stated the nurses do not help when she works by herself on overnights. Staff K stated frequently the call lights take longer than 15 minutes to respond to. Staff K acknowledged the residents frequently seem upset that it takes so long to answer their call lights. On 3/23/26 at 11:48 AM Staff L, CNA stated some nights there are only 2 CNA's and 2 nurses and there had been times when there was only one CNA and 2 nurses. Staff L stated the nurses would help because there was no choice. Staff L explained a lot of things are not completed because of the lack of staff. Review of a document provided by the facility titled, Payroll documented Staff M was the only CNA present in the facility from 6:00 PM on 3/8/26 - 12:00 AM on 3/9/26.On 3/23/26 at 5:48 PM Staff M, CNA stated he worked the overnight shift 6:00 PM - 6:00 AM. Staff M explained at times there are only 2 CNA's. Staff M said there was a time when he was the only CNA as well. Staff M stated that day was 3/8/26. Staff M stated when he entered the building at 6:00 PM on 3/8/26 he was by himself until 12:30 AM. Staff M stated then a CNA came in and then around 1:00 AM another CNA entered the facility. Staff M stated he had to put around 50 residents to bed that evening. Staff M stated on nights like that call light response is much longer than 15 minutes. Staff M acknowledged that night call lights were on for 45 minutes. Staff M explained the charge nurse called the Director of Nursing (DON) and she said she tried to call CNA's to come in but there was none to come in. Staff M stated the charge nurse asked if the DON was going to come in and she said she was busy. Staff M stated the charge nurse called the corporate compliance hotline and told them how short they were. Staff M stated there were 2 nurses that night. Staff M explained the nurses were Staff N, Licensed Practical Nurse (LPN) and another nurse that was her 2nd time working. Stated that night the nurses did not help him put the residents to bed.On 3/23/26 at 6:42 PM Staff I, Registered Nurse (RN) stated she worked on 3/8/26 and Staff M was the only CNA working that evening. On 3/24/26 at 1:35 PM Staff D, Licensed Practical Nurse (LPN) stated the residents had voiced concerns about the call light response being very long. Staff D stated she did not know how the staff ratio is determined. Staff D stated she had seen pm shift only have one CNA and 2 nurses. Staff D stated she had frequently seen the call light response take longer than 15 minutes and it has been noticed. Staff D explained the facility was trying to address the concern. On 3/24/26 at 2:58 PM Staff N, LPN stated she worked 6:00 PM - 6:00 AM. Staff N acknowledged she frequently heard complaints from residents about the length of time it takes to respond to call lights at the facility. Staff N stated it can be a daily thing sometimes. Staff N stated on 3/8/26 she had worked with one CNA and two nurses. Staff N stated she spoke with the Director of Nursing (DON) and the Administrator about the concern. Staff N stated the DON stated they would not come in to work that night. Staff N stated the DON and the Administrator stated they are working on the issue. Staff N explained she told the DON and the Administrator it really puts the residents and on the staff's licenses at risk. Staff N stated Staff M was working and both the nurses were running. Staff N explained 2 CNA's came in at about 12:30 am or 1:00 AM. Staff N stated there had been an evening when she was the only nurse. Staff N explained she had to put her foot down and tell the management she was uncomfortable doing that. Staff N stated the management would not send a staff in until she said she was going to clock out and go home. ON 3/25/26 at 6:10 PM Staff E, LPN stated she works 6:00 PM - 6:00 AM. Staff E stated she felt there was an unsafe staff to resident ratio. Staff E stated the facility did not have that many of their own staff. Staff E stated residents frequently complained about the call light response being lengthy. On 3/25/26 at 2:18 PM the DON stated she expected the 6:00 PM - 6:00 AM shift to have 3 CNA's and 2 nurses and 6:00 AM - 6:00 PM shift to have 4 CNA, a bath aide and 2 nurses. The DON stated staffing was based on the facility census and that was at the 85% occupancy. The DON explained if the census increased additional staff can be added. The DON stated she oversees the staff but another staff completed the staffing. The DON acknowledged there was concerns with staffing at the facility and dependability with the agency staff. The DON stated she would want the call light response time less than 15 minutes. The DON stated they review the call light information as they can review and there had been grievances related to excessive call light times. The DON stated she did not get any calls about the staffing on 3/8/26. The DON stated she had not been aware there was one CNA present in the building on that day. The DON stated she felt that staff should have called her if there was only one CNA present in the building. The DON acknowledged that Staff M was the only CNA until 12:00 AM on 3/9/26. Review of a policy provided by the facility revised 05/07 documented it was the policy of this facility to provide the resident a means of communication with nursing staff. Answer the light/bell within a reasonable time (~ 15 minutes).

Based on observations, resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 57 residents.1. The Minimum Data Set (MDS) dated [DATE] documented Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. On 3/18/26 at 10:36 AM Resident #30 stated dinner meals are served cool. Resident #30 stated she does not ask the staff to reheat the food she just does not eat the food. Resident #30 explained the staff would not reheat the food if she asked. 2. The MDS dated [DATE] for Resident #33 documented a BIMS of 15 indicating no cognitive impairment. On 3/18/26 at 7:58 AM Resident #33 stated most meals are served cold. Resident #33 stated she eats most meals in her room. Resident #33 stated she would like the meals to be served warmer. Resident #33 stated she would ask the staff to warm the food up but it depends on who the Certified Nurse Assistant (CNA) working if they will warm it up. Review of a policy provided by the facility revised 8/18 titled, Checking Food Temperatures documented meals will be served at appropriate temperatures to ensure food safety and cross contamination. Temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the portioning, transporting and serving process until received by the customer. 3. Observation on 3/19/26 at 12:11 p.m., of a room tray delivered. The meal arrived on a tray with a metal cover over the food. The meal consisted of enchilada, lettuce salad with salad dressing on the top of lettuce, apple crisp and juice. The dietary staff checked the temperature of the enchilada and the food temperature read 129.6 degrees. Review of the facility provided policy titled Checking Food Temperatures revised 8/2018 revealed meals will be served at appropriate temperatures to ensure food safety and cross contamination. Hot foods should be held at or above 135 degrees F. Interview on 3/25/2026 at 2:11 p.m., with the Administrator revealed the food should be served at safe temperatures.

Based on observation, clinical record review, and staff interview, the facility failed to implement proper hand hygiene protocols to prevent the spread of infection during the administration of oral medication, insulin administration, and enteral tube medication administration for 4 of 4 resident observed for medication administration (Residents #2, #16, #19 and #48). Additionally, the facility failed to adhere to current Centers for Disease Control and Prevention (CDC) guidelines by not utilizing Enhanced Barrier Precautions (EBP) during enteral tube medication administration to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 58 residents. Findings include: 1.Observation on 3/19/26 at 8:16 AM, showed Staff J, Licensed Practical Nurse (LPN) accessed Resident #48's medication record via computer, obtained medication from the medication cart, and prepared the dose in a medication cup. Staff J approached Resident #48, grasped the resident's drinking glass by the top rim, and assisted with medication ingestion. Staff J then provided the drink, returned to the medication cart, doffed gloves and discarded the medication cup. Staff J failed to perform hand hygiene immediately before or immediately after medication administration then initiated medication administration for Resident #16. Staff J accessed Resident #16's medication record via computer, obtained medication from the medication cart, and prepared the dose in a medication cup. Staff J then prepared Resident #16's insulin pen and approached Resident #16. Staff J assisted Resident #16 to ingest the medications using applesauce, entered the bathroom to perform hand hygiene, returned, and discarded the medication cup. Staff J donned gloves, lifted the resident's shirt, applied an alcohol wipe to the skin, and administered the insulin subcutaneously in the right flank area. With soiled gloves, Staff J returned to the medication cart, discarded the insulin tip, and doffed the gloves. Staff J failed to perform hand hygiene, accessed the computer, entered the medication cart to retrieve medications, and subsequently prepared Resident #19's medications without performing hand hygiene. During an interview on 3/19/26 at 2:25 PM, the Director of Nursing (DON) reported that staff were required to perform hand hygiene immediately before and after medication administration for each resident. The DON also reported that staff were required to perform hand hygiene immediately before donning gloves and immediately after doffing gloves. When informed of the observation, the DON identified Staff J as an agency staff member and stated that follow-up education for hand hygiene would occur immediately. During an interview on 3/19/26 at 2:28 PM, the Administrator reported that she expected staff to follow infection control guidelines for hand hygiene. 2. The MDS dated [DATE] for Resident #2 documented a BIMS of 11 indicating moderate cognitive impairment. The MDS also documented placement of a feeding tube on admission and while as a resident. Observation on 3/18/26 outside of Resident #2 room revealed a sign for Enhanced Barrier Precautions for Resident #2 requiring gown and gloves for direct resident care. Observation on 3/19/26 at 9:04 AM of Resident #2's enteral medication administration by Staff C, Licensed Practical Nurse (LPN) revealed Staff C unlocked the medication cart, opened the computer to check medications, removed medications from medication packages, crushed medications individually, poured water poured a cup, opened a new syringe and dated, drew up 10cc of water for each medication, mixed each medications with a spoon, knocked on door, entered room, applied gloves, (no hand hygiene completed), did not don gown, checked residual, completed an auscultation of air bolus for placement, flushed 30cc H20, pushed water through syringe with palm of hand, drew up medication separately, pushed forcefully with palm of hand, Staff C explained she had to use force because the syringe itself is difficult to push, flushed with 10cc h20 between medications, obtained new syringe, obtained fresh water about 4 0z, removed gloves, no hand hygiene completed, applied gloves, flushed enteral tube with remaining water, removed gloves, picked up trash, completed hand hygiene, left room, obtained 81mg low dose from other cart, returned to medication cart, crushed medication, completed hand hygiene, applied gloves, flushed with 30cc, administered medication, flushed with 70cc H20, removed gloves and completed hand hygiene. Review of Resident #2's EHR titled, Care Plan documented Resident #2 required bolus feeding through the Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube entering the stomach for nutrition and or medication administration). On 3/25/26 at 2:18 PM the DON stated Resident #2 required Enhanced Barrier Precautions (EBP) because of the placement of a PEG tube. The DON explained the nurse should have worn a gown when administering medications through Resident #2's enteral tube. The DON stated the nurse should have completed hand hygiene when entering or leaving the room or at the medication cart. Review of a policy provided by the facility dated 6/25 titled, Enhanced Barrier Precautions Policy and Procedure documented it was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). CMS notes that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. This policy aims to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDROs) within the facility by implementing Enhanced Barrier Precautions (EBP). This policy seeks to prevent the spread of MDROs among residents and staff members by expanding the use of personal protective equipment (PPE) during high-contact resident care activities for certain residents. High-contact resident care activities are activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Examples of high-contact resident care activities requiring gown and glove use for residents on EBP include, but are not limited to dressing, bathing/showering, changing briefs or assisting with toileting (including ostomy care), device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing.

Based on observations, resident and staff interviews, and policy review the facility failed to ensure residents had the proper supplies for urinary independence for 1 of 1 residents reviewed (Resident #17). The facility reported a census of 57 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 documented diagnoses of morbid obesity and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment Interview on 3/18/2026 at 11:29 a.m., with Resident #17 revealed she uses a female urinal and she uses it on a daily basis. Observation of her urinal was noted to have brown areas on the outside and noted to have a urine scale in the bottom of the urinal. She explained the brown areas on the outside of the urinal is feces that has been there awhile. She explained the facility has not changed the urinal for approximately 3 months and does not clean it weekly. Observation of the urinal top also showed a bend in the top of the urinal and she stated that it does not work as well when it has the bend. The facility did not provide a policy on urinal care. Interview on 3/25/2026 at 3:23 p.m., with the Director of Nursing (DON) revealed she doesn't know what the facility staff does with Resident #17's urinal. The DON revealed the male urinals are changed monthly so hers should be as well. She is unsure if the facility has any new urinals for her in the facility at this time but they should.

Based on the Electronic Health Record (EHR) review, resident family interview, family interview, staff interview and policy review the facility failed to provide access to personal funds managed by the facility or manage personal funds deposited at the facility for 2 of 3 residents reviewed (Resident #11 and #30). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #11 had a Brief Interview for Mental Status (BIMS) of 10 indicating moderate cognitive impairment.On 3/17/26 at 6:39 PM Resident #11's Nephew, financial and care Power of Attorney (POA) stated he was not sure if Resident #11 could get his money on the weekend or in the evening. 2. The MDS dated [DATE] for Resident #30 documented a BIMS of 14 indicating no cognitive impairment.On 3/18/26 at 10:33 AM Resident #30 stated she was unable to get her personal funds in the evening or on the weekends so she had to keep money in her purse to ensure she had money when she wanted it. Resident #30 stated she had personal items come up missing from her room so it did worry her to keep her money in her purse in her room.On 3/24/26 at 2:05 PM Staff A, Social Services Director/Social Worker stated she takes care of the resident trust fund. Staff A stated the residents can ask any staff and she would get the money. Staff A explained the facility kept petty cash on hand. Staff A explained the facility kept about $400.00 on hand and would be replaced when it ran out. Staff A acknowledged her position was Monday - Friday 8:00 AM - 4:30 PM. Staff A stated the residents would be able to call her or the administrator in the evenings. Staff A explained if she needed to she could come in on the weekend or in the evening. Staff A stated she would be able to arrange something to get the money. Staff A stated it would be her or the Administrator that would have to come in and get the money for the residents in the evening or on the weekend. Staff A stated she was the only staff member with a key to the petty cash box. Staff A acknowledged the residents did not have access to their funds 24 hours a day or 7 days a week. On 3/24/26 at 2:22 PM Staff B, Certified Nurse Assistant (CNA) stated she does not know if the residents can get their money at night or on the weekend. On 3/24/26 at 2:26 PM Staff C, Licensed Practical Nurse (LPN) stated she would have to call Staff A and ask her what to do. Staff C explained she did not have access to any money for the resident. Staff C said only Staff A had access to money for the residents.On 3/24/26 at 2:33 PM the Administrator stated the residents would have to contact Staff A to get money when she was not at the facility. Staff A stated the residents can have access to money when they need it and Staff A made sure the residents had money on Friday before she left. The Administrator acknowledged the residents who have money in the resident trust do not have access to the money 24 hours a day or 7 days a week. The Administrator explained the residents only had access when Staff Staff A was at the facility.Review of a policy provided by the facility dated 6/16 titled, Resident Funds documented it was the policy of the facility to ensure resident funds maintained or managed by the facility are protected. The objectives of our resident fund policies are to provide a means for protecting resident funds managed by the facility, provide for an individual accounting of funds received and disbursed on the resident's behalf and establish uniform guidelines to follow in implementing policies and procedures to protect the residents funds. A separate record is maintained for each resident's personal funds account, including receipts and expenditure. It shall be the responsibility of the Administrator to inform all residents, prior to or upon admission, of the facility's policy and procedure governing the management of resident funds.

Based on Electronic Health Records (EHR) review, staff interview, family interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) when a resident had a change in condition that lead to a transfer to the Emergency Department (ED) for 1 of 3 residents (Residents #10) reviewed. The facility reported a census of 57 residents.Findings included:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. Review of Resident #10's EHR titled, Census documented Resident #10 was transferred to the hospital 1/7/26 and returned 1/22/26.Review of Resident #10's EHR titled, Progress Note documented an entry at 5:40 AM on 1/7/26 by Staff E, Licensed Practical Nurse (LPN) on-call provider gave orders to send Resident #10 to the ED via ambulance for evaluation and supply oxygen, updated resident on orders as resident is own POA.Review of Resident #10's EHR titled, Progress Note documented an entry at 11:31 AM on 1/7/26 by Staff D, LPN had spoken with ED nurse with report that Resident #10 was transferred to another hospital in Sioux Falls because of urosepsis and kidney failure. Staff D documented she called and notified Resident #10's Daughter.Review of Resident #10's EHR titled, Profile documented Daughter as emergency contact #1, POA, care conference person. On 3/17/26 at 10:56 AM Resident #10 Daughter/POA stated when Resident #10 went to the ED on 1/7/26 she was not notified till he went to the second hospital. Resident #10's Daughter/POA explained Resident #10 was life flighted to second hospital and she was not notified until after Resident #10 was in second hospital. Resident #10's Daughter/POA stated she was called by the nursing home about 30 minutes before the second hospital notified her. Resident #10's Daughter/POA stated she spoke to Staff D, Licensed Practical Nurse. Resident #10's Daughter/POA stated she told Staff D she was not notified her father was sent to the hospital and Staff D apologized. On 3/24/26 at 1:35 PM Staff D, LPN stated she called Resident #10's daughter / POA and notified her that Resident #10 was transferred to the ED. Staff D stated when she arrived the previous nurse Staff E, LPN had not notified the Resident #10's Daughter and Resident #10's daughter was upset. Staff D stated if the resident was their own POA Staff D would ask to notify the emergency contact. Staff D explained if the ambulance was called it would be an emergency and the emergency contact should be notified. On 3/25/26 at 6:10 PM Staff E, LPN stated she was familiar with Resident #10. Staff E explained Resident #10 was his own POA. Staff E stated if Resident #10 was not his own POA; she would notify the emergency contact. Staff E explained she did not notify Resident #10's POA when transferred to the hospital on 1/7/26. Staff E acknowledged she sent Resident #10 out right at 6:00 AM. Staff E said she texted Staff D to let Resident #10's daughter know Resident #10 was transferred. Staff E acknowledged that she should have let the daughter know but she did not at that time. On 3/18/26 at 10:54 AM the Director of Nursing (DON) stated Resident #10 was transferred to the hospital via emergency ambulance on 1/7/26. The DON stated Resident #10 was his own POA at the time but Resident #10's daughter was emergency contact #1 and should have been notified of the transfer to the ED and was not.Review of policy with review date of 7/24 titled, Change of Condition Reporting documented a licensed nurse will inform family/responsible party of change of condition and document notification. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response.

The facility failed to properly complete the Centers of Medicare & Medicaid form #10123 for 1 of 3 sampled residents. (Residents #4). The facility reported a census of 58 residents.Findings Include: The ABN form #10123 dated 12/23/25 for Resident #4 revealed the Social Worker documented a 48 hour notice waived. During an interview on 3/18/26 at 1:14 PM, the Social Worker reported that she had completed form #10123 and documented that Resident #4 waived a 48-hour notice. She further stated she could not recall the rationale for the waiver and indicated she would investigate the matter. During an interview on 3/18/26 at 2:51 PM, the Social Worker reported that she had been unable to locate documentation or rationale regarding the resident's waiver of the 48-hour notice on form #10123. When asked if a 48-hour notice should be documented as waived by the resident because the facility failed to provide the proper 48 hour advance notice, the Social Worker stated no. The undated Advance Beneficiary Notice of Non Coverage Part A failed to address form #10123 or the required 48 hour notice of Medicare Provider Non-Coverage. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 instructed when to deliver the NOMNC A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. During an interview on 3/19/26 at 2:25 PM, the Director of Nursing (DON) reported that she was not familiar with the requirements of ABNs. During an interview on 3/19/26 at 2:28 PM, the Administrator reported she was not fully educated regarding Advanced Beneficiary Notices (ABN's) and expected the Social Worker to adhere to ABN guidelines.

Based on clinical record review, facility policy review and staff interview the facility failed to discontinue antipsychotic medication when ordered to be stopped therefore the medication was continued to be administered for 1 out of 5 residents (Resident #20 ) for unnecessary medication. The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of order signed by the physician on 10/16/25 revealed discontinue quetiapine. Review of October Medication Administration Record (MAR) revealed quetiapine was administered daily from October 17- 31, 2025. Review of November MAR revealed quetiapine was administered daily from November 1- 30, 2025. Review of December MAR revealed quetiapine was administered daily from December 1-11, 16, 18, 27-30 with a discontinue date of 12/31/25. Review of facility provided policy titled Unnecessary Drugs with a revised date of 7/2025 revealed each resident's entire drug/medication regimen be managed and monitored to promote or maintain the resident's highest practicable mental, psychical, and psychosocial well-being. Residents receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s). Interview on 3/24/2026 at 2:12 p.m., with the Director of Nursing revealed the quetiapine should have been discontinued in October when the order was signed.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 2 of 4 residents reviewed for abuse (Resident #3 and #50). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of coronary artery disease, diabetes mellitus and muscle weakness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12 indicating no cognitive impairment. Review of facility provided Incident Report dated 3/8/26 at 3:21 p.m., revealed Staff I, Registered Nurse (RN) was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated, just letting you know Resident #2 was in this resident room attempting to get in bed with her. This writer hung up and immediately rushed down the hall with a care giver. Staff I met Resident #3 in her bed, resting in bed, and call light within reach. Resident #3 stated, I was in bed, my door was halfway closed when this man came in and just kept coming towards me. He touched my leg and I told him to stop immediately. He moved my bedside table away from me and I thought he wanted to take my dentures on the table, but he had this weird look you know, placed his hand under my blanket and tried to touch me. I pushed my call light and screamed twice. My neighbor heard me and pushed his call light as well, and he took off then the aide came in and I told them. Interview on 3/17/2026 at 11:08 a.m., with Resident #3 revealed she had been laying in bed and her door opened and a guy in a wheelchair came into her room and touched her feet. He then moved her tray over that was next to the bed and all of a sudden his wheelchair was going up the side of my bed and his hand was going up my leg. She stated she screamed and pushed the call like. After she screamed he scooted out of my room. 2. The MDS assessment dated [DATE] for Resident #50 documented diagnoses of need for assistance with personal care, lack of coordination and hypertension. The MDS showed the BIMS score of 6 indicating severe cognitive impairment. Review of facility provided Incident Report dated 3/8/26 at 3:22 p.m., revealed Staff I, RN was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated just letting you know, Resident #2 was in Resident #3's room attempting to get in bed with her. Staff I immediately rushed down the hallway to make sure the resident was safe. Staff I and caregiver check rooms to make sure Resident #2 is out of the hallway and is safe. At about 3:22 p.m., Staff I and caregivers found Resident #2 in bed with Resident #50 with her pant and brief halfway down and Resident #2's left hand was in this resident's pants on her buttocks. Resident #2's wheelchair was parked in front of Resident #50's bed and door was locked. Resident #50 was lying in bed on her right side facing the window half asleep and Resident #2 was on bed and not moving. Review of Resident #50's Progress Notes revealed revealed Staff I, RN was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated just letting you know, Resident #2 was in Resident #3's room attempting to get in bed with her. Staff I immediately rushed down the hallway to make sure the resident was safe. Staff I and caregiver check rooms to make sure Resident #2 is out of the hallway and is safe. At about 3:22 p.m., Staff I and caregivers found Resident #2 in bed with Resident #50 with her pant and brief halfway down and Resident #2's left hand was in this resident's pants on her buttocks. Resident #2's wheelchair was parked in front of Resident #50's bed and door were locked. Resident #50 was lying in bed on her right side facing the window half asleep and Resident #2 was on bed and not moving. Resident #50 was unable to state or describe what happened. Both residents were separated immediately. Notified Director of Nursing (DON) immediately via phone call. Review of the facility provided policy titled Abuse: Prevention of and Prohibition Against with a reviewed date of 1/2022 revealed the following:a. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. b. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Interview on 3/24/2026 at 2:11 p.m., with the Administrator revealed once she became aware of the situation that evening she immediately reported it to the state. It should have been reported sooner. Interview on 3/24/2026 at 2:26 p.m., with the DON revealed she did not know about the incident until later in the evening about the touching or being in bed with another resident. The DON confirmed she had been called around 3:00 p.m., but the staff never told her about the incident.

Based on clinical record review and staff interview the facility failed to complete a recapitulation of stay after discharge for 2 of 3 residents reviewed for discharges (Resident #61 and #63). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #61 documented diagnoses of hypertension, Bell's Palsy and prediabetes. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the Census tab revealed stop billing on 1/12/26. Review of the January 2026 notice to the Long Term Care Ombudsman revealed the resident was discharged to home on 1/12/26. Review of the medical record lacked a recapitulation of stay. 2. The MDS assessment dated [DATE] for Resident #63 documented diagnoses of hypertension, muscle weakness and cardiac murmur. The MDS showed the BIMS score of 14 indicating no cognitive impairment. Review of the Census tab revealed stop billing 1/15/26. Review of the Progress Notes revealed on 1/14/26 at 2:38 p.m., Resident will be returning to assisted living upon discharge from skilled services. Review of the medical record lacked a recapitulation of stay. Review of facility provided policy titled Discharge Summary with a revision date of 12/2023 revealed It is the policy of this facility that a discharge summary shall be prepared when a resident is expected to be discharged . A recapitulation of the resident's stay that includes, but is not limited to: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. Interview on 3/25/2026 at 11:28 a.m., with the Director of Nursing revealed if it is not in the assessments then it was not completed.

Based on Medication Administration Records - Treatment Administration Records (MAR-TAR) Electronic Health Records (EHR) review, document review, policy review and staff interviews the facility failed to incorporate the required recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination and failed to refer a resident with a later identified with newly evident or possible serious MD or ID related condition to the appropriate state-designated authority for a level II evaluation for 3 out of 4 residents (Resident #4, #5, and #15) reviewed for PASRR requirements. The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. MDS also documented diagnoses of major depressive disorder and schizophrenia. Review of Resident #4's document dated 11/19/25 titled, Notice of PASRR Level II outcome documented ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) as a required behavioral health support for Resident #4. Review of Resident #4's MAR-TAR documented physician's order with a start date of 11/24/25 for clozapine (a second generation antipsychotic used for the treatment of schizophrenia) oral tablet to give 100 mg by mouth at bedtime for mood Review of Resident #4's EHR titled, Care Plan documented an intervention with an initiation date of 12/13/25 Resident #4 would receive ongoing psychiatric medication management once a month by a psychiatrist, once a month to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services. Review of Resident #4's EHR titled, Progress Note dated 12/9/25 at 1:44 PM by Staff A, Social Worker documented a referral for psychiatric medication management has been submitted. Initial consultation pending scheduling. Progress Note dated 3/6/26 at 12:54 PM by Staff A documented Due to resident's current payer status, resident will need to complete a payment agreement prior to being seen for an initial psychiatric evaluation. Efforts to reach resident's current payee have been unsuccessful resulting in inability to render services. Frustration from her current payee situation has led Resident #4 to refuse services as well due to her current financial situation. Rep Payee appointment was held with SSA on 2/27/26. Rep Payee determination is currently pending determination. Progress Note dated 3/9/25 at 9:48 AM by Staff A documented neuropsychiatric evaluation cannot be completed until Resident#4 agreed to complete the initial psychiatric evaluation. Continued efforts will be made to engage Resident #4 in initial psychiatric evaluation. Staff A met with Resident #4 today to clarify if Resident #4 would be willing to meet for initial psychiatric evaluation, ongoing medication management, and neuropsychiatric evaluation. Resident #4 stated I don't think so. I don't think I can pay. Staff A reminded Resident #4 the facility was working on financials and had applied for rep payee. Resident #4 stated maybe later then and propelled away in a wheelchair. Review of document dated 3/12/26 titled, Notice of PASRR Level II Outcome documented on 1/28/26- A ServiceMatters review was completed to see if all identified PASRR services and supports noted in the PASRR report from December 2025 were being care planned and delivered. The ServiceMatters review found the nursing facility was not compliant because it had not developed your care plan according to state standards and/or had not incorporated PASRR-identified specialized and rehabilitative services. Technical assistance was provided by Maximus to help the facility become compliant. Document further documented on 3/9/26-A ServiceMatters review was completed to see if all identified PASRR services and supports noted in the PASRR report from December 2025 were being care planned and delivered. The ServiceMatters review found the nursing facility was not compliant because it had not developed your care plan according to state standards and/or had not incorporated PASRR-identified specialized and rehabilitative services. Technical assistance was provided by Maximus to help the facility become compliant. On 3/19/26 at 1:44 PM Staff A acknowledged the initial PASRR completed on 11/19/25 had recommended for Resident #4 to have ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services). Staff A stated there was a Progress Note completed on 12/9/25 that they had reached out and then again on 3/6/26 something saying that there was a billing issue that needed to be resolved. On 3/26/26 at 10:27 AM Staff A stated Resident #4 has a rep payee that they do not have great communication with. Staff A stated they could not have the payment agreement by the rep payee. Staff A stated the facility that would have completed the psychiatric evaluation explained they would have to have a payment agreement signed prior to the evaluation of Resident #4. Staff A stated when she spoke with Resident #4 she would get upset because she was going to have to pay out of pocket for the services. Staff A stated she came under skilled care with Medicare and just applied for Medicaid 3/25/26 because they finally got a bank statement. Staff A acknowledged she had tried initially when Resident #4 had entered the facility. Staff A acknowledged she did not make any other attempts. Staff A stated applying for the rep payee and Medicaid in the state of Iowa to pay for the psychiatric services was probably dropped for this resident. On 3/25/26 at 2:18 PM the Director of Nursing (DON) stated in regards to Resident #4 PASSR stated she would like to have seen the financial aspect taken care of faster to ensure the meeting with the psychiatrist could have occurred per the PASSR recommendations. Review of a policy provided by the facility reviewed 5/22 titled, PASRR documented it was the policy of the facility to ensure that each resident is properly screened using the PASRR specified by the State. The purpose was to determine if the resident had a mental disorder as defined in paragraph (k)(3)(1), of the SOM unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission: That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and; If the individual requires such level of services, whether the individual requires specialized services. 2. The MDS assessment dated [DATE] for Resident #5 documented diagnoses of anxiety disorder, depression and hallucinations. The MDS included a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of the MDS dated [DATE] included current diagnosis of anxiety disorder, depression and hallucinations. Review of the current diagnosis list revealed major depressive disorder, recurrent moderate, hallucinations and generalized anxiety disorder. Review of the PASARR dated 10/21/24 lacked inclusion of anxiety disorder, depression and hallucinations. The clinical record lacked an updated PASARR to include anxiety disorder, depression and hallucinations. . 3. The MDS assessment dated [DATE] for Resident #15 documented diagnoses of schizophrenia. The MDS included a Brief Interview for Mental Status (BIMS) score of 14 indicating moderate cognitive impairment. Review of the MDS dated [DATE] included current diagnosis of schizophrenia. Review of the current diagnosis list revealed schizophrenia, unspecified. Review of the PASARR dated 2/26/26 listed diagnosis of psychotic delusional disorder. The clinical record lacked an updated PASARR to include schizophrenia. Review of the facility provided policy titled PASRR with a reviewed date of 5/2022 revealed it is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the stated. Interview on 3/23/26 at 10:37 a.m., with the Social Worker revealed the PASARR should have been updated with proper diagnosis and to include all mental health diagnosis.

Based on Electronic Health Record (EHR) review, document review, staff interviews and policy review the facility failed to revise a comprehensive care plan to include updated recommendations when a Preadmission Screening and Resident Review (PASRR) Level II Outcome was completed for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. MDS also documented diagnoses of major depressive disorder and schizophrenia.Review on of Resident #4's EHR titled Care Plan on 3/18/26 documented you will receive this service for one year through 3/13/2027. Continued need will be assessed by the case manager once a year through 12/21/2030. Behavioral Health would provide case management services and the social worker at the NF will be responsible for arranging for these services prior to discharge on [DATE]. You will have home cleaning service once a week for one year through 3/13/2027. Continued need will be assessed by the home health agency once a year through 3/13/2027. A home care service will provide home cleaning services and the social worker at the NF will be responsible for arranging for this service prior to discharge on [DATE]. You will have help from your children with transportation for one year and continue as needed through the next five years. Your daughter and son will help with transportation and the social worker/director of nursing at the NF will be responsible for coordinating this support with your family prior to discharge on [DATE].Review of document dated 3/12/26 titled, Notice of PASRR Level II Outcome documented on 1/28/26- A Service Matters review was completed to see if all identified PASRR services and supports noted in the PASRR report from December 2025 were being care planned and delivered. The Service Matters review found the nursing facility was not compliant because it had not developed your care plan according to state standards and/or had not incorporated PASRR-identified specialized and rehabilitative services. Technical assistance was provided by Maximus to help the facility become compliant. Document further documented on 3/9/26-A Service Matters review was completed to see if all identified PASRR services and supports noted in the PASRR report from December 2025 were being care planned and delivered. The Service Matters review found the nursing facility was not compliant because it had not developed your care plan according to state standards and/or had not incorporated PASRR-identified specialized and rehabilitative services. Technical assistance was provided by Maximus to help the facility become compliant.On 3/26/26 at 10:27 AM Staff A, Social Service Director acknowledged that she had updated the care plans on 3/19/26. Staff A stated she had got the updated PASSR on 3/12/26. Staff A stated updated the care plan on 3/19/26 and had changed the duration dates to match the new PASSR as well as the appointment expectations and things like that. Staff A explained on 3/18/26 she was told by management after the surveyor revealed concerns to make sure that the Resident #4's Care Plan was updated. Staff A explained Resident #4's Care plan should have been changed immediately when she received the PASSR.On 3/25/26 at 2:18 PM the Director of Nursing (DON) stated she would have liked to see Resident #4's Care Plans updated after the PASSR was completed in a timely manner and in this situation that did not occur. Review of a policy provided by the facility reviewed on 11/22 titled, Care Planning it was the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The Care Plan would be revised as needed, and interventions will be implemented. The comprehensive care plan would be developed by the IDT within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plans. The resident's comprehensive plan of care would be reviewed and/or revised by the IDT after each assessment and updated as appropriate. The Care Plan would be revised as needed for order changes or Resident changes in condition, and interventions would be implemented as appropriate.

Based on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly for 2 of 3 residents reviewed for bathing (Resident #20 and #50). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of facility provided documentation titled Follow Up Question Report dated 1/19/26-3/19/26 revealed the following information:2/7/26- bathing was documented as refused. Resident received a bath on 2/4/26 and again on 2/11/26. Resident went 6 days without a bath. 3/11/26- bathing was documented as not applicable. Resident received a bath on 3/7/26 and again on 3/14/26. Resident went 6 days without a bath. Review of Care Plan with a revision date of 2/7/25 revealed resident is totally dependent on staff to provide a bath as necessary. 2. The MDS assessment dated [DATE] for Resident #50 documented diagnoses of need for assistance with personal care, lack of coordination and hypertension. The MDS showed the BIMS score of 6 indicating severe cognitive impairment. Review of facility provided documentation titled Follow Up Question Report dated 1/19/26-3/19/26 revealed the following information:1/24/26- bathing was documented as resident refused. Resident received a bath on 1/21/26 and again on 1/27/26. Resident went 6 days with no bath. 2/9/26- bathing was documented as not applicable2/12/26- bathing was documented as not applicable. Resident had a bath on 2/6/26 and again on 2/13/26. Resident went 6 days with no bath. 3/2/26- bathing was documented as not applicable. Resident had a bath on 2/23/26 and again on 3/3/36. Resident went 7 days with no bath. 3/10/26- bathing was documented as resident refused. 3/11/26- bathing was documented as not applicable3/12/26- bathing was documented as not applicable3/13/26- bathing was documented as not applicable3/14/26- bathing was documented as not applicable3/16/26- bathing was documented as not applicable. Resident received a bath on 3/6/26 and received a bath again on 3/17/26. Resident went 11 days with no bath. Review of the facility provided policy titled Bath, Shower with a revised date of 5/2007 revealed It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Clinical staff members will offer residents a shower at minimum of 2 times per week. If a resident is unable to shower on a specific day, the resident will be offered a shower on the next available day. Interview on 3/24/2026 at 2:23 p.m., with the Director of Nursing revealed when the resident refused their shower the staff need to continue to offer. They need to try multiple times and try a different person. If they still do not take it that day the staff need to continue to try the next day until they bathe.

Based on Electronic Health Record (EHR) review, Medication Administration Record - Treatment Administration Record (MAR-TAR) review, policy review and staff interviews the facility failed to provide appropriate interventions for the urinary catheter to provide appropriate services to prevent urinary tract infections to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented Resident #10 had a diagnosis of neuropathic bladder.Review of document dated 2/25/26 titled, Hospital Discharge Summary documented Resident #10 had a chronic indwelling foley catheter placed on 2/11/26-present and a urinary tract infection associated with indwelling urethral catheter noted on 2/20/26-present. Hospital Discharge Summary documented Resident #10 had the catheter last changed on 2/21/26 prior to discharge and care and management per facility guidelines/protocol.Review of Resident #10's EHR titled, Care Plan documented no focus, goal, or interventions related to placement of a catheter.Review of Resident #10's EHR titled, Tasks documented no tasks related to the placement of a catheter.Review of Resident #10's EHR titled, MAR-TAR documented no orders related to the placement of a catheter.Review of Resident #10's EHR titled, Progress Note documented Resident #10 did have a catheter on 2/25/26 and 3/1/26.On 3/26/26 at 10:26 AM Staff D, Licensed Practical Nurse (LPN)/Admissions stated Resident #10 did have a catheter when he returned from the hospital on 2/25/26 and had the catheter until sent to the hospital on 3/5/26. Staff D acknowledged there were no orders documented at the facility for Resident #10's catheter after discharge from the hospital on 2/25/26. Staff D acknowledged there were no task for nursing staff to empty Resident #10's catheter or to record the output from Resident #10's catheter. Staff D acknowledged there were no treatments, tasks or cares for cleaning Resident #10's catheter in place after Resident #10 was discharged from the hospital on 2/25/26. Staff D acknowledged there was not a care plan developed for Resident #10 for the placement of the catheter. Staff D acknowledged she did not notify the physician of the presence of a catheter upon return and she completed the return assessment. Staff D explained that orders, care plan, tasks, cares, and urine output should have all been initiated upon return from the hospital on 2/25/26.On 3/26/25 at 11:10 AM the Director of Nursing (DON) acknowledged Resident #10 did not have an order, care plan, task, treatment / care of catheter in his EHR from his discharge on [DATE]. The DON stated she expected all of these would have been discussed with the resident and resident's physician to obtain orders. The DON explained Resident #10's output should have been documented as well. Review of a policy provided by the facility reviewed 7/23 titled, Documentation and Charting documented it was the policy of the facility to provide A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Guidance to the physician in prescribing appropriate medications and treatments. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. Nursing service personnel with a record of the physical and mental status of the resident. Assistant in the development of a Plan of Care for each resident. The elements of quality medical nursing care.

Based on observations and diet orders the facility failed to assure the food was prepared and appropriate to meet resident's needs according to their assessment, diet orders and care plan. Observations determined that 3 residents did not get the food in their ordered texture and 2 of the 3 residents have an order for an altered diet and are identified as moderately impaired cognition, (Resident #5, #6 and #7). This failure resulted in residents receiving Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 25, 2024 on July 26, 2024 at 4:07 p.m. The Facility Staff removed the Immediate Jeopardy on July 26, 2024 through the following actions: a. Staff education was provided to the individual's passing meals on 7/25/24. b. The dietary manager was also re-educated on all diets on 7/25/24. c. All diets were reviewed and dietary cards were updated with new pictures and new diets on 7/25/24. d. The dietary staff were all reeducated about appropriate diets by the administrator on 7/26/24. e. Dietary staff educated the process of [NAME] verifying the diet served matches the plate and diet cards then put into the serving window and dietary aide or staff member who is serving double checks to ensure correct food is matching diet card before going to serve plate. f. Education given to dietary staff in regards to ensuring we are all aware of Which Resident is who and serving the correct plate to the correct resident. g. Resident who was served incorrect diet immediately was placed on speech therapist caseload 7/26/24. h. Education given to all staff in regards to therapeutic diets on 7/25/24. i. The other residents involved will also be evaluated for therapeutic caseload . j. When new staff are hired we are to train and educate in regard to diet orders process of modified diet process of serving drinks and food. k. All kitchen staff meetings occurring with continuing education. l. Monthly QAPI meetings discussing the kitchen. m. Continued education with all staff in regards to food processes modified diet serving processes and diet orders. n. Daily and weekly audits to ensure timeliness of food served correct diet served temperatures, hand washing and glove use. o. Management staff as well as dietary staff will use the diet order cards with reference to therapeutic diet sheets and recipes and reference to the diet manual as well as confirm any questions with the dietitian prior to meals being placed in front of a resident. p. A certified dietary manager from a sister facility will be here on 7/28/24 to provide ongoing side by side training with dietary staff. Ongoing training will be held for the next 7 days with all dietary staff until return demonstration of correct meal service is obtained for three consecutive meals ongoing audits and education will be provided weekly times for weeks with return demonstration of skills each week and sign off sheets completed for competency. Skills will be based on puree mechanical soft and serving size and liquid consistency. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 46 residents. Findings Include: Observation of meal service on 7/25/24 starting at 12:23 p.m., revealed the following observations: Resident #6 received her meal try and told the aide seated next to that she could not eat the meal they served her as she cannot eat lettuce. Resident #6 received a chicken wrap with pieces of lettuce, tomato, and a pieces of chicken in the wrap. One piece was noted to be approximately half dollar size. On the plate was also potato salad and potato chips with lemon pudding in a cup next to the plate. Staff sitting next her said you're right as your diet is a mechanical soft diet. Resident #6 at this time requested a peanut butter and jelly sandwich. Staff B, Speech therapist (ST) confirmed Resident #6 was to have ground meat and a mechanical soft diet. Resident #7 received his meal of a chicken wrap with pieces of lettuce, tomato, and pieces of chicken in the wrap with potato chips and potato salad on the plate. Resident #7 immediately began eating the potato chips on his plate. Staff B was in the dining room and was asked if Resident #7 was to have potato chips on a mechanical soft diet and she revealed no and removed the plate from the resident and requested appropriate texture from the dietary staff. Resident #5 received her plate of a chicken wrap with pieces of lettuce, tomato and pieces of chicken in the wrap with potato chips and potato salad on the plate. Resident #5 picked up her wrap to take a bite. Staff B approached the resident and confirmed Resident #5 was a mechanical soft diet and this was not appropriate for her. Removed the meal and requested an appropriate texture meal from the dietary staff. Review of facility provided document titled Diet Type Report revealed the following information: a. Resident #5 diet type included a mechanical soft diet. b. Resident #6 diet type included a mechanical soft diet with ground and moist meat. c. Resident #7 diet type included a mechanical soft diet with ground meat. Review of Resident #5's Order Summary Report signed by the physician on 7/10/24 revealed a regular diet with mechanical soft texture. Review of Resident #6's Order Summary Report signed by the physician on 7/8/24 revealed a regular diet with mechanical soft texture and ground moist meats. Review of Resident #7's Order Summary Report signed by the physician on 7/8/24 revealed a regular diet with mechanical soft texture and ground meats. Interview on 7/25/24 at 1:17 p.m., with Staff B revealed if an altered diet is ordered then the diet should be followed. Interview on 7/26/24 at 8:44 a.m., with Staff C, Dietary Manager revealed on 7/25/24 she did not have enough chicken for the noon meal and she called the dietician to for substitutions so she made a decision to make chicken wraps. Staff C revealed she has only been in her position for approximately a week and half but has worked in the kitchen since April and has not had any training as a dietary manager. Interview on 7/26/24 at 2:22 p.m., with Staff D, Dietician revealed she had not been contacted on 7/25/24 by the facility for any menu changes. Staff D further revealed mechanical soft diets should not have had the chicken that was not ground or cut up lettuce. Staff D stated the mechanical soft diet residents should not be eating potato chips either. She explained that the consistency was not correct for them. Mechanical soft diets are not to have anything hard or crunchy. Interview on 7/26/24 at 10:24 a.m., with Resident #6 revealed the facility had given her the wrong food yesterday. She told the lady she could not eat it as she cannot eat lettuce. She further explained that she has told the kitchen several times she cannot eat certain foods but they send them to her anyway. Interview on 7/26/24 at 11:36 a.m., with Resident #9 revealed he had been given the wrong food yesterday and the staff took it away. Interview on 7/26/24 at 2:26 p.m., with Staff E, Certified Nursing Assistant (CNA) revealed there has been issues with the residents getting appropriate thickened liquids. CNA's usually catch it before the residents drink it. Interview on 7/26/24 at 2:54 p.m., with Staff F, CNA revealed they have been serving meals out of the kitchen and sandwiches with crust will be served to mechanical soft residents and the CNA's will catch it and take it back to have them correct the diet. Staff F further revealed they have had to correct the kitchen staff as they served a resident regular liquids when they should have been thickened liquids. Interview on 7/26/24 at 3:03 p.m., with Staff G, CNA revealed Resident #9 was served chicken fried steak in the wrong consistency and he started to eat it and the staff had to take it away. Staff G further revealed Resident #5 had been served a tortellini dish and the staff had to tell the kitchen staff that she couldn't have it as it was the wrong consistency and that the residents are getting the wrong drinks. Some residents are thickened liquids and are not getting them and the seasoned staff have been fixing it. Review of facility provided policy titled Therapeutic Diets with a reviewed date of 5/2021 revealed the following information: a. A therapeutic diet must be prescribed by the residents attending physician. b. A tray Identification system is established to ensure that each resident receives his or her diet as ordered. c. Mechanically altered diets will be considered therapeutic diets. Interview on 7/26/24 at 12:56 p.m., with the Administrator revealed she expects all residents to receive the proper texture they are ordered.

Based on observations and diet orders the facility failed to assure the food was prepared and appropriate to meet resident's needs according to their assessment, diet orders and care plan. Observations determined that 5 residents, (Residents #11, #15, #26, #27 and #34) did not get the food in their ordered texture and 3 of the 5 residents that have an order for an altered diet are identified as moderately impaired cognition and 1 resident did have an episode of choking from being served the incorrect diet on 10/14/23. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 14, 2023 on January 24, 2024 at 3:26 p.m The Facility Staff removed the Immediate Jeopardy on January 24, 2024 through the following actions: a. All dietary staff have been educated on preparing food for each resident based on diet order that is written on individual dietary cards and updated by all appropriate staff as changes happen/as diets are modified, change. b. Plates are prepared by dietary staff with card present and second checked by second dietary staff serving. c. Specific modified diet orders have been defined and are listed in the kitchen with complete definition. d. Nurse/designee will audit diet orders and match them to prepared plates prior to serving 1 times weekly for next 90 days or as determined by findings as reviewed at monthly QAPI meeting. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 42 residents. Findings Include: 1. Observation of meal service on 1/24/24 starting at 12:15 p.m., revealed the following observations: Resident #11 ordered a deli sandwich for her lunch meal. Staff P, Dietary Cook told Staff G, Licensed Nursing Home Administrator (LNHA) and Certified Dietary Manager (CDM) Resident #11 is ok to have deli meat as it is soft enough for her to chew and all she needed to do was cut the crust off of the bread. Asked Staff P if the deli sandwich with the crust cut off was what Staff P was going to serve Resident #11 and Staff P replied yes. Asked Staff P to look at Resident #11 ' s diet card and the diet card read all meat is to be ground except bacon. Staff G stated the facility would make a new sandwich with ground deli meat for Resident #11. Staff P explained they had never had the proper training in the kitchen and the former Dietary Manager (DM) told staff it was ok for residents on ground meat to have deli meat as it is a soft meat for them to eat. Staff P further explained staff had told them it was ok to serve shredded meat to residents on a ground diet as long as there is plenty of gravy or au [NAME] sauce on the meat. Observation of Resident #26 ' s plate sitting next to him at the table with meat left on the plate. Meat was shredded pork loin. Staff G verified the meat was shredded pork and not ground meat. Staff P reviewed the diet card and diet read Resident #26 to have ground meat. During meal service asked Staff P if there was ground meat ready to be served. Staff P stated not yet we do that when we are ready for it. Observation of Resident #34 ' s meal being served by Staff G. Staff G asked Staff P to verify Resident #34 ' s diet was a regular diet. Staff P stated yes Resident #34 was a regular diet and discussion was held regarding the texture and Staff P stated Resident #34 was able to have shredded pork. Staff P wrote Resident #34 ' s initials on top of the styrofoam container for her meal and placed on a room tray on the service cart. Staff P was asked if the room trays are ready to be served and Staff P verified the trays were being served to the residents. Staff P got Resident #34 ' s diet card and diet card revealed ground meat. DM overheard the discussion and told Staff P do not serve that to Resident #34, needed to have ground meat. DM manager served ground meat to Resident #34. Review of facility provided document titled Diet Type Report dated 1/24/24 revealed the following information: Resident #34 diet type included ground meat (moist). Resident #27 diet type included ground meat. Resident #11 diet type included mechanical soft ground meats with extra gravy and condiments. May have regular bacon. Resident #26 diet type included ground. Resident #15 diet type included mechanical soft texture for meats but may have regular texture bacon. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of chronic obstructive pulmonary disease (COPD), heart failure and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. Review of Resident #11 ' s Progress Notes revealed the following information: On 10/14/23 at 1:06 p.m., resident had a small coughing episode at noon lunch table. Resident spit out small amount of chicken as well as potato salad. Extra fluids were available for resident at the time and she did take small bites during this meal. Temperature this shift 97.5, lungs remain clear to auscultation. Review of fax sent to the physician on 10/14/23 revealed the resident had a coughing spell during the meal. Appeared to choke on a small piece of cut up chicken and potato salad. Physician replied with continue to have speech therapy work with her signed 10/16/23. Review of Order Summary Report signed by the physician dated 10/2/23 revealed diet type included mechanical soft ground meats with extra gravy and condiments. May have regular bacon. Interview on 1/25/24 at 9:11 a.m., with Staff M, Dietitian revealed if a resident is ordered a ground meat diet then the resident should not be served shredded pork. The meat should have been a ground meat consistency. Resident # 11 is to receive ground meat diet and should not be received as a deli meat sandwich unless the meat has been ground. Staff could also offer an alternative such as tuna salad sandwich or other meat salad sandwich. Interview on 1/25/24 at 10:30 a.m., with Staff Q, Speech Therapist revealed Resident #11 is ordered ground meat. Resident #11 is aware of the order and Staff Q has tried to advance her diet but this has lead to choking issues so has worked with Resident #11 and allows her to have regular bacon as they did extra education and training on how to safely eat the bacon. Resident #11 should not have been served regular deli meat and it should have been ground up. All residents receiving a diet order for ground meat should receive the ground meat as ordered. The ground meat is for their safety. 3. Resident #15's MDS with Assessment Reference Date (ARD) 11/13/23 showed the resident had a BIMS's score of 15, cognitively intact for daily decision making and required set up assist with eating. 4. Resident #26's MDS with ARD 12/11/23 showed the resident had a BIM's score of 4, severely impaired cognitive status and required set up assist with eating. 5. Resident #27's MDS with ARD 10/30/23 showed the resident had a BIM's of 5, severely impaired cognitive status and was independent with eating. 6. Resident #34's MDS with ARD 12/18/23 showed the resident had a BIM's of 11, moderately impaired cognitive status and had supervision to touching assistance with eating. Review of facility provided policy titled Dining and Meal Service last updated 11/2019 revealed food will be at the proper texture or consistency to meet each individual ' s needs and desires. Mechanically altered diets, such as pureed diets, are prepared and served as separate entree items (except when meant to be combined food such as stews, casseroles, etc.). Interview on 1/24/24 at 2:27 p.m., with the DM revealed if a resident is ordered ground meat then the resident should have been served ground meat.

Based on clinical record review, staff interview, and facility policy/procedure the facility failed to assess, document, notify the provider and family and provide skin assessments and complete neurological assessments for three of three residents reviewed after post falls/injuries. (Resident #4, #5, #12). Resident #4 was transferred to the local clinic on 3/1/22, where it was determined that sutures had to be utilized to connect the skin on the residents right hand from a fall that occurred on 2/28/22. The facility reported a census of 47 residents. Findings include: Review of a the facility policy and procedure for change of condition reporting dated 7/2021, instructed: Acute Medical Change- 1. Any sudden or serious change in a residents condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and /or acute care evaluation. The licensed nurse in charge will notify the physician. 2. Licensed nurse will inform the primary physician (alternate physician of Medical Director) of resident status as soon as possible once resident needs have been met and immediacy of nursing care is completed. 3. Licensed nurse will inform family/responsible party of change of condition and document notification. 4. All nursing actions, will be documented in the licensed progress notes as soon as possible after resident needs have been met. Review of the facility policy/procedure for skin and wound management dated 5/2021, instructed: 1. A weekly skin assessment will be completed on all residents and documented in the resident medical record or progress note. 2. Each wound will be measured in centimeters weekly. Measurements, size, and depth, drainage, odor, color and a short statement on progress (or lack of) will be documented on the Skin Pressure Weekly or Skin Ulcer Non-Pressure Weekly. 3. Treatments ordered by the physician will be used. 5. All treatments involving breaks in the skin required clean technique, unless otherwise ordered by the physician. 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4 for which indicated severe decision making abilities. The MDS identified the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident had no falls, and no skin injuries. The MDS further documented resident required extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene, limited assistance for transfer, and supervision with set up help for ambulation in the room and corridor. The Clinic Note dated 3/1/22 at 1:22 p.m., documented, patient here for evaluation of a fall that occurred yesterday morning around 7:40 a.m. Our office was not notified about this until today. Her wounds were cleaned and Steri-Strips were applied. The injury was not witnessed. Patient has significant Alzheimer's dementia and does not verbalize very well. She denies having pain. No recent fever or chills. No other cold or flu symptoms reported. There is a contusion on the right lateral forehead in the hairline. There is a small skin tear on the left dorsal hand. Other skin tear on the right forearm, right dorsal hand over the fifth metacarpal and along the lateral aspect of the fifth digit. The dorsal aspect of the hand is swollen. The right foot was swollen over the metatarsals. X-Rays were taken of the right hand and right foot. No obvious fractures were noted. The wounds were cleansed with [NAME]-Clens Will present [MEDICATION(S)] with epi was used locally approximately 5 cc. The right fifth digit 4 centimeter laceration had 5 stitches placed in a simple fashion. The right dorsal hand 3 centimeter laceration had 3 stitches placed in a simple fashion. Antibiotic ointment with [MEDICATION(S)] and 2 inch kling was used for dressing. Assessment: 1. Forehead contusion unwitnessed fall. 2. Multiple skin superficial skin tears with steri-strips. 3. Lacerations 4 centimeters to the right fifth digit and 3 centimeter to the right lateral hand repaired in a single-layer. 8 stitches total. Review of the Fall report dated 2/28/22 at 7:22 a.m., documented Environmental/housekeeper summoned nursing staff as resident fell as she was walking out of her room with walker. Resident was observed laying flat on her right side on the floor with right arm underneath her and left arm on top of her side. Blood noted from underneath head and from underneath her right abdomen area. [NAME] was a couple of feet outside the room door from where the resident was laying and in the hallway. [NAME] had clothing on top as well as resident purse. Resident was wearing regular socks only to feet. Floor was clean and dry. Resident was not wearing glasses and was wearing her nightgown. Resident is unable to give account of the incident due to her memory loss and confusion. Injuries observed at time of incident: left hand skin tear. (back) Notes: Resident noted to have skin tear to right inner wrist on the pinky finger side. Has skin v-shaped skin tear to top of left hand. Laceration to outside of right pinky finger. Laceration to outside palm of right hand. Bruise/hematoma to right forehead/temporal area. Review of the Progress Notes dated 2/28/2022 7:42 a.m., documented the following: Environmental/housekeeper summoned nursing staff as resident fell as she was walking out of her room with walker. Resident was observed laying flat on her right side on the floor with right arm underneath her and left arm on top of her side. Blood noted from underneath head and from underneath her right abdomen area. [NAME] was a couple of feet outside the room door from where the resident was laying and in the hallway. [NAME] had clothing on top as well as resident purse. Resident was wearing regular socks only to feet. Floor was clean and dry. Resident was not wearing her glasses and was wearing her nightgown. Resident unable to give accounts of the incident due to her memory loss and confusion. Resident assessed. Vital Signs taken. Blood Pressure (BP) was elevated but with follow-up assessments and vital signs, residents BP did decrease to normal level. Other VSS. Neurological assessments started and completed as resident is able due to impairment from Dementia. Range Of Motion assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] with no external rotation. Shoulders and hips without bruising or injuries and resident is able to move them appropriately as well. Resident assisted up with the help of 3 caregivers and gait belt and assisted into wheelchair. Abrasion/skin tear/hematoma to head cleansed. Skin tears cleansed and applied steri-strips/dressing applied as resident would allow. She did have pain to right hand/finger and would pull away from charge nurse as charge nurse was treating these areas. The charge nurse was the only staff member to visual extent of the skin tear/laceration to right palm/finger. Once treated by charge nurse, resident was assisted with dressing, toileting and morning cares. Intervention is to apply gripper socks at night and encourage resident to keep them on. Further review of the progress notes documented the following: On 2/28/2022 at 7:17 p.m., Acetaminophen ( medication to treat pain) Tablet, Give 650 mg by mouth every 6 hours as needed for pain, given for pain in her hand. On 2/28/2022 at 11:45 p.m., Acetaminophen Tablet, Give 650 mg by mouth every 6 hours as needed for pain, PRN Administration was: Unknown, Follow-up Pain Scale was: 2 On 3/1/2022 at 4:56 a.m., Resident continues on fall f/u with neuros. VS obtained: 152/69-97.6-52-20-pulse oxygen =95%R on room air. Resident Right hand redressed per writer. Purple bruising noted throughout Right hand. Steri strips applied to 5th digit of Right hand. Steri strips reinforced et applied to laceration on Right hand. Resident PAINAD score: 2. Call light within reach. On 3/1/2022 at 9:15 a.m., Residents right hand and fingers swollen, tender when touched. Resident flinches and hollers out in pain. Hand is bruised. Several lacerations noted on the pinky finger. On 3/1/22 at 9:35 a.m., This nurse called clinic. Appointment set up for 10:00 a.m., to have hand evaluated and possible x-rays. On 3/1/22 at 9:37 a.m., This nurse contacted residents son. Son was not aware of the fall that occurred on 2/28/22. This nurse advised son of the injuries. Son unable to transport resident to the appointment but would like to be updated on findings. Facility to transport. On 3/1/22 at 3:16 p.m., new orders received from clinic appointment for dressing change daily and to remove sutures in 10 days. On 3/3/22 at 10:06 a.m., Appointment made for fall follow-up with Dr. on 3/11/22 at 10:30 a.m. On 3/6/22 at 2:38 p.m., Fall F/U: VSS. Resident slept in this morning as she is usually a late riser. Neurological status intact. No ROM impairments per usual. Ambulates with a walker and supervision. No injuries noted due to most recent fall. Stitches to right hand mostly intact with 1 stitch missing. Skin is healing. Resident will not keep dressing in place. Resident is a pleasant mood today and cooperative with cares. On 3/9/22 at 2:31 a.m., Resident noted to be picking at right hand stitches, residents right hand is swollen, purple in color, no foul odor noted at this time. Resident educated on needing to not pull and or pick at stitches in hand due to high risk of infection. Review of the Skin Evaluation Weekly form documented on 3/7/22 at 2:21 a.m., no new findings at this time, skin is normal to ethnicity, Clear/Dry/Intact. Review of the Skin Evaluation Weekly form documented on 3/20/22 at 12:38 p.m.,Resident's skin is Clear/Dry/Intact with no new areas of concern noted. Review of the Skin Evaluation Weekly form documented on 3/27/22 at 11:45 a.m.,No current skin issues. In an interview on 9/19/22 at 2:45 p.m., the Corporate Nursing Consultant confirmed and verified the clinical record lacked any documentation of skin assessment being done after the fall on Resident #4, and that the expectation of the staff is to do a complete assessment and then to notify the family and the physician right after the fall and not the next day. The Nurse Consultant confirmed it has been an expectation to assess, measure, and document all new skin areas, and visualize at least every week. In an interview on 9/26/22 at 2:45 p.m., the facility Director of Nursing (DON) worked on 2/28/22 and was with the charge nurse when Resident #4 was on the floor. The DON explained the charge nurse was given direction on how to fill out the incident/accident report, make sure to notify the family and physician and to do skin sheets for the skin tears and lacerations on the resident right palm and little finger. The DON stated that when she came back to work on 3/1/22, the Incident/Accident Report was not completed and that the skin sheets were also not completed and the DON had to fill out all the forms and it is an expectation of the nurses to follow the policy and procedures to notify families, physician and to do an assessment on all skin areas and to fill out skin sheets and to do them weekly. On 9/26/22 at 4:00 p.m. the DON confirmed and verified that there are no neuro sheets for Resident #4 in her clinical record and it is an expectation that neuros be completed after an unwitnessed fall 2) According to the MDS assessment dated [DATE] Resident #5 scored 9 on the BIMS indicating moderate cognitive impairment. The resident required supervision with bed mobility, transfer, ambulation, dressing, eating, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan initiated 2/16/ 22 identified the resident had the potential for pressure ulcer development related to pain, dementia, and incontinence. Interventions included daily body checks, monitoring abrasion left outer wrist 4/7/22, abrasion to bridge of nose 4/1/22, abrasion to chin 4/7/22, abrasion to left 5th finger, abrasion to left side of forehead, abrasion to left orbital area, bruising to face 4/25/22, bruising left arm 4/25/22, bruising left leg 4/25/22, bruising right arm 4/25/22, bruising right leg 4/25/22, skin tear left elbow 4/1/22, skin tear left forearm 4/1/22, skin tear right elbow 4/1/22, and a weekly head to toe skin at risk assessment. The Progress Notes dated 3/31/22 at 7:25 p.m. noted the resident fell outside in the grass. A visitor witnessed the fall. They assessed the resident for injuries, and range of motion performed with no pain, he did have skin tears on the bridge of his nose. Vitals were within range, neuros started, and the Director of Nursing (DON), family and MD aware. The Progress Notes dated 4/2/22 at 10:48 p.m. documented at 7:30 p.m. a CNA made the charge nurse aware the resident was on the ground outside. Upon assessment, the resident exited the facility without his wheeled walker and fell on the cement. The door alarm alerted staff who then immediately checked the door and observed the resident on the ground outside. The resident laid face down with his bilateral upper extremities (BUE) at his side and bilateral lower extremities (BLE) extended out. They assessed the resident for indications of major injuries with no indication noted. The resident's vital signs were within normal limits, pupils equal and reactive to light. The resident alert and oriented to self, resident's baseline. The resident had abrasions to the left side of his face and left upper extremity (LUE). The Resident wore shoes. Staff assisted the resident off of the ground into his wheel chair with assist of two and a gait belt. The resident tolerated the activity well. The resident had the following new skin areas: 1) Left fifth digit abrasion 0.4 X 0.8 X 0.1 cm, 2) Left fifth digit knuckle abrasion 1.0 X 1.3 X 0.1 cm, 3) Left outer wrist abrasion 1.1 X 0.6 X 0.1 cm, 4) Left upper side of forehead/scalp abrasion 7.0 X 3.0 X 0.1 cm, 5) Left upper forehead abrasion 2.5 X 2.0 X 0.1 cm, 6) Left eyebrow abrasion 0.3 X 4.0 X 0.1 cm, 7) Left eye area abrasion 2.5 X 5.5 X 0.1 CM 0.1 X 2.0 X 0.1 cm, 9) Bridge of nose abrasion 1.5 X 2.5 X 0.1 cm, 10) Chin abrasion 1.0 X 2.0 X 0.1 cm. All areas were cleansed, patted dry, triple antibiotic (ATB) ointment applied, and covered with non adhesive dressing. Staff were educated to ensure the resident utilized his wheeled walker when ambulating. Staff verbalized understanding. A Weekly Skin Evaluation dated 4/2/22 contained the information in the Progress Notes after the fall. The clinical record lacked any additional assessment off the skin areas or neuro sheets for post fall assessment. A Weekly Skin Evaluation dated 4/19/22 indicated bruising to the residents face, bilateral arms and legs, and continued monitoring. The evaluation lacked any measuremets or descriptions of the skin impairments. On 9/26/22 at 1:15 p.m. the DON stated she could not find the neuro sheets or skin sheets for the injuries the resident had with the 4/2/22 fall. 3) According to the MDS assessment dated [DATE] Resident #12 scored 8 on the BIMS indicating moderate cognitive impairment. The resident required extensive assist with bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 3/7/22 documented the resident had an actual impairment to skin integrity related to fragile skin and falls. Interventions included keeping the skin clean and dry, using lotion on dry skin, monitoring skin tear to left arm, left leg, right arm, and right leg all dated 3/7/22, and providing skin treatments per the physician's order. The Progress Notes dated 4/5/22 documented at 5:25 a.m. a CNA reported the resident was on the floor in her bathroom. Upon assessment, the resident laid on top of her walker on her left side on the bathroom floor. The resident stated she attempted to go to the bathroom without assistance. The call light remained off. The resident had bare feet however did wear gripper socks that she removed herself while resting in bed. The call light was attached to her bed within her reach. They assessed the resident and she complained of left hip pain and stated she could not move. They placed a call and the resident transferred to the hospital. The resident had a laceration to the left side of her forehead and her left hand. A History and Physical dated 4/5/22 at 8:41 a.m. documented the resident came to the emergency room after a fall getting out of bed. The resident hit her head and face. When the resident arrived the nursing staff had to spend an extensive amount of time cleaning the resident up as she was covered in hard, dry stool. The staff at the nursing home stated they didn't know how long the resident laid on the floor. The resident seen originally by the Physicians Assistant and then the Physician. When the Physician received the resident she had already received 2 doses of intravenous [MEDICATION(S)] 25 mcg and quit comfortable. On arrival she complained of hip pain and had multiple skin tears just lateral to her left eye. The PA took care of the facial laceration with steri strips. The Progress Notes dated 4/5/22 at 12:25 p.m. documented the resident returned from the ER with new orders for antibiotic, ([MEDICATION(S)]) for infection. The resident had left side maxillofacial fractures and a suspected non displaced right sacral fracture. The clinical record lacked assessment of the residents skin injuries or the neuro assessments for a fall with hitting her head. The Assessment tab in Point Click Care (PCC) showed 1 Weekly Skin Evaluation done after the fall on 4/5/22. The assessment documented scattered bruises and skin tears on the residents body from recent falls with no measuments or assessment of the areas. On 9/26/22 at 5:10 p.m. the DON stated she could not find the neuro sheet for the 4/5/22 incident, or skin assessments.

Based on record review, facility policy, and family, physician and staff interviews, the facility failed to provide accurate assessment and timely intervention for all residents who had an onset of adverse symptoms which represent a change in mental, emotional, or physical condition for one of three residents reviewed (Resident #1). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] noted Resident #1 had [DIAGNOSES REDACTED]. The MDS noted people always understood Resident #1 and she always understood them. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated Resident #1 did not have any cognitive deficits. Resident #1 required extensive assistance of one or two staff members for activities of daily living (ADLs). The Care Plan initiated on [DATE] noted Resident #1 had a risk for falls related to history of having a stroke and medication use. The Care Plan instructed staff to anticipate the resident's needs and observe for injuries if she fell . According to the Care Plan, Resident #1 could call for assistance when in pain, ask for medication, say how much pain she experienced and say what increased her pain or relieved it. The facility Fall Guidelines instructed staff to assist with the immediate needs of the resident, call the family for notification of the incident and seek their approval for newly implemented interventions and call the physician for notification of the incident and immediate order changes that may be implemented. The (MONTH) 2007 revised Nursing Clinical Policy/Procedure related to Care of Residents in Emergency Situations noted the facility will provide appropriate and expedient care in emergency situations; which includes falls and abrupt changes in behavior of physical condition. Any changes in physical condition or behavior will warrant the following nursing observations and measures; which includes the initial assessment. Notification of Resident's family will be made to report any change in the Resident's condition. If an emergency situation arises: 1. Call the attending Physician. Fully explain the emergency giving a brief medical history of [REDACTED]. 2. If the attending Physician cannot be reached, the staff Physician or an alternative will assume responsibility or emergency treatment. 3. If hospitalization is necessary, obtain phone orders or written orders from a Physician to transfer the Resident to the hospital. 4. Call the responsible party. 5. Complete a transfer form and send it with the Resident. 6. Call the hospital and notify them of the transfer. A Nursing Note dated [DATE] at 1:35 a.m. noted the nurse's post fall neurological assessment of Resident #1. The nurse documented the resident as alert and oriented. The nurse administered as needed (PRN) Tylenol earlier for Resident #1's complaints of back pain. A Nursing Note dated [DATE] at 7:20 a.m. noted details related to an unwitnessed fall Resident #1 sustained on [DATE] at 8:58 p.m. According to the nurse, Resident #1's roommate came into the hall and hollered for help. The nurse noted staff found Resident #1 on the floor of the bathroom leaning against a wall. Resident #1 told the nurse she fell while self-transferring from her wheelchair to the toilet. A Daily Skilled Note dated [DATE] at 12:00 p.m. noted Resident #1 was lethargic, very sleepy and said she did not feel well; I feel foggy. Resident #1 complained of upset stomach and did not eat much. The nurse documented she administered PRN Tylenol because Resident #1 said she had back pain and rated it 9 out of 10. A Fax correspondence dated [DATE] notified Resident #1's physician of the resident's complaints of back pain since her [DATE] fall. The nurse informed the physician Resident #1 had been very sleepy, had not eaten her meals and refused all morning medications. The physician ordered [MEDICATION NAME] (pain medication) 50 milligrams every 6 hours for severe pain. A Nursing Note dated [DATE] at 3:14 p.m. noted a post fall follow up assessment that revealed Resident #1 complained of back pain. A Medication Administration Note dated [DATE] at 5:03 p.m. noted administration of PRN Tylenol had been ineffective. Resident #1 still rated her pain as 9 out of 10. A Nursing Note dated [DATE] at 5:13 p.m. noted Resident #1's physician said to continue monitoring the resident after the nurse informed him the resident said she still did not feel well. A Nursing Note dated [DATE] at 6:00 p.m. noted a Case Manager from a hospital called to inform the facility the resident's wound cultures tested positive and the Dr. ordered intravenous (IV) antibiotics to be administered. Once the nurse learned of an allergy alert related to the antibiotic, she attempted to contact the prescribing physician. Because that Dr. could not be reached, the nurse contacted Resident #1's primary physician who ordered staff to transfer Resident #1 to the hospital with increased lethargy and minimal oral intake throughout the day. Resident #1 stated she did not feel well. Chest X-ray results dated [DATE] at 7:30 p.m. documented Resident #1 had a mildly enlarged heart accentuated by low lung volumes and the absence of part of her left clavicle (collar bone). The emergency room (ER) Record dated [DATE] at 9:24 p.m. noted the history of Resident #1's present illness. The Record noted Resident #1 had recently been seen for a [MEDICAL CONDITION]. They drew blood at that time, which tested positive. They drew a subsequent blood culture. Another positive result confirmed the initial result; resident required antibiotic therapy. Due to weakness and fever, Resident #1 presented to ER for further treatment. Further testing revealed Resident #1's chest x-ray negative, but urinalysis grossly positive for a urinary tract infection. They implemented antibiotic therapy, but could not reach Resident #1's primary care Provider for input. Resident discharged back to nursing home on antibiotic therapy. The ER's Diagnostic Impression revealed: Acute urinary tract infection and acute positive blood cultures with a [MEDICAL CONDITION]. The ER Record lacked any information related to Resident #1's complaints of pain associated with the [DATE] fall. A Nursing Note dated [DATE] at 11:55 p.m. noted Resident #1 returned to the facility. A Weekly Skilled Review dated [DATE] at 1:05 p.m. noted Barriers to Safe and Effective Discharge included Resident #1 felt unwell and experienced back pain related to a recent fall. A Medication Administration Note dated [DATE] at 2:30 p.m. noted staff administered [MEDICATION NAME] 50 mg severe pain. A Nursing Note dated [DATE] at 5:07 p.m. noted Resident #1 reported she felt nauseated. The nurse notified the Dr. and requested orders via fax. A Daily Skilled Note dated [DATE] at 7:00 p.m. noted Resident #1's anxiety and documented she remained in bed during the shift. The nurse documented she administered PRN medication because Resident #1 continued to complain of post fall back pain rated 10 out of 10. The nurse documented Resident #1 could make her needs known. A Nursing Note dated [DATE] at 9:00 p.m. noted the nurse contacted the on-call provider, who prescribed medication for Resident #1's complaints of nausea and vomiting. At 10:00 p.m., the nurse contacted the on-call provider, and received an order for [REDACTED]. A Daily Skilled Note dated [DATE] at 11:07 a.m. noted Resident #1 received [MEDICATION NAME] for sharp back pain, rated 10 out of 10. At 8:23 p.m., Resident #1's blood pressure reading was ,[DATE]. The resident was lethargic, short of breath and hyperventilated due to being very anxious at times. The nurse encouraged Resident #1 to take deep breaths. The nurse administered PRN pain medication for Resident #1's aching, cramping back pain. A Daily Skilled Note dated [DATE] at 9:40 a.m. noted Resident #1 as being lethargic, quieter, and more tired and withdrawn than unusual. The nurse administered medication due to Resident #1's complaints of nausea and lower back pain. A Medication Administration Note dated [DATE] at 9:51 p.m. documented staff gave Resident #1 PRN IM medication for nausea. A Medication Administration Note dated [DATE] at 9:53 a.m. documented staff gave Resident #1 PRN [MEDICATION NAME] for severe back pain. A Medication Administration Note dated [DATE] at 11:12 a.m. noted Resident #1 received PRN [MEDICATION NAME] for severe kidney pain. A Nursing Note dated [DATE] at 5:34 p.m. documented a CNA notified the nurse Resident #1 started shaking at the table. The nurse documented someone mentioned Resident #1 did it for attention and then stopped. Staff took the resident's vital signs, which were normal. The nurse documented she would continue to monitor Resident #1 for behaviors. A Medication Administration Note dated [DATE] at 8:37 p.m. noted Resident #1 received PRN [MEDICATION NAME] for severe back pain. A Daily Skilled Note dated [DATE] at 9:34 p.m. noted Resident #1 complained of back pain but voiced no other complaints. The nurse documented Resident #1 could make her needs known. A Medication Administration Note dated [DATE] at 5:42 a.m. noted Resident #1 received PRN medication for nausea. A Daily Skilled Note dated [DATE] at 12:45 p.m. documented Resident #1's blood pressure was ,[DATE] with a temperature of 96.3 F. Resident #1 was depressed and more withdrawn during the shift. A Medication Administration Note dated [DATE] at 2:54 p.m. noted Resident #1 received PRN [MEDICATION NAME] for severe pain. An MDS Note dated [DATE] at 8:23 p.m. noted Resident #1 reported frequent pain in the past 5 days, as high as 8 out of 10. The resident stated the pain interrupted her sleep and limited day-to-day activities. A Daily Skilled Note dated [DATE] at 3:13 p.m. showed Resident #1 cried and argued with staff during the shift. The nurse gave her medication for nausea and vomiting and documented Resident #1 could make her needs known. An MDS Note dated [DATE] at 1:32 p.m. noted Resident #1 reported frequent pain in the past 5 days, as high as 8 out of 10, which interrupted her sleep and limited day to day activities. A Medication Administration Note dated [DATE] at 5:21 p.m. documented staff gave Resident #1 PRN [MEDICATION NAME] for severe pain. A Daily Skilled Note dated [DATE] at 9:48 p.m. documented Resident #1's temperature as 94.6 F. The Nurse noted Resident #1 yelled, called staff names, refused medication and kicked them out of her room. A Nursing Note dated [DATE] at 4:38 a.m. documented Resident #1 had been awake on and off during the shift and complained of occasional pain to the right kidney area. A Medication Administration Note dated [DATE] at 6:51 a.m. noted Resident #1 received PRN [MEDICATION NAME] for severe pain. A Daily Skilled Note dated [DATE] at 10:40 a.m. documented Resident #1 as depressed and rude and noted she yelled and cried at staff. The nurse gave PRN pain medication for sharp back pain rated 10 of 10. A Medication Administration Note dated [DATE] at 2:06 p.m. documented staff gave Resident #1 PRN [MEDICATION NAME] for severe pain. A Nursing Note dated [DATE] at 2:12 p.m. documented Resident #1 yelled you don't do anything for me and you don't care at the nurse. The nurse offered PRN [MEDICATION NAME] for the Resident's complaint of pain. Resident #1 yelled even louder that the medication did not help. A Medication Administration Note dated [DATE] at 4:49 p.m. noted Resident #1 received PRN Tylenol for pain. At 6:47 p.m. documented the PRN [MEDICATION NAME] as ineffective and resident still rated lower back pain at 7 out of 10. At 8:47 p.m. staff documented the PRN Tylenol Resident #1 received was ineffective and she still rated her pain 7 out of 10. A Daily Skilled Note dated [DATE] at 9:07 p.m. noted Resident #1 hollered and moaned as she laid in bed while staff attempted to talk to her. Resident #1 hollered and whimpered, 'my kidneys hurt' when they tried to move her. The Nurse gave the resident cranberry juice. According to the note, Resident #1 hyperventilated when she got herself worked up. The Nurse administered PRN pain medication for Resident #1's complaint of lower back pain she rated 7 out of 10. According to a Nursing Note dated [DATE] at 1:16 a.m., staff administered the Resident PRN Tylenol because she complained of lower back pain again. A Medication Administration Note dated [DATE] at 3:30 a.m. noted Resident #1 received PRN [MEDICATION NAME] for severe pain as she hollered and cried with movement. A Medication Administration Note dated [DATE] at 7:08 a.m. noted that the PRN Tylenol Resident #1 received was ineffective as she still rated her pain 6 out of 10 with movement. Fax correspondence to Resident #1's Physician dated [DATE] noted the resident still complained of severe lower right back pain that radiated to the front that she described as sharp and fast at times and throbbing continuously at other times. The nurse informed the Dr. the PRN [MEDICATION NAME] and Tylenol only provided slight relief and the resident stated it did not really help. The resident also said she fell on [DATE]. Resident #1 went to ER at that time, but returned to the facility without any new orders. Resident #1 continued working with therapy related to a left heel ulcer. The fax documented the resident asked staff to notify the physician of her symptoms and requested further treatment for [REDACTED].#1's back pain. A Medication Administration Note dated [DATE] at 5:30 p.m. noted that Resident #1 received PRN [MEDICATION NAME] for severe back pain. A Daily Skilled Note dated [DATE] at 9:42 p.m. noted Resident #1 got very anxious, restless and hollered continuously with movement and also when other people were in the room. Staff sent a fax to the doctor because the resident still complained about lower left back pain that radiated to the front. A Medication Administration Note dated [DATE] at 11:49 a.m. documented staff gave Resident #1 PRN [MEDICATION NAME] for severe back pain. A Nursing Note dated [DATE] at 1:53 p.m. noted the Physician ordered PT via return fax. A Daily Skilled Note dated [DATE] at 8:00 p.m. noted Resident #1 continued to complain of back and side pain. A Daily Skilled Note dated [DATE] at 10:30 a.m. noted Resident #1 had pale skin and became rude towards staff and anxious about seeing the doctor at 2:15 p.m. for pain. The nurse administered pain medication to the resident for the sharp back pain she rated 10 out of 10. A Medication Administration Note dated [DATE] at 2:33 p.m. documented the PRN [MEDICATION NAME] Resident #1 staff gave was ineffective because she still rated her pain 10 out of 10. A Healthcare Clinic Note dated [DATE] at 2:23 p.m. noted the Physician's encounter with Resident #1. The doctor noted the resident presented with complaints of lower back pain she described as intermittent shooting pain in the lower back that goes to the right side. Resident #1 said it hurt worse with movement and she now required assistance of 2 people for transfers. The resident rated her pain 10 out of 10 and said [MEDICATION NAME] and Tylenol did not help. The Physician noted the Nursing Home sent a fax on [DATE]; at which time he ordered PT for her back pain. The Physician noted his Assessment and Plan: 1. Right gluteal (buttocks) pain that appears to be secondary to muscular strain. Official films are pending. 2. [MEDICATION NAME]. 3. Tylenol. 4. [MEDICATION NAME] (local anesthetic) patch. 5. PT. 6. Return to care for any worsening or failure to improve. X-ray results dated [DATE] of the right hip and lumbar (lower) spine both proved negative for fracture. A Daily Skilled Note dated [DATE] at 9:55 p.m. noted Resident #1 received PRN pain medication because she continued to complain of a dull, achy back pain rated 10 out of 10. A Daily Skilled Note dated [DATE] at 1:57 p.m. documented Resident #1's temperature at 95.9 F. The resident became anxious and rude towards staff regarding her pain. The nurse administered pain medication for the sharp back pain Resident #1 rated 10 out of 10. A Medication Administration Note dated [DATE] at 4:31 p.m. noted the PRN [MEDICATION NAME] Resident #1 received was ineffective as she still rated her pain 10 out of 10. A Nursing Note dated [DATE] at 4:52 p.m. documented Resident #1 continued to have behaviors. Resident #1 continued to express concerns about staff and treated them rudely. A Daily Skilled Note dated [DATE] at 10:44 p.m. noted Resident #1 frequently became upset and anxious toward staff. Resident #1 described her pain as sharp and rated it 7 out of 10. A Medication Administration Note dated [DATE] at 2:34 a.m. documented PRN [MEDICATION NAME] as ineffective resident continued to rate her pain at 10 out of 10. The resident told the nurse it doesn't help, it didn't work. A Daily Skilled Note dated [DATE] at 10:13 a.m. noted Resident #1's blood pressure was ,[DATE] and her temperature was 96.8 F. Resident #1 requested staff to transfer her with the EZ Stand (mechanical sit to stand machine) due to back pain. The resident complained of shortness of breath and received pain medication for her complaints of sharp back pain rated 10 out of 10. A Nursing Note dated [DATE] at 2:51 a.m. noted Resident #1 received PRN pain medication for complaints of right lower back pain. The resident moaned with movement and hollered at staff. A Daily Skilled Note dated [DATE] at 10:43 a.m. noted Resident #1's blood pressure was ,[DATE] and her temperature as 96.8 F. At 10:46 p.m. Resident #1's refused to let the nurse take her vital signs. The resident told the nurse she wanted to go to the ER for back pain and referred to the doctor as a quack. Resident #1 told the nurse she believed that nobody believed she was in pain. A Daily Skilled Note dated [DATE] at 8:32 p.m. noted Resident #1 moaned with staff in the room but stopped when they exited. Resident #1 told the nurse PRN [MEDICATION NAME] did not help her pain and requested to be seen by the rounding doctor. Resident #1 rated her right lower back to side pain as 8 out of 10. A Medication Administration Note dated [DATE] at 8:52 p.m. noted the PRN [MEDICATION NAME] Resident #1 received was ineffective as she still rated her pain 6 out of 10. The resident told the nurse the pain never goes away. At 10:06 p.m. noted Resident #1 received PRN [MEDICATION NAME] earlier for lower right back pain but continued to moan and complain when staff are in her room. A Nursing Note dated [DATE] at 2:51 a.m. noted Resident #1 still complained of lower right back pain and continued to moan with movement. A Daily Skilled Note dated [DATE] at 1:06 p.m. noted Resident #1 moaned and cried when staff entered her room and told them she was in pain. Resident #1's moans and cries stopped when they left her room. The Nurse documented she applied PRN topical pain ointment and administered PRN [MEDICATION NAME] for the sharp back pain the Resident rated 10 out of 10. An untitled document dated [DATE] at 10:46 a.m. noted Resident #1's primary Physician's assessment of the resident. His subjective findings: Resident #1 complained of pain with movement; despite being treated with a [MEDICATION NAME], Tylenol and [MEDICATION NAME]. The Dr. noted Resident #1 worked with PT for her left heel diabetic ulcer. His objective findings: Resident's hips non-tender with range of motion. The lumbar spine revealed moderate tenderness, but her primary pain was located along the right SI joint (between the hip and tailbone). The physician noted he injected the area with a steroid and anesthetic mixture; which provided some improvement of her pain. The physician's plan included Tylenol 650 mg three times a day (TID) and every 4 hours as needed and a heating pad for ½ hour TID. He instructed the facility to call or return sooner if there were any problems. A Daily Skilled Note dated [DATE] at 1:48 p.m. documented Resident #1's temperature measured 96.8 F. The note also showed Resident #1 became anxious at times while in pain, cried in the dining room during lunch because of her pain, and rated her pain as 10 out of 10. A Daily Skilled Note dated [DATE] at 2:30 p.m. noted Resident #1's temperature was 96.4 F. The nurse documented Resident #1 continued to complain of chronic back pain rated 10 out of 10. A Nursing Note dated [DATE] at 9:46 a.m. documented Resident #1 had tons of behaviors that morning. After screaming at the nurse that she wanted a doctor to come and see her, Resident #1 became very upset when the nurse told her the doctor would not be coming into the nursing home on a Saturday. A Daily Skilled Note dated [DATE] at 1:19 a.m. noted Resident #1 refused to allow staff to assist to get ready for bed. Resident #1 called her sister. The nurse spoke to the resident's Mother and sister. The resident rated her back and side pain 10 out of 10. A Daily Skilled Note dated [DATE] at 10:32 a.m. noted Resident #1 could make her needs known and rated her sharp back and side pain 10 out of 10. A Daily Skilled Note dated [DATE] at 8:05 a.m. noted Resident #1 could make her needs known and rated her back and side pain 8 out of 10. A Nursing Note dated [DATE] at 1:49 a.m. noted Resident #1 became upset and said nobody takes me seriously; nobody cares about me. The Nurse applied topical ointment and administered [MEDICATION NAME] for the resident's complaints of back and side pain. When asked if she would like to be repositioned, Resident #1 said she did not want to be touched, she either wanted 911 to be called or to be taken to ER. The nurse suggested they wait for the pain pill to kick in to see how she felt. The resident repeated nobody cared and everyone ignored her. A Nursing Note dated [DATE] at 7:21 a.m. noted Resident #1 got up at 6:15 a.m. and complained of pain so severe she needed to go to the hospital. The resident refused to let anyone touch her saying nobody cared about her. When the nurse inquired about her pain, Resident #1 yelled I've already told you stupid people; I won't say it again because you people don't give a damn about me. The resident was inconsolable. The nurse called the resident's sister. The nurse noted the resident's sister did not want to send her to ER at that time; she would come and speak to Resident #1. A Medication Administration Note dated [DATE] at 10:38 a.m. noted Resident #1 said I have sharp shooting pain in my upper back. A Daily Skilled Note dated [DATE] at 10:54 a.m. noted Resident #1 complained of shooting back pain and her family demonstrated concern for the resident. A phone call placed to the on-call ER physician who felt it was necessary for the resident to be further evaluated. Resident #1 was transported to ER via ambulance at 11:44 a.m. The computed tomography scan (CT) results dated [DATE] of the [MEDICATION NAME] (middle to upper) spine revealed acute fractures of T9 and T10 ([MEDICATION NAME] vertebrae). The ER Record dated [DATE] at 10:08 p.m. revealed Resident #1 presented with mid back pain. The author noted the resident reported she fell about 3 weeks prior. According to the resident, they x-rayed her lumbar spine and pelvis; which proved to be unremarkable. The resident also said her pain continued and had been getting worse. Resident #1 received [MEDICATION NAME] (narcotic pain medication) 100 mcg IV; which reduced her pain to 4 out of 10 on the pain scale. The author's note revealed the Hospitalist accepted Resident #1 for further evaluation and treatment. The assessment showed the resident had a compression fracture of T9 and T10 and leukocytosis (elevated white blood cell count; often an indicator of infection). The Hospitalist Consultation dated [DATE] noted the Physician's Plan for Resident #1's [DIAGNOSES REDACTED]. The Physician recommended bed rest until they could acquire a particular brace, which he wanted the resident to wear at all times when she was upright. The Physician also recommended a [MEDICATION NAME] MRI (imaging) to evaluate her for discitis/osteo[DIAGNOSES REDACTED] (infection in the spine; bone and spaces). The Physician recommended antibiotic therapy and external stabilization with the brace for at least 2 months. The details of the Consult documented Resident #1 being transferred to their hospital for management of severe back pain in the setting of possible fracture. As reported by the resident, she fell while ambulating in her nursing home several weeks ago. Since that time, she has had severe and progressive pain involving the mid position of her back, which caused her to be less ambulatory (referring to the resident's ability to walk). The Physician noted CT results obtained at an outside hospital demonstrated changes at the T9 and T10 level. The Physician also noted several positive blood cultures were grown overnight. An Infectious Disease Consultation dated [DATE] documented positive bacteremia and an infected left heel wound led to the consultation. According to the record, Resident #1 received antibiotic therapy for 2 weeks after being diagnosed while in the hospital with bacteremia on [DATE]. The record revealed Resident #1 fell in the nursing home about 3 weeks prior and developed mid back pain, which she said persistently got worse. The resident rated that pain 15 out of 10. A CT obtained at an outside facility revealed abnormalities at T9 and T10 with concern for infection. The outside facility also obtained blood cultures which were positive for bacteria. The consult documented Resident #1 had a chronic, non-healing left heel wound and with a concern for osteo[DIAGNOSES REDACTED] and antibiotic therapy initiated. MRI results dated [DATE] showed abnormal swelling in the T9 and T10 vertebrae with erosions along the endplates of the T9-T10 disc; findings consistent with T9-T10 discitis and vertebral inflammation and adjacent osteo[DIAGNOSES REDACTED]. The Certificate of Death documented Resident #1 died on [DATE] at 3:10 p.m. of [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] of the [MEDICATION NAME] region and discitis of the [MEDICATION NAME] region. The Discharge Summary dated [DATE] noted the hospital course began on [DATE] upon admission and ended on [DATE] at the time of death. It documented back pain as reason for the visit and indicated the resident was delirious on admit. The resident fell 3 weeks prior and a hip x-ray and pelvic x-ray were negative for fracture, and was sent for progressive confusion and increased pain. They placed Resident #1 on bed rest and recommended a brace. Laboratory findings caused concern for osteo[DIAGNOSES REDACTED], which an MRI confirmed as positive. Resident #1 began antibiotic therapy, but her hospital course became complicated by [MEDICAL CONDITION]. Although neurology followed her, her mental status did not improve. They believed recurrent aspiration caused her deterioration, which led to a palliative care consult during hospitalization . Family opted for comfort care on [DATE] due to increased shortness of breath and non-response to [MEDICATION NAME] (diuretic) therapy. Because they deemed Resident #1 as too unstable to transfer, staff kept her comfortable in the hospital, where she died . An interview on [DATE] at 2:10 p.m. with Staff D, CNA revealed Resident #1 had a lot of pain some days. Staff D said the resident said her back hurt. Prior to the fall, Staff D said Resident #1 complained about non-specific generalized pain. According to Staff D, Resident #1 complained of pain more frequently after the fall; specifically back pain. Staff D reported before the fall, one person could transfer Resident #1 with either a walker or an EZ stand. The CNA said they had to use the EZ stand after the fall when the resident's pain was bad. Staff D stated Resident #1 moaned and complained of pain when they were nearby. The CNA said she could hear Resident #1 stop moaning when she thought they could not hear her; while telling her roommate they think I'm faking. Staff D said they did not discount the resident's complaints, although she had a history of [REDACTED]. An interview on [DATE] at 2:45 p.m. with Staff E, CNA revealed she knew Resident #1 fell because she heard about it in report the morning following the event. Staff [NAME] said Resident #1 had quite a bit of lower back pain; she went from being able to help them during transfers to not being able to do much. Staff [NAME] thought the resident had given gave up, probably due to the pain. Staff [NAME] recalled how Resident #1 had non-specific generalized pain before the fall and Staff [NAME] wondered if Resident #1 faked her pain sometimes. She recalled a time when Resident #1 came around when she called the resident's name during a [MEDICAL CONDITION] she was supposedly having. Staff [NAME] said she questioned how legitimate her complaints were after that because she had heard Resident #1's moaning stop once she left the room. Staff [NAME] stated Resident #1 did not always fake it, she believed she had back pain after the fall, and they finally realized Resident #1 actually had some fractured vertebrae. An interview on [DATE] at 9:50 a.m. with Staff B, CNA revealed she knew Resident #1 had a fall that led to her decline. Staff B said Resident #1 had a lot of post fall back pain. She said she knew because Resident #1 yelled, moaned, and verbalized it very loudly. The CNA said I'm torn between believing whether she was in pain or not because of the noticeable difference in how she acted when her family was here. Staff B recalled before the fall, Resident #1 typically rose around 6:30 a.m. prior to the fall, but gradually wanted to stay in bed longer or not get up at all after the fall. Staff B reported they had to use the EZ Stand for transfers at times before the fall, but Resident #1 no longer participated in transferring and required EZ stand transfer with assist of 2 staff after the fall. An interview on [DATE] at 10:10 p.m. with Staff C, CNA revealed she knew Resident #1 fell . Staff C said Resident #1 began to complain about side pain a couple days after she fell , and complained of back pain about a week later. According to the CNA, her pain got pretty severe; Resident #1 hollered quite a bit and started screaming in the middle of the night. According to Staff C, it seemed like Resident #1 cried more when her family visited and had a history of [REDACTED].#1 had pain, but wondered about the severity based on the way she acted when family visited. Staff C reported the had started to scream about 20 minutes after a nurse gave her something. An interview on [DATE] at 3:45 p.m. with Staff A, LPN, revealed Resident #1 complained of back pain after her fall; varying between her upper back, lower back and her side. The LPN said she notified the doctor a couple of times. An interview on [DATE] at 7:50 a.m. with the Assistant Director of Nursing (ADON) revealed she called the on-call physician on [DATE] to inquire about sending Resident #1 to ER to obtain x-rays due to complaints of post fall back pain. The Physician prescribed [MEDICATION NAME] IM instead of sending her for x-rays. The ADON said she not only was surprised that he wanted to try [MEDICATION NAME] for pain relief; but also surprised that he wanted to try that instead of sending her for x-rays because of her recent fall. When asked about a Nurse's Note on [DATE] where she recorded Resident #1's temperature of 96.2 F with complaints of pain, the ADON said she did not contact the doctor. She believed they addressed the resident's fall issues with the physician on multiple occasions; but did not make any headway in getting them addressed. The ADON said they have discretion to send residents to ER without a physician's orders [REDACTED].#1 faked her pain at times because she be

Based on observation, record review and staff interviews, the facility failed to prevent the development of heel pressure sores and failed to promote healing with timely dietary intervention (Resident #1). The facility reported a census of 47 residents and the sample consisted of 4 residents with pressure ulcers. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Ulcer: inability to see the wound bed. 1. Resident #1 had an initial MDS (Minimum Data Set) assessment with a reference date of 6/9/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 identified the resident had a severe cognitive impairment. The MDS identified the resident required extensive assistance of 2 or more staff members for bed mobility and transfers. The resident did not walk in the corridor and only walked in room once or twice with the assist of 2 or more staff. The MDS identified the resident to be at risk for pressure ulcers and had no pressure, [MEDICAL CONDITION] or venous ulcers at this time. The resident only had a pressure reducing device in the chair. The Care Plan, initiated on 6/1/17, identified the resident had the potential/actual impairment of skin integrity regards to decreased mobility and the need for assistance with activities of daily living. The interventions directed the staff to assist the resident with repositioning as needed (6/2/17), apply [MEDICATION NAME] to buttocks twice a day (6/2/17), encourage good nutrition and hydration in order to promote healthier skin (6/1/17), apply pressure reducing mattress on bed (6/1/17), observe skin with cares (6/2/17), use caution during transfers and bed mobility to prevent striking arms, legs, and hands against sharp or hard surfaces and use assistive devices for bed mobility (6/1/17). The Care Plan indicated the resident used a wheelchair for mobility. A quarterly MDS assessment with reference date of 10/24/2017, indicated the resident still required extensive assist of 2 staff for bed mobility. The resident walked in the corridor and in room once or twice with the assistance of 2 staff members. The MDS identified active [DIAGNOSES REDACTED]. A Braden Scale (for predicting pressure sore risk) dated 10/23/2017, identified a score of 17. A score of 17 represented a mild risk for the development of pressures. The document titled LN-Skin Pressure Ulcer Weekly dated 6/21/17 identified the development of a right heel ulcer that measured 2 cm (centimeters) by 1 cm. on 6/19/17. A cushion placed on the resident's bed to float the heels off the bed. The left heel measured 3 cm by 5 cm, appeared dark purplish, soft and tender to touch. A Treatment Administration Record (TAR) dated 6/19/17-8/23/17 identified the treatment as to apply [MEDICATION NAME] to bilateral heels BID (twice daily) until healed. The physician clinic note dated 6/20/17, identified the resident had pressure points on his heels and the physician recommended he wear a soft slipper when he tries to be mobile in a wheelchair. The resident had been using his heels (to propel). The Care Plan indicated the following interventions following the development of the pressure ulcers: Monitor areas to right and left heel (6/19/17). A nurse sent a fax to the physician about a concern with applying [MEDICATION NAME] twice a day since 6/19/17 and the wound needed debrided. The nurse asked if physical therapy could evaluate and treat. The physician gave approval with an order on 7/28/17. The therapy note dated 7/31/17 identified the resident had 75-100 percent wound bed covered on the right heel and 100 percent coverage on the left heel. On 9/26/17, the physician ordered heel lift boots on each foot at all times (to suspend the heels and promote healing). A physician phone order dated 9/11/17 directed staff to give [MEDICATION NAME] packet (nutritional supplement) 1 packet by mouth 3 times a day for wound healing related to the pressure ulcer of the right heel and left heel. The skin Committee IDT notes dated 6/23/17 identified both heels reveal pressure type areas. The left (heel area) measured 3 cm by 5 cm and the right heel measured 2 cm by 1cm. The nurse notified the PCP (Primary Care Physician) and family and treatment begun. The nurse updated the Care Plan. The Weekly Wound Documentation form dated 6/21/17 indicated the right heel as a dark purple area and measured 2 cm by 1 cm. A cushion on the bed to float heels and [MEDICATION NAME] applied to the dark purple area. The left heel identified as dark purple to outer edge and measured 2 cm by 2.5 cm. A cushion was placed on the resident's bed to float heels off bed and [MEDICATION NAME] applied to the dark purple area. The Weekly Wound Documentation form dated 6/28/17 identified the right heel s dark purple area measured 2.5 cm by 1.4 cm. Float heels, cleanse with wound cleaner and paint with [MEDICATION NAME]. The left heel measured 4.6 cm by 3.0 cm. Cleanse with wound cleaner and apply [MEDICATION NAME] The skin Committee IDT notes dated 6/30/17 identified the bilateral heels showed unstageable ulcers. The left measured 4.6 by 3.0 and the right measured 2.5 by 1.4 cm, both are treated with [MEDICATION NAME] paint to keep dry. No c/o (complaints of) pain with palpation The Weekly Wound Documentation form dated 7/5/17 identified the right heel as dark black/brown hard skin area that measured 2.6 cm by 2.1 cm. Cleanse with wound wash, paint with [MEDICATION NAME], float heels. The left heel, dark black/brown hard skin, measured 4.6 cm by 3.6 cm and cleanse with wound wash, paint with [MEDICATION NAME]. The skin Committee IDT notes dated 7/7/17 reviewed Weekly Wound Documentation form and no recommendations added. The Weekly Wound Documentation form dated 7/12/17 indicated the right heel blackish brown area measured 2 cm by 2.5 cm. [MEDICATION NAME] and monitor. The left heel dark blackish brown measured 3.5 cm by 3.5 cm. Apply [MEDICATION NAME] and monitor. The Weekly Wound Documentation form dated 7/19/17 indicated the right heel blackish brown area measured 2 cm by 1.5 cm, [MEDICATION NAME] and monitor, left heel dark blackish brown measured 3 cm by 3 cm, Apply [MEDICATION NAME] and monitor. The skin Committee IDT notes dated 7/21/17 reviewed the Weekly Wound Documentation form and added no recommendations. The Weekly Wound Documentation form dated 7/26/17 identified the outer right heel as blackish brown area measured 2.6 cm by 1.6 cm. [MEDICATION NAME] treatment and float heels off bed, outer left heel blackish brown measured 3.2 cm by 6 cm. [MEDICATION NAME] treatment and float heels off bed. The skin Committee IDT notes dated 7/28/17 reviewed weekly wound documentation form, added recommendation to possibly get PT (Physical Therapy) involved for debridement A fax to the physician dated 7/28/17 identified the resident had a pressure ulcer to both outer heels. The staff had been applying [MEDICATION NAME] twice a day since 6/19/17 and areas are dry and need debrided. The nurse requested an order for [REDACTED]. The AMT wound nurse at the facility on 11/15/17 at 2:00 PM documented the following assessment included: Left heel: partial thickness, pressure ulcer stage II, size 2.4 by 1.8 with depth 0.2 cm. Serosanguineous drainage. Periwound/wound edges: periwound tissues: intact/uninvolved tissues flush with wound base. Wound edges/margins: Edge [MEDICATION NAME] flush with wound base. Clinical Rational/Wound Comments: Antimicrobial wound get to contribute moisture to the wound and to provide sustained antimicrobial action to wound. Collagen to promote angiogenesis and support healing. Semipermeable cover to sustain moist wound environment to promote autolysis and moist wound healing. Daily dressing changes are needed due to dressing becomes dislodged within 24 hours due to repositioning. Heel right lateral: Full thickness pressure ulcer Stage III, size 0.7 by 0.5, depth 0.2 cm wound bed-red 75%, pale pink/red; Hypogranulation tissue; yellow 25%, Adherent [MEDICATION NAME] slough Periwound/wound Edges: Periwound tissues; Intact/Uninvolved tissues flush with wound base. Wound edges/Margins; Irregular wound edges; additional periwound wound Edges comments; dry, tan/brown ridged wound edge. Clinical rationale/Wound Comments: collagen to promote angiogenesis and support healing. Calcium alginate AG to manage exudate and provide sustained antimicrobial action to wound. Semipermeable dressing to sustain moister wound environment to promote autolysis and moist wound healing. Daily dressing changes are needed. Treatment Intervention: Cleanse Right later heel wound with NS (Normal Saline), Apply collagen powder, then calcium alginate AG. Cover with absorptive dressing. Change dressing daily. An interview on 11/15/17 at 1:00 PM, the Clinical Resource Nurse clarified the wound documentation for 10/29, 11/5 and 11/13 has been corrected and should have read heels not ankles. An observation on 11/14/2017 at 7:40 AM revealed Resident #1 used a call light to request to get out of bed. Staff A, RN (Registered Nurse) arrived to give the resident morning medication. A lift pillow noted in recliner. Staff A confirmed the lift pillow should be placed in the bed too when the resident laid in bed. Staff A then left the room without placing the lift pillow under Resident #1's legs to float the heels. An observation of the pressure ulcers treatment on 11/15/2017 at 1:30 PM with Staff A, RN and Staff B LPN, (License Practical Nurse) revealed the left heel area clean, no signs and symptoms of infection and edges healing around the wound bed. Area is a straight open area with no active bleeding or drainage. The right heel, healing and area open with pink center and maturation (caused from moisture) around edges. Resident #1 skin coloring on legs from knee to feet appeared normal coloring with left foot slightly [MEDICAL CONDITION] (swollen with fluid in tissue). During an interview on 7/14/17 at 2:20 PM Staff B was not aware of any policy or protocol for requesting dietary interventions when a wound has been noted. Staff B stated the nurse needs to notify the physician, get a treatment and notify the family. Staff B stated she was not aware of who or when the dietary would be notified. During an interview on 7/14/17 at 4:20 PM the Clinical Leader stated upon reviewing the papers requested, it was noted the dietician was not notified until 9/11/17. The Leader placed a call to the dietician immediately. During a phone interview on 7/15 at 1:17 PM the AMT Wound Nurse C, stated they are here to educate and make recommendations on treatments for wounds. The recommended treatments must be approved by the physician. The wound nurse does not assess or [DIAGNOSES REDACTED]. An observation on 11/15/2017 at 2:00 PM, the DON (Director of Nursing) pulled back the dressing on Resident #1's left heel. AMT wound Nurse D looked at the ulcer and commented the area is improved and the edges were clean. The DON changed gloves and proceeded to pull back the dressing on the right heel. The Wound Nurse D looked at the ulcer and commented 2 dark callous looking areas on bottom of the wound edge in corners and the top wound edge area showed maturation, but healing nicely. The Wound Nurse D reviewed the facility documentation of the ulcers and relied on this for measurements. Wound Nurse D, confirmed skin normal color from knee to feet, and this helps increase the healing process.

Based on record review and interviews with physician, staff and the resident, the facility failed to promptly assess and provide timely interventions when a significant change of skin condition with pain occurred (Resident #4). The sample consisted of 4 residents and the facility reported a census of 45 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/20/16 with [DIAGNOSES REDACTED]. The resident scored a 15 on a BIMS (Brief Interview for Mental Status) evaluation which indicated no cognitive impairment. The MDS indicated Resident #4 required extensive assistance of two or more staff for bed mobility, transfer, and toilet use. The resident required extensive assistance of one staff for hygiene. Resident #4 used a wheelchair for mobility. The Care Plan updated 7/19/13, updated 10/18/16 identified a problem of pain related to arthritis and [MEDICAL CONDITION] change to knee. An intervention initiated 9/20/16 and resolved 10/6/16 reflected the resident's acceptable level of pain as 8. An intervention initiated 7/19/13 and resolved 10/18/16, reflected the resident as able to call for assistance when in pain, reposition self, request medication, report pain level and report what increases/alleviates pain. The Care Plan initiated 7/11/14 identified a problem of self-care performance deficit related to [MEDICAL CONDITION], pain and weakness. Interventions dated 1/14/15 directed staff to use an EZ Stand for transfers. On 12/7/16 at 12:27 p.m. during observation of transfer and incontinent cares observation revealed two Band-Aid like dressings near Resident #4's right knee. Resident #4 stated therapy put a thing on it, walked away and forgot it. It burned my leg and it hurt. The resident stated the injury happened in September. The resident described the machine had a round thing on top and I got burned. Staff Q, certified nursing assistant (CNA), confirmed the resident's statement. Staff Q stated Resident #4 received diathermy, a physical therapy modality for pain relief. Staff Q stated the skin injury started as blisters. Initially facility staff thought the resident's blisters were related to fluid buildup. They later determined [MEDICAL CONDITION] the result of diathermy light. Staff Q had not observed other residents burned after receiving diathermy. A hospital wound assessment, dated 10/17/16, reflected a burn on the anterior right knee. Resident #4 reported the burn occurred as a result of physical therapy (PT) using e-stim on it and held in place too long. The assessment reflected there are [MEDICAL CONDITION] to each other, with the largest intact bulla and the smaller one partially open. Resident #4 reported sheets irritate and cause discomfort. The nursing assessment identified the right knee with two wounds adjacent to each other with measurements as follows: a. The upper wound with partial thickness, intact peri-wound, irregular shape of 0.9 cm (centimeters) by 1.5 cm The lower wound had an intact blister which measured 3.5 by 1.7 by exceeds skin level. A dressing was applied as the resident reported sheets irritated the burn/blister. Resident #4 was discharged on [DATE] with orders for the right knee wound care/dressing change as follows: Cleanse wound base using normal saline and sterile gauze, then pat dry. Apply non-bordered [MEDICATION NAME] dressing held in place with kling wrap. Change dressing every 3 days and as needed for looseness to protect intact bulla and partially open bulla. Review of the clinical record revealed a facility form titled Skin Assessment/Evaluation effective date 10/19/16, signature date 10/21/16, under section A directed document all Ulcers, Wounds and Other Skin Problems identified Resident #4's groin as red and open areas to the right knee. Review of the Daily Skilled Progress Note dated 10/18/16 at 11:30 a.m. reflected the registered nurse assessed Resident #4's skin color as pallor and noted the resident has a burn, and blister to the right knee. The clinical record lacked evidence to indicate the nursing assessment included measurement of the burn or blister area. According to a Skin Ulcer Non-Pressure Weekly skin sheet dated 10/26/16, with no onset date documented, reflected the resident reported mild, continuous pain to his/her right knee. The 10/26/16 right knee wounds measurements as follows: The upper wound on the resident's right knee measured 1.3 by 2.1 centimeters (cm) and had a scant amount of purulent drainage. The lower wound on the resident's right knee measured 3.7 by 2 cm. There was no exudate. The wound bed was black/brown (eschar) with macerated wound edges. The note indicated the physician was notified and directed staff to obtain a wound culture. A Skin Ulcer Non-Pressure weekly skin sheet dated 11/17/16 reflected no pain noted during dressing change. The 11/17/16 right knee wound measurements as follows: The right upper outer knee wound measured 1.8 by 1.7 by 0.3 cm with a moderate amount of serous drainage. b. The right knee wound, onset date 10/18/16 with various explanations for wounds on right knee. The note reflected the wound etiology could be friction from EZ stand transfer, tight slacks related to [MEDICAL CONDITION] or related to physical therapy treatment and more than likely a combination of all three. The wound measured 4 by 2 by 0.3 cm with moderate serous drainage. A bulla is a fluid filled cavity, i.e. blister. On 12/7/16 at 2:57 p.m. Staff G, physical therapist (PT) stated she performed physical therapy for Resident #4 and supervised Staff I, physical therapy assistant (PTA) as she performed physical therapy for Resident #4. Staff G and Staff I performed the modality diathermy on Resident #4. She described diathermy as an electromagnetic therapy that increases tissue intensity for heat to reduce pain, inflammation and increase circulation. Diathermy is performed with the use of a machine with settings of Low, Medium, High and Non-thermal. Therapy staff are trained to use the diathermy machine. The therapist selects the setting and a preset time appears. Staff G stated the therapist can't change the time, however can change the intensity. The intensity of diathermy is determined by the physical therapist. Resident #4's plan of treatment included low diathermy and non-thermal (no heat). Staff G stated she provided physical therapy treatment on 10/13/16, however no modalities were completed. Resident #4 did not report a burn at that time. Staff G stated she became aware of the right knee skin injury on 10/18/16, and an evaluation on 10/19/16. Resident #4 told Staff G he/she thought right knee burn occurred as a result of therapy services. Staff G reviewed the 10/14/16 hospital documentation and began her investigation. Staff G stated Staff I, PTA, documented she provided higher heat therapy intensities than ordered. The therapy investigation concluded the resident's polyester pants, increased moisture from incontinence and friction from use of the EZ Stand (a mechanical stand aid) were contributing factors to the resident's knee. She added diathermy with heat is contraindicated for residents that have metal joint replacements. The heat treatment will heat the metal joint replacement appliance and cause tissue damage, i.e. burn, from the inside-out. Staff G received an order to debride Resident #4's burn wound. She debrided the wound twice. Staff G stated if the burn was only related to heat used during diathermy, the tissue damage would have been deeper than 0.8 cm she noted. She again referred to the heated metal knee replacement appliance will burn tissue from the inside out. Staff G stated on 10/14/16 Staff I and Staff F, certified occupational therapy assistant (COTA), saw bubbling on Resident #4's knee under his/her pants. Staff I felt the bubbled area however did not remove the resident's pants to observe the resident's skin. Staff I and Staff F failed to notify nursing or therapy staff, and failed to document their findings. On 12/7/16 at 3:02 p.m. the Director of Rehab entered and joined the interview with Staff G. Staff G and the Director of Rehab confirmed Resident #4 had metal in his/her right knee. The resident had his/her total knee replacement years before, before the Director of Rehab was employed by the facility. On 12/7/16 at 5:07 p.m. during a follow up interview Staff G stated the hospital wound documentation that indicated the resident received E-Stim and completed too long is not accurate. Staff G stated the machine used for diathermy has preset time settings which cannot be adjusted. Therapy staff can adjust the heat intensity setting. On 12/7/16 at 5:15 p.m. observation of the Megapulse II, the machine used to provide diathermy to residents in the facility, in the presence of Staff G, the Administrator and Director of Rehab revealed when Staff G made the desired setting selection, the therapy time automatically populated. Settings and times as follows: a. With setting Variable, the Megapulse II automatically selected 30 minutes. With the setting at 1 Delta (low thermal), the Megapulse II automatically selected 20 minutes. With the setting thermal, the Megapulse II automatically selected 20 minutes. With the setting non-thermal, the Megapulse II automatically selected 30 minutes. Upon review of the user's manual, it was discovered the time can be changed on the Megapulse II, however per Staff G and Director of Rehab staff don't change time. Photos of the machine were obtained at this time. The lower corner of the Megapulse II machine included reference information regarding desired goals for use, protocol and application site. On the lower portion of the reference information included a warning section which directed do not to apply directly over metal with a thermal setting. On 12/8/16 at 3:27 p.m. Staff G clarified physical therapy documentation, and referenced the Megapulse II user ' s manual. Staff G stated Variable setting is non-thermal, and no heat is used with this setting. Staff G stated 2 Delta is a thermal heat. 2 Delta is used for increased range of motion, joint capsules, tendons, etc. 1, 2, 3 or 4 Delta is measured with 1 Delta as lowest heat and 4 Delta highest heat. Staff G stated SWD is short wave diathermy, which is an electromagnetic energy that cycles. SWD can be used with or without heat, and can be used at different heat ranges. She stated SWD heats a larger area and heats tissue 2 inches down. Physical Therapy notes revealed the following regarding diathermy treatment: On 10/5/16 Staff G, PT, provided diathermy treatment on 2 Delta to Resident #4's right knee for 20 minutes. On 10/10/16 Staff I, PTA, provided diathermy treatment on 4 Delta to Resident #4's right knee for 20 minutes. On 10/6/16 Staff G provided SWD diathermy treatment. The documentation lacked evidence to indicate if heat was utilized. On 10/11/16 Staff I provided SWD diathermy treatment. The documentation lacked evidence to indicate if heat was utilized. On 10/12/16 Staff I provided SWD diathermy treatment. The documentation lacked evidence to indicate if heat was utilized. On 12/8/16 at 12:11 p.m. Staff I, PTA, stated she provided diathermy treatment to Resident #4 related to arthritic pain. Staff I stated the machine used for diathermy treatment has pre-set settings. The time parameters can be changed but typically are not changed. Staff I was aware settings for residents are set up by the supervising physical therapist, and were not adjusted without prior approval.Staff I used a non-thermal setting for Resident #4. She was aware that meant no heat was provided and treatment lasted 30 minutes. Staff I was aware heat is contraindicated for residents with metal implants. Staff I was aware Resident #4 has metal in his/her knee. She added if her documentation reflected she used heat, her documentation was incorrect. Staff I confirmed she felt blisters on Resident #4's leg prior to hospital transfer. She stated she didn't know it was a blister. Staff I stated nursing staff dressed the resident prior to her therapy visit so should have observed the area. Resident #4 had chronic arthritic pain with frequent complaints of knee pain. Staff interviews as follows: On 12/7/16 at 3:20 p.m. Staff E, licensed practical nurse (LPN) stated he provided nursing care to Resident #4 prior to the 10/14/16 hospitalization . Staff E completed transfer paperwork. Staff E stated Resident #4 reported a blister on his/her knee, however, he was unable to recall if he looked at the blister. Staff E thought the resident was confused. Resident #4 is usually alert and oriented. Staff E stated he didn't put the concern with the blister together until therapy asked about a blister prior to the transfer. Staff E reported the resident mentioned a blister from therapy, however, Staff E didn't think therapy had any device that would cause a burn/blister. Staff E stated when Resident #4 returned from the hospital and therapy investigation began and they informed him they did have modalities that could cause a blister/burn. On 12/7/16 at 3:54 p.m. Staff F, COTA (Certified Occupational Therapist) stated she provided services to Resident #4 prior to the 10/14/16 hospitalization . Resident #4 reported Staff I burned his/her leg. When asked if she felt a bubble or blister on 10/14/16 prior to hospital transfer, Staff F responded, no, no, no I never felt them. Staff F confirmed she was in the resident's room with Staff I and provided transfer assistance. Staff F helped the resident get cleaned up, then provided transfer assistance with Staff I prior to hospitalization . She then stated her memory was bad and unable to recall for certain. Staff F stated, I just do my thing and do right by the resident. On 12/7/16 at approximately 4:00 p.m. Staff J, CNA, stated prior to Resident #4's hospitalization the resident reported the lamp from therapy was on too long. She stated there was white drainage and a clear dressing on the wound. The nurse was aware of the area and placed the clear dressing on the wound. Staff J had observed therapy staff provide diathermy before and knew the machine had an arm with a bulb that is placed above the body part. No other residents [MEDICAL CONDITION] blisters from the machine. On 12/8/16 at 12:46 p.m. Staff H, registered nurse (RN), stated prior to Resident #4's 10/14/16 hospitalization she observed a pink spot on the resident's right knee. The resident did not complain of pain when the nurse touched the area. Staff H thought the pink area was from warm water. Staff H described the area as a 5-6 inch circle on or slightly above the resident's right knee. Staff H was not certain she documented the area because the resident did not complain of discomfort. She thought the area may be red from use of a heating pad. On 12/7/16 at 2:25 p.m. Resident #4's physician stated to his knowledge the resident's right knee skin injury resulted from hot pack used by physical therapy, and in this case was too hot for Resident #4's legs. He stated initially the wound started as 3 blisters and appeared as a bad sunburn.

Based on observation, record review and resident and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from the physical or environmental hazards and during a transfer for 4 of 4 residents (Resident #1, #2, and #3, #4). The facility reported a census of 45 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/20/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The resident scored a 15 on a BIMS (Brief Interview for Mental Status) evaluation which indicated no cognitive impairment. The MDS indicated Resident #4 required extensive assistance of two or more staff for bed mobility, transfer, and toilet use. The resident required extensive assistance of one staff for hygiene. Resident #4 used a wheelchair for mobility. The Care Plan, initiated 7/11/14, identified a problem with self-care performance deficit related to osteoarthritis, pain and weakness. The interventions dated 1/14/15 directed staff to use an EZ Stand (assistance with a mechanical transfer device) for transfers. On 12/7/16 at 12:27 p.m. during observation of transfer and incontinent cares, observation revealed two Band-Aid like dressings near Resident #4's right knee. Resident #4 stated therapy put a thing on it, walked away and forgot it. The resident stated It burned my leg and it hurt. The resident stated the injury happened in September. The resident described the machine as a round thing on top which caused a burn. Staff Q, certified nursing assistant (CNA), confirmed the resident's statement. Staff Q stated Resident #4 received diathermy, a physical therapy modality for pain relief. Staff Q stated the skin injury started as blisters. Initially facility staff thought the resident's blisters were related to fluid buildup. They later determined the burns were the result of the diathermy light. Staff Q stated she had not observed other residents burned after receiving diathermy. On 12/7/16 at 2:57 p.m. Staff G, physical therapist (PT) was interviewed and stated she performed physical therapy for Resident #4 and supervised Staff I, physical therapy assistant (PTA) as she performed physical therapy for Resident #4. Staff G and Staff I performed the modality diathermy on Resident #4. Staff G described diathermy as an electromagnetic therapy that increases tissue intensity for heat to reduce pain, inflammation and increase circulation. Diathermy is performed with the use of a machine with settings of low, medium, high and non-thermal. Staff G stated Staff I, PTA, documented she provided diathermy at higher therapy intensities than ordered. Staff I's documentation revealed she used a higher level of heat during diathermy. Heat is contraindicated for residents that have metal joint replacements because diathermy treatment will heat the metal joint replacement appliance from inside-out. Staff G stated she discovered upon return from a 10/14/16 hospitalization , Resident #4 reported a burned area to his/her right knee as a result of physical therapy treatment from Staff I. Staff G began her investigation and determined the resident's right knee was likely the result of friction during EZ Stand transfer, tight polyester pants worn by the resident and as a result of increased heat used during diathermy therapy. No other residents were injured as a result of heat used during diathermy treatment. 2. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 9/13/16 with [DIAGNOSES REDACTED]. The resident was unable to complete a BIMS (Brief Interview for Mental Status) evaluation due to cognitive impairment. The MDS indicated Resident #1 required extensive assistance of two or more staff for bed mobility, transfer, and toilet use. The Care Plan initiated 5/9/14 identified a problem of self-care performance deficit related to impaired balance and Alzheimer's dementia. The interventions dated 10/4/16, directed staff use an EZ Stand for transfer during the day. On 12/7/16 at 10:00 am. observation of a transfer and incontinent cares revealed Staff C, certified nursing assistant (CNA), and Staff B, registered nurse (RN), provided transfer and toilet assistance. Observation identified staff transferred the resident from his/her recliner to the bathroom per EZ Stand. Resident #4 held the EZ Stand hand rest with arms bent at his/her elbows in which his/her elbows were triangular and slightly outward during transfer into the bathroom. Staff provided verbal cues to tuck his/her arms in as he/she passed through the bathroom door. Following incontinence cares, observation revealed the following: a. Observation of Resident #1's left elbow revealed purplish circular areas on his/her left elbow that were approximately 3 inches in length. b. Observation of Resident #1's right elbow revealed a purple acicular area the approximate size of a dime above the resident's right elbow. Staff B, registered nurse (RN), stated she was not aware of the areas, and staff did not report areas of concern following morning cares. Staff B stated the skin injuries to Resident #1's elbows lined up with the bathroom door frame. The resident's spouse was present during the transfer and observation of the bruised areas. Resident #1's spouse stated he/she has always bruised easily. Resident #1's spouse was not aware of the bruised elbows. On 12/8/16 at 2:57 p.m. the DON stated she was not aware of Resident #1's bruised areas. The DON stated when she is notified of skin injuries such as a bruised area; she completes an assessment and investigates the cause of injury. The DON stated she provides transfer assistance to Resident #1 when she works as a CNA. She felt the resident's bruised elbows occurred during transfer into the bathroom and his/her elbows hit the doorframe during transfer. Review of the clinical record lacked evidence to indicate any assessment of the resident's bruised elbows. 3. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 11/15/16 with [DIAGNOSES REDACTED]. The resident scored 15/15 on a BIMS (Brief Interview for Mental Status) evaluation which indicated no cognitive impairment. The MDS indicated Resident #2 required extensive assistance of one staff for bed mobility, transfer, and toilet use. The Care Plan initiated 11/25/15 identified a problem of self-care performance deficit related to CVA (cerebrovascular accident or stroke) with [DIAGNOSES REDACTED]. The interventions dated 12/21/15 directed at least 1 staff provide assistance in and out of bed, and with mobility. The resident ambulated with a walker or wheelchair. Observation on 12/7/16 at approximately 10:50 am. identified Staff R, CNA, placed a front wheeled walker in front of Resident #2. She then placed a gait belt around the resident's waist and assisted the resident out of his/her electric lift chair. Staff R provided transfer assistance to the bathroom. Following incontinence cares, observation revealed dark purple circular areas just above the resident's right and left wrist. Resident #2 stated that's where someone grabbed and squeezed too hard a couple days ago. The resident stated I just bruise easily. At the time of the observation, Resident #2 correctly identified the current date, year, and President of the United States. Staff R stated she observed the bruised areas this morning and propelled the resident to the dining room. On 12/7/16 at 11:23 a.m. Staff A, licensed practical nurse (LPN), stated a couple days ago she heard Resident #2 had bruised areas but did not document this because the Director of Nursing (DON) usually does those assessments with her investigations. On 12/8/16 at 2:57 p.m. the DON stated she was not aware of Resident #2's bruised areas. The DON stated when she is notified of skin injuries such as a bruised area; she completes an assessment and investigates the cause of injury. 4. Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of 9/20/16 with [DIAGNOSES REDACTED]. The resident scored a 6 on the BIMS (Brief Interview for Mental Status) evaluation. A score of 6 identified a severe cognitive impairment. The MDS indicated Resident #3 required extensive assistance of two or more staff for bed mobility, transfer, and toilet use. The Care Plan initiated 4/18/13 identified a problem of self-care performance deficit related to history of stroke with right sided hemiparesis and dementia. The interventions dated 4/18/13 directed 1-2 staff provide assistance with transfer, bed mobility, and toilet use. On 12/7/16 at 10:58 am observation identified Staff C, CNA, propel Resident #3 down the hallway in a wheelchair. The resident's hands rested on his/her abdomen. Observation revealed purple areas on the posterior portion of the resident's hands. Review of the resident's skin sheets identified the following: a. On 11/7/16 at 7:55 a.m. Resident #3 sustained a skin injury to his/her leg during staff assisted transfer to the whirlpool. b. On 12/5/16 at 8:16 a.m. Resident #3 sustained a skin injury to his/her leg. The injury appeared near the skin tear identified on 11/7/16. The clinical record lacked evidence to indicate the facility completed an investigation regarding the resident's bruised hands. On 12/7/16 at 11:23 a.m. Staff A, LPN, stated she was not aware of bruised areas on the posterior portion of Resident #3's hands. Staff A stated the DON completes the assessments and investigation of skin concerns. On 12/8/16 at 2:57 p.m. the DON stated she was not aware Resident #3 had bruised areas on the posterior portion of his/her hands. On 12/8/16 at 4:08 p.m. the DON stated upon notification of skin injuries, staff are to complete an assessment, notify the physician and implement an intervention to prevent future incidents.

Based on record review and staff interviews, the facility failed to provide continued assessment of a resident with a change in physical condition for 1 of 13 residents reviewed (Resident #6). Resident #6 had a concerning low blood pressure (BP) and staff notified the resident's physician. After staff notified the resident's physician, staff did not continue to assess the resident ' s vital signs. The resident was later admitted into the hospital due to a lower blood pressure and irregular heartbeat. The facility reported a census of 57 residents. Findings included: 1. According to an Admission Record form dated 8/19/14, Resident #6 had [DIAGNOSES REDACTED]. An Order Recap Report form dated 8/12/14 included a physician's orders [REDACTED]. A Minimum Data Set (MDS) assessment with an assessment reference date of 8/29/14 identified Resident #6 scored a 15 on the BIMS (Brief Interview for Mental Status). A score of 15 identified no cognitive problems. The same MDS revealed the resident required assistance from staff with transfer and walking. Review of an electronic chart Weights and Vitals Summary report form reflected the staff began to record Resident #6's pulse on 8/12/14 (admitted ). The following documentation revealed: 8/1214 at 6:44 P.M. - 79 and regular 8/13/14 at 8:50 A.M. - 57 and regular 8/14/14 at 9:49 A.M. - 72 and regular 8/14/14 at 8:35 P.M. - 76 and regular 8/15/14 at 7:15 A.M. - 65 and regular 8/16/14 at 1:03 P.M. - 76 and irregular 8/17/14 at 11:19 A.M. - 63 and regular 8/18/14 at 9:30 A.M. - 86 and regular 8/19/14 at 11:20 A.M. - 80 and irregular 8/20/14 at 2:19 P.M. - 110 and regular (even though staff documented the resident's pulse on 8/20/14 at 2:19 P.M., further review of a physician clinic note, dated 8/20/14 at 10:36 A.M., revealed the resident had gone to the physician's clinic on 8/20/14 at 10:36 A.M. and then directly on to an emergency room (ER) and admitted to a hospital. The record reflected the resident as not in the facility on 8/20/14 at 2:19 P.M.). Review of an electronic chart Weights and Vitals Summary report form revealed Resident #6's BP readings beginning on the date of admission to the facility on [DATE]: 8/12/14 at 6:43 P.M. - 120/60 8/13/14 at 8:50 A.M. - 122/72 8/14/14 at 9:49 A.M. - 140/60 8/14/14 at 8:34 P.M. - 140/78 8/15/14 at 11:28 A.M. - 122/78 8/16/14 at 1:00 P.M. - 118/70 8/17/14 at 11:18 A.M. - 120/60 8/18/14 at 9:30 A.M. - 130/80 8/19/14 at 11:19 A.M. - 104/60 8/19/14 at 6:35 P.M. - 104/60 (Note: Staff documented the resident's BP on 8/19/14 at 11:19 A.M. and 6:35 P.M. as exactly the same. Even though staff documented a BP reading on 8/19/14 at 6:35 P.M. on a weights and vitals form, further record review revealed staff failed to document any further assessment of the resident on 8/19/14 at 6:35 P.M., in a progress note section of the record, such as a pulse and hear rate or other vital signs). 8/20/14 at 2:19 P.M. - 146/90 (Note: even though staff documented the resident's BP on 8/20/14 at 2:19 P.M., further review of a Physician clinic note, dated and timed 8/20/14 at 10:36 A.M., (as noted below) revealed the resident had gone to his/her physician's clinic on 8/20/14 at 10:36 A.M., then directly on to an emergency room (ER) and admitted to a hospital. The record reflected the resident as not in the facility on 8/20/14 at 2:19 P.M.). Review of Resident #6's record revealed the following: 8/19/14 at 11:17 A.M. - Nursing staff documented the resident's BP as 104/60 and a pulse of 80 beats per minute (bpm) and an irregular rhythm. Review of an Occupational Therapy (OT) note dated 8/19/14 at 3:40 P.M. reflected Resident #6 became very weak and nearly collapsed with ambulation. The OT documented the resident's pulse as very weak, barely palpable and the resident ' s blood pressure (BP) as 97/64 when sitting. The OT reflected that after a few minutes, the resident stood and documented his/her BP as 70/46. The OT documented the nursing staff was notified of the resident's extremely low BP. The Progress Notes dated 8/19/14 at 4:32 P.M. documented the resident's BP bottomed out (becomes lower) at 71/46 during a therapy (Physical Therapy) session. (Note: According to the American Heart Association a normal BP reading is 120/80). The note reflected the staff notified the physician of the resident ' s lowered blood pressure and the physician decreased the resident's [MEDICATION NAME] medication to 25 mg ER daily. (Note: Even though the OT documented the nursing staff was notified of the resident's extremely low BP at 3:40 P.M., record review identified no documented assessment completed by nursing staff until 4:32 P.M. on 8/19/14. The nursing note lacked any assessment of the resident's pulse and/or heart rate after the OT assessed the residents pulse as weak and barely palpable. The facility Progress Notes dated 8/19/14 at 8:57 P.M. reflected the resident had no complaints of nausea and vomiting. The resident identified the resident as alert and oriented. The documentation lacked an assessment of the resident's BP and/or vital signs such as a pulse. The facility Progress Notes dated 8/20/14 at 2:04 A.M. reflected the resident slept through the night and exhibited no signs or symptoms of pain. The documentation lacked assessment of the resident's BP and/or vital signs such as a pulse. The Progress Notes dated 8/20/14 at 9:15 A.M. reflected the certified nursing assistant walked the resident to the restroom and the resident became week and lethargic. The resident passed out and then was carried to the bed. The resident was positioned with head down and feet raised. The resident then became responsive and alert again. The nurse documented the resident ' s vital signs as a BP146/90 and pulse 110 bpm. (Note: According to the American Heart Association a normal pulse is considered between 60 -100 bpm). The resident had a pulse oximetry of 93 percent. Normal is 95-100 percent. Further review of the same documentation revealed staff did not document the resident's pulse as regular or irregular. The Progress Notes of 8/20/14 at 9:45 a.m. reflected the resident out of the facility and at a doctor appointment. The resident ' s physician was notified of the occurrence this morning. A Clinic Note dated 8/20/14 at 10:36 A.M., identified the resident as poorly responsive when arrived to the clinic. A blood pressure was obtained at 72/52 and pulse 139 and irregular. The physician determined the resident had [MEDICAL CONDITION] with a rapid response, a history of hypertension (elevated blood pressure) and a history of metastatic [DIAGNOSES REDACTED] in the abdomen. The resident. The physician documented the resident would be sent to the emergency room for an evaluation. Review of an emergency room Record/History and Physical Exam from dated 8/20/14 at 3:40 P.M., revealed a medical provider's assessment of the resident included [MEDICAL CONDITION], apparently new onset, with an uncontrolled ventricular response. The medical provider documented the resident as being admitted to a hospital for observation. Review of a hospital Discharge Summary report dated 8/24/14, reflected the resident required a hospital stay from 8/20 to 8/23/14 to reduce the resident's heart rate from 120 -140 bpm rate to 70 - 80 bpm rate. On 10/7/14 at 1:55 P.M., the facility Director of Nursing was interviewed and confirmed she expected the nurses to regularly assess a resident's BP and vital signs after a BP reading as low as 71/46. On 10/8/14 at 2:25 P.M., the resident's physician was interviewed and stated a further assessment of the resident's BP reading and pulse would probably been a good idea. If the resident ' s blood pressure remained low or the pulse was noted to be rapid/irregular, she/he could have been seen in the emergency room that evening and treated sooner. On 10/9/14 at 8:05 A.M. Staff B, Registered Nurse, was interviewed and stated she would check the blood pressure and vitals several times if a resident had experienced a blood pressure of 71/40. Staff B stated the staff also needed to listen to the resident ' s heart rate and rhythm. On 10/9/14 at 8:15 A.M., Staff C, Licensed Practical Nurse, was interviewed and stated if a resident's heart rate dropped to 71/40, staff needed to continue to monitor the resident's BP and vital signs over a course of time. Staff C confirmed staff needed to listen to the resident's heart to check for rhythm as well.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and did not have a written health care plan, based on the assessment of the alarm system (Resident #13, #2). The staff was aware that Resident #13 removed or deactivated the alarm and the care plan lacked revision of this problem. Resident #2 did not have a planned alarm in place at the time of the resident ' s fall. The sample consisted of 12 residents and the facility identified a census of 49 residents. Findings included: 1. Resident #13 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 7/28/13 which identified the resident with severe cognitive impairment. The resident scored five out of 15 on the Brief Interview for Mental Status (BIMS) test. The MDS documented the resident required limited staff assistance with ambulation in the corridor, extensive staff assistance with bed mobility, transfers, ambulation in the room, and toilet use, and without upper and lower extremity range of motion impairment. The MDS documented the resident required staff assistance to balance when moved from a seated to standing position, walked, moved on and off the toilet, and for surface to surface transfers. The resident did not have falls during the previous assessment period. The MDS documented the resident's [DIAGNOSES REDACTED]. A Hospitalist History and Physical report dated 8/5/13 documented the resident fell out of a wheel chair, sustained a left hip fracture, is in significant distress with pain, cardiac symptoms included bradycardia, second degree heart block, and occasional heart block, and had Alzheimer's dementia. The report A Fall Risk Evaluation completed 7/22/13, identified the resident at a high risk for falls and scored 16 on the fall risk score. A Care Plan with an originated date of 7/29/13 documented the resident a fall risk, unaware of safety needs, confused, incontinent and with gait/balance problems. Interventions included: a. An alarm at all times, initiated 1/27/13. b. Encourage participation in group exercises daily and walk to meals. c. Keep needed items within reach when in room. d. Nonskid footwear initiated 5/9/13. e. Used a walker and wheel chair for mobility. f. Visual checks at night. The same Care Plan identified a problem with Activities of Daily Living (ADL) 7/29/13 related to impaired balance and confusion and directed the resident required one to two staff when toileted and transferred. The August 2013 medication record documented the resident received Ativan 0.5 milligrams three times daily as needed for anxiety and staff administered the Ativan 8/4/13 at 9:00 a.m. for increased restlessness. The Nursing Progress notes documented the following: a. On 1/27/13 at 8:30 a.m., staff found the resident on the floor after the resident slid out of bed, without injury, and a bed alarm (was) placed. b. On 5/9/13 at 10:11 a.m., staff found the resident on the floor in room after the alarm sounded, the resident sustained [REDACTED]. Nonskid footwear. c. On 8/4/13 at 8:32 a.m., the resident very confused and restless, noncompliant with pressure alarm, attempted to stand and walk without assistance to find car, the resident taken outside to look for car, and satisfied the car not present. d. On 8/4/13 at 9:00 a.m., staff administered Ativan for restlessness after walked outside, snacks and drinks offered, and the resident concerned about his/her car. e. On 8/4/13 at 5:39 p.m., staff documented the resident napped until lunch, ate 100% of lunch, and remained calmer all day. f. On 8/4/13 at 9:30 p.m., staff walked by the television area, found the resident on the floor in front of the wheel chair, the resident stated the left hip hurt, and the resident was transferred to the hospital. An Incident Description documented staff found the resident on the floor in the television area on 8/4/13 at 9:05 p.m., the chair alarm failed to sound and the chair alarm disconnected and off. The report documented the resident grabbed the left hip and had no memory of how the fall occurred. A Major Injury Determination form signed and dated by a physician on 8/5/13 at 12:00 p.m., documented the resident sustained [REDACTED]. On 8/13/13 at 2:45 p.m., Staff D, Certified Nurse's Aide (CNA) was interviewed and stated the resident's alarm sounded several times the evening of the fall/fracture when the resident frequently attempted to reposition self in the wheel chair while he/she sat in the television room. Staff D stated the resident sat on a pressure pad alarm with the alarm box attached to one of the wheel chair handles. Staff D stated the resident's alarm lacked an on/off switch, when the resident stood the alarm sounded until the resident sat down again, or until staff pushed a button on the alarm box. Staff D stated he/she discovered the resident on the floor after the fall and the alarm failed to sound. Staff D stated he/she had not checked the alarm box after the fall to make sure the alarm cord attached to the box, never saw the resident tamper with the alarm, but heard Staff I (CNA) state the resident tampered with the alarm during the night in the past. On 8/14/13 at 10:30 a.m., Staff E (CNA) was interviewed and stated she worked as a medication aide on the evening shift from 4:00 p.m. to 9:00 p.m. 8/4/13, the evening Resident#13 fell and had a hip fracture. Staff E stated the resident's alarm sounded frequently that evening after the resident attempted to stand and when scooted in the wheel chair. Staff E stated sometimes the alarm cord fell out of the alarm box because the cord was slightly loose, the cord stayed connected to the box when the resident sat still, and the resident's pressure pad came forward and fell to the floor several times that evening when the resident scooted in the wheel chair. Staff D stated he/she finished the medication pass at 8:00 p.m. that evening and sat with the resident until his/her shift was completed at 9:00 p.m. Staff E identified the resident more restless that evening than in the past, more quiet with one to one. The staff toileted the resident about 7:45 p.m., gave the resident juice, ice cream, rubbed back, and the resident refused a sandwich. Staff E stated the resident wanted to leave the facility to find his/her car and spouse. Staff E stated the facility had no other pressure pad alarms like the resident used to replace the alarm with the loose clip. The resident had personal alarms with a clip in the past and the resident would remove the alarm and throw it. Three alarms had been ordered at the time of the fall. Staff E stated she sat with the resident on the night of the fall/fracture because the resident knew how to turn the alarm off and turned the alarm off that evening. On 8/14/13 at 12:45 p.m., Staff E stated when he/she left the facility at 9:00 p.m. 8/4/13, the alarm box located on the resident's wheel chair handle. When asked if staff able to move the alarm box elsewhere since the resident able to turn the alarm off, Staff E stated "where". Staff E stated the cord on the alarm box approximately four to six feet long and the resident able to stand to find the alarm box wherever placed, and shut the alarm off. Staff E stated the resident able to shut the alarm off ever since the alarm started. On 8/15/13 at 8:35 a.m., Staff E stated he/she never told anyone the resident's clip alarm loose and the resident turned the alarm off the evening of 8/4/13. Staff E stated other staff should know the resident shut the alarm off and removed the cord from the box since the alarm started, did so frequently that evening, and believed the resident had done the same all day long. On 8/14/13 at 12:55 p.m., Staff C, Registered Nurse (RN) was interviewed and stated he/she worked the evening shift 8/4/13 when the resident fell and fractured hip. Staff C stated the resident a high fall risk and sat in the television area with a pressure pad alarm on the evening of the fall/fracture. Staff C stated the resident normally rocked back and forth in the wheel chair, which set off the alarm, and this happened frequently that evening. Staff C asked Staff E to sit with the resident until 9:00 p.m. on 8/4/13 while Staff C finished medications and treatments because the resident's alarm sounded frequently. Staff C stated he/she aware the resident had turned the pressure pad alarm on the bed off in the past and a 1 2 3 pressure pad alarm placed on the resident's bed. Staff C stated he/she never witnessed the resident turn the pressure pad alarm off while sat in the wheel chair and aware other staff had witnessed the resident turn the alarm off. Staff C stated he/she never administered Ativan to the resident that evening because the resident was not restless. The resident normally rocked in the wheel chair, and when the resident rocked, staff toileted the resident, provided one to one time, or other interventions. Staff C stated staff attempted to keep confused residents up (not in bed) until 8:00 or 8:30 p.m., snacks passed from 7:30 p.m. to 8:00 or 8:15 p.m., and this routine normally helped residents to calm/settle down. Staff C stated was unaware why the resident remained up in the television area and when fell at 9:05 p.m. on 8/4/13. Staff C stated she saw the resident on the floor in the television area. The pressure pad rested on the seat of the wheel chair. The alarm box was located on the resident's wheel chair with the cord not connected to the box. The resident was assessed and sent to the hospital. On 8/14/13 at 5:20 p.m., Staff C was interviewed and stated Staff E failed to inform her of the resident's alarm not working properly that evening. On 8/14/13 at 1:15 p.m., Staff A, Director of Nursing (DON) stated on the night of the fall/fracture, the pressure pad alarm on the resident's wheel chair had a broken clip and slipped out of the alarm box. Staff A demonstrated an alarm like the resident used the night of the fall/ fracture. Staff A described the clip to be like a telephone wall jack. Staff A stated the resident had to push the button in on the alarm box at the same time the clip came out of the box to prevent the alarm from sounding. Staff A stated she expected staff to replace alarms when the alarm failed to function properly. Staff A stated the facility were without other pressure pad alarms like the resident used at the time of the fall, and had 1 2 3 pressure pad alarms, a motion sensor alarm, and a seat belt alarm available. On 8/15/13 at 7:45 a.m., Staff I (CNA) stated he/she worked the evening the resident fell on [DATE]. Staff I stated in the past and prior to the fall on 8/4/13, the resident had pushed the button on the alarm box and removed the clip to prevent the alarm from sounding. Staff I stated she probably had not told anyone the resident could turn off the alarm. 2. Resident #2 had a MDS assessment with a reference date of 7/23/13 which identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 1 to 2 staff for all transfers and activities of daily life. The resident did have a history of falls while in the facility. The Care Plan for 7/2013 revealed the resident required assist of 1 to 2 staff with all transfers and may use the EZ stand lift when unsteady (5/13/2013). The resident required frequent walk by checks (7/13/2013), a motion sensor to alert staff if self- transporting to his/her room (1/13/2013) and a tamper resistant alarm in chair and wheelchair (5/13/2013). Review of the Nurse's Notes dated 8/7/13 at 9:22 A.M. revealed the housekeeping staff found the resident on the bathroom floor. Wheelchair alarm not in place in wheelchair at the time. Review of the Fall Incident report on 8/7/13 at 9:21 A.M. revealed the resident fell in the bathroom and the wheelchair alarm not placed in the wheelchair at this time. The resident sustained [REDACTED].

Based on observation, clinical record review, and interviews, the facility failed to complete an accurate elopement risk assessment for Resident #1 to ensure he/she received adequate supervision from hazards. The nursing staff assessed Resident #1 ' s elopement risk and discontinued the resident ' s safety intervention (wander guard) on 8/2/12. On 8/16/12, Resident #1 walked away from the nursing home without being noticed and fell in the street and sustained a laceration above his/her left eye. A witness to the incident reported an oncoming automobile swerved around where the resident laid on the street without stopping. This constituted an immediate jeopardy to the health and safety of the resident. Clinical record review and staff interviews determined Resident #1 ' s care plan safety intervention had been discontinue based on an inaccurate elopement risk score and the safety intervention was necessary to alert staff of Resident #1 ' s supervision needs. The facility reported a census of 53 residents with 5 residents reviewed for safety. Findings Include: According to the Minimum Data Set (MDS) assessment, dated 06/12/12, Resident #1 entered the facility on 11/15/11. Resident #1 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS documented Resident #1 required extensive assistance with activities of daily living (ADL's) including transfer, ambulation, locomotion, dressing, and toilet use. The MDS documented Resident #1 had falls with and without injury. Resident #1's [DIAGNOSES REDACTED]. A). The Elopement assessment dated [DATE] appeared incomplete with the question regarding medication which may cause confusion unanswered. The clinical record documented Resident #1 did take medications which may cause confusion with a start date of 11/15/11. The additional yes answer would give Resident #1 a score of 4. Each yes answer is assigned 1 point. A 4+ score indicated may have potential for elopement. Add intervention to care plan. The Elopement assessment dated [DATE] scored Resident #1 at 4. A narrative documented Resident #1 had a wander guard alarm, picture and information in the wanderer book and care plan. The Elopement assessment dated [DATE] and 06/12/12 indicated the following answers regarding Resident #1: 1. Is the resident ambulatory? Yes. 2. Does the resident have a habit of wandering. Yes. 3. Does the resident exhibit pacing, agitated behavior? No. 4. Is the resident asking to go home? No. 5. Does the resident have a [DIAGNOSES REDACTED].? Yes. 6. Has the resident ever eloped? No. 7. Has the family voiced concerns that resident may have a tendency to wander? No. 8. Is the resident currently taking medication which may cause confusion? No. The assessment scored Resident #1 at 3. A narrative on 03/23/12 documented wander guard felt appropriate, picture and information in wander guard book and care plan. A narrative on 06/12/12 documented wander guard bracelet in place and picture and information in wanderer book and on care plan. A narrative dated 08/02/12 documented bracelet discontinued due to a score of 3 for 2 quarters, consistent. The Medication Administration Record dated August 2012 documented Resident #1 received Zoloft 100 mg every day with a start date of 01/13/12, and Namenda 10 mg 2 times a day with a start date of 11/15/11. The facility medication reference, Nursing 2009 Drug Handbook pages 547-548 documented the adverse reactions to Namenda included confusion. The reference pages 609-610 documented the adverse reactions to Zoloft included confusion. A Consent for Psychotropic Medication Use documented Resident #1 had an order for [REDACTED]. The side effects of the drug included confusion. The consent was signed by Resident #1's Durable Power of Attorney (DPOA). A Consent for Psychotropic Medication Use documented Resident #1 had an order for [REDACTED]. The side effects included confusion. The consent was signed by Resident #1's DPOA. The Social Services Progress Notes dated 06/11/12 documented Resident #1 did admit to the writer that he/she would like to leave the facility at times. Resident #1 missed his/her ex boy/girlfriend. Resident #1 did have a [DIAGNOSES REDACTED]. The Care Plan identified Resident #1 had Alzheimer's disease and vascular dementia and the interventions included: a. Picture and information in the wanderer book, Resolved (discontinued) on 08/02/12. b. The nurse to check wander guard nightly and make sure it is worked properly, Resolved 08/02/12. Added 08/16/12: c. Picture and personal identifying information in the wanderer binder. d. The overnight nurse to check the wander guard bracelet nightly to make sure it worked properly. A Behavior Symptoms report dated 08/15/12 at 9:59 p.m. documented Resident #1 exhibited wandering and abusive language. A typed note dated 08/16/12 documented Staff K Certified Medication Assistant (CMA)/Certified Nursing Assistant (CNA) saw Resident #1 sitting on the swing in front of the nursing home, as he/she usually did, after dinner, at approximately noon. The Director of Nursing (DON) left the facility at 12:15 p.m. for a break and noticed the ambulance by the nursing home. The DON drove to the ambulance and saw Resident #1 lying in a driveway. Resident #1 had a laceration above the left eye. Resident #1 immediately recognized the writer, stood and walked with the writer to the nearby gurney. When asked, Resident #1 stated he/she went for a walk. The DON went to the physician's clinic and explained what happened and told the physician that a wander guard would be placed and that Resident #1 would have supervision when sitting outside. An emergency room Record dated 08/16/12 documented Resident #1 presented to the hospital with emergency medical services after he/she fell while walking using his/her 4 wheeled walker. Resident #1 stated he/she wanted to go outside the facility to go downtown. Resident #1 had a fall and lacerations of the left temple. Resident received 6 sutures of Prolene and 4 stitches interrupted single. An Incident Report dated 08/16/12 at 12:30 p.m. documented Resident #1 fell , resulting in a laceration/skin tear requiring treatment. Resident #1 last seen sitting on the swing in the front of the building. Resident #1 walked away from the front of the building and fell striking his/her head. The report documented Resident #1 ambulated independently, no apparent cause. The prevention section documented unanticipated resident behavior, and wander bracelet to Resident #1's walker. A Physical Therapy (PT) Evaluation and Certification dated 08/20/12 documented Resident #1 referred to PT due to a new onset of pain indicating a need for PT to decrease complaints. The history included a recent fall when trying to escape the facility resulting in a fall and increased complaints of right lower back pain. The prior level of function included distance on level surfaces of 150 feet. The background assessment precautions included agitation, confusion, fall risk and multiple falls. The gait analysis fall predictors included impulsive ambulation, reduced proactive balance and reduced reactive balance. During an observation on 09/07/12 at 11:30 a.m. at the residence where Resident #1 fell , a pickup pulled into the drive and then the garage.The man/woman came out and identified him/herself. He/she said he/she called the ambulance the day Resident #1 fell . He/she drove east toward his home and could see something near his driveway, then he saw an arm waving and realized it was a person. He/she said a car coming west swerved around where the person laid without stopping. He/she said the walker stood up on the street and the resident laid in the groove between the street and his/her driveway. He/she said the groove was rough and dipped so the resident could have caught the wheel, and the wind may have contributed to the fall. The street also sloped down. He/she said the resident gave his/her name, but would not say he/she lived at the facility. He/she called 911. The resident bled from his/her head. He/she thought the ambulance took 5 to 10 minutes to respond. He/she said there were no speed limit signs in the immediate area, but the streets were 25 miles an hour. He/she said the street running north and south by the facility led to the hospital further south. He/she stated, you could not visualize the area where Resident #1 fell from the facility, the condominiums blocked the view. During observation on 09/07/12 at 7:00 a.m. the drive from the location where staff found Resident #1 on 08/16/12, was a little more than 1/10th of a mile to the facility parking lot (1/10th mile equal 528 feet, the prior level of function included distance on level surfaces of 150 feet). During an observation of the environment on 09/07/12 at 11:00 a.m., the surveyor walked the perimeter of the facility from the front to about 1/2 way around on the east side with concrete (the nursing facility connected to the assisted living facility to the north). Where the concrete ended they had a grassy inclining area, not easily navigated. On the west side of the building noted grassy, uneven ground, and a fenced in area. A combined field also noted west of the building. Interviews: During an interview on 09/06/12 at 11:13 a.m. the Director of Nursing (DON) stated Resident #1 normally sat in the swing when he/she went outside, or sometimes walked around. Resident #1 went in and out without staff assistance. The DON stated she was leaving the facility and noticed an ambulance. The DON stated, she stopped the ambulance to see what was happening and noticed Resident #1 was there. The DON stated Resident #1 stated he/she went for a walk and fell . Resident #1 had a walker. The DON did not consider it an elopement. During an interview on 09/06/12 at 12:25 p.m. Staff A Certified Nursing Assistant (CNA) stated the day Resident #1 fell and needed sutures he/she sat on the swing by the front door. She said someone called about a person falling (Resident #1). Staff A stated they checked and Resident #1 was not on the swing so the staff went to look for him/her. Staff D stated they walked to where the ambulance was located, and learned Resident #1 had fallen. Staff A then walked the State surveyor to the location/area of where Resident #1 had fallen. The path walked cover a sidewalk to the parking lot, up the driveway, right on Avenue L, and right on 20th street. Staff A was unsure which residence (building) Resident #1 fell in front of. Staff A stated Resident #1 stated he/she was going to the bank. Staff A stated after the fall, Resident #1 consistently talked about leaving the facility. Resident #1 did not go anywhere routinely without his/her walker. During an interview on 09/06/12 at 12:46 p.m. Staff B CNA stated Resident #1 loved sitting out on the swing. Staff B stated Resident #1 had a wander guard, then they took it off. He/she had the wander guard on his/her ankle. Staff B stated he/she did really great. Staff B stated she never saw Resident #1 leave the swing. After the fall, Resident #1 talked about going to the bank or to see this guy/gal. She didn't recall Resident #1 saying it before the fall. Resident #1 always had the walker with him/her. During an interview on 09/06/12 at 12:50 p.m. the Activity Director (AD) stated Resident #1 talked about missing his/her boy/girlfriend from the beginning, intermittently, wanting to find him/her. Resident #1 wanted to know how much money he/she had. The AD stated about 1-1/2 to 2 weeks before the fall Resident #1 brought up more the wish he/she could find the boy/girlfriend. They told Resident #1 the boy/girlfriend went to California. The AD stated she never saw Resident #1 walk around outside. During an interview on 09/06/12 at 3:00 p.m. Staff E CNA stated Resident #1 had an ankle bracelet. She thought they took it off because Resident #1 stated he/she would not run away. Staff E stated she thought Resident #1 did okay for awhile after they took it off. Staff E did not recall if Resident #1 talked about leaving the facility before he/she fell . Staff E stated Resident #1 could get out him/herself and always took the walker. During an interview on 09/06/12 at 3:09 p.m. the Social Worker (SW) stated Resident #1 forgetful at times. The SW stated she was not concerned about Resident #1 eloping from the facility. She talked about the bank off and on, and she thought the boy/girlfriend would take care of him/her. When questioned about her documentation on 06/11/12 regarding Resident #1 saying he/she would like to leave the facility at times, the SW stated Resident #1 did not say he/she would physically leave the facility. The SW looked at her documentation and then the Elopement Assessment from 06/12/12 regarding the resident asking to go home, marked no, she said "I see what you mean". The SW stated Resident #1 always used the walker and she had seen him/her walk in the parking lot once. During an interview on 09/06/12 at 3:14 p.m. Staff G Licensed Practical Nurse (LPN) stated Resident #1 made the comment he/she would get out of here one of these days, and it got progressively worse. Staff G stated it started prior to the fall on 08/16/12. Staff G stated normally Resident #1 took the walker with him/her. He/she kept things in it. After they removed the wander bracelet Resident #1 could go in and out him/herself. Staff G thought they removed the wander bracelet because they did not think Resident #1 needed it. When questioned about needing it if he/she talked about getting out of here, Staff G said Resident #1 never tried to leave before. During an interview on 09/06/12 at 3:47 p.m. Resident #1's family member stated Resident #1 always talked about leaving the facility. The family member said he/she talked to staff about it and they said they would keep an eye on Resident #1. The family member stated the facility called when they put the wander guard alarm on, but they did not call and tell him/her when they took it (the wander guard) off. The family member stated had the facility staff informed her/him of Resident #1 ' s wander guard being removed (on 8/2/12), he/she would have requested the wander guard not be removed. During an interview on 09/06/12 at 3:49 p.m. Staff I Activity Assistant stated Resident #1 always wanted to leave the facility and go to California to be with his/her boy/girlfriend. One day Resident #1 wanted to leave the facility to go downtown. Resident #1 thought he/she could go with Staff I. Staff I stated he/she talked about these things before the fall. During an interview on 09/06/12 at 5:14 p.m. Staff J LPN stated she documented 08/15/12 Resident #1 wandering. Staff J stated Resident #1 wandered in the halls, looking out doors. Staff said this was unusual for Resident #1, he/she usually went to bed at 8:00 to 8:15 p.m. and it was going on 10:00 p.m. She said it seemed to escalate. Staff J stated Resident #1 talked about leaving, but not aware if he/she talked about it prior to the fall. During an interview on 09/07/12 at 7:52 a.m. Staff K Certified Medication Assistant (CMA)/Certified Nursing Assistant (CNA) stated the day Resident #1 walked away and fell , she came to the facility for a pizza party. She saw Resident #1 outside on the swing which was not unusual, she did not think anything of it. Staff K came in sometime around noon, she could not give a specific time. Staff K stated someone called saying they found a person (Resident #1) on the ground, and the first thing she thought of was Resident #1. She did not know why she thought of Resident #1. Staff K stated at the time Resident #1 could go in and out on his/her own. Staff K stated surprise Resident #1 walked that far. Staff K stated when she walked to the flag pole with Resident #1, he/she needed to stop and rest. Staff K stated sometimes Resident #1 was a little unsteady. She said Resident #1 always took the walker with him/her. During an interview on 09/07/12 at 8:41 p.m. Staff L CMA/CNA stated the day Resident #1 walked away and fell , she answered the phone and someone stated they got a page that someone fell by the apartments and asked about Resident #1. Staff L called team time to search for Resident #1. They were just starting the search when the DON called and said she had him/her. Staff L walked over with Staff A. Resident #1 said he/she was going to the bank. Staff L stated Resident #1 sat outside all the time. He/she talked about going downtown or to the bank prior to the fall. Staff L stated if a resident wore a wander bracelet they had to be supervised outside. If a resident did not they could go outside when they wanted, unsupervised. Staff L stated they looked outside once in awhile, but with no specific frequency. Staff L stated Resident #1 walked pretty good. She never saw Resident #1 walk around outside, he/she just sat in the swing. She said Resident #1 was more agitated and said he/she was going to the bank. Staff L stated although Resident #1 had talked about going to the bank, he/she never went. She said Resident #1 took his/her walker everywhere. During an interview on 09/07/12 at 9:12 a.m. Staff D Registered Nurse (RN) MDS Coordinator stated when she did the elopement assessment regarding medications she looked at their medication reference and if the adverse effects included confusion, she marked yes to that question on the assessment. Staff D stated she did not talk to the family about concerns. Staff D stated she would not necessarily think Resident #1 saying he/she thought about leaving the facility the same as asking to go home. She would be more concerned if Resident #1 said they were leaving after lunch. At 9:26 a.m. Staff D returned and said the answer to the medication question in March and June should be yes. She said it would increase the score to 4, indicating risk of elopement. Staff D stated she kept Resident #1 on the wander bracelet because she still thought it appropriate. Staff D stated she did not make the decision to discontinue the wander bracelet. During an interview on 09/07/12 at 10:32 a.m. the Administrator stated residents, staff, and family go in and out all the time. She said they had no policy for monitoring residents when they went outside. During the day the front door, the service door and door #1 alarms were off. Each of these doors had a wander alarm, so if a resident with a wander bracelet attempted to go out, the alarm would activate. When someone without a wander bracelet went out, no alarm sounded. These doors were alarmed at night. All other door alarms were on during the day. The door alarm panel located by the medication room showed the front, service and door 1 alarms turned off. During an interview on 09/07/12 at 11:17 a.m. the DON stated Resident #1's family visited weekly. The DON documented on the Elopement Assessment to discontinue the wander bracelet. She based the decision to discontinue it solely on the assessment score. She said if Resident #1 had a score of 4 or more she would not discontinue the bracelet. The DON agreed the assessment was not accurate. The DON stated they had no other policies regarding monitoring residents who went in and out of the facility independently. She said they did monthly elopement drills. The Progress Notes dated 08/20/12 at 8:53 p.m. documented Resident #1 wandered out of the facility after supper and the wander guard did not alarm. Staff replaced the wander guard. A Secure Care Band Alarm Check Log for August 2012 documented Resident #1 discontinued on 08/02/12. The same log added Resident #1 on 08/16/12. Resident #1 lacked initials staff checked the band 08/17/12 through 08/22/12. During an interview on 09/07/12 at 10:32 a.m. the Administrator stated regarding the alarm check log, she talked to the nurses working the shifts where initials were lacking and they stated they were checked on those dates. Removal of the immediate jeopardy was on 9/7/12. The facility responded to the situation and on 9/7/12 and placed a wander guard on Resident #1 ' s and staff would provide supervision when the resident was sitting outside. The facility also placed a door alarm on the front door. The facility also placed a sign out sheet by the front door area for residents to complete when they are sitting outside. Staff was educated on 9/7/12 in the manner of Team Time for the present care givers in regards to resident safety and system changes. The facility also assessed elopement scores & BIMS (Brief Interview Mental Status) to ensure residents could be outside safety. On 9/10/12, the facility reviewed all residents BIMs/elopement risk and updated their care plans. On 9/13/12, the facility in-service the nursing staff on reviewing elopement risks. On 9/13/12 the facility updated Resident #1 ' s care plan for when outdoors to have staff present with him/her. These actions lowered the deficiency from a scope and severity level of J to D, with the need for ongoing monitoring of elopement risk and accurate assessments scores. The Policy and Procedure for Elopement Drills indicated the nursing home staff are expected to know the locations of residents. The facility policy Elopement/Secure Care Protocol documented the purpose to provide a safe environment for wanderers at risk by alerting staff of departure from the facility. The procedure included: a. Using the Admission Elopement Scale or as deemed necessary, a resident would be assessed to aid in identifying potential wanderers at risk for leaving the facility unattended. If the resident is at risk, a Secure Care Bracelet would be applied after an explanation to the family or guardian Between 08/02/12 and 08/16/12, the care plan lacked interventions related to Resident #1 going outside regarding supervision due to his/her high fall risk and cognitive status. B.) Resident #1's fall history included: a. A Change in Condition Report-Post Falls/Trauma report dated 01/20/12 at 7:45 p.m. documented Resident #1 fell in his/her bathroom, stating he/she slipped in loose stool. b. A Change in Condition Report-Post Falls/Trauma report dated 01/29/12 documented Resident #1 fell in his/her room, stating he/she got up and slid on his/her bottom. c. A Change in Condition Report-Post Falls/Trauma report dated 02/01/12 at 1:48 a.m. documented Resident #1 fell in his/her room, stating he/she put boots on and slid out of bed. d. A Change in Condition Report-Post Falls/Trauma report dated 02/15/12 at 9:45 a.m. documented Resident #1 fell when he/she followed staff through the assisted living door. Resident #1 went through door with walker, stumbled and fell . Resident #1 not at risk for wandering outside the facility, but did go for group walks in assisted living hallways. Staff applied a wander guard to alert staff if Resident #1 attempted to go through the assisted living door to walk, due to Resident #1's dementia. e. A Change in Condition Report-Post Falls/Trauma report dated 03/02/12 at. 2:00 p.m. documented Resident #1 fell in the assisted living activity room. Resident #1 had a wander guard on and the door sounded at hall 1. The alarm sounded from the wander guard, as Resident #1 walked through the hall 1 door. f. A Change in Condition Report-Post Falls/Trauma report dated 03/31/12 at 12:50 p.m. documented Resident #1 fell in his/her room. The report indicated Resident #1 had a history of [REDACTED]. The report documented Resident #1 had an alarm sounding. Resident #1 went to the emergency room for exam of posterior head bleeding. An emergency room Record dated 03/31/12 documented Resident #1 apparently fell on the floor. He/she stated tripping, landing on the back of his/her head. Resident #1 had a history of [REDACTED]. g. An Incident Report dated 05/25/12 at 5:50 p.m. documented Resident #1 fell in his/her room when walking with the walker from the dining room back to his/her room. Resident #1 stated he/she bent over, lost his/her balance and fell . A Physical Therapy (PT) Evaluation and Certification dated 07/13/12 documented the reason for the referral; Resident #1 exhibited increased right knee pain causing difficulty with gait activities. The history included falls, use of assistive device for gait, and dementia. The complexities impacting treatment included concomitant cognition deficits. Background assessment precautions included confusion and fall risk. The fall predictors included decreased sensory input through feet, poor negotiation of obstacles, reduced reactive balance and reduced recognition of unsafe situations. Due to the documented physical impairments and associated functional deficits, Resident #1 at risk for falls.